Surgery Vs. Physical Therapy for Lumbar Spinal Stenosis

Surgery and physical therapy for lumbar spinal stenosis had similar outcomes

(RxWiki News) If you have lumbar spinal stenosis, you may eventually be faced with a decision about whether to have surgery. However, you might be just as well off with physical therapy.

A new study found that patients who followed a specific physical therapy program had similar outcomes to those who had surgery for lumbar spinal stenosis.

The authors of this study said patients with lumbar spinal stenosis should discuss the options with their doctors.

Joseph Rempson, MD, director of the Center for Concussion Care and Physical Rehabilitation at Overlook Medical Center in Overlook, NJ, said the treatment for lumbar spinal stenosis should be determined on a case-by-case basis.

"However, if it is an option based on clinical history and presentation I believe conservative treatment is always most appropriate," Dr. Rempson told dailyRx News. "However, for those patients for whom physical therapy is beneficial, the patient consistently needs to perform their home exercise program as instructed by the physical therapist as part of general routine once their formal physical therapy sessions have ended."

Anthony Delitto, PT, PhD, led this study. Dr. Delitto is from the Department of Physical Therapy at the University of Pittsburgh.

Lumbar spinal stenosis (LSS) occurs when the spinal canal narrows, putting pressure on the nerve. It can also occur when the openings for nerves that run from the spinal cord to the legs become narrowed.

Some people develop LSS but have no symptoms. Others have pain and weakness. LSS is the most common reason for spinal surgery in the US.

Dr. Delitto and colleagues split a group of 169 patients with LSS into two groups. The groups were randomly assigned to either surgery or physical therapy.

Patients in the surgery group underwent a procedure called spinal decompression. In spinal decompression, the opening for the spinal cord is widened.

Those in the physical therapy (PT) group received a standardized physical therapy program and other conservative therapy. The PT program included exercises to flex the lower back, strengthen the legs and increase flexibility.

PT patients received general conditioning like walking on a treadmill. Patients in the PT group also received education about ways to prevent postures that could increase their pain or damage the spine.

Both groups received other treatments like pain medications.

Dr. Delitto’s team followed the patients for two years. Both groups reported similar symptom relief and improvements in physical function.

In both groups, improvements began at about 10 weeks after surgery or treatment. Improvement continued throughout the study period.

However, almost half of the patients in the original PT group crossed over into the surgery group within the two-year study period, Dr. Delitto and team found. These patients reported higher pain levels than those who did not cross over.

"Thirty-one patients crossing over during the study does not mitigate the significance of the study," Dr. Rempson said. "What this study suggests is that there are 2 viable approaches in the management of symptomatic lumbar stenosis, both surgical and nonsurgical. This is significant because some individuals prefer a non operative alternative as some patients are high risk surgical candidates secondary to their medical history."

In an editorial about this study, Jeffrey N. Katz, MD, of Brigham and Women's Hospital at Harvard Medical School, wrote, “From a clinical standpoint, Delitto and colleagues' trial suggests that a strategy of starting with an active, standardized PT regimen results in similar outcomes to immediate decompressive surgery over the first several years … data suggest that patients with LSS should be offered a rigorous, standardized PT regimen. Those who do not improve and ultimately consider surgery should be informed that the benefits are likely to diminish over time. Finally, because long-term outcomes are similar for both treatments yet short-term risks differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”

The study and editorial were published April 6 in the Annals of Internal Medicine.

The National Institutes of Health (NIH) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) funded this research.

Study authors Dr. Sara R. Piva, Dr. Deborah A. Josbeno and Dr. William C. Welch received grants from the NIH. Dr. Delitto received grants from the NIH and the NIAMS.

Review Date: 
April 5, 2015