Written by Steve Young
This was part of a letter of thanks I recently received from one of my patients. I was treating an elderly patient who had back and leg pain that was brought on by walking. She had made some progress with respect to her pain and function with treatment that consisted of manual therapy, stationary cycling and exercise. After five sessions she sent me a very kind letter stating she had seen an osteopath and he had told her that her stenosis was so severe that her only option was to see a surgeon. She thanked me for my services and for “Attempting to fix the unfixable”.
Was the advice of the osteopath reasonable? What is the cost and benefit ratio for surgical intervention for lumbar spinal stenosis?
Obviously, the message conveyed to the patient (being unfixable) was disabling, fear provoking and destroyed any expectation of recovery through physiotherapy (ref). Furthermore, it was inaccurate on a number of levels. On imaging, over 20% of older adults have spinal stenosis and remain asymptomatic, suggesting that the correlation between anatomy and symptoms is not always linear. Another study looked at Oswestery Disability Questionnaire scores and found that there was no correlation between perceived disability and radiological severity of spinal stenosis in patients awaiting surgery for spinal stenosis (ref). As is seen repeatedly in the research, an image only tells part of the patient’s story and generally serves two purposes: ruling out serious pathology and guiding surgical intervention.
Is surgical intervention a supported intervention for lumbar spinal stenosis? If we were to look at the research a few years ago, it would indeed seem so (ref). A number of studies using two and four year follow-ups found that surgical intervention, in the form of either a decompression or decompression and fusion shows significantly improved outcomes over conservative management. More recent studies have demonstrated an interesting trend where the benefit of surgery dissipates so that by the eight year mark, no significant benefit was noted for the surgical group over the conservative management group (ref). Even more interesting is that a significant portion of patients treated conservatively do not worsen, suggesting those with spinal stenosis do not have to progressively worsen with time.
Four years of benefit from a surgery is probably an acceptable outcome but we should also consider the risk and cost associated with the surgery. Richard Deyo has done some interesting research based on medicare produced data in the US and spinal stenosis surgeries (ref). The beauty of this data is that it provides us with an overview of large population samples. Using 32,000 lumbar spinal stenosis surgeries, Deyo determined that the average cost in US dollars for surgery ranged from $23,000 for a simple decompression to $80,000 for a multilevel fusion. I’ll give you one guess which surgery had increased utilization over the five year period of the study…. A 15 fold increase in complex multilevel fusion over the five year time period Deyo measured.
So surgical intervention for lumbar spinal stenosis comes at a high cost with a time limited efficacy but is there risk involved? Deyo followed his 32,000 patients medical records for 30 days and found that one in 20 experienced a life threatening complication such as a stroke or pnemounia in that time period and approximately one in 200 died. Of those receiving a complex fusion, one in five was discharged to skilled nursing facility. Apparently the surgery also carries a heavy risk along with its significant cost.
Can physiotherapy potentially offer an efficacious alternative to surgery, even in a patient that presented with significant stenotic changes? In some of the earlier studies, physiotherapy was a component of care for some patients but was not a consistent intervention for all conservatively managed patients. More recently, Delitto et al. studies 169 patients who were already accepted as patients appropriate for surgery (ref). Half were treated with a flexion based physiotherapy treatment program while the other half went ahead with their prescheduled surgery. At two year follow-up, there were no significant differences between the two groups! The physiotherapy group demonstrated just as much improvement as the surgical intervention group. There is one hitch to this study and that is about half of the group being treated with physiotherapy switched to the surgical group after randomization. Here is where it gets interesting - the number one reason patients reported for transferring to the surgical group:
They couldn’t afford the co-pay for physiotherapy!
That’s right, the really expensive surgical intervention that has high risk for significant adverse complications is fully funded while the low risk and low cost intervention that is equally efficacious is not. If we are looking for ways to improve our healthcare outcomes while reducing cost, this might be a great place to start. I’m not suggesting that surgery is never an option for these patients but as is the case with most orthopaedic conditions, physiotherapy should be a first line intervention. If patients move forward with surgery, this should be done with a shared decision making model where the patient is fully aware of both benefits and potential risks.
If you are wondering what happened to my patient, she contacted me a few weeks later to say she wasn’t going ahead with surgery (We have some really good surgeons in our region who help patients make informed decisions). I can happily report that she is making good progress. What has treatment consisted of? That’s my next post….
Come see us speak at the Canadian Physiotherapy Association Congress in beautiful Victoria, BC.
Curtis Tait, Brad Jawl and yours truly will be speaking on lumbar spinal stenosis management on May 27, 2016. Please stop by and introduce yourself!