Clinical Question

Is surgery more effective than physical therapy in patients referred for surgery for spinal stenosis?

Bottom Line

Assigning patients to six weeks of physical therapy is as effective as initially sending them for decompression surgery, with fewer complications, even in patients who have a strong preference for surgery. A trial of six weeks of physical therapy makes sense for many patients with confirmed spinal stenosis before getting out the scalpel. (Level of Evidence = 1b –)

Synopsis

The investigators enrolled 169 patients (average age: 66 to 69 years) with image-confirmed lumbar stenosis who consented to surgery. This approach to enrollment eliminated many patients, presumably those with milder symptoms. The patients were randomly assigned (allocation concealed) to surgery or physical therapy. The decompression surgery was the typical procedure used in research and practice. Physical therapy, administered twice weekly for six weeks, consisted of lumbar flexion exercises and conditioning to identify the issues of strength and flexibility identified at enrollment. Analysis was by intention to treat, meaning that patients assigned to physical therapy were analyzed as being in that group even if they eventually received surgery, which 57% of them did over the two years of follow-up (most of them within the first 10 weeks of the study).

Approximately 20% in each group sought additional physical therapy. Two years after identification, general quality of life (as measured by the 36-Item Short Form Health Survey, a typical measure of quality of life) improved equally in both groups, to an average score of 48 to 50 from a baseline of 26 to 28 out of a possible 100. Analyzing by actual treatment rather than by intention to treat yielded similar results, although the study may not have had enough power to find a difference if one existed. Pain, disability, and neurogenic symptoms improved similarly in both groups. Complications were common in the back surgery group, including the need for reoperation. Many patients were not returned to “normal” but continued to visit a back surgeon or primary care physician for back pain two years after the intervention.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: DelittoAPivaSRMooreCGet alSurgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med2015; 162( 7): 465– 473.