Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial.
METHODS
Randomized trial and concurrent observational cohort study.


OBJECTIVE
To compare 4 year outcomes of surgery to nonoperative care for spinal stenosis.


BACKGROUND
Surgery for spinal stenosis has been shown to be more effective compared to nonoperative treatment over 2 years, but longer-term data have not been analyzed.


METHODS
Surgical candidates from 13 centers in 11 US states with at least 12 weeks of symptoms and confirmatory imaging were enrolled in a randomized cohort (RC) or observational cohort (OC). Treatment was standard decompressive laminectomy or standard nonoperative care. Primary outcomes were SF-36 bodily pain (BP) and physical function scales and the modified Oswestry Disability index assessed at 6 weeks, 3 months, 6 months, and yearly up to 4 years.


RESULTS
A total of 289 patients enrolled in the RC and 365 patients enrolled in the OC. An as-treated analysis combining the RC and OC and adjusting for potential confounders found that the clinically significant advantages for surgery previously reported were maintained through 4 years, with treatment effects (defined as mean change in surgery group minus mean change in nonoperative group) for bodily pain 12.6 (95% confidence interval [CI], 8.5-16.7); physical function 8.6 (95% CI, 4.6-12.6); and Oswestry Disability index -9.4 (95% CI, -12.6 to -6.2). Early advantages for surgical treatment for secondary measures such as bothersomeness, satisfaction with symptoms, and self-rated progress were also maintained.


CONCLUSIONS
Patients with symptomatic spinal stenosis treated surgically compared to those treated nonoperatively maintain substantially greater improvement in pain and function through 4 years.
Weinstein
James N
JN
Department of Orthopaedics, Dartmouth Medical School, Hanover, NH 03756, USA. SPORT@dartmouth.edu
Tosteson
Tor D
TD
Lurie
Jon D
JD
Tosteson
Anna
A
Blood
Emily
E
Herkowitz
Harry
H
Cammisa
Frank
F
Albert
Todd
T
Boden
Scott D
SD
Hilibrand
Alan
A
Goldberg
Harley
H
Berven
Sigurd
S
An
Howard
H
D000368:Aged; D015331:Cohort Studies; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007796:Laminectomy / Q000379:methods; D017116:Low Back Pain / Q000150:complications / Q000601:surgery / Q000628:therapy; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D013130:Spinal Stenosis / Q000150:complications / Q000601:surgery* / Q000628:therapy*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
Spine (Phila Pa 1976). 1991 Jun;16(6):615-9
1862399
Spine (Phila Pa 1976). 1997 Dec 15;22(24):2807-12
9431616
JAMA. 2003 Sep 24;290(12):1624-32
14506122
Med Care. 1994 Jan;32(1):40-66
8277801
J Spinal Disord. 1993 Dec;6(6):461-72
8130395
JAMA. 2006 Nov 22;296(20):2441-50
17119140
J Bone Joint Surg Am. 1991 Jul;73(6):802-8
2071615
Med Care. 1992 Jun;30(6):473-83
1593914
Spine (Phila Pa 1976). 1986 Jan-Feb;11(1):28-30
2939566
Spine (Phila Pa 1976). 1995 Sep 1;20(17):1899-908; discussion 1909
8560339
JAMA. 2006 Nov 22;296(20):2451-9
17119141
JAMA. 1989 Aug 18;262(7):907-13
2754790
Spine (Phila Pa 1976). 2000 Mar 1;25(5):556-62
10749631
J Bone Joint Surg Am. 2009 Jun;91(6):1295-304
19487505
N Engl J Med. 2007 May 31;356(22):2257-70
17538085
J Am Geriatr Soc. 1996 Mar;44(3):285-90
8600197
N Engl J Med. 2008 Feb 21;358(8):794-810
18287602
Spine (Phila Pa 1976). 1996 Aug 1;21(15):1787-94; discussion 1794-5
8855463
Spine (Phila Pa 1976). 2000 Nov 15;25(22):2940-52; discussion 2952
11074683
Spine (Phila Pa 1976). 2006 Nov 1;31(23):2707-14
17077740
J Bone Joint Surg Am. 1992 Apr;74(4):536-43
1583048
Spine (Phila Pa 1976). 2006 Apr 1;31(7):806-14
16582855
Spine (Phila Pa 1976). 2008 Dec 1;33(25):2789-800
19018250
Spine (Phila Pa 1976). 2006 Sep 1;31(19):2263-9
16946665
Spine (Phila Pa 1976). 2002 Jun 15;27(12):1361-72
12065987
Spine (Phila Pa 1976). 2007 Jan 1;32(1):1-8
17202885