DEAR DOCTOR K:
I have painful spinal stenosis in my lower back. My doctor wants me to have surgery, but that seems extreme. Is surgery really my best option?
Lumbar (low back) spinal stenosis is a common problem, particularly in older people. Spinal stenosis is a condition that affects the bones of the spine — the vertebrae. The vertebrae are stacked on top of each other like a roll of dimes. Each of the vertebrae has a hole in the center of it, the spinal canal, through which the spinal cord travels. The spinal cord carries the nerves that connect the brain to the rest of the body.
Stenosis means that the space inside the spinal canal has narrowed. This puts pressure on the spinal nerves, causing pain. (I’ve put an illustration of the lumbar spine, below.)
Doctors usually recommend so-called “conservative” treatments first. These include pain relievers, anti-inflammatory medicines and physical therapy. Corticosteroid injections into the spine can also help. If symptoms don’t improve, doctors often recommend surgery.
Most previous studies have shown that, at first, symptoms improve faster with surgery than with conservative treatments, including physical therapy. But after six to 10 years, symptoms are no different for people who have had conservative therapy only and those who have had surgery.
A recent study in the Annals of Internal Medicine suggests that physical therapy may relieve spinal stenosis as effectively as surgery does. The study included 170 people in their late 60s with lumbar spinal stenosis. They all had severe back pain and problems with movement.
The study participants were randomly assigned to receive either surgery or physical therapy. The surgery removed areas of bone that were narrowing the spine and pressing on nerves. The physical therapy program lasted six weeks, and the longer-term results were based on that six weeks.
People in both groups had tests of movement at 10 weeks, six months and one year after surgery or physical therapy. They also were asked about pain. After two years, they filled out a survey to assess overall results.
At the two-year mark, the two groups had similar outcomes for pain relief, better movement and improved quality of life. Not everyone showed improvement.
There was one hitch with this study. More than half of the patients assigned to receive physical therapy decided they wanted surgery, instead. (The study noted that the symptoms of people who chose to have surgery were no different than the symptoms of those who stuck with physical therapy alone.) And a few of the patients assigned to receive surgery decided they wanted physical therapy instead. So the study was not a perfect comparison of physical therapy to surgery.
The researchers used statistical tests to evaluate the impact on the study results of people having a treatment that they weren’t assigned to. They concluded that the results of physical therapy and surgery were comparable. I’m a little dubious.
Given these results, I think it’s worth giving physical therapy a try before surgery. If your symptoms don’t improve, then talk with your doctor about whether and when to have surgery.
A closer look at your lumbar vertebrae
Each vertebra has a cylindrical body with a bony ring attached to its back surface as well as bony processes that project out in different directions from this ring. Intervertebral discs, tucked between each pair of vertebrae, serve as shock absorbers.
Each intervertebral disc has a gelatinous central part, called the nucleus pulposus, and a fibrous covering, called the annulus fibrosus. Each vertebra normally has seven spiky projections called processes that help stabilize your spine (five are shown above; the other two are not visible in this illustration).