Surgery More Effective Than Nonsurgical Treatment for Spinal Stenosis

Caroline Cassels

Surgery is more effective than nonsurgical therapy for the relief of symptoms associated with lumbar spinal stenosis, a new study suggests.

In a randomized trial, investigators at Dartmouth Medical School, in Hanover, New Hampshire, found surgery offered a significant advantage over nonsurgical treatment in terms of pain relief and functional improvement that was maintained at 2 years of follow-up.

“Patients with spinal stenosis without degenerative spondylolisthesis who underwent surgery showed significantly greater improvement in pain, function, satisfaction, and self-rated progress than did patients who were treated nonsurgically,” the authors write.

Led by James N. Weinstein, DO, the study is published in the February 21 issue of the New England Journal of Medicine.

Known as the Spine Patient Outcomes Research Trial (SPORT), the multicenter study included patients from 13 US medical centers with multidisciplinary spine practices. The study included a randomized cohort of 289 patients and a concurrent observational cohort of 365 subjects who opted not to be randomized.

All patients were potential surgical candidates and had a history of neurogenic claudication or radicular leg symptoms for a minimum of 12 weeks. In addition, all subjects had confirmatory cross-sectional imaging showing spinal stenosis at 1 or more levels.

Nonsurgical treatment before study enrollment was not prespecified but included physical therapy, epidural injections, chiropractic, and the use of anti-inflammatory or opioid agents.

Study interventions included standard posterior decompressive laminectomy or “usual care,” which was recommended to include, at least, active physical therapy, education or counseling with home exercise instruction, and the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) if possible.

 

Little Evidence of Harm

The study’s primary outcomes were measures of bodily pain and physical function on the Medical Outcomes Study 36-item Short-Form general health survey (SF-36) and on the modified Oswestry Disability Index measured at 6 weeks, 3 months, 6 months, and 1 and 2 years.

Secondary outcomes included patient-reported improvement, satisfaction with current symptoms and care, and the bothersomeness of both stenosis and low back pain.

The effect of treatment was defined as the difference in the mean change from baseline between the surgical group and the nonsurgical group. In the randomized cohort, 138 patients were assigned to surgery and 151 to nonsurgical treatment.

At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, and 43% of those who were randomly assigned to receive nonsurgical care had crossed over and received surgical treatment.

The investigators report that the as-treated analysis, which combined both cohorts and was adjusted for potential confounders, showed a significant advantage for surgery by 3 months for all primary outcomes, which remained significant at 2 years.

They also report that the treatment effect for surgery was seen as early as 6 weeks, appeared to peak at 6 months, and persisted for 2 years. However, there was only moderate improvement among patients in the nonsurgical group during the 2-year study period.

The investigators note that there was little evidence of harm for either treatment. “Often, patients fear they will get worse without surgery, but this was not the case for the majority of patients in the nonsurgical group, who, on average, showed small improvements in all outcomes,” they write.

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institutes of Health Office of Research on Women’s Health, the National Institute of Occupational Safety, and Health of the Centers for Disease Control and Prevention.

Tags: Spinal Stenosis

Category: Clinical Studies, News