Functional Criteria in Step 3 Evaluations

A reminder: The mental and physical Listings (evaluated at Step 3 of the sequential evaluation process) contain explicit and implicit functional criteria that need to be evaluated by the adjudicator along with the objective medical evidence of severity. (A Step 3 determination of "disabled" should be issued without regard to age, education, or work experience.) But, as I've noticed in successful fed court appeals, many times adjudicators evaluate only the medical evidence at Step 3, believing that functional limitations are only part of the Step 4 RFC determination.

Make sure you're looking for the best evidence of functional impairments, which are the medical records - but functional evidence is often not there. However, treating source opinions and lay testimony can suffice to meet the functionality requirements of the Listings. Depending on the Listing, a rep should present functional impairment evidence in conjunction with a Step 3 analysis. For example, if a mental impairment Listing requires "marked" or "extreme" limitations, you must equate these indefinite terms to the claimant's functional limitations. If the mental health records are silent on functioning, you should get a treating source opinion on functioning and/or the claimant's testimony about how (to what extent) his/her mental impairment affects ability to concentrate, focus, persist, handle criticism, relate to others, etc. (The same approach to obtaining functional impairment evidence should be used with physical Listings.)

As early as Step 3, it's all about how a claimant's impairments affect functioning. You should be getting medical treating source opinions about the claimant's functioning whenever possible.

Contributed by James W. Keeter, Esquire.
Mr. Keeter is an Orlando Attorney who specializes in Social Security Disability.

Tips for Effective Hearing Representation

Recently attended a lecture by seasoned SS attorneys Sarah Bohr and Charles Martin, who have handled AC and fed ct appeals for about 30 years each. Here are some tips that they provided for effectively representing a claimant at ALJ hearings:

1. Give theory of case - address the sequential evaluation process
- is claimant working?
- does claimant have medically determinable impairments that significantly affect functioning?
- does claimant's impairment meet listings?
- why can't claimant do PRW? what specific demands of EACH job can claimant not do? what limitations preclude PRW? what MDI causes limitations? what medical opinions demonstrate limitations? what medical signs or lab findings support limitations?
- why can claimant not perform other work? does any Grid rule direct finding of "disabled"? does any limitation preclude application of the Grids? which limitation? what evidence supports limitation?

2. Identify source of each critical element. Prepare an accurate and complete summary of evidence for the ALJ (in advance of hearing).

3. Claimant's testimony. This must be used with medical evidence to establish specific functional limitations, to establish limits of RFC. Don't elicit testimony about the pain scale (this is useless) or other subjective issues. Concrete and specific functional limitation evidence is what's needed.
- ask about effects of medical treatment
- address significant negative factors (e.g., medical noncompliance, daily activities that appear inconsistent with stated limitations, etc.)
- ask about the vocational impact of the claimant's symptoms
- get claimant to describe why he/she can't do PRW
- prove that a job isn't PRW (e.g., earnings insufficient, duration insufficient)
- prove PRW was composite job (ALJ must consider claimant's ability to handle most exertionally demanding part of such jobs)
- prove mental symptoms are disabling (see POMS DI 25020.010A.3b) - develop evidence regarding each of the PRTF elements; almost every case has mental impairment elements (if you don't mention them, you've missed them!)
- establish limits of ADL's (e.g., if claimant says he reads books, then clarify dates, type of book, frequency of reading, amount of time per reading session, problems with comprehension, etc.)
- examine the record and get claimant's testimony regarding gaps in medical treatments
- "operationalize" the claimant's pain (e.g., elicit testimony regarding the specific impact of pain on the claimant's ability to operate or function during the day)

4. Lack of literacy. Claimant must be able to both read AND write in English to be literate.
- prove deficits in adaptive functioning with school records

5. VE's. Do's and Don'ts"

- ALWAYS ask for DOT codes for ALL jobs!!
- NEVER question a VE who has NOT testifed adversely to your client!!
- Ask hypotheticals with specific functional limitations caused by claimant's symptoms!! (BTW, "moderate" limitations are severe by definition)
- Get the VE to say "no jobs"!! (always ask VE the impact of claimant's testimony)
- ALWAYS be prepared to ask your own hypo to the VE!! (they should include the claimant's serious limitations, supported by the evidence)

6. Transferable skills. Skills can ONLY be transferred to same or lower skill level (SVP level; and worker function rating - identified by middle three digits of DOT number for a job).
- SVP 3 skills usually do not give rise to transferable skills
- Age interferes with transferable skills
- Transferability can only be found if there's very little vocational adjustment for claimant's over age 55
- medical limitations can affect transferability of skills (e.g., poor vision might prevent ability to interpret blueprints, CTS might prevent word processing, a stroke might cause IQ loss, etc.)

