Reading Rheum

Although imaging techniques have facilitated the detection of spinal stenosis, the therapy of this entity remains uncertain. Major unresolved issues exist regarding the outcomes of non-operative and surgical therapy for spinal stenosis. For example, a long-term observational study of 10 years duration of 148 spinal stenosis patients assigned to surgery or non-operative therapy described early benefits of surgical intervention that waned over the duration of the investigation.¹ Another issue involves the relative benefit of decompressive laminectomy with or without fusion. Randomized controlled trials addressing some of these issues were lacking until the study by Malmivaara and colleagues.

This two-year, randomized, controlled trial of 94 Finnish individuals about 63 years of age with moderate spinal stenosis showed greater benefit from surgery than medical therapy. (See Table 4) Patients with severe leg pain or neurologic deficits were excluded. Greater benefits with surgery were documented in disability and pain, but not walking ability. Of note is the finding of the gradual dilution of the beneficial effect of surgical intervention at two years. The 10 individuals with spinal fusion had less back and leg pain than non-fused surgical patients.

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Table 4: Surgical Versus Non-Operative Results at Two Years Follow-up

The Malmivaara study has significant limitations. For example, the duration of the study is short and patients need to be followed for a longer period of time to determine the durability of the benefit of surgical decompression. Also, I have major concerns about the nature and intensity of the non-operative therapy used. For example, in this study, medical therapy was defined as a choice of nonsteroidal anti-inflammatory drugs (NSAIDs) and three sessions of physical therapy. No mention is made of patient satisfaction with their nonsteroidal therapy. Was more than one NSAID offered in the case of inefficacy or toxicity? Further, narcotic therapies were not offered as analgesics and the use of lumbar epidural injections was not mentioned. Thus, I believe that non-operative therapy was sub-optimal in this clinical trial.

The take-home message from this study is that non-operative and surgical therapy for lumbar spinal stenosis without severe neurologic deficits both offer reasonable outcomes for pain relief and improved function. The experimental evidence showing the clear benefit of non-operative versus surgical intervention is not extant. The authors suggest that non-operative therapy be the initial regimen with surgical therapy reserved for those who have persistent leg pain or physical dysfunction incompatible with activities of daily living. This is a recommendation for spinal stenosis therapy with which I concur.

Reference

1. Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: eight to 10-year results from the Maine lumbar spine study. Spine 2005;30:936-943.