Research finds shared decisions about lumbar stenosis surgery vs therapy helpful

Surgical and nonsurgical options for lumbar spinal stenosis may offer similar long-term benefits for patients, but results of a recently published randomized trial showed health care providers should determine the best course of treatment based on potential risks and evidence for each patient.

According to William C. Welch, MD, FAANS, FACS, FICC, one of the investigators, patients with lumbar spinal stenosis will see similar improvements in physical function scores on the SF-36 survey at 2-years follow-up.

William C. Welch

Welch told Spine Surgery Today, “The investigators attempted, in earnest, to conduct a truly randomized study with little crossover. While the study remained randomized, crossover occurred between the groups. Outcomes were similar, which suggests patients are ultimately satisfied with their treatment choices—findings similar to the Spine Patient Outcomes Research Trial study. Based on this trial, I offer patients who have not received physical therapy (PT) that option, but inform them surgery is a very viable treatment for neurogenic claudication due to lumbar spinal stenosis.”

Welch, who is a Spine Surgery Today Editorial Board member, and colleagues compared results of 74 patients who underwent surgery and 73 patients who underwent a PT program for lumbar spinal stenosis. They compared the patients’ results in the short-term at 10 weeks and in the long-term at 6, 12 and 24 months.

The investigators found the mean functional improvement between those who received PT and those who had surgery was not statistically significant at 24 months. Patients who received PT experienced a mean improvement in SF-36 physical function scores of 19.2 points vs. 22.4 points mean improvement for patients who had surgery.

An intention-to-treat (ITT) analysis revealed no differences between PT and surgery at any points during follow-up through the 2-year primary endpoint (P < .50), Welch said."

Data showed considerable patient crossover occurred from the PT to the surgery group. About 44 patients crossed over to surgery, and 24 of those patients achieved a successful outcome. Of the 29 patients who did not crossover from the PT group, 15 patients attained a successful outcome at final follow-up.

The investigators noted the crossovers made it difficult to interpret the groups’ actual success, but alternative analytic techniques produced the same interpretation of the data.

At final follow-up, the ITT analysis showed patients in each group began to improve by week 10, continued to improve through week 26 and maintained their improvements through the remaining follow-up.

The investigators concluded patients with lumbar spinal stenosis who were surgical candidates and underwent decompressive surgery achieved similar long-term functional gains as those who underwent an evidence-based PT program. Despite this, there was a similar proportion of patients in both groups who did not achieve a clinically significant improvement.

Until additional research is undertaken, patients with lumbar spinal stenosis should make a decision with their primary care provider to determine their best treatment option based on the available evidence, the investigators noted. – by Robert Linnehan

Reference:

Delitto A, et al. Ann Intern Med. 2015;doi:10.7326/M14-1420.

For more information:

William C. Welch, MD, FAANS, FACS, FICC, can be reached at Department of Neurosurgery, Pennsylvania Hospital, 301 S. 8th St. #2b Philadelphia, PA 19106; email: william.welch@uphs.upenn.edu.

Disclosure: Welch reports he is a consultant for the ISTO Technologies data safety monitoring board.