Total disc replacement for chronic low back pain

In the linked randomised controlled trial (doi:10.1136/bmj.d2786), Hellum and colleagues compare the efficacy of surgery with disc prosthesis versus intensive rehabilitation for patients with chronic low back pain.1

Back pain is a common condition that usually improves. Some cases become chronic, however, and mortality can be increased.2 Evidence is accumulating for the efficacy of rehabilitation programmes combined with cognitive behavioural therapy (combined physical and psychological programme; CPP) in patients with chronic disease. The physical element of such programmes usually includes aerobic training, resistance training with the use of gym equipment, and stretching exercises. The psychological content includes cognitive behavioural therapy, counselling, and pain management skills. Programmes place an emphasis on self reliance, coping strategies, goal setting, and problem solving. Treatment is mainly delivered in groups.

Physical training forms the main part of programmes for chronic low back pain in primary care and secondary care settings.3 4 CPP is recommended by the Department of Health for units delivering spinal care and is supported by guidelines from the National Institute for Health and Clinical Excellence.5

Surgery has been used for many years to treat chronic low back pain. Spinal fusion is based on the concept that the pain …