interesting study from this week's NEJM looking at surg vs. nonsurg management for spinal stenosis...
ABSTRACT
Background Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials.
Methods Surgical candidates with a history of at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis (as confirmed on imaging) were enrolled in either a randomized cohort or an observational cohort at 13 U.S. spine clinics. Treatment was decompressive surgery or usual nonsurgical care. The primary outcomes were measures of bodily pain and physical function on the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years.
Results A total of 289 patients were enrolled in the randomized cohort, and 365 patients were enrolled in the observational cohort. At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery. Despite the high level of nonadherence, the intention-to-treat analysis of the randomized cohort showed a significant treatment effect favoring surgery on the SF-36 scale for bodily pain, with a mean difference in change from baseline of 7.8 (95% confidence interval, 1.5 to 14.1); however, there was no significant difference in scores on physical function or on the Oswestry Disability Index. The as-treated analysis, which combined both cohorts and was adjusted for potential confounders, showed a significant advantage for surgery by 3 months for all primary outcomes; these changes remained significant at 2 years.
Conclusions In the combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically.
full text at nejm.com. Interestingly, their conservative therapy arm was "usual care," or PT, home exercise, and NSAIDs.
In addition, they have a case discussion in this issue of an elderly patient with spinal stenosis (written by a rheumatologist and an orthopod) that basically discounts evidence for injections ; they cite the recent neurology position paper and a paper from Spine that describes the increase in lumbosacral populations in the medicaid population.
As a fellow, it is upsetting that there is not even a voice from pain management included in this kind of a paper, read by internists, FPs, neurologists, orthopods (our referral base), as well as reported to the general public. Also, the fact that there is no long-term prospective placebo-controlled, randomized clinical trial looking at fluoroscopic-guided interlaminar epidural steroid injections for spinal stenosis is disheartening, considering the number that are done. And I am aware of the Pain Physician article by Botwin et al looking at caudals for spinal stenosis, but they did not even mention this.
I guess I am venting, but if pain management is to gain significant traction as a legitimate subspecialty, the quality of our data needs to be vastly improved. I was at the AAPM meeting in Orlando, and comparing the quality of some of the results presented there to the American College of Cardiology meeting that I've also attended in the past was a joke.
anyone else's thoughts?
ABSTRACT
Background Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials.
Methods Surgical candidates with a history of at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis (as confirmed on imaging) were enrolled in either a randomized cohort or an observational cohort at 13 U.S. spine clinics. Treatment was decompressive surgery or usual nonsurgical care. The primary outcomes were measures of bodily pain and physical function on the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years.
Results A total of 289 patients were enrolled in the randomized cohort, and 365 patients were enrolled in the observational cohort. At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery. Despite the high level of nonadherence, the intention-to-treat analysis of the randomized cohort showed a significant treatment effect favoring surgery on the SF-36 scale for bodily pain, with a mean difference in change from baseline of 7.8 (95% confidence interval, 1.5 to 14.1); however, there was no significant difference in scores on physical function or on the Oswestry Disability Index. The as-treated analysis, which combined both cohorts and was adjusted for potential confounders, showed a significant advantage for surgery by 3 months for all primary outcomes; these changes remained significant at 2 years.
Conclusions In the combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically.
full text at nejm.com. Interestingly, their conservative therapy arm was "usual care," or PT, home exercise, and NSAIDs.
In addition, they have a case discussion in this issue of an elderly patient with spinal stenosis (written by a rheumatologist and an orthopod) that basically discounts evidence for injections ; they cite the recent neurology position paper and a paper from Spine that describes the increase in lumbosacral populations in the medicaid population.
As a fellow, it is upsetting that there is not even a voice from pain management included in this kind of a paper, read by internists, FPs, neurologists, orthopods (our referral base), as well as reported to the general public. Also, the fact that there is no long-term prospective placebo-controlled, randomized clinical trial looking at fluoroscopic-guided interlaminar epidural steroid injections for spinal stenosis is disheartening, considering the number that are done. And I am aware of the Pain Physician article by Botwin et al looking at caudals for spinal stenosis, but they did not even mention this.
I guess I am venting, but if pain management is to gain significant traction as a legitimate subspecialty, the quality of our data needs to be vastly improved. I was at the AAPM meeting in Orlando, and comparing the quality of some of the results presented there to the American College of Cardiology meeting that I've also attended in the past was a joke.
anyone else's thoughts?
