• Jon D Lurie, Tor D Tosteson, Anna Tosteson, William A Abdu, Wenyan Zhao, Tamara S Morgan, and James N Weinstein.
• *Geisel School of Medicine, Hanover, NH †The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; and ‡Dartmouth-Hitchcock Medical Center, Lebanon, NH.
• Spine. 2015 Jan 15; 40 (2): 63-76.

Study DesignRandomized trial with a concurrent observational cohort study.ObjectiveTo compare 8-year outcomes of surgery with nonoperative care for symptomatic lumbar spinal stenosis.Summary Of Background DataSurgery for spinal stenosis has been shown to be more effective than nonoperative treatment during 4 years, but longer-term data are less clear.MethodsSurgical candidates from 13 centers in 11 US states with at least 12 weeks of symptoms and confirmatory imaging were enrolled in a randomized cohort or observational cohort. Treatment was standard, decompressive laminectomy versus standard nonoperative care. Primary outcomes were SF-36 (MOS 36-Item Short-Form Health Survey) Bodily Pain and Physical Function scales and the modified Oswestry Disability Index assessed at 6 weeks, 3 months, 6 months, and yearly up to 8 years.ResultsData were obtained for 55% of participants in the randomized group and 52% of participants in the observational group at the 8-year follow-up. Intent-to-treat analyses showed no differences between randomized cohorts; however, 70% of those randomized to surgery and 52% of those randomized to nonoperative had undergone surgery by 8 years. As-treated analyses in the randomized group showed that the early benefit for surgery out to 4 years converged over time, with no significant treatment effect of surgery seen in years 6 to 8 for any of the primary outcomes. In contrast, the observational group showed a stable advantage for surgery in all outcomes between years 5 and 8. Patients who were lost to follow-up were older, less well-educated, sicker, and had worse outcomes during the first 2 years in both surgical and nonoperative arms.ConclusionPatients with symptomatic spinal stenosis show diminishing benefits of surgery in as-treated analyses of the randomized group between 4 and 8 years, whereas outcomes in the observational group remained stable. Loss to follow-up of patients with worse early outcomes in both treatment groups could lead to overestimates of long-term outcomes but likely not bias treatment effect estimates.

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