Is spinal stenosis better treated surgically or nonsurgically?

For patients with clinical and radiographic lumbar spinal stenosis, is surgery or continued nonsurgical treatment a better option for improvements in baseline disability scores; and what proportion of patients treated surgically and nonsurgically get better, worse, or remain the same with time? We prospectively evaluated 125 consecutive patients for this non-randomized cohort study. Of the patients choosing surgery, 54 underwent decompression only and 42 had decompression and fusion for preexisting spondylolisthesis; twenty-nine patients declined surgery. At 2 years followup, the average improvements in Roland-Morris questionnaire score in the decompression only, decompression with fusion, and nonsurgical groups were 6.9, 6.1, and 1.2, respectively. The percentages of patients who were better, worse, or the same were similar for those who had decompression only (63.3%, 4.1%, and 32.7%, respectively) and decompression with fusion (61.5%, 2.6%, and 35.9%, respectively) but different from those treated without surgery (25.0%, 12.5%, and 62.5%, respectively). We observed no occurrences of cauda equina syndrome or severe neurologic dysfunction in any of the groups after 2 years. A majority of patients declining surgery had persistent symptoms. The majority of patients who choose surgery will be improved but will have residual symptoms and therefore should be counseled about realistic expectations.