Decompression With or Without Fusion for Lumbar Stenosis

Abstract

Study Design. Retrospective database review. Objective. Compare 1-year episode of care costs between single-level decompression and decompression plus fusion for lumbar stenosis. Summary of Background Data. Lumbar stenosis is the most common indication for surgery in patients over 65. Medicare direct hospital costs for lumbar surgery reached $1.65 billion in 2007. Despite stenosis being a common indication for surgery, there is debate as to the preferred surgical treatment. Cost-minimization analysis is a framework that identifies potential cost savings between treatment options that have similar outcomes. We performed a cost-minimization analysis of decompression versus decompression with fusion for lumbar stenosis from the payer perspective. Methods. An administrative claims database of privately insured patients (Humana) identified patients who underwent decompression (n = 5349) or decompression with fusion (n = 8540) for lumbar stenosis with and without spondylolisthesis and compared overall costs. All patients were identified and costs identified for a 1-year period. Complication rates and costs were described using summary statistics. Results. Mean treatment costs at 1 year after surgery were higher for patients who underwent decompression and fusion compared to patients who underwent decompression alone ($20,892 for fusion vs. $6329 for decompression; P < 0.001). Facility costs (P < 0.001), surgeon costs (P < 0.001), and physical therapy costs (P < 0.001) were higher in the fusion group. Cost differences related to infection or durotomy reached significance (P < 0.04). No difference in cost was identified for supplies. Conclusion. Decompression had significantly lower costs for the treatment of lumbar stenosis, including treatment for postoperative complications. If cost minimization is the primary goal, decompression is favored for surgical treatment of lumbar stenosis. Other factors including shared decision-making directed toward patient's values, patient-reported outcomes, and preferences should also be recognized as drivers of healthcare decisions. Level of Evidence: 3

A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy

“…[ 99 ] The rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 Medicare beneficiaries from 2002 to 2007. [ 100 ] The same study reported an increase in life-threatening complications from 2.3% in patients who underwent decompression to 5.6% in those who had complex fusions with higher thirty-day rehospitalization rates in fusion patients - 0.8% in decompression versus 13.0% in complex fusion - resulting in higher adjusted mean hospital charges for complex fusion surgeries of $80,888 compared with $23,724 for decompression alone. [ 101 ] Lumbar fusion spending increased more than 500%, from 75 million dollars to 482 million dollars from 1992, when it represented 14% of total spending for back surgery, to 47% by 2003.…”

A cost-utility analysis between decompression only and fusion surgery for elderly patients with lumbar spinal stenosis and sagittal imbalance

“…As many societies continue to age, the number of degenerative spinal diseases is also increasing 1 , 24 . Among lumbar degenerative diseases, spinal stenosis is the most common cause of surgery and incurs a huge economic burden 2 , 3 , 25 . The surgical options for lumbar spinal stenosis are largely divided into decompression only and decompression and fusion surgery 5 .…”

“…In addition to clinical and radiological outcomes, medical cost is also an important issue. In all countries, fusion surgery is more costly than decompression surgery and places a large burden on health insurance 3 , 7 , 11 , 24 , 25 , 29 , 44 . All patients in this study were beneficiaries of the national health insurance system, and the results showed that fusion surgery cost $49,833 US dollars/QALY more than decompression surgery.…”

“…Recently, many countries have been entering aging or aged societies 1 . Lumbar spinal stenosis (LSS) is the most common lumbar degenerative disease and incurs a large socioeconomic burden on those societies 2 , 3 . Since LSS can occur along with other conditions, such as sagittal imbalance, decision-making and treatment options may vary widely 4 – 6 .…”

“…Although it is known that sagittal imbalance can be associated with poor functional outcomes, the criteria for imbalance are based on normal healthy adults and may not universally apply to elderly patients, especially those in Asian societies who prefer to sit on the floor 9 , 10 . Moreover, instrumented fusion surgery is associated with a higher cost and complication rate than decompression surgery 3 , 11 , 12 . A randomized controlled trial study showed that the clinical outcome of decompression surgery was comparable to that of fusion surgery for patients with stable LSS 12 , 13 .…”