Letter to the Editor: Beyond the dichotomy: Integrating precision rehabilitation, patient-centered goals, and nursing leadership in lumbar spinal stenosis care

Abstract

This letter comments on the prospective study by Ayyildiz et al comparing surgical and conservative management for lumbar spinal stenosis. We applaud the authors for demonstrating comparable efficacy in core outcomes with complementary benefits, reinforcing that lumbar spinal stenosis treatment is not one-size-fits-all. While endorsing supervised physical therapy as a crucial first-line option, we propose advancing the discourse by integrating contemporary paradigms. The differential treatment effects on various functional scales underscore the need for precision rehabilitation to match patient phenotypes with optimal interventions. Furthermore, these outcome variations highlight the imperative to define success using patient-important outcomes within a biopsychosocial model, where nursing-led support is vital for self-efficacy and long-term success. Ultimately, we advocate for a shift from a binary choice to an integrated, stepped-care pathway. In this model, all patients commence with nurse-coordinated, precision-based conservative care, with surgery reserved for those who do not achieve their functional goals. This approach optimizes resources, minimizes surgical risks, and positions nursing as central to assessment, education, and personalized care coordination, ensuring treatment aligns with what matters most to the patient.

Key Words: Lumbar spinal stenosis; Rehabilitation; Patient-centered care; Nursing role; Integrated care pathway

Core Tip: The management of lumbar spinal stenosis should shift from a binary choice to an integrated, precision-based stepped-care pathway. All patients begin with nurse-coordinated conservative care, including tailored physical therapy and biopsychosocial support. Surgery is reserved for those who do not achieve personal functional goals after this optimized nonoperative phase. This model enhances resource efficiency, minimizes surgical risks, and establishes nursing leadership as central to personalized assessment, education, and care coordination, ensuring treatment aligns with patient-centered outcomes.

TO THE EDITOR

We read with great interest the prospective study by Ayyildiz et al[1], which provided valuable longitudinal data and compared the surgical and conservative management of lumbar spinal stenosis (LSS). The authors are commended for their clinically relevant finding that these approaches offer complementary rather than superior benefits. In particular, the report reinforces the notion that treatment of LSS is not a one-size-fits-all endeavor[1]. Their work adds to a growing body of literature, such as the Cochrane review by Zaina et al[2]. These previous reports have struggled to declare a definitive winner between the surgical and conservative management of LSS and highlight the nuanced nature of treatment efficacy. The conclusions of this study rightly support supervised physical therapy as the foundational first-line treatment. From a nursing and rehabilitative perspective, this is a crucial message that aligns with efforts to minimize invasive procedures and their associated risks, such as surgical complications and post-laminectomy syndrome[3]. However, we believe the discourse can be advanced beyond the simple “surgery vs conservative” dichotomy by integrating contemporary paradigms in musculoskeletal care, including precision medicine, the biopsychosocial model, and the implementation of integrated care pathways.

The imperative for precision rehabilitation in LSS

The finding that each treatment excelled in different functional domains [e.g., surgery in Nottingham Extended Activities of Daily Living (NEADL) and conservative care in the Swiss Spinal Stenosis Questionnaire] is the most insightful aspect of this study. It aligns with the emerging concept of “precision rehabilitation”. Rather than asking which treatment is better overall, the critical question is: “Which patient, with which specific phenotype, will benefit most from which intervention?”.

Mounting evidence suggests that LSS is a heterogeneous condition with distinct clinical phenotypes. For instance, Pierce et al[4] proposed a classification based on symptom prioritization. They identified different phenotypes, such as “pain-dominated”, “disability-dominated”, and “balanced” profiles. Similarly, other research points to physiological phenotypes, such as patients with predominant neurogenic claudication due to central canal stenosis vs those with radicular pain from lateral recess stenosis, who may respond differently to targeted physical therapy techniques[5]. Furthermore, central sensitization, where the central nervous system amplifies pain processing, is increasingly recognized as a key factor in chronic LSS-related pain and disability[6]. Patients with high levels of central sensitization may exhibit a poor response to surgery alone and may require a conservative approach that incorporates cognitive-behavioral strategies and neuromodulatory agents.

The superior improvement in severity during walking (SSS), a condition-specific measure, in the conservative group may indicate that patients with certain functional and psychosocial profiles will respond exceptionally well to targeted, nonoperative neuromotor re-education. The supervised exercise program in this study, which probably incorporated flexion-based and stabilization exercises, directly targeted biomechanical deficits in the LSS by improving the cross-sectional area of the spinal canal and neuromuscular control[7]. As frontline clinicians, nurses are ideally positioned to conduct comprehensive assessments of phenotypic differences. They can provide tailored patient triage and education by screening for central sensitization using tools such as the Central Sensitization Inventory, assessing specific functional limitations, and evaluating the psychosocial drivers of pain. This ensures the patient starts on the optimal path of care from the outset.

