Original Research
7 April 2015

Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial

Publication: Annals of Internal Medicine
Volume 162, Number 7

Abstract

Background:

Primary care management decisions for patients with symptomatic lumbar spinal stenosis (LSS) are challenging, and nonsurgical guidance is limited by lack of evidence.

Objective:

To compare surgical decompression with physical therapy (PT) for LSS and evaluate sex differences.

Design:

Multisite randomized, controlled trial. (ClinicalTrials.gov: NCT00022776)

Setting:

Neurologic and orthopedic surgery departments and PT clinics.

Participants:

Surgical candidates with LSS aged 50 years or older who consented to surgery.

Intervention:

Surgical decompression or PT.

Measurements:

Primary outcome was physical function score on the Short Form-36 Health Survey at 2 years assessed by masked testers.

Results:

The study took place from November 2000 to September 2007. A total of 169 participants were randomly assigned and stratified by surgeon and sex (87 to surgery and 82 to PT), with 24-month follow-up completed by 74 and 73 participants in the surgery and PT groups, respectively. Mean improvement in physical function for the surgery and PT groups was 22.4 (95% CI, 16.9 to 27.9) and 19.2 (CI, 13.6 to 24.8), respectively. Intention-to-treat analyses revealed no difference between groups (24-month difference, 0.9 [CI, −7.9 to 9.6]). Sensitivity analyses using causal-effects methods to account for the high proportion of crossovers from PT to surgery (57%) showed no significant differences in physical function between groups.

Limitation:

Without a control group, it is not possible to judge success attributable to either intervention.

Conclusion:

Surgical decompression yielded similar effects to a PT regimen among patients with LSS who were surgical candidates. Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS.

Primary Funding Source:

National Institutes of Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases.

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Supplemental Material

Supplement. Physical Therapy Exercise Program; Technical Description of Complier Average Causal Effects (CACE) Analyses and Inverse Probability Weighting (IPW) Analyses; and Study Protocol

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 162Number 77 April 2015
Pages: 465 - 473

History

Published online: 7 April 2015
Published in issue: 7 April 2015

Keywords

Authors

Affiliations

Anthony Delitto, PT, PhD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Sara R. Piva, PT, PhD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Charity G. Moore, PhD, MSPH
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Julie M. Fritz, PT, PhD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Stephen R. Wisniewski, PhD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Deborah A. Josbeno, PT, PhD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Mark Fye, MD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
William C. Welch, MD
From University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Utah, Salt Lake City, Utah; and University of Pennsylvania, Philadelphia, Pennsylvania.
Grant Support: By the National Institutes of Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant AR-NS45622; Dr. Delitto).
Reproducible Research Statement: Study protocol: See Supplement 3 for more details. Statistical code: Available from Dr. Moore (e-mail, [email protected]). Data set: Not available.
Corresponding Author: Anthony Delitto, PT, PhD, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 16260.
Current Author Addresses: Drs. Delitto, Piva, and Josbeno: Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219.
Dr. Moore: Department of Medicine, University of Pittsburgh, M240 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261.
Dr. Fritz: Department of Physical Therapy, School of Health Professions, University of Utah, Health Profession Education Building, 520 Wakara Way, Salt Lake City, UT 84108.
Dr. Wisniewski: Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 127 Parran Hall, Pittsburgh, PA 15261.
Dr. Fye: University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213.
Dr. Welch: University of Pennsylvania, Penn Neurosurgery, Pennsylvania Hospital, Washington Square West Building, 235 South 8th Street, Philadelphia, PA 19106.
Author Contributions: Conception and design: A. Delitto, J.M. Fritz, S.R. Wisniewski, W.C. Welch.
Analysis and interpretation of the data: A. Delitto, C.G. Moore, S.R. Wisniewski, W.C. Welch.
Drafting of the article: A. Delitto, S.R. Piva, C.G. Moore, J.M. Fritz, M. Fye, W.C. Welch.
Critical revision of the article for important intellectual content: A. Delitto, S.R. Piva, C.G. Moore, D.A. Josbeno, W.C. Welch.
Final approval of the article: A. Delitto, S.R. Piva, C.G. Moore, J.M. Fritz, M. Fye, W.C. Welch.
Provision of study materials or patients: M. Fye, W.C. Welch.
Statistical expertise: C.G. Moore, S.R. Wisniewski.
Obtaining of funding: A. Delitto, J.M. Fritz, W.C. Welch.
Administrative, technical, or logistic support: A. Delitto, S.R. Piva, D.A. Josbeno, M. Fye, W.C. Welch.
Collection and assembly of data: J.M. Fritz, S.R. Wisniewski, D.A. Josbeno, M. Fye, W.C. Welch.

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Anthony Delitto, Sara R. Piva, Charity G. Moore, et al. Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial. Ann Intern Med.2015;162:465-473. [Epub 7 April 2015]. doi:10.7326/M14-1420

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