Anthony Delitto, PT, PhD; Sara R. Piva, PT, PhD; Charity G. Moore, PhD, MSPH; William C. Welch, MD
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1420.
Delitto A., Piva S., Moore C., Welch W.; Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis. Ann Intern Med. 2015;163:397-398. doi: 10.7326/L15-5129-4
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Published: Ann Intern Med. 2015;163(5):397-398.
We agree with Dr. Barrer that conservative care should precede considering surgery. However, we disagree that not having prior PT is a “breach of … care.” Exactly what constitutes conservative care is not universally agreed upon. Physical therapy is 1 form, as is watchful waiting, epidural steroids, drug regimens, and many combinations. In our study, surgeons deemed patients surgical candidates largely because conservative care—including, in some cases, previous PT—had been unsuccessful.
As for the high crossover rate, complier average causal effect and inverse probability weighting analyses were done to address that issue. In terms of success rates of surgery, it would be helpful if Dr. Barrer had included references, because definitions of success can vary. We defined it as improvement by an SD of 0.5 regardless of crossover status, because we believed that the risks of surgery warranted setting a high bar.
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