This news story presents a summary of a major new study comparing surgery to nonoperative treatments for lumbar spinal stenosis. However, its explanation of the nature of the new evidence and the apparent advantages of surgery is incomplete, and could leave a reader with a lopsided view of the benefits of surgery. Because of the design of the study (named SPORT) and the large numbers of people in the randomized trial who crossed over and chose a different treatment from the one they were assigned, it may be difficult to gauge the “true” magnitude of the difference between surgery and nonoperative care.
Although the published research presented several analyses, the news story focused on those that showed the greatest advantage for surgery; e.g. dramatic differences in patient-perceived “major improvement” of 63% vs. 29%. (See more details in "Evidence" and “Quantification of Benefits” above.) The “truth,” many observers would say, likely lies somewhere between the minimal/modest benefits that the news story did not report and the larger benefits that it did.
Moreover, the story seems to imply that surgery should be the treatment of choice for all patients with spinal stenosis. In fact, the study proves that it isn’t. All people who chose nonoperative therapies had the option of receiving surgery if they wished. But some 40% stuck with their nonoperative decision through the two years of observation. As in earlier research, those who chose surgery appeared to be worse off in many ways (worse symptoms, more distress, etc.) than those who chose nonoperative treatments. The news story thus misses a central point of the research: surgery appears to be a good choice for some people—those with persistent, bothersome symptoms that don’t improve with nonoperative strategies—but it is not for everyone. Given the older age of this patient population and the small but real risks of surgical intervention, many patients may rightly select nonsurgical treatment as the "right" option for them, even knowing that on average their outcomes may be slightly inferior to those selecting surgery.
A few final notes: The news story failed to mention the possible harms of either treatment. It would also have been very interesting for readers to hear from a spine researcher not associated with the study who could provide some of the missing nuance. And it would be nice to hear just a little more context–perhaps a sentence about another recent trial from Finland that showed smaller advantages for surgery at 2 years.
Finally, it is troubling that fully a third of the text of this news story was directly lifted from a press release. This text encompassed most of the analysis of the results, which was incomplete and arguably biased.
The article reports the costs of surgery ($10,000-12,000) though it does not mention the cost of nonoperative care or compare the costs of the two treatment regimens. It’s unclear from the article whether the surgery costs encompass all aspects of surgery, from surgeon fees through hospitalization.
The story used absolute measures to report the patients’ outcomes, but it focused on results that showed the greatest advantage for surgery. The researchers presented several analyses. One analysis showed a very small but significant (~8/100 points) advantage for surgery at 2 years in pain reduction, but no advantage in function or disability; these were the outcomes of the randomized patients, analyzed according to their assigned treatments (an intention-to-treat analysis), and likely underestimate the value of surgery. Another analysis looked at all patients according to the treatments they actually received, and showed a modest but significant 11- to 14-point advantage for surgery in pain relief, function and disability. The news story did not report either of these analyses. The “truth,” many observers would say, likely lies somewhere between the minimal/modest benefits that the news story did not report and the larger benefits that it did.
The story did not mention harms of either type of treatment. The researchers reported that about 1 in 10 people who received surgery had an intraoperative or postoperative complication, although few of these were serious.
The design of the SPORT study is complex. The article notes that it included patients randomly assigned to surgery or nonoperative care. It also points out that some of the patients randomly assigned to nonoperative care changed their minds and had surgery. The article fails to note two other important features of the study, however. About a third of patients randomly assigned to surgery changed their minds and opted for nonsurgical care. Also, there was another, equally large cohort of patients enrolled in the study whose treatments were not randomly assigned and who instead chose their treatments, creating what is known as an observational cohort. This is a key design feature in all of the SPORT studies. It is important because the results of observational cohorts may compare people who have dissimilar levels of pain or disability or different socioeconomic backgrounds, which limits their conclusions.
In general, the story does not exaggerate spinal stenosis, though it may be a stretch to characterize the problem as “common.” (It exists in about 3% of people who visit a doctor with back pain, and is a common cause of back surgery in the elderly.) And while it is true that spinal stenosis can cause “debilitating pain,” the condition can often be less dire as well. Although people who received nonoperative care in this SPORT study did not do as well as those who received surgery, some 40% of all enrolled patients still preferred to manage their problem without surgery at the two-year mark and, on average, showed modest improvement.
The story only quoted one source – the study’s lead investigator. The story should have included some input from observers not directly involved the study about their interpretation of the results.
The article notes some of the common alternatives to surgery—drugs and physical therapy—although it does not mention another very common treatment, epidural steroid injections.
The news story notes that laminectomy is one of the most common operations performed in the U.S., suggesting that it is widely available. Most readers are likely aware of the availability of nonoperative treatments such as pain medications and physical therapy.
The story notes that laminectomy is one of the most common operations performed in the U.S., suggesting that it is not novel. Most readers likely know that nonoperative treatments such as pain medications and physical therapy are not new.
By pure word count, fully a third of the text was borrowed verbatim from a press release. 169 of the 490 words in the story – or 34% – were identical to the phrases found in a Rush University Medical Center news release found on the Newswise online service – one used commonly by journalists. This is unacceptable in a high school journalism class – much less in the Wall Street Journal.
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
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