Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis

Abstract

Background Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials. Methods Surgical candidates with a history of at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis (as confirmed on imaging) were enrolled in either a randomized cohort or an observational cohort at 13 U.S. spine clinics. Treatment was decompressive surgery or usual nonsurgical care. The 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 the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years. Results A total of 289 patients were enrolled in the randomized cohort, and 365 patients were enrolled in the observational cohort. At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery. Despite the high level of nonadherence, the intention-to-treat analysis of the randomized cohort showed a significant treatment effect favoring surgery on the SF-36 scale for bodily pain, with a mean difference in change from baseline of 7.8 (95% confidence interval, 1.5 to 14.1); however, there was no significant difference in scores on physical function or on the Oswestry Disability Index. 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; these changes remained significant at 2 years. Conclusions In the combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically.

Factors influencing the surgical decision for the treatment of degenerative lumbar stenosis in a preference-based shared decision-making process

“…Furthermore, his/her own MRI scan was shown, and a description of the stenotic grade was provided. Finally, the patient was informed about the evidence supporting the advantages and disadvantages of each available treatment option from well-designed studies on LSS [12][13][14][15]. This process took an average of 10 min.…”

Degenerative lumbar stenosis: update

“…There is class I evidence that in patients with persistent symptoms for more than 12 weeks, decompressive surgery (without fusion) improves function and pain control when compared to patients in the non-surgical treatment group. The effects of the surgical procedure were followed for at least 2 years 26,27 .…”

“…The traditional procedure is a decompressive laminectomy, consisting of removal of the spinous processes, lamina, ligamenta flava, and medial portions of the facet joints 26,27 . Fenestration is a modified partial laminectomy and facetectomy with preservation of the midline structures and the dorsal tension band.…”

Dural lesions in decompression for lumbar spinal stenosis: incidence, risk factors and effect on outcome

“…Incidence figures on dural lesions in spinal stenosis surgery in the literature mainly refer to retrospective studies of the complication with the drawbacks of retrospectivity hampering the studies. In the large prospective SPORT study an incidence of 5% is presented [21]. Whether or not a dural lesion peroperatively is a predictor of inferior outcome of surgery is also subject to some controversy [3,6,19].…”