7. Other jobs (Step 5). Challenge the VE's incidence of other jobs. They're often disproven numbers. Subjects to ask the VE about job incidence:
- can you identify every data source you consulted in arriving at job incidence?
- are you aware of any limitations that the publisher of this data has placed on the accuracy?
- what percentage of jobs are SVP 1 and 2? Show me ...
- can you provide me with notes you made in preparing for your testimony today? when did you make these notes? before or after you reviewed the file? before or after the claimant's testimony?
- isn't it impossible for you to remember every detail of every job you have observed, the conditions under which it was observed, and the purpose of the observation?
- what methodology did you use to get from the published data you consulted to the job incidence or numbers that you testified about today? what's the mathematical formula you used? can you show me your calculations? why use this formula and not any other ones?

Contributed by James W. Keeter, Esquire

Dealing with Medical Experts at Hearings

At a recent Soc Sec seminar, there was lots of discussion about how to deal with ME's at evidentiary hearings. The point of the following is not to convince an ALJ that the ME is wrong (that probably won't happen), but to provide some ammo for subsequent appeal of an unfavorable decision.

Here are some of the tips provided:

1. Always ask ME if diagnosis can produce the symptoms described; whether they treat patients with similar findings with similar therapies - if ME disagrees with treating doc, ask ME if he believes treater committed malpractice - or whether ME is just expressing a difference of opinion as to medical judgment.

2. If ME gives negative opinion, ask him/her to verify the "foundation" (or basis in the record) for reaching such an opinion. Ask the exhibit numbers reviewed, whether ME has reviewed statements by the claimant and others describing the claimant's limitations. Often, the ME will not have seen recently-submitted evidence or anything outside the medical exhibits. Also, ask the ME to assume that the claimant's testimony is true and accurate, and how such credibility would affect the ME's opinion. Also, most times that an ME gives harmful testimony, the claimant's subjective complaints have been ignored - which should lead you to ask the ME whether or not it's standard medical practice to assume that a patient is truthful in the absence of clear evidence to the contrary.

3. Seek to weaken adverse ME testimony. See if you can get the ME to agree with you about certain aspects of the claimant's medical condition. For instance, see if the ME will agree with the diagnosis and treatment recommendations of the claimant's treating physicians; if the ME will agree that the claimant's symptoms can reasonably be expected to result from the alleged impairments; if the testimony of the claimant and his family are medically acceptable sources for evidence of the underlying medical conditions. For pain complaints, ask the ME the following (you can lead an ME witness on cross examination):
Isn't it true that medical science has never been able to quantify or measure pain?
Isn't it true that the primary method physicians use to determine the degree of pain a patient experiences is to ask the patient?
You don't need to get the ME to agree that the claimant is disabled, just get the ME to agree that the impairment(s) could cause the limitations alleged, and that there is no way to be certain that they have not caused these limitations.

4. If an ME testifies about the claimant's RFC, then there are several lines of questioning you can pursue:
Would it meet the medical community's standard of care for a physician to diagnose or treat a patient without ever examining and interviewing the patient?
Are there things you learn by examining the patient and interviewing him that you will not know if you only read medical records? And you have never examined or interviewed the claimant, have you?
Have you testified as a medical expert at Soc Sec hearings before? How many times? Have you usually or always given your opinion of the claimant's RFC? Have you ever examined the claimant and interviewed him before the hearing? Did you receive any formal training in medical school on predicting future limitations of lifting, carrying, standing, walking, and other physical abilities by reviewing medical records without ever examining the patient? Was this subject part of any internship or residency you have completed? Was it part of the training required for any board certifications you have achieved? Are you familiar with the medical research on the accuracy of this kind of assessment? Can you name any authoritative source which you have relied on to develop and test your expertise in this skill? Have you examined a claimant after a hearing to attempt to validate the predictions you made by reviewing med records only?
What methodology have you used, if any, to derive functional limitations or abilities from the medical evidence? Please explain how you applied that methodology today?
Regarding validation, what medical studies have you read which investigated the functional limitations produced by this claimant's impairments? Please cite the specific article, and provide me with a copy of the page(s) you consulted in giving your testimony today. Please list all medical factors which could demonstrate limitations of the kind the claimant alleges. What data do you have to demonstrate that the testimony you have given here today is accurate? What follow-up have you done to compare your predictions with the actual activities of the claimants whose cases you have testified in? Have you ever made any effort to validate your testimony with actual examination and testing? Are you aware of any published studies which support or challenge the scientific validity of predictions of functional capacity from reviewing only paper? Please give me a copy. I'll accept them after the hearing, Judge. Can you summarize the substance of the medical literature on this topic?
Regarding reliability, what degree of scientific medical certainty do you assign to your prediction of this person's functional capacity, sustained over a 40-hour work week for a year? What is the basis of your conclusion?
5. Also, it can never hurt a case to request that the ALJ order additional medical examinations that appear warranted by the evidence.