Prioritizing patient-important outcomes within a biopsychosocial framework

The differential outcomes on the Istanbul Low Back Pain Disability Index, NEADL, and symptom SSS scales underscore the importance of defining “success” based on patient-specific goals. For an elderly patient living alone, the ability to perform grocery shopping (a NEADL item) is paramount for independence, whereas for an active individual, a reduction in SSS may be the key to maintaining quality of life and social participation. This resonates strongly with the current emphasis on patient-related outcome measures and the biopsychosocial model of care, which posits that illness and recovery are influenced by the interplay among biological, psychological, and social factors[8].

Surgery may directly address biological “impingement”, but high-quality conservative care, as delivered in this study, addresses a wider spectrum of biopsychosocial factors. A structured physical therapy program, combined with regular supervision, inherently provides a therapeutic alliance, fosters a sense of empowerment, and builds self-management skills, all of which are core components of modern pain management[9]. Weekly phone calls mentioned in the methodology, a classic nursing intervention, are a prime example of a low-cost, high-impact strategy. This intervention fosters adherence, provides crucial psychosocial support, allows for the early identification of barriers to recovery, and reinforces education elements that are crucial for long-term success but are often under-measured in traditional clinical trials that focus solely on biomedical outcomes.

The fact that the conservative group’s pain at rest and at night only showed significant improvement at the one-year mark, unlike the earlier improvement in the surgical group, is telling. This suggests that conservative care facilitates a slower and more adaptive process of neuroplastic change and coping strategy development, ultimately leading to sustainable pain modulation. This aligns with the concept of “pain self-efficacy”, which is a strong predictor of functional recovery in chronic musculoskeletal conditions[10]. Nursing-led support was instrumental in building self-efficacy throughout the conservative management journey.

The evolving role of nursing in a stepped-care pathway

We argue that the optimal management of LSS is not a choice between the two paths but an integrated, stepped-care pathway in which nursing and rehabilitation specialists play central roles as coordinators and first-line providers. In this pathway, all patients commence a period of precision-based nurse-led conservative care. This initial step involves a comprehensive biopsychosocial assessment, patient education about the condition and active self-management strategies, coordination of supervised physical therapy, and continuous monitoring of progress using validated patient-related outcome measures.

Patients who do not achieve their personal functional goals after an adequate trial of this optimized conservative approach will then be seamlessly escalated for surgical consultation. This model, supported by growing evidence, maximizes resource efficiency, minimizes surgical risks for those who will improve without it, and ensures that surgical candidates are truly those with recalcitrant, mechanically driven symptoms[11]. For patients requiring surgical escalation, the intervention chosen must also be phenotype-matched, ranging from traditional decompression to less invasive stabilization techniques like percutaneous cement discoplasty for specific degenerative patterns[12]. The authors’ data provide a strong foundation for implementing patient-centered pathways (Figure 1). Furthermore, one review emphasized that even patients who undergo surgery should be incorporated into a structured rehabilitation program to enhance recovery, a process that is ideally overseen by nursing and rehabilitation professionals[13]. This stepped-care pathway ensures that surgical candidates are truly those with recalcitrant, mechanically driven symptoms who have failed a robust nonoperative program, rather than those who were never offered one. The role of the nurse evolves from a passive implementer of orders to a proactive leader in assessment, education, motivational interviewing, and care coordination, ensuring that the patient’s journey is continuous, coherent, and aligned with their values.

Figure 1 The precision care ecosystem for lumbar spinal stenosis. This diagram illustrates a dynamic, nurse-coordinated care model for lumbar spinal stenosis. Central hub: Nursing-led coordination, integrating patient data to direct care. Inner ring: Precision assessment of clinical phenotypes, patient goals (patient-related outcome measures), and biopsychosocial factors. Outer pathway: A stepped-care intervention, starting with supervised physical therapy. Based on continuous assessment, care is either maintained or escalated to surgical decompression, followed by mandatory structured rehabilitation that feeds back into the system. Core principle: The model is patient-centered and forms a closed loop, ensuring continuity of care and prioritizing conservative management.

CONCLUSION

In conclusion, the study by Ayyildiz et al[1] is a significant step forward in robustly demonstrating the complementary role of surgery and conservative care. By framing the findings through the lens of precision rehabilitation, patient-centered outcomes, and a biopsychosocial model, we can move the field beyond the traditional and limiting dichotomy. The future of LSS management lies in interdisciplinary collaboration within structured stepped-care pathways. In the future, nursing leadership will be indispensable. They will lead the charge toward comprehensive assessment, personalized education, and the coordination of personalized care journeys that ultimately align treatment with what matters most to the patient.

ACKNOWLEDGEMENTS

We thank WeChat official account: “previsiont” for its insights on consciousness.