Spine surgeons and patients frequently assume that a longer duration of symptoms in spinal stenosis portends less improvement following decompression due to irreversible changes in nerve tissue subjected to long-term compression. This can lead to a decision to perform surgery sooner rather than later in order to maximize the likelihood of a good outcome. While non-operative treatment is likely less effective for radiculopathy and claudication in the setting of lumbar stenosis, it can be effective in some patients and allow a subset of this elderly, frail population to avoid surgery with its inherent risks and recovery time.1 However, surgeons may avoid or cut short efforts at non-operative treatment due to concerns about delayed surgery resulting in worse outcomes. In order to better understand the effect of duration of symptoms on lumbar laminectomy outcomes, Dr. Movassaghi and colleagues rom Rush University reviewed over 200 lumbar stenosis patients who underwent laminectomy without fusion from 2008-2015 and had at least 3 months of follow-up. They stratified the patients based on duration of symptoms for more than or less than one year. At baseline, the two groups were similar, though the longer symptom duration patients were slightly older and had somewhat worse SF-12 physical function scores. This group also was significantly more likely to undergo a multilevel decompression. At final follow-up, there were no significant differences in Oswestry Disability Index, SF-12, or VAS back or leg pain scores after controlling for baseline differences. There were also no significant differences in reoperation rate or patient satisfaction. Based on these findings, the authors concluded that duration of symptoms did not affect surgical outcomes in lumbar stenosis.
This is a well-done retrospective cohort study that addressed a question that surgeons and patients face daily. The results were somewhat different from those reported from the Spine Patient Outcomes Research Trial (SPORT), which found slightly less improvement following surgery for lumbar stenosis in patients with symptom duration greater than one year.2 However, that study also reported no outcome differences between the symptom duration groups in the degenerative spondylolisthesis cohort and no differences in treatment effect of surgery between the symptom duration groups (the benefit of surgery compared to non-operative treatment) for either the stenosis or degenerative spondylolisthesis cohorts. The Maine Lumbar Spine Study (MLSS) reported lower long-term patient satisfaction for patients who were initially treated non-operatively and subsequently underwent surgery in a delayed fashion.3 The current study is somewhat limited compared to SPORT or MLSS by its retrospective nature, though selection bias cannot be eliminated in any study addressing this question as duration of symptoms cannot be randomized. The authors did do a multivariate analysis to control for baseline differences. While these studies have come to somewhat contradictory conclusions, the overall conclusion seems to be that duration of symptoms may have a small but probably clinically unimportant effect on surgical outcomes in lumbar stenosis. There is no evidence to suggest that non-operative treatment should be avoided out of concern about worsening surgical outcomes due to treatment delay. Treatment of lumbar stenosis is a preference-sensitive decision that should take into account patient symptoms, comorbidities, and goals of treatment. The appropriate time to have surgery is when the patient feels that the likely benefits of surgery outweigh the risks and recovery time associated with the operation.
Please read Dr. Movassaghi's article on this topic in the March 1 issue. Does this change your opinion about the effect of symptom duration on lumbar laminectomy outcomes? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2010;35:1329-38.
2. Radcliff K, Rihn J, Hilibrand A, et al. Does the Duration of Symptoms in Patients with Spinal Stenosis and Degenerative Spondylolisthesis Affect Outcomes? Analysis of the Spine Outcomes Research Trial. Spine 2011.
3. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976) 2005;30:936-43.