Contributed by James W. Keeter, Esquire

Orlando ODAR October Update

The following information was provided by Karen James from the ODAR office in Orlando:

• A new Administrative Law Judge, Janet Mahon, is reporting to our office on Tuesday, Oct. 13.  She will be attending training and most likely will begin hearing cases after the first of next year. 
• Due to the addition of new judges we have had some changes in personnel assignments.  I will send out an updated chart soon.
• Currently we are working up cases with hearing request dates of March, April and May 2008.  We have received the older cases back from Falls Church that were sent out for workup, and the schedulers are in the process of scheduling hearings for them.  
• The judges from the National Hearing Center have begun holding hearings on our cases.  We  transferred an additional 150 cases to them today.  I will fax or email a list of cases sent sometime within the next two weeks.  The transferred cases have hearing request dates of June 2008 through August 2008. 
• Some representatives have expressed concern over the hearing dates for the cases transferred to the National Hearing Center.  Judge Murdock has assured me the NHC is scheduling our hearings timely.  However, since we recently received three new judges, our office has been able to schedule hearings for some cases earlier than anticipated.   

        I urge you to take advantage of the video hearings provided by the NHC.  The judges at the NHC conduct only video hearings, and are well equipped to handle them.  Judge Murdock has informed me that in most cases the decisions are issued within one month of the hearing. 

• Questions regarding the cases transferred to Tulsa can be directed to Jenna Vaughn at 918-581-6709.  Her email address is Jenna.Vaughn@ssa.gov.
• The assistance we are receiving from the NHC, Tulsa and the Denver and Seattle screening units has resulted in a decrease in the number of cases pending and a decrease in processing time.  We had over 9300 cases pending in July  but now have 8660 pending.  We have decreased our average age of pending cases from 300 days in July to 286 days and our average processing time has decreased from 527 days to 489 days.
• Recently I have been asked by a few representatives about cases that are worked up and scheduled out of order.  Most of the time this is a result of either the field office or a congressional office asking us to expedite processing due to dire need or an indication of possible suicide.  If you have a question about any case that you think is being scheduled out of order, please direct your inquiry to me or the appropriate group supervisor.
• If you ask us to expedite a case, please verify the claimant's current address and telephone number, obtain documentation if necessary, and send this information with the request.   
• We are reviewing cases for on-the-record approvals (both self identified and ones requested by representatives), and in many instances the SSA-1696 and fee agreement are not in the electronic file.  Please review the CDs we send you when we receipt in the case and if you do not see your SSA-1696 and fee agreement, input them via Electronic Records Express.  Also, please verify that you have an updated address when sending on-the-record requests, as we are receiving quite a few decisions back marked "undeliverable".
• I appreciate your cooperation and prompt attention to requests for documentation needed to approve on-the-record decisions when contacted by our staff. 
  

As always, please contact me or the group supervisors with any questions or concerns you may have.  
Thank you-
Karen

Social Security Unveils Initiative To Automate Disability Claims

On Monday, the Social Security Administration announced plans to expand connectivity with health care providers in an effort to accelerate electronic disability claims processing, Government Health IT reports.

Virginia as a Model

In February, SSA launched an electronic disability claims system with MedVirginia, Virginia's regional health information organization.

The two groups exchange information through the federal Connect gateway for linking to the National Health Information Network.

Building Up

Jim Borland, SSA's special adviser for Health IT, said SSA hopes to build upon the MedVirginia initiative by connecting with other health care providers nationwide.

The project could help the agency convert its paper-based disability determination system into an automated process, which could save labor, money and time.

