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Randomized Controlled Trial
. 2012 Oct 1;37(21):1791-802.
doi: 10.1097/BRS.0b013e3182634b04.

Who should have surgery for spinal stenosis? Treatment effect predictors in SPORT

Adam Pearson  1 , Jon Lurie, Tor Tosteson, Wenyan Zhao, William Abdu, James N Weinstein
Affiliations
Randomized Controlled Trial

Who should have surgery for spinal stenosis? Treatment effect predictors in SPORT

Adam Pearson et al. Spine (Phila Pa 1976). .

Abstract

Study design: Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis.

Objective: To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis.

Summary of background data: The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS.

Methods: SpS patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received. Fifty-three baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODIsurgery - ΔODInonoperative). Variables with significant subgroup × treatment interactions (P < 0.05) were simultaneously entered into a multivariate model to select independent TE predictors.

Results: Other than smokers, all analyzed subgroups including at least 50 patients improved significantly more with surgery than with nonoperative treatment (P < 0.05). Multivariate analysis demonstrated: baseline ODI ≤ 56 (TE -15.0 vs. -4.4, ODI > 56, P < 0.001), not smoking (TE -11.7 vs. -1.6 smokers, P < 0.001), neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, P = 0.002), predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, P = 0.035), not lifting at work (TE -12.5 vs. -0.5 lifting at work, P = 0.017), and the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, P < 0.001) were associated with greater TE.

Conclusion: With the exception of smokers, patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes. Smoking cessation should be considered before surgery for SpS.

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Figures

Figure 1
Figure 1
These graphs compare surgical and nonoperative outcomes and treatment effect (TE) among the groups defined by the six independent TE predictors.
Figure 1
Figure 1
These graphs compare surgical and nonoperative outcomes and treatment effect (TE) among the groups defined by the six independent TE predictors.
Figure 1
Figure 1
These graphs compare surgical and nonoperative outcomes and treatment effect (TE) among the groups defined by the six independent TE predictors.
Figure 1
Figure 1
These graphs compare surgical and nonoperative outcomes and treatment effect (TE) among the groups defined by the six independent TE predictors.
Figure 1
Figure 1
These graphs compare surgical and nonoperative outcomes and treatment effect (TE) among the groups defined by the six independent TE predictors.
Figure 1
Figure 1
These graphs compare surgical and nonoperative outcomes and treatment effect (TE) among the groups defined by the six independent TE predictors.
See this image and copyright information in PMC

References

    1. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine. 1996;21:1787–94. discussion 94-5. - PubMed
    1. Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study. Spine. 2000;25:556–62. - PubMed
    1. Malmivaara A, Slatis P, Heliovaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine. 2007;32:1–8. - PubMed
    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. - PMC - PubMed
    1. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. The New England journal of medicine. 2008;358:794–810. - PMC - PubMed

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