Spinal Stenosis: To Operate or Not To Operate?
Abstract & Commentary
By Michael Rubin, MD, FRCP(C), Professor of Clinical Neurology, Weill Cornell Medical College, New York, NY Dr. Rubin reports he is on the speaker's bureau for Athena Diagnostics.
Synopsis: Surgical decompression results in a better outcome than other therapies for symptomatic lumbar spinal stenosis.
Source: Weinstein JN, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358: 794-810.
Lumbar spinal stenosis may be treated conservatively using physical therapy, pain management, and epidural steroid injections; or aggressively by surgical intervention. Which works better? SPORT (Spine Patient Outcomes Research Trial) endeavors to answer this question. Over a 5-year period from March 2000 to March 2005, 13 U.S. medical centers spanning 11 states screened 1696 potential patients, of whom 1091 were eligible and 654 agreed to participate. Of these, 289 were enrolled in a randomized cohort and 365 patients, declining randomization, were enrolled in a concurrent observational cohort. All patients complained of at least 12 weeks of neurogenic claudication or radicular symptomatology, and imaging studies in all patients confirmed the presence of lumbar spinal stenosis at 1 or more levels. Patients with spondylolisthesis and lumbar instability were excluded. Surgery comprised standard posterior decompressive laminectomy, while nonsurgical care included physical therapy, home exercise, chiropractic, epidural injections, anti-inflammatory medication, or opioid analgesics. Primary outcomes measured body pain and physical function using the Medical Outcomes 36-item Short Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, and at 3, 6, 12, and 24 months. Secondary outcome measures included patient self-reported improvement and satisfaction with symptoms and care, and the troublesomeness of stenosis and low back pain. Statistical analysis comprised a mixed-effects model of longitudinal regression and use of the Wald test, with p<0.05 defined as statistically significant on the basis of a two-sided hypothesis test.
Of 289 patients in the randomized cohort, 138 were assigned to surgery and 151 to nonsurgical management. By 2 years, 67% of the former and 43% of the latter patients had undergone surgery. Despite the significant non-adherence, analysis of the randomized cohort demonstrated a significant benefit favoring surgery using the SF-36 scale for body pain, but not for physical function or on the Oswestry Disability Index. An as-treated analysis combining both cohorts significantly favored surgery by 3 months for all primary outcomes, and remained so at 2 years. Surgery is superior to conservative management for lumbar spinal stenosis.
Commentary
Previously, Neurology Alert (2007;25:81-83) reviewed evidence favoring surgery for lumbar degenerative spondylolisthesis.1 With the present study also favoring surgery for lumbar spinal stenosis without lumbar instability, the next question is: Which surgical approach is best?
Among 152 consecutive lumbar spinal stenosis patients without isthmic spondylolisthesis, traditional laminectomy with removal of posterior elements including the laminae, spinous processes, interspinous ligaments, and facet joints, was compared to a more limited decompressive procedure, involving complete excision of the ligamentum flavum, partial excision of the laminae, the base of the spinous process, and the facet process bilaterally, while preserving the spinous processes, interspinous ligaments, facet capsules, and part of laminae. Patients were prospectively enrolled and sequentially divided into undergoing either procedure.2 Outcome measurements included a visual analog scale (VAS) and the Oswestry Disability Index (ODI) for back and leg pain and walking tolerance, comparing pre- and post-surgery.
Elimination or improvement of leg numbness and weakness was comparable in both groups but an overall good to excellent grade at the final interview was more likely with the more radical surgery (89% vs. 63%). Either method may be safely recommended for spinal stenosis without spondylolisthesis, but added benefit accrues with traditional laminectomy.
References
1. Weinstein JN, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257-2270.
2. Fu YS, et al. Long-term outcomes of two different decompressive techniques for lumbar spinal stenosis. Spine 2008;33:514-518.
Surgical decompression results in a better outcome than other therapies for symptomatic lumbar spinal stenosis.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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