title: Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial.
abstract: METHODS
  A randomized controlled trial.
  
  
  OBJECTIVE
  To assess the effectiveness of decompressive surgery as compared with nonoperative measures in the treatment of patients with lumbar spinal stenosis.
  
  
  BACKGROUND
  No previous randomized trial has assessed the effectiveness of surgery in comparison with conservative treatment for spinal stenosis.
  
  
  METHODS
  Four university hospitals agreed on the classification of the disease, inclusion and exclusion criteria, radiographic routines, surgical principles, nonoperative treatment options, and follow-up protocols. A total of 94 patients were randomized into a surgical or nonoperative treatment group: 50 and 44 patients, respectively. Surgery comprised undercutting laminectomy of the stenotic segments in 10 patients augmented with transpedicular fusion. The primary outcome was based on assessment of functional disability using the Oswestry Disability Index (scale, 0-100). Data on the intensity of leg and back pain (scales, 0-10), as well as self-reported and measured walking ability were compiled at randomization and at follow-up examinations at 6, 12, and 24 months.
  
  
  RESULTS
  Both treatment groups showed improvement during follow-up. At 1 year, the mean difference in favor of surgery was 11.3 in disability (95% confidence interval [CI], 4.3-18.4), 1.7 in leg pain (95% CI, 0.4-3.0), and 2.3(95% CI, 1.1-3.6) in back pain. At the 2-year follow-up, the mean differences were slightly less: 7.8 in disability (95% CI, 0.8-14.9) 1.5 in leg pain (95% CI, 0.3-2.8), and 2.1 in back pain (95% CI, 1.0-3.3). Walking ability, either reported or measured, did not differ between the two treatment groups.
  
  
  CONCLUSIONS
  Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability. The relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years. Longer follow-up is needed to determine if these differences persist.
authors.affiliation: Finnish Office for Health Technology Assessment, National Research and Development Center, FinOHTA/Stakes, Helsinki, Finland. antti.malmivaara@stakes.fi
authors.forename: Antti
authors.initials: A
authors.lastname: Malmivaara
authors.forename: Pär
authors.initials: P
authors.lastname: Slätis
authors.forename: Markku
authors.initials: M
authors.lastname: Heliövaara
authors.forename: Päivi
authors.initials: P
authors.lastname: Sainio
authors.forename: Heikki
authors.initials: H
authors.lastname: Kinnunen
authors.forename: Jyrki
authors.initials: J
authors.lastname: Kankare
authors.forename: Nina
authors.initials: N
authors.lastname: Dalin-Hirvonen
authors.forename: Seppo
authors.initials: S
authors.lastname: Seitsalo
authors.forename: Arto
authors.initials: A
authors.lastname: Herno
authors.forename: Pirkko
authors.initials: P
authors.lastname: Kortekangas
authors.forename: Timo
authors.initials: T
authors.lastname: Niinimäki
authors.forename: Hannu
authors.initials: H
authors.lastname: Rönty
authors.forename: Kaj
authors.initials: K
authors.lastname: Tallroth
authors.forename: Veli
authors.initials: V
authors.lastname: Turunen
authors.forename: Paul
authors.initials: P
authors.lastname: Knekt
authors.forename: Tommi
authors.initials: T
authors.lastname: Härkänen
authors.forename: Heikki
authors.initials: H
authors.lastname: Hurri
mesh_terms: D000368:Aged; D019299:Decompression, Surgical; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007796:Laminectomy; D008159:Lumbar Vertebrae / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D013130:Spinal Stenosis / Q000534:rehabilitation* / Q000601:surgery*