Differential Postsurgery Outcomes Across Physical Therapy Care Pathways in Lumbar Spinal Stenosis Surgery: Analyses of a National Registry-Based Cohort

Abstract Importance Lumbar spinal stenosis (LSS) is the most common indication for spinal surgery. Physical therapist treatment is consistently recommended throughout the care pathway for LSS, including before and after surgical treatment. However, the effectiveness of pre- and postsurgery rehabilitation interventions are unclear. Objective The objective of this study was to explore 1-year postsurgery outcomes associated with different physical therapy care pathways in patients who had undergone surgery for LSS. Design This was a registry-based multicenter study using data from the Swedish National Spine Surgery Registry. Setting Swedish spine clinics participating in the Swedish National Spine Surgery Registry, with an estimated national coverage of 95%. Participants Participants were patients surgically treated for LSS between 2021 and 2023 and with data on physical therapist treatment prior to a surgical decision, while waiting for surgery, and after surgery (N = 7969). Intervention(s) or Exposure(s) Patient-reported exposure to physical therapy before and after LSS surgery, categorized into four physical therapy care pathways. Main Outcomes and Measures Outcomes were patient-reported pain intensity, disability, health-related quality of life, general health, gait function, analgesic use, repeat surgeries, satisfaction with surgery, and perceived participation in decision-making. Multivariable logistic regression and univariate analysis of variance were used to assess differences in 1-year postsurgery outcomes between 4 physical therapy care pathways. Results Compared to patients who reported pre- and postsurgery physical therapy, patients with only presurgery physical therapy demonstrated better outcomes across all measures and had higher odds of reaching the thresholds for meaningful and acceptable outcomes at 1 year after surgery (odds ratio [OR] = 1.39 to 1.56). In contrast, patients with only postsurgery physical therapy had higher pain intensity, worse gait function and health-related quality of life, and less improvement in disability and gait function. They also had lower odds of reaching clinically acceptable thresholds in pain intensity (spinal OR = 0.83 [96% CI = 0.74 to 0.93]; leg OR = 0.78 [95% CI = 0.67 to 0.88]) and disability (OR = 0.83 [95% CI = 0.72 to 0.96]). Few differences were observed between patients with both pre- and postsurgery physical therapy and those with no physical therapy. The latter group was small, and comparisons should be interpreted accordingly. Conclusions Presurgery physical therapy may be beneficial to consider for patients undergoing surgery for LSS, while additional postsurgery physical therapy may not be warranted for all. Relevance The results may inform the development of surgical care pathways for LSS.