SSA plans to use money from the federal economic stimulus package to award contracts to:

• Health care providers and specialists;
• Medical organizations;
• Health information exchanges; and
• RHIOs.

Timeline

On June 29, the agency posted a request for information on the Federal Business Opportunities Web site to measure interest in the initiative. Responses are due July 22.

The agency expects to publish a request for proposals Aug. 7 and could begin awarding contracts in January, Borland said (Mosquera, Government Health IT, 7/6).

FACT SHEET ON THE OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE PROGRAM

A. Beneficiaries in Current-Payment Status, December 31, 2008

Type of benefit			Number of beneficiaries [In thousands]	Monthly rate [In millions]	Average monthly amount
Total			50,898	$53,666	a
	Retired workers and their family members, total		35,169	38,853	a
		Retired workers	32,273	37,207	$1,153
		Spouses	2,370	1,348	569
		Children	525	298	568
	Survivors of deceased workers, total		6,456	6,336	a
		Children	1,915	1,427	745
		Widowed mothers and fathers with child beneficiaries in their care	160	133	835
		Aged widow(er)s, and aged parents	4,152	4,618	1,112
		Disabled widow(er)s	230	157	684
	Disabled workers and their family members, total		9,274	8,478	a
		Disabled workers	7,427	7,896	1,063
		Spouses	155	44	285
		Children	1,692	537	318
a Since the benefit amounts for workers and for the various types of family members and survivors are based on different proportions of the worker's benefit, average monthly amounts for groups of these different kinds of beneficiaries are not meaningful.

B. Selected Categories of Beneficiaries (Included Above) in
Current-Payment Status, December 31, 2008

Type of benefit		Number of beneficiaries [In thousands]	Monthly rate [In millions]
Disabled beneficiaries (OASDI)—Workers, disabled children aged 18 and over, and disabled widow(er)s		8,529	$8,647
Children (OASDI)		4,132	2,263
	Student children	142	92
	Disabled children aged 18 and over	871	594
	Children under age 18	3,118	1,577
Survivor children and widowed mothers and fathers		2,074	1,560
Beneficiaries aged 62 and over (OASDI)		40,275	44,827
Beneficiaries aged 65 and over (OASDI)		35,819	40,242

C. Average Monthly Family Benefits in
Current-Payment Status, December 31, 2008

Selected family a group	Number of families [In thousands]	Average family benefit	Average number of beneficiaries per family
Retired worker alone	29,570	$1,140	1.000
Retired worker and spouse, aged 62 and over	2,257	1,877	2.000
Disabled worker, spouse under full retirement age, and 1 or more children	73	1,795	3.944
Widowed parent and 2 children	50	2,372	3.000
Children of deceased workerb	1,153	983	1.333
Aged widow(er) alone	3,973	1,112	1.000
a A family means beneficiaries entitled on one worker's account. b In most cases, the family includes a widowed parent whose benefits are withheld due to earnings.

D. Measures of Protection

1. Coverage
   About 162 million people will work in OASDI-covered employment in 2009.

   About 94 percent of workers in paid employment and self-employment are covered under the OASDI program.

2. Benefit receipt among the elderly
   As of December 31, 2008, about 90 percent of the population aged 65 and over were receiving benefits.
3. Protection for survivors of young workers
   About 97 percent of persons aged 20-49 who worked in covered employment in 2008 have acquired survivorship protection for their children under age 18 (and surviving spouses caring for children under age 16).
4. Disability protection
   About 91 percent of persons aged 21-64 who worked in covered employment in 2008 can count on monthly cash benefits if they suffer a severe and prolonged disability.

E. Operations of OASI and DI Trust Funds, Combined
[In billions]

			Calendar year 2007	Fiscal year 2008	Cumulative 1937 through end of —
					Calendar year 2007	Fiscal year 2008
Income			$784.9	$802.7	$12,253.4	$12,849.4
	Contributions		656.1	671.2	10,898.3	11,423.3
	Other		128.8	131.5	1,355.1	1,426.1
Expenditures			594.5	617.0	10,014.9	10,483.1
	Benefit payments		584.9	607.2	9,806.8	10,266.6
		OASI	489.1	503.0	8,532.0	8,912.7
		DI	95.9	104.2	1,274.7	1,353.9
	Other		9.6	9.8	208.2	216.6
Assets, end of period			2,238.5	2,366.3	2,238.5	2,366.3
Note: Totals may not equal the sums of rounded components.

