Surgical and nonsurgical management of lumbar spinal stenosis - Four-year outcomes from the Maine lumbar spine study

Study Design. A prospective cohort study of patients with lumbar spinal ste nosis recruited from the practices of orthopedic surgeons and neurosurgeons throughout Maine. Objective. To assess 4-year outcomes for patients with lumbar spinal stenos is treated surgically or nonsurgically, Summary of Background Data. Surgery for lumbar spinal stenosis has increase d dramatically despite the lack of randomized trials comparing surgical wit h nonsurgical treatments. Long-term evaluation of surgical series has docum ented deterioration in initial symptomatic improvement, but few studies hav e compared long-term outcomes of surgical and nonsurgical treatment. Methods. Eligible, consenting patients had baseline interviews with mailed follow-up questionnaires at 3, 6, and 12 months, then annually thereafter. Clinical data were obtained at baseline from a physician questionnaire. Out comes included patient-reported symptoms of leg and back pain, functional s tatus. and satisfaction. Results. Of 148 patients with lumbar spinal stenosis initially enrolled, 4- year outcomes were available on 119 patients (80.4%): 67 of 81 (83%) treate d surgically and 52 of 67 (78%) treated nonsurgically. The surgically treat ed patients had more severe symptoms and worse functional status at baselin e and better outcomes at 4-year evaluation than the nonsurgically treated p atients. After 4 years, 70% of the surgically treated and 52% of the nonsur gically treated patients reported that their predominant symptom, either le g or back pain, was better (P = 0.05). Satisfaction of patients with their current state at 4 years was reported by 63% of the surgically treated and 42% of the nonsurgically treated patients (P = 0.04). Surgical treatment re mained a significant determinant of 4-year satisfaction, even after adjustm ent for other independent predictors (P = 0.001), For the nonsurgically tre ated patients, there was no significant change in outcomes over 4 years, wh ereas the initial improvement seen in the surgically treated patients modes tly decreased over the subsequent 4 years. Conclusions, For the patients with severe lumbar spinal stenosis, surgical treatment was associated with greater improvement in patient-reported outco mes than nonsurgical treatment at 4-year evaluation, even after adjustment for differences in baseline characteristics among treatment groups. The rel ative benefit of surgery declined over time but remained superior to nonsur gical treatment. Outcomes for the nonsurgically treated patients improved m odestly and remained stable over 4 years. Determining whether outcomes cont inue to converge will require longer-term evaluation.