Spinal fusion surgery for isolated low back pain

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Low back pain is the most common type of back issue and a major contributor to the burden of musculoskeletal conditions in Australia and globally.1 As the population ages, the prevalence of these conditions continues to rise, contributing to reduced work productivity, early retirement and income poverty.1

Back problems are the second most common reason Australians seek care from their general practitioner, and are a leading cause of presentation to emergency departments and disability.1,2

People who live in regional areas (compared to major cities) or areas of disadvantage, or have a disability are more likely to have back problems.2

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Variations in care

Despite broad international consensus on evidence-based approaches for managing low back pain, many people do not receive care aligned with clinical guidelines.

The Fourth Australian Atlas of Healthcare Variation published marked differences in hospitalisation rates for adults across Australia for lumbar spine surgery.3 Rates of surgery were higher in inner regional areas than in major cities or outer regional areas.3

In NSW, there is an opportunity to address clinical variation in the management of low back pain.

Population rates of lumbar spinal fusion for isolated back pain vary considerably across local health districts (LHDs), ranging from 57 to 164 per 100,000 (age-standardised rate for the 5-year period financial year 2019–20 to 2023–24 and excluding border LHDs where some patients may receive procedures interstate).*

There is marked variation between NSW public and private hospitals. In 2023–24, 302 spinal fusion surgeries for a diagnosis of pain were performed in public hospitals, compared with 1,651 in the private sector.*

*Source: NSW Admitted Patient Data Collection

Evidence-based management of isolated low back pain

The Australian Commission on Safety and Quality in Health Care’s Low Back Pain Clinical Care Standard recommends conservative management as the first-line approach to low back pain. This includes physiotherapy, lifestyle modifications and judicious use of medications, particularly opioids. Diagnostic imaging should be used only when serious underlying pathology is suspected.1 Early and appropriate management of low back pain can reduce the risk of recurrence and progression to persistent or chronic pain. In most cases, surgical intervention is not indicated.

Refer to the Model of care for the management of low back pain (PDF 576.7 KB) for evidence-based guidance on how to care for people with back pain.

Spinal fusion surgery for isolated low back pain

Spinal fusion with or without decompression is not recommended as a treatment for isolated low back pain.1,4

Spinal fusion surgery is not recommended:

  • for chronic nonspecific low back pain1,5
  • as an addition to decompression surgery in patients with lumbar spinal stenosis with dominant back pain when there is no radiographic or clinical evidence of spinal instability or deformity.6

Spinal fusion surgery may be recommended for spinal instability or deformity associated with mechanical low back pain.

Give patients clear, evidence-based information about their condition, with opportunities to ask questions and express concerns. Support informed, collaborative decision making by discussing the benefits, risks and costs of treatment options and aligning care with the patient’s expectations.

Culturally safe care for Aboriginal patients

Providing patient-centred care requires a respectful understanding of cultural values, beliefs and communication preferences.

Facilitate access for Aboriginal patients to receive investigations, assessments and treatments closer to Country where possible, and support access to non-surgical services, such as physiotherapy, to treat back pain. Maintain flexibility and sensitivity to Aboriginal healing practices through open communication with the entire health team.

Use inclusive, plain language and ensure that any resources or information shared are culturally appropriate, accessible and tailored to the needs of Aboriginal patients and communities. Coordinate care with the local Aboriginal health and social work teams, or other relevant teams.

Keep both the patient and their family or support network meaningfully involved in a shared decision-making process. Take the time to have a yarn about the benefits risks, and implications of all available treatment options. The Finding your way shared decision-making model can support discussions.

Proceeding with spinal fusion surgery for isolated low back pain

There is limited evidence supporting the effectiveness of spinal fusion for isolated low back pain.6 In cases without spinal instability or deformity, spinal fusion is a low-value procedure due to the lack of demonstrated benefit.

Given the limited evidence, all proposed cases should be reviewed by a surgical multidisciplinary panel, with the factors outlined below carefully considered when determining whether it is appropriate to proceed. Surgeons and their patients should be encouraged to consider participation in randomised controlled trials that will generate evidence on the effectiveness, safety and long-term outcomes of spinal fusion for low back pain.

Factors for consideration

Consider the following when completing the ‘Recommendation for admission’ form for any spinal fusion for the treatment of back pain:

  • Has a comprehensive clinical assessment been completed (including history, physical examination, and relevant investigations)?
  • Is there obvious structural pathology of concern that is likely to be the source of pain, such as severe degenerative disc associated with adjacent Modic changes and correlating with discovertebral uptake on SPECT?
  • Has the patient completed a minimum 12-week trial of evidence based conservative management including:
    • multimodal pain management
    • physiotherapy or functional restoration programs
    • cognitive behavioural therapy (if indicated)
    • lifestyle interventions, e.g. smoking cessation, weight loss?
  • Has the patient been seen by a chronic pain specialist prior to surgery?
  • Has a shared decision-making process taken place, involving the patient, primary care provider and relevant multidisciplinary specialists?
  • Has the patient been fully informed of the potential risks, benefits and long-term consequences of spinal fusion surgery?

Consider a plan to register the case in Australian Spine Registry.

References

  1. Australian Comission on Safety and Quality in Health Care. Low Back Pain Clinical Care Standard. Sydney: ACSQH; 2022.
  2. Australian Institute of Health and Welfare. Back problems. Australian Institute of Health and Welfare. AIHW; 2024. [Cited 30 June 2025].
  3. Australian Commission on Safety and Quality. The Fourth Atlas of Healthcare Variation. Sydney: ACSQHC; 2021.
  4. National Institute of Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. National Institute of Health and Care Excellence, 2020.
  5. Carelon Medical Benefits Management. Clinical Appropriateness Guidelines, Muskuloskeletal, Appropriate Use Criteria: Spine Surgery. Carelon Medical Benefits Management, 2023.
  6. Försth P, Ólafsson G, Carlsson T, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med. 2016 Apr 14;374(15):1413-23. DOI: 10.1056/NEJMoa1513721.
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