Social Security- Fast Facts

• In 2009, nearly 51 million Americans will receive $650 billion in Social Security benefits.

  December 2008 Beneficiary Data

  Retired workers	32 million	$37.2 billion	$1,153 average monthly benefit
  dependents	2.9 million	$ 1.6 billion
  Disabled workers	7.4 million	$ 7.9 billion	$1,063 average monthly benefit
  dependents	1.8 million	$ .6 billion
  Survivors	6.5 million	$ 6.3 billion	$1,112 average monthly benefit

• Social Security is the major source of income for most of the elderly.

  • Nine out of ten individuals age 65 and older receive Social Security benefits.
  • Social Security benefits represent about 40% of the income of the elderly.
  • Among elderly Social Security beneficiaries, 52% of married couples and 72% of unmarried persons receive 50% or more of their income from Social Security.
  • Among elderly Social Security beneficiaries, 20% of married couples and about 41% of unmarried persons rely on Social Security for 90% or more of their income.
    
• Social Security provides more than just retirement benefits.
  • Retired workers and their dependents account for 69% of total benefits paid.
  • Disabled workers and their dependents account for 18% of total benefits paid.
    • About 91 percent of workers age 21-64 in covered employment and their families have protection in the event of a long-term disability.
    • Almost 1 in 4 of today’s 20 year-olds will become disabled before reaching age 67.
    • 69% of the private sector workforce has no long-term disability insurance.
      
  • Survivors of deceased workers account for about 13% of total benefits paid.
    • About one in eight of today’s 20 year-olds will die before reaching age 67.
    • About 97% of persons aged 20-49 who worked in covered employment in 2008 have survivors insurance protection for their young children and the surviving spouse caring for the children.

• An estimated 162 million workers, 94% of all workers, are covered under Social Security.

• 52% of the workforce has no private pension coverage.
• 31% of the workforce has no savings set aside specifically for retirement.

• In 1935, the life expectancy of a 65-year-old was 12½ years, today it's 18 years.

• By 2034, there will be almost twice as many older Americans as today -- from 38.6 million today to 74 million.

• There are currently 3.3 workers for each Social Security beneficiary. By 2034, there will be 2.1 workers for each beneficiary.

Understanding CD4 Count in HIV Cases

CD4 Count: What Does It Mean?

CD4 cells are a type of white blood cell that fights infection. Another name for them is T-helper cells. CD4 cells are made in the spleen, lymph nodes, and thymus gland, which are part of the lymph or infection-fighting system. CD4 cells move throughout your body, helping to identify and destroy germs such as bacteria and viruses.

The CD4 count measures the number of CD4 cells in a sample of your blood drawn by a needle from a vein in your arm. Along with other tests, the CD4 count helps tell how strong your immune system is, indicates the stage of your HIV disease, guides treatment, and predicts how your disease may progress. Keeping your CD4 count high can reduce complications of HIV disease and extend your life.

How HIV Affects CD4 Cells

HIV targets CD4 cells by:

• Binding to the surface of CD4 cells
• Entering CD4 cells and becoming a part of them. As CD4 cells multiply to fight infection, they also make more copies of HIV
• Continuing to replicate, leading to a gradual decline of CD4 cells

HIV can destroy entire "families" of CD4 cells. Then the diseases these "families" were designed to fight can easily take over. That's when opportunistic infections are likely to develop.

When to Have a CD4 Count Test

Your doctor will recommend a CD4 count test:

• When you're first diagnosed with HIV. This is called a baseline measurement. It allows you to compare against future measurements.
• About 2 to 8 weeks after starting or changing treatment.
• Every 3 to 6 months after that (is a reasonable time interval).

What the CD4 Count Test Results Mean

CD4 counts are reported as the number of cells in a cubic millimeter of blood. A normal CD4 count is from 500 to 1,500 cells per cubic millimeter of blood. It is more important to pay attention to the pattern of results than to any one test result.

In general, HIV disease is progressing if the CD4 count is going down. This means the immune system is getting weaker and you are more likely to get sick. In some people, CD4 counts can drop dramatically, even going down to zero.

The test does not always correspond with how well you are feeling. For example, some people can have high CD4 counts and do poorly. Others can have low CD4 counts and have few complications.

If your CD4 count goes down over several months, your doctor may recommend:

• Beginning or changing antiretroviral therapy.
• Starting preventive treatment for opportunistic infections.

