Question: In patients with spinal stenosis without degenerative spondylolisthesis, is surgery more effective than nonsurgical treatment?
Design: Randomized (allocation concealed)*, blinded (data safety and monitoring committee)*, controlled trial with 2-year follow-up (Spine Patient Outcomes Research Trial [SPORT]).
Setting: 13 medical centers in 11 states in the United States.
Patients: 289 patients who had a history of neurogenic claudication or radicular leg symptoms for =12 weeks and lumbar spinal stenosis at =1 level confirmed by imaging. Patients with lumbar instability were excluded. 88% of patients completed follow-up at 6 months, 85% at 1 year, and 76% at 2 years. 278 patients (mean age, 66 y; 62% men) completed =1 follow-up assessment.
Intervention: Patients were allocated to standard posterior decompressive laminectomy (n = 138) or usual care (n = 151), which consisted of active physical therapy, education or counseling with home exercise instructions, and nonsteroidal anti-inflammatory drugs (if tolerated).
Main outcome measures: Bodily pain and physical function, assessed on the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and on the modified Oswestry Disability Index.
Main results: Analysis was by intention to treat. Surgical and nonsurgical treatment groups did not differ with regard to SF-36 bodily pain at any time point except at 2 years when the surgical group had a greater reduction in pain than the nonsurgical group did (Table), at which point follow-up had dropped below 80%. Groups did not differ with regard to scores on the SF-36 physical function or Oswestry Disability Index at any time point (Table).
Conclusion: In patients with spinal stenosis without degenerative spondylolisthesis, surgery reduced pain at 2 years but not at earlier follow-up points. Surgical and nonsurgical treatment groups did not differ with regard to physical function or scores on the Oswestry Disability Index.
Weinstein and colleagues present a controlled trial of excellent quality to support their conclusions that patients who had spinal stenosis without degenerative spondylolisthesis who received surgical treatment demonstrated greater improvement in pain than patients who were treated nonsurgically. This article will allow surgeons to recommend spinal decompression procedures for patients whose perceived quality of life is diminished and whose conditions are unresponsive to nonoperative treatment.
The authors did not use a specific nonoperative regimen as a comparison to the standardized surgical decompression; thus, the reader can make no conclusion about the variety of nonoperative options and how they might individually compare to surgical decompression. Also, the study included patients who had symptoms for as few as 12 weeks. This may explain why the physical function between the surgical treatment and nonsurgical treatment groups was similar. Because approximately 40% of patients had symptoms for less than six months, this still could be a factor in some of the positive outcomes in the nonsurgical group. Patients who have substantial spinal symptoms for less than 12 weeks can generally respond to a variety of nonoperative approaches that can result in pain subsidence for a variable period of time. However, nonoperative treatment may result in persistent pain, as evidenced by the 2-year results demonstrating reduction of bodily pain in the surgical group compared with the nonsurgical group.
In summary, surgeons can clearly use the information from this study to discuss treatment options with their patients who have lumbar stenosis.