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Spinal Stenosis: Surgical vs. Nonsurgical Therapy

Outcomes with surgery appeared to be superior, but several problematic aspects of this study preclude us from drawing definitive conclusions.

Lumbar spinal stenosis is a common cause of radicular leg pain and neurogenic claudication in older adults. In this multicenter U.S. study, investigators compared surgical and nonsurgical care in patients who had experienced at least 12 weeks of symptomatic lumbar spinal stenosis without degenerative spondylolisthesis.

In a randomized cohort, 289 patients were assigned to surgery or usual care. At 2 years, only 67% of those assigned to surgery actually had undergone surgery, whereas 43% of those assigned to usual care had crossed over to surgery. In an intent-to-treat analysis at 2 years, both groups reported less pain, but the surgery group reported significantly less pain than the usual-care group. Physical function and disability scores did not differ significantly in the two groups.

In addition, 365 patients who refused randomization were enrolled in an observational cohort: 219 initially chose surgery (with 96% proceeding to surgery), and 146 initially chose nonsurgical care (with 22% eventually crossing over to surgery). In an as-treated analysis in which the randomized and observational cohorts were combined and adjusted for potential confounders, mean scores on pain, function, and disability showed significantly more improvement in surgery patients than in usual-care patients through 2 years of follow-up.

Comment: These findings must be regarded as tentative, given the substantial crossover in the intent-to-treat analysis of the randomized portion of the study, and the likely confounding in the as-treated analysis. The authors conclude that surgical outcomes were superior to nonsurgical outcomes. But the study also showed that both surgery and nonsurgery patients improved over time. Thus, patients can be reassured that an initially noninvasive approach, with eventual surgery if symptoms become intolerable, is reasonable. The same issue of the New England Journal of Medicine includes a review article on lumbar spinal stenosis.

— Allan S. Brett, MD

Published in Journal Watch General Medicine February 20, 2008

Citation(s):

Weinstein JN et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008 Feb 21; 358:794.

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