Spinemathema podcast · Episode 5 · About 8 minutes · October 2026

Episodes are narrated using an AI model of Mr Sadek’s own voice, from scripts he has written and approved.

Read the full article with references: Surgery or Physiotherapy for Lumbar Spinal Stenosis? What the Delitto Trial Found

Transcript

Hello and welcome to the Spinemathema podcast. I’m Ahmed Sadek, a neurosurgeon. In this episode I’m looking at one landmark spine trial and explaining what it means for patients.

Today’s trial is about lumbar spinal stenosis, and it asked a very practical question. If a surgeon has already offered you an operation, could a structured course of physiotherapy do just as well? The trial was led by Anthony Delitto and colleagues in the United States, and it was published in the Annals of Internal Medicine in two thousand and fifteen.

Let me start with what spinal stenosis is. The spinal canal in your lower back is the tunnel that carries the nerves to your legs. With age and wear and tear, that tunnel can become narrower. When it squeezes the nerves, people often get pain, heaviness or cramping in the buttocks and legs when they walk or stand. In the United States, it’s now the most often cited reason for lower back surgery.

Why was this trial needed? The authors pointed out that earlier studies comparing surgery with non surgical care had used a carefully standardised operation, but the non surgical treatment was often loosely defined. So they set out to compare surgery against a specific physiotherapy programme, with clear content and a clear schedule.

Here’s how it worked. People were recruited between two thousand and two thousand and five through two medical centres in Western Pennsylvania. To take part, you had to be fifty or over, have stenosis confirmed on a scan, and have leg symptoms when walking. For example, not being able to walk a quarter of a mile because of leg pain or cramping. And here’s the unusual part. Everyone had already been told by a surgeon that they were a candidate for an operation, and they had already agreed to have it.

People were excluded if they had a slipped vertebra that needed a fusion operation, severe disease of the blood vessels, serious dementia, or a fracture at the level to be treated.

Four hundred and eighty one people were eligible. But three hundred and twelve of them said no, most because they didn’t want to risk being put in the physiotherapy group, and went straight to surgery. That left one hundred and sixty nine people, who were randomly split into two groups.

Eighty seven were assigned to surgery. That was a decompression, where the surgeon removes bone and thickened tissue to make more room for the nerves. Nobody had a fusion, and the average hospital stay was three days. All but two people in this group had their operation.

Eighty two were assigned to physiotherapy. That meant two sessions a week for six weeks. The exercises focused on gently bending the lower back forwards, general fitness such as cycling or treadmill walking, leg strengthening and stretching, and advice to avoid arching the back. People in this group could switch to surgery at any time if they wanted to.

The main measure was physical function, using a standard questionnaire scored from nought to one hundred, at two years. The people doing the assessments didn’t know which treatment each patient had had. Patients were even asked to wear t-shirts to cover any surgical scars at their follow up visits.

So what did they find? Both groups got better. Improvement started at around ten weeks, carried on to about six months, and then held steady to two years. Physical function improved by an average of about twenty two points in the surgery group, and about nineteen points in the physiotherapy group. After the researchers adjusted for the trial design, the difference between the groups was less than one point, and it wasn’t statistically significant.

But there’s a twist. Fifty seven percent of the physiotherapy group went on to have surgery within the two years, and about two thirds of those switched within the first ten weeks. The researchers used extra statistical methods to allow for this, and they still found no significant difference.

They also looked at how many people reached a meaningful improvement at two years. That was sixty one percent in the surgery group, fifty five percent of those who switched from physiotherapy to surgery, and fifty two percent of those who stuck with physiotherapy alone. So roughly half to two thirds of people did well, whichever path they took. And forty three percent of the physiotherapy group avoided surgery for at least two years.

What about side effects? There were thirty three complications related to surgery, the most common being a further operation and slow wound healing or infection. There were nine complications linked to physiotherapy, all of them reports of symptoms getting worse. Six people died during the study, but none of those deaths was related to the trial.

Now, the limitations. First, the trial was smaller than planned. The team aimed for ninety six people in each group but stopped early because recruitment was slow. The authors themselves described the results as likely to be indeterminate. In other words, the true difference could plausibly favour physiotherapy by around eight points or surgery by around ten points. So the trial can’t rule out a meaningful difference in either direction.

Second, there was a lot of switching. With more than half the physiotherapy group having surgery, the trial really compares starting with surgery against starting with physiotherapy.

Third, about two thirds of eligible people declined to take part, and those who joined may not be typical. Fourth, there was no untreated group, so we can’t say how much of the improvement was due to treatment rather than natural ups and downs. And finally, these patients were treated between two thousand and two thousand and seven. Surgical techniques have continued to develop since then.

It’s also helpful to put this trial in context. A Cochrane review published in two thousand and sixteen looked at five trials of surgery versus non surgical treatment for stenosis. The reviewers said they had very little confidence in concluding which approach is better.

So what does this mean for you? If you have lumbar spinal stenosis without any warning signs, this trial suggests that a proper course of physiotherapy is a reasonable first step, even if surgery has already been mentioned. A good number of people avoid an operation. But it also shows that many people do go on to choose surgery, and that they tend to improve too. The evidence isn’t strong enough to say that one option is clearly better for everyone.

The authors of this trial specifically recommended shared decision making, and I think that’s exactly right. Your choice will depend on how far you can walk, how much your symptoms limit you, your general health, and what matters most to you.

One safety point before I finish. If you develop numbness around your bottom or genitals, new problems controlling your bladder or bowels, or leg weakness that’s getting rapidly worse, please seek urgent medical help. These can be signs of cauda equina syndrome, which needs emergency assessment.

Thank you for listening. Please remember that this podcast is general information and not a substitute for advice about your own situation, so do speak to your own doctor. You’ll find the full article, the diagrams and all the references at spinemathema dot com. And if you found this helpful, please subscribe to the Spinemathema channel on YouTube.

This podcast is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.