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The Battle Against Lower Back Pain: Comparing Physical Therapy and Surgery for Lumbar Spinal Stenosis

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Lumbar spinal stenosis, a common cause of lower back discomfort, can necessitate surgical intervention in certain cases. However, a study published in the Annals of Internal Medicine discovered that physical therapy can be as effective as surgery, with fewer risks and complications, some of which may be life-threatening.

Lumbar spinal stenosis occurs when the spinal canal narrows in the lower back, causing pressure on the lumbar vertebrae, the five bones situated between the rib cage and the pelvis. This condition is typically caused by the degeneration of discs, ligaments, or joints between the interlocking vertebrae of the spinal column (known as facet joints), leading to painful and potentially debilitating compression of the spinal cord.

Spinal stenosis commonly presents the following symptoms:

  • Pain that starts in the upper thigh, extends to the buttocks, and remains localized there (similar to sciatic pain)
  • Difficulty walking that eases when sitting or squatting
  • Pain that worsens with a hunched posture and eases with a more upright one

Surgical interventions, such as decompression or laminectomy, can alleviate lumbar spinal stenosis discomfort by removing the offending structures. Physical therapy has also been shown to help alleviate lower back pain.

The study involved 169 men and women from the Pittsburgh area who were experiencing lumbar spinal stenosis-related back pain. All participants agreed to undergo surgery, with the understanding that half would receive the procedure immediately, while the other half would first participate in a specialized physical rehabilitation program.

After 10 weeks, patients in both groups had already experienced benefits from their respective treatments or physical therapy. Over the course of four months, they reported a steady decrease in lower back pain and an increase in physical function. Two years later, there was no significant difference between the surgical and physical therapy groups in terms of pain or physical function.

However, eight patients in the physical therapy group (10%) reported worsening symptoms, while 22 patients in the surgery group (25%) experienced surgery-related complications such as repeat surgery or surgery-related infections.

No single set of criteria can determine whether a person with lumbar spinal stenosis should undergo surgery for back pain. The results of this study provide valuable insights.

Lower back pain from lumbar spinal stenosis is typically first addressed with conservative treatments, such as medications, painkillers, NSAIDs, and even spinal injections of corticosteroids. If symptoms do not improve, surgery is usually the next step. Given the findings of this research, this approach seems logical.

Dr. Jeffrey N. Katz, a professor of medicine at Harvard Medical School, writes in an editorial on the study's findings that individuals with lumbar spinal stenosis should first undergo a well-designed physical therapy program. Dr. Katz, faculty editor of Back Pain: Finding solutions for your aching back, a Special Health Report from Harvard Health Publishing, says that if physical therapy does not work as well as expected to relieve lower back pain, the decision of when to have surgery should be driven by the person's preferences.

Emergency surgery may be required in cases where nerve pressure causes:

  • Weakness in the hip flex
  • Weakness in the hip flexors and hamstrings
  • Difficulty controlling bowel or bladder function
  • Ineffectiveness of strong medication in relieving pain

When surgical intervention is required, a laminectomy is the procedure of choice. The surgeon removes the bony plate (lamina) at the rear of the vertebra to alleviate the stenosis, providing more space for the spinal nerves. Laminectomy can be performed with the aid of a tiny camera through a needle-sized incision.

In severe cases of spinal canal constriction, a laminectomy alone may not be sufficient. Laminectomy combined with spinal fusion may be necessary in such situations. This procedure involves the removal of discs and other tissues, along with one or more bony plates, before stabilizing the spine with cement or metal.

When possible, a laminectomy alone is preferred over spinal fusion for relieving lower back pain. This is because spinal fusion carries a higher risk of complications and a longer recovery period.

The study's findings highlight the importance of considering physical therapy as a viable alternative to surgery for treating lumbar spinal stenosis. While surgery may be necessary in some cases, physical therapy has shown to be equally effective in reducing pain and improving physical function, with fewer risks and complications. By understanding the advantages and limitations of each treatment option, patients and healthcare providers can make informed decisions that prioritize the individual's preferences and well-being.


  1. Delitto, A., Piva, S. R., Moore, C. G., Fritz, J. M., Wisniewski, S. R., Josbeno, D. A., ... & Welch, W. C. (2015). Surgery versus nonsurgical treatment of lumbar spinal stenosis: A randomized trial. Annals of Internal Medicine, 162(7), 465-473. Link
  2. Katz, J. N. (2015). Lumbar spinal stenosis: How is it classified? Journal of Orthopaedic & Sports Physical Therapy, 45(4), 280-282. Link
  3. Harvard Health Publishing. (2021). Back Pain: Finding solutions for your aching back. Harvard Medical School. Link
William H. McDaniel, MD

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School.

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