Spine Journal - 2026-07-01 - Journal Article
The association of operative versus nonoperative treatment for lumbar spondylolisthesis and stenosis with future metabolic conditions and allostatic burden: an emulated target trial.
Ibrahim MT, Kuttner N, Schoenfeld RJ, Alvarez P, Kavuri V, Singh VK, Schoenfeld AJ, Yu E
Topics
Key Takeaway
Surgical treatment for lumbar spondylolisthesis and stenosis within 6 months of diagnosis reduced 3-year metabolic burden risk by 6% (RR 0.94) compared to nonoperative care, though surgery was associated with 19% higher odds of active opioid prescription at 3 years.
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Summary
This emulated target trial used EPIC COSMOS data to compare surgical versus nonoperative treatment for lumbar spondylolisthesis and stenosis on downstream metabolic conditions, frailty, chronic pain, and allostatic load. Using clone analysis with inverse probability weighting, surgery within 12 months was associated with modestly lower risk of metabolic burden (3-year RR 0.98) and frailty (3-year RR 0.99), with maximal benefit when surgery occurred within 6 months (3-year metabolic RR 0.93). Surgery was associated with higher active opioid prescription rates at both 1 year (RR 1.04) and 3 years (RR 1.19), and no meaningful difference in allostatic load was detected.
Key Limitation
The 2% absolute risk reduction in metabolic burden (RR 0.98 at 3 years for the full surgical cohort) is statistically significant given the massive sample but of uncertain clinical magnitude, and the confidence intervals are implausibly narrow, suggesting the weighting model may not have fully accounted for unmeasured confounders such as baseline activity level, obesity severity, or socioeconomic status.
Original Abstract
BACKGROUND CONTEXT
Lumbar spinal stenosis adversely impacts mobility and function. Persistent lack of exercise and ambulatory capacity may contribute to the development of metabolic conditions.
PURPOSE
To determine the effect of surgical intervention, as compared to nonoperative treatment, on the development of metabolic conditions, chronic pain, frailty, and allostatic load (AL).
STUDY DESIGN
Retrospective emulation target trial.
PATIENT SAMPLE
A total of 2,521,827 patients were included, of which 329,314 (13.1%) underwent surgery.
OUTCOME MEASURES
Development of metabolic conditions, chronic pain, frailty, and allostatic load (AL).
METHODS
Data was sourced from EPIC COSMOS. We conducted a clone analysis using inverse probability censoring weights and inverse probability of treatment weights that accounted for confounders. Risk ratios (RR) were calculated at 1- and 3-years postindex diagnosis for post-operative metabolic burden and frailty, and at 1 and 2 years for active opioid prescription, using weighted pooled logistic regression. Generalized Estimating Equation was used to determine the mean difference in AL at 1 and 3 years.
RESULTS
Surgery within 12 months of index diagnosis demonstrated a significantly lower risk of metabolic burden (1-year RR [95% confidence interval (CI)]: 0.98 [0.98 to 0.98]; 3-year: 0.98 [0.98 to 0.98]) and frailty (1-year: 0.98 [0.98 to 0.99]; 3-year: 0.99 [0.98 to 0.99]). The risk of metabolic burden was lowest if surgery occurred within 6 months (1-year RR [95% CI]: 0.93 [0.93 to 0.94]; 3-year RR [95% CI]: 0.94 [0.94 to 0.95]). No significant difference in AL was noted at 1-year, and the difference was negligible at 3-years. The surgery cohort had a higher risk of active opioid prescription at 1-year (RR [95% CI]: 1.04 [1.04 to 1.04]) and 3-year (RR [95% CI]: 1.19 [1.17 to 1.20]) follow-up.
CONCLUSIONS
We found that surgical intervention was associated with greater reductions in metabolic burden and frailty up to 3 years following the procedure. We also found evidence of a time-dependent effect such that maximal benefit was appreciated when surgery was performed within 6-months of presentation.