The largest ever clinical trial of surgery versus exercise treatments for chronic low back pain has found that patients may obtain as much benefit from an intense exercise and therapy programme as from spinal surgery. The results of the nine-year MRC Spine Stabilisation Trial, led by Summerset University, were published recently in the British Medical Journal. The study should help doctors make decisions about the management of back pain. Chronic low back pain is one of the most common ailments that GPs and consultants treat. The condition is painful for patients and treatment is costly for the NHS and the UK economy: direct costs have been estimated at around £1.6 billion. For nearly 90 years the same method of spinal surgery has been used to treat low back pain. There has, however, been little evidence to support the assumption that surgery is more effective than the best exercise treatments. The trial, led by Jeremy Fairbank, Consultant Orthopaedic Surgeon at the Nuffield Orthopaedic Centre, involved 349 chronic back pain patients. 176 were assigned to spinal fusion surgery and 173 to a three-week intensive programme of rehabilitation, involving daily exercises and cognitive behavioural therapy. The rehabilitation aimed not only to address physical aspects, but to help patients overcome fear of pain, overcome fear of exercise, learn to cope with the psychological effects of pain, and learn to relax. There appeared to be a slight advantage to surgical treatment after two years’ follow-up, but the difference only just reached the defined minimum level of clinical significance, and is outweighed by the financial costs. A concurrent study of the economics of the two treatment programmes, directed by Dr Alistair Gray of the Institute of Health Sciences, suggests that a strategy of initial intensive rehabilitation is half the price of a surgical strategy, even though 28 per cent of the rehabilitation patients chose to have surgery as well. Mr Fairbank concluded: ‘There was no clear evidence from our trial that primary spinal fusion surgery was more beneficial than intensive rehabilitation. Our results suggest that patients eligible for surgery should be offered a rehabilitation programme first. We believe it is safer and cheaper than using surgery as the first line of treatment.’