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SPORT 8-year lumbar stenosis outcomes differed from those at earlier follow-up
The SPORT study provides details on the outcomes of surgery vs non-surgery to help patients make individualized decisions, according to researchers.
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The recently published SPORT study results showed that at 8 years post-treatment some groups of patients with symptomatic lumbar spinal stenosis who opted for conservative care did as well at long-term follow-up as patients who underwent surgery.
Earlier results of the Spine Patient Outcomes Research Trial (SPORT) study for this indication suggested surgery offered more benefits for patients with symptomatic lumbar spinal stenosis. However, Jon D. Lurie, MD, MS, at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., and colleagues recently updated those results with findings from longer-term follow-up of the patients.
Jon D. Lurie
According to Lurie, some conservative care patients may see no differences in pain, function or disability at 8 years follow-up from the patients who initially underwent surgery.
A change in outcomes
“The pros and cons of surgery vs. nonoperative treatment are likely to be very individual based on the severity of symptoms, degree of activity limitation, activity goals, age, comorbid conditions, etc. As a result, the value of SPORT is not in providing one definitive answer to the question of whether surgery is better than nonoperative treatment, but in providing detailed data on the risks and outcomes of each treatment to help patients make individualized, shared decisions that are best for them and their particular circumstances,” Lurie told Spine Surgery Today.
Lurie and colleagues analyzed 654 patients with spinal stenosis from the SPORT study, of whom 289 patients were randomly assigned to either surgical or non-surgical treatment.
The results at 8 years follow-up showed surgery was performed in 70% of the patients randomized to surgery, as well as in 52% of the patients who were initially assigned to non-surgical treatment.
The remaining 365 patients in the study declined to be randomized; 60% of them opted for surgery. Of those patients who opted for conservative care, 27% eventually opted for surgery at a later date.
Convergence of results seen
In the randomized group, through 4 years follow-up, surgery was found to offer better outcomes; however, at 8 years follow-up, outcomes were not significantly different between those who underwent either surgical or non-surgical treatment, based on information in the study.
Lurie and colleagues noted that patients in the randomized cohort — whether in the non-surgical or surgical group — saw convergence in outcomes after 5 years.
However, in contrast to the randomized cohort, the observational cohort showed a stable advantage for surgery in all outcomes between years five and eight, according to the investigators.
Better decision-making
“For some patients the early advantage for surgery will clearly be the right choice and the comparability of long-term results will be relatively unimportant. For other patients, the fact that outcomes seem quite similar in the long term may be the deciding factor in choosing not to have surgery. Both decisions can be correct as long as the patients are informed, engaged and participating in making a choice that is most consistent with their values and preferences,” Lurie said.
Patients lost to follow-up tended to be sicker, less well educated, had worse earlier outcomes and were older in both the operative and nonoperative cohort. Treatment effect estimates may not be affected by a loss of patients with worse early outcomes in both groups, Lurie and colleagues wrote in the study, but they could lead to over estimates of long-term outcomes. – by Robert Linnehan
Reference:
Lurie JD, et al. Spine. 2015;doi:10.1097/BRS.0000000000000731.
For more information:
Jon D. Lurie, MD, MS, can be reached at the Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756; email: jon.d.lurie@dartmouth.edu.
Disclosure: The authors report relevant financial activities outside of the submitted work that include consultancy, stocks, travel, accommodations and meeting expenses.
Perspective
Back to TopStephen J. Atlas, MD, MPH
Lumbar spinal stenosis is a common cause of low back and leg symptoms in older individuals. For those with severe, progressive symptoms, surgery with decompressive laminectomy should be considered as part of a shared, patient-physician decision making process. Lurie presents outcomes of such a process over 8-year follow-up for randomized and observational cohorts.
Stephen J. Atlas
In as-treated analyses, the relative benefit of surgery compared to non-surgical care narrows over time and primary outcomes no longer differ among those in the randomized cohort. Interestingly, surgical benefit remains in the observational cohort, perhaps due to greater differences in baseline symptom severity.
Finally, those lost to follow-up, about 50%, had worse outcomes and this was true for both surgical and non-surgical patients. This implies the long-term outcomes reported, regardless of treatment received, present a rosier picture than is likely the case. In sum, these results support considering decompressive laminectomy for patients with persistent severe symptoms attributable to lumbar spinal stenosis. However, the degenerative process is likely ongoing with recurrent symptoms and 20% having additional surgery.Perspective
Back to TopCarlo Ammendolia, DC, PhD
Carlo Ammendolia
This study is a futile attempt at assessing long-term outcomes for lumbar spinal stenosis. The authors use data from a cohort study (level 2 evidence) to assess treatment effectiveness where unknown confounders cannot be accounted for. More importantly it is not possible to make firm conclusions about treatment effectiveness when almost 50% of participants are lost to follow-up. In terms of outcomes, the Oswestry Disability Index, a primary outcome, did not reach the minimally clinical important difference (MCID) (12.8) in any follow-up period beyond year 1 when comparing combined surgical cohorts to the nonoperative group. Since both groups improved, comparing the proportion of participants reaching MCID would be more meaningful.
In summary, in highly select patients, surgery for lumbar spinal stenosis is beneficial but long-term benefits are still questionable.Click Here to Manage Email Alerts