Surgical and nonsurgical spinal stenosis treatment outcomes similar after eight years

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For patients with spinal stenosis, long-term outcomes are comparable with surgery or conservative treatment, according to a study published in the journal Spine.

While earlier reports suggested an advantage of surgery, the updated analysis finds no significant difference in pain, functioning, and disability at eight years’ follow-up, report Jon D Lurie and colleagues of Dartmouth-Hitchcock Medical Center, USA.

 
The results—representing the largest and highest-quality study to date—provide new evidence on what patients can expect several years after deciding whether or not to have or not have surgery for spinal stenosis.

The researchers analysed data from the ‘Spine outcomes research trial’ (SPORT), which is one of the largest clinical trials of surgery for spinal disorders. In SPORT, patients meeting strict criteria for spinal stenosis (or other common spinal diagnoses) were randomly assigned to surgery or nonsurgical treatment (such as physical therapy and medications).

Lurie and colleagues analysed 654 patients with spinal stenosis, treated at 13 US hospitals. Of these, 289 were randomly assigned to surgical or nonsurgical treatment. By eight years’ follow-up, surgery was performed in 70% of patients randomised to surgery as well as 52% of those initially assigned to nonsurgical treatment. The remaining 365 patients, who declined to be randomised, were observed after choosing between the two options. Of these patients, 60% opted for surgery. Of those who initially chose nonsurgical treatment, 27% eventually underwent surgery. Long-term follow-up data were available for more than 50% of patients in both studies. Outcomes were assessed in terms of pain, functioning, and disability.

In ‘as-treated’ analysis of the randomised study, surgery provided better outcomes during the first four years. But with longer follow-up, the difference between treatments narrowed. From six to eight years, outcomes were not significantly different between surgical and nonsurgical treatment. In contrast, in the observational study, the advantage of surgery remained stable from five to eight years. Lurie and colleagues believe that this may reflect greater differences in the initial characteristics of the two groups.

Patients without available follow-up data were older, sicker, and had worse outcomes in the first two years, with either treatment. “The long-term outcomes are therefore likely to be somewhat over-optimistic on average in both groups,” the researchers write, “but the comparison between surgical and non-operative outcomes appears likely to be un-biased.” Both treatments were found to be safe, and 18% of patients receiving surgical treatment surgery underwent repeat surgery for recurrent spinal stenosis within eight years.

The results suggest important implications for discussing the expected long-term outcomes of treatment for spinal stenosis. While surgery provides better outcomes for the first few years following treatment, the results of surgical and nonsurgical treatment appear to converge during longer-term follow-up. While some groups of patients who initially opt for surgery may continue to do better over time, those who choose nonsurgical treatment can do quite well even up to eight years. The researchers note that, regardless of the method of treatment, patients suffering from spinal stenosis can expect to have some pain and reduced functioning compared to people in the general population of similar age.