Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006–2016

Yamaguchi, Jonathan T.; Weiss, Hannah; García, Roxanna M.; Driscoll, Conor; Stein, Eli; Hopkins, Ben; Cloney, Michael; Smith, Zachary A.; Hsu, Wellington K.; Dahdaleh, Nader S.

doi:10.1016/j.clineuro.2020.106310

Cited by 9 publications

(10 citation statements)

References 43 publications

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“…The rapid growth of decompression with fusion procedures, which in our data set increased by 113% from 2016 to 2019, corroborates pre-2016 patterns (which we did not directly assess as a result of the transition from the ICD-9 to the ICD-10 ) observed in a variety of data sources, including the NIS, Medicare claims database, Quality Outcomes Database, and American College of Surgeons National Surgical Quality Improvement Program, across a variety of degenerative lumbar spinal pathologies . Our results notably extended the results of Bae et al, who reported a fusion rate of 82.7% in patients with lumbar stenosis and degenerative spondylolisthesis (although this study included multilevel fusion procedures, which were excluded in the current study), and Al Jammal et al, who reported a fusion rate of 65.4% for all patients with lumbar stenosis regardless of lumbar spondylolisthesis codiagnosis.…”

Section: Discussionsupporting

confidence: 89%

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

et al. 2023

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ImportanceUse of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population.ObjectiveTo assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019.Design, Setting, and ParticipantsThis retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023.Main Outcome and MeasureThe primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone.ResultsAmong 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P &lt; .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P &lt; .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P &lt; .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P &lt; .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P &lt; .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P &lt; .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P &lt; .001).Conclusions and RelevanceIn this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

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Section: Discussionsupporting

confidence: 89%

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

et al. 2023

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“…As SSI is a known cause of both 30-day readmission and reoperation after PSF, it is understandable that CCI would be associated with these negative outcomes. 1,20 Indeed, Yamaguchi et al 1 found that SSI was the most common cause of readmission and of reoperation after elective posterior lumbar fusion.…”

Section: Discussionmentioning

confidence: 99%

“…osterior spinal fusion (PSF) is an increasingly common procedure. 1 Surgical site infection (SSI) is a particularly feared complication after PSF because it threatens the integrity of the surgical instrumentation and can require reoperation. 1,2 Most PSF patients do not require intensive care, and patients selected for admission to the ICU postoperatively may represent a high-risk subpopulation.…”

mentioning

confidence: 99%

Surgical Site Infection in the Intensive Care Setting After Posterior Spinal Fusion: A Case Series Highlighting the Microbial Profile, Risk Factors, and the Importance of Comorbid Disease Burden

Cloney

Hopkins

Shlobin

et al. 2022

Operative Neurosurgery

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BACKGROUND:Most posterior spinal fusion (PSF) patients do not require admission to an intensive care unit (ICU), and those who do may represent an underinvestigated, high-risk subpopulation.OBJECTIVE:To identify the microbial profile of and risk factors for surgical site infection (SSI) in PSF patients admitted to the ICU postoperatively.METHODS:We examined 3965 consecutive PSF patients treated at our institution between 2000 and 2015 and collected demographic, clinical, and procedural data. Comorbid disease burden was quantified using the Charlson Comorbidity Index (CCI). We performed multivariable logistic regression to identify risk factors for SSI, readmission, and reoperation.RESULTS:Anemia, more levels fused, cervical surgery, and cerebrospinal fluid leak were positively associated with ICU admission, and minimally invasive surgery was negatively associated. The median time to infection was equivalent for ICU patients and non-ICU patients, and microbial culture results were similar between groups. Higher CCI and undergoing a staged procedure were associated with readmission, reoperation, and SSI. When stratified by CCI into quintiles, SSI rates show a strong linear correlation with CCI (P = .0171, R = 0.941), with a 3-fold higher odds of SSI in the highest risk group than the lowest (odds ratio = 3.15 [1.19, 8.07], P = .032).CONCLUSION:Procedural characteristics drive the decision to admit to the ICU postoperatively. Patients admitted to the ICU have higher rates of SSI but no difference in the timing of or microorganisms that lead to those infections. Comorbid disease burden drives SSI in this population, with a 3-fold greater odds of SSI for high-risk patients than low-risk patients.

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“…This may then be associated with increased rates of intervention, resource utilisation, and the potential for adverse outcomes 17 . Surgical intervention for LBP is continuing to increase in Australia and disproportionately in privately insured patients 18‐20 . Although spinal surgery has a role in the management of back pain related to significant instability, particularly in the context of cancer, infection or previous surgery, its role in the management of non‐specific LBP remains without an evidence base.…”

mentioning

confidence: 99%

“…17 Surgical intervention for LBP is continuing to increase in Australia and disproportionately in privately insured patients. 18 , 19 , 20 Although spinal surgery has a role in the management of back pain related to significant instability, particularly in the context of cancer, infection or previous surgery, its role in the management of non‐specific LBP remains without an evidence base. The objective of this review was to evaluate the current evidence base for spinal surgery in the treatment of axial LBP and highlight important factors that may influence practice.…”

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confidence: 99%

The role of spinal surgery in the treatment of low back pain

Evans

O'Donohoe

Morokoff

et al. 2022

Medical Journal of Australia

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Summary Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide. Acute LBP is frequently self‐resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors. Chronic LBP should be managed with a holistic biopsychosocial approach of generally non‐surgical measures. Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent. Spinal surgery for back pain has increased substantially over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third‐party payers to this increase, and their involvement in published research, requires careful consideration.

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Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006–2016

Cited by 9 publications

References 43 publications

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Surgical Site Infection in the Intensive Care Setting After Posterior Spinal Fusion: A Case Series Highlighting the Microbial Profile, Risk Factors, and the Importance of Comorbid Disease Burden

The role of spinal surgery in the treatment of low back pain

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