NEW YORK (Reuters Health) – Patients with degenerative spondylolisthesis with stenosis have less pain and greater function following surgery than do patients treated with usual care, investigators in the US report in the New England Journal of Medicine for May 31.
Reporting in the same issue of the Journal, Dutch investigators observed that, for severe sciatica, the primary benefit of early surgery is faster reduction of pain.
According to lead author Dr. James Weinstein and other investigators, the goal of the Spine Patient Outcomes Research Trial (SPORT) was to determine an optimal treatment strategy for patients with symptomatic degenerative spondylolisthesis.
Study subjects were 601 patients with neurogenic claudication or radicular leg pain and spinal stenosis. The patients were offered the choice of enrolling in a randomized trial of early surgery versus usual care, or in a second observational study. The intent-to-treat analysis included 301 patients in the randomized trial and 300 in the observational study.
Surgery consisted of a "standard posterior decompressive laminectomy with or without fusion," while nonsurgical treatment included physical therapy and exercise.
At 2 years, there were no statistically significant differences between groups in the randomized trial in terms of pain, physical function, and disability, Dr. Weinstein, from Dartmouth Medical School in Lebanon, New Hampshire, and his team report.
However, because of the high rate of crossover, there were significant differences between the "as-treated" groups, which included 372 patients who underwent surgery within the first 2 years and 235 who received only nonsurgical treatment.
"Effects for the combined cohorts were statistically significant in favor of surgery for all primary and secondary outcomes," the SPORT team writes. Observed as early as 6 weeks, "treatment effects (of surgery) were stable for 2 years."
In the Dutch study, led by Dr. Wilco Peul from the Leiden University Medical Center, the goal was to determine the optimal timing of disk surgery in patients with severe sciatica.
Participants, who had incapacitating lumbosacral radicular syndrome, were randomized to early surgery (within about 2 weeks, n = 141) or to conservative treatment (n = 142). Fifty-five in the usual care group had surgery after a median period of 14.6 weeks because of intractable pain. Surgery consisted of "annular fenestration, curettage, and removal of loose degenerated disk material from the disk space…without attempting to perform a subtotal diskectomy."
Surgical patients were less disabled after 4 weeks of recovery than the conservatively treated patients. The greatest difference between groups in functional disability, leg pain and perceived recovery occurred between 8 and 12 weeks.
Median time to recovery was 4.0 weeks in the early surgery group and 12.1 weeks in the conservative treatment group. However, after 52 weeks of follow-up, the degree of improvement in functional disability and leg pain did not differ between groups. Dr. Peul’s team concludes that early surgery is a valid treatment option for well-informed patients.
They suggest that "patients are more likely to choose surgery if they are not able to cope with leg pain, find the natural course of recovery from sciatica unacceptably slow, and want to minimize the time to recovery from pain."
N Engl J Med 2007;356:2245-2270.