Public health guidelines recommend starting on preventive antiretroviral therapy if CD4 counts are under 200, whether or not you have symptoms. This is a later stage of HIV infection called AIDS (acquired immunodeficiency syndrome). Some doctors start therapy earlier, when the CD4 count reaches 350. If therapy is effective, your CD4 count should go up or become stable.

Most doctors recommend starting medication for opportunistic infections at these levels:

• Less than 200: pneumocystis pneumonia (PCP).
• Less than 100: toxoplasmosis and cryptococcal meningitis.
• Less than 75: mycobacterium avium complex (MAC).

Factors That Can Affect Your CD4 Count

You should know that other factors can influence how high or low your CD4 count is.

• CD4 counts tend to be lower in the morning and higher in the evening.
• Acute illnesses such as pneumonia, influenza, or herpes simplex virus infection can cause CD4 counts to go down for a while.
• If you have a vaccination or when your body starts to fight an infection, your CD4 counts can go up.
• Cancer chemotherapy can cause CD4 counts to go way down.
• Fatigue and stress can also affect test results.

For these reasons:

• Try to use the same lab each time.
• Have your tests done at the same time of day each time.
• Wait for at least a couple of weeks after an infection or vaccination before getting a CD count test.

WebMD Medical Reference

View Article Sources

SOURCES: Lab Tests Online: "CD4 Count." New Mexico AIDS InfoNet: "CD4 Cell Tests."

Reviewed by Daniel Perlman, MD

© 2007 WebMD, Inc. All rights reserved.

©2005-2007 WebMD, Inc. All rights reserved.
WebMD does not provide medical advice, diagnosis or treatment.

My Notes:

Woman indicted after allegedly lying to Social Security about illnesses

by Matthew Perenchio | Editor

.

A federal grant jury indicted a Black River Falls woman last week after she allegedly told the Social Security Administration she had a number of illnesses and up to a year to live in order to collect disability benefits.

Lisa Marie Miller, 32, was charged June 3 with two counts of making false statements to the Social Security Administration. A federal grand jury in the Western District of Wisconsin sitting in Madison returned the indictment.

If convicted, Miller faces a maximum penalty of 10 years in federal prison.

According to the indictment, Miller applied for Social Security disability benefits online on Oct. 30, 2008, and falsely stated she suffered from breast cancer, diabetes, kidney disease and post-traumatic stress disorder.

Four days later, as part of the process to complete her Supplemental Security Income application, Miller reportedly stated her doctors told her she only had eight months to a year to live.

The charges against Miller were the result of an investigation conducted by the Social Security Administration.

The case has been assigned to Assistant U.S. Attorney John W. Vaudreuil.

.

Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis

Background: The management of degenerative spondylolisthesis associated with spinal stenosis remains controversial. Surgery is widely used and has recently been shown to be more effective than nonoperative treatment when the results were followed over two years. Questions remain regarding the long-term effects of surgical treatment compared with those of nonoperative treatment.

Methods: Surgical candidates from thirteen centers with symptoms of at least twelve weeks' duration as well as confirmatory imaging showing degenerative spondylolisthesis with spinal stenosis were offered enrollment in a randomized cohort or observational cohort. Treatment consisted of standard decompressive laminectomy (with or without fusion) or usual nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at six weeks, three months, six months, and yearly up to four years.

Results: In the randomized cohort (304 patients enrolled), 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. In the observational cohort (303 patients enrolled), 97% of those who chose surgery received it whereas 33% of those who chose nonoperative care eventually received surgery. The intent-to-treat analysis of the randomized cohort, which was limited by nonadherence to the assigned treatment, showed no significant differences in treatment outcomes between the operative and nonoperative groups at three or four years. An as-treated analysis combining the randomized and observational cohorts that adjusted for potential confounders demonstrated that the clinically relevant advantages of surgery that had been previously reported through two years were maintained at four years, with treatment effects of 15.3 (95% confidence interval, 11 to 19.7) for bodily pain, 18.9 (95% confidence interval, 14.8 to 23) for physical function, and –14.3 (95% confidence interval, –17.5 to –11.1) for the Oswestry Disability Index. Early advantages (at two years) of surgical treatment in terms of the secondary measures of bothersomeness of back and leg symptoms, overall satisfaction with current symptoms, and self-rated progress were also maintained at four years.

Conclusions: Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years.