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Physical Therapy or Surgery for Spinal Stenosis?

Earlier this year, researchers at the University of Pittsburgh conducted a prospective trial to compare physical therapy to decompression surgery for spinal stenosis. They enrolled 169 participants, age 50 or older, who were candidates for decompression surgery. The researchers randomly assigned half the cohort to two times per week physical therapy for six weeks and the other half to the spinal decompression group.

 

Surprisingly, there were no differences between the groups in relief of symptoms or function. In other words, twice weekly physical therapy for six weeks was roughly equivalent to surgery. Participants in both groups showed improvement after 10 weeks with continued improvement through 26 weeks. Both groups maintained significant progress two years after the beginning of the trial.

After two years, physical function (as measured by the Short Form-36)was 22.4 for the surgery group and 19.2 for the physical therapy group (lower scores mean more disability). While surgery outcome scores were slightly higher at the end of the trial, the authors state that these results were not statistically different from one another. These results seem to suggest that physical therapy is as effective as decompression surgery for spinal stenosis.

There are some important caveats to consider, however. While every participant was defined as a “candidate for surgery” by the authors, the fact that half could be treated with physical therapy indicates that the spinal stenosis could not have been severe. If it were, patients would not be able to tolerate physical therapy. Therefore, patients with severe spinal stenosis may require decompression surgery because physical therapy is not an option.

Another point that was not clear from this article is whether patients received physical therapy prior to the trial. The standard of care is to offer patients with spinal stenosis targeted, physician-directed physical therapy before entertaining the possibility of decompression surgery. Does this mean that all study participants had at least one round of physical therapy? Ordoes it mean that no study participants had physical therapy?

Finally, patients who fail to achieve a benefit from physical therapy will likely require spinal decompression surgery at some point, regardless. Therefore, surgery still remains a last resort treatment.

While this prospective study raises a number of important points and emphasizes the effectiveness of physical therapy, it really does not change management of spinal stenosis. Patients who can participate in a rigorous program of physical therapy should do so before trying spinal decompression surgery.

If a spine surgeon recommends surgery before physical therapy it means the patient’s symptoms are too severe to undergo physical therapy, the patient prefers surgery over physical therapy, or the surgeon is not adhering to the standard of care for some reason. If you have mild or moderate spinal stenosis, it is perfectly reasonable to undergo evidence-based physical therapy prior to surgery. If this physical therapy fails or your spinal stenosis is too severe, spinal decompression surgery is still the best option.

Reference

  1. Delitto A, Piva SR, Moore CG, et al. Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial. Annals of internal medicine. 2015;162(7):465-473.

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