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Spinal Stenosis: Physical Therapy before Surgery

Spinal stenosis: physical therapy before surgery

Clinical question

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

Bottom line

Assigning patients to 6 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 6 weeks of physical therapy makes sense for many patients with confirmed spinal stenosis before getting out the scalpel. (LOE = 1b-)

Reference

Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis. A randomized trial. Ann Intern Med 2015;162(7):465-473.

Study design
Randomized controlled trial (single-blinded)

Funding
Government

Allocation
Concealed

Setting
Outpatient (specialty)

Synopsis
The investigators enrolled 169 patients (average age: 66-69 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 6 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 2 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 Short Form-36 Health Survey, a typical measure of quality of life) improved equally in both groups, to an average score of 48-50 from a baseline of 26-28 of a possible 100. Analyzing by actual treatment rather than by intention to treat yielded similar results though 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 re-operation. Many patients were not returned to “normal” but continued to visit either a back surgeon or primary care physician for back pain 2 years after the intervention.

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