Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial

• Published in: Annals of internal medicine Vol. 162; no. 7; pp. 465 - 473
• Main Authors: Delitto, Anthony, Piva, Sara R, Moore, Charity G, Fritz, Julie M, Wisniewski, Stephen R, Josbeno, Deborah A, Fye, Mark, Welch, William C
• Format: Journal Article
• Language: English
• Published: United States American College of Physicians 07-04-2015
• Subjects: Aged; Clinical outcomes; Decompression, Surgical - adverse effects; Female; Humans; Intention to Treat Analysis; Lumbar Vertebrae - surgery; Male; Medical treatment; Physical Therapy Modalities; Primary care; Reoperation; Sex Factors; Spinal cord; Spinal Stenosis - surgery; Spinal Stenosis - therapy; Surgical Wound Infection - etiology; Treatment Outcome; Wound Healing
• ISSN: 0003-4819; 1539-3704
• DOI: 10.7326/M14-1420

Primary care management decisions for patients with symptomatic lumbar spinal stenosis (LSS) are challenging, and nonsurgical guidance is limited by lack of evidence.
To compare surgical decompression with physical therapy (PT) for LSS and evaluate sex differences.
Multisite randomized, controlled trial. (ClinicalTrials.gov: NCT00022776).
Neurologic and orthopedic surgery departments and PT clinics.
Surgical candidates with LSS aged 50 years or older who consented to surgery.
Surgical decompression or PT.
Primary outcome was physical function score on the Short Form-36 Health Survey at 2 years assessed by masked testers.
The study took place from November 2000 to September 2007. A total of 169 participants were randomly assigned and stratified by surgeon and sex (87 to surgery and 82 to PT), with 24-month follow-up completed by 74 and 73 participants in the surgery and PT groups, respectively. Mean improvement in physical function for the surgery and PT groups was 22.4 (95% CI, 16.9 to 27.9) and 19.2 (CI, 13.6 to 24.8), respectively. Intention-to-treat analyses revealed no difference between groups (24-month difference, 0.9 [CI, -7.9 to 9.6]). Sensitivity analyses using causal-effects methods to account for the high proportion of crossovers from PT to surgery (57%) showed no significant differences in physical function between groups.
Without a control group, it is not possible to judge success attributable to either intervention.
Surgical decompression yielded similar effects to a PT regimen among patients with LSS who were surgical candidates. Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS.
National Institutes of Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases.