Context
In recent decades, the fastest growth in lumbar surgery occurred in older patients with spinal stenosis. Trials indicate that for selected patients, decompressive surgery offers an advantage over non-operative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in elderly patients, so benefits and risks must be carefully weighed in the choice of surgical procedure.
Objective
Examine trends in use of different types of stenosis operations and the association of complications and resource use with surgical complexity.
Design, Setting, and Patients
Retrospective cohort analysis of Medicare claims for 2002–2007, focusing on 2007 to assess complications and resource use in U.S. hospitals. Operations for Medicare recipients undergoing surgery for lumbar stenosis (n=32,152 in the first 11 months of 2007) were grouped into 3 gradations of invasiveness: decompression alone, simple fusion (one or two disc levels, single surgical approach) or complex fusion (more than 2 disc levels or combined anterior and posterior approach).
Main Outcome Measures
Rates of the 3 types of surgery, major complications, postoperative mortality, and resource use.
Results
Overall, surgical rates declined slightly from 2002–2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared to decompression alone was 2.95 (95% CI 2.50–3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR 1.94; 95% CI 1.74–2.17). Adjusted mean hospital charges for complex fusion procedures were $80,888 compared to $23,724 for decompression alone.
Conclusions
Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased, while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.