Muristek
To the Editor In a recent Review of the diagnosis and management of lumbar spinal stenosis, the authors concluded that “[s]elected patients with continued pain and activity limitation may be candidates for decompression surgery.” However, the assumption that surgery is beneficial is based on their statement, “These trials of decompression have important limitations including the substantial crossover in SPORT [the Spine Patient Outcomes Trial].” The conclusions of the SPORT trial favoring surgery over nonoperative care were based on the as-treated analyses, in which 40% of participants from the nonoperative group crossed over to the surgical group; the intention-to-treat analyses, however, were not clinically or statistically significant. A 2015 study that randomized 169 patients to decompressive surgery or nonoperative care found no between-group differences in physical function improvement or pain in the intention-to-treat or complier average causal effect analyses, concluding that “without a control group it is not possible to judge success attributable to either intervention.” The most recent Cochrane review comparing surgery with nonoperative care for lumbar spinal stenosis was published in 2016 and included 5 randomized clinical trials with a total of 643 participants. This Cochrane review concluded that existing evidence demonstrated no clear benefit of surgery compared with nonoperative treatment and that the quality of evidence was generally considered low.
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