title: Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes.
abstract: METHODS
  A prospective, multicenter observational study.
  
  
  OBJECTIVE
  1) Identify correlates of the decision to perform arthrodesis in patients undergoing laminectomy for lumbar spinal stenosis. 2) Compare symptoms, walking capacity, and satisfaction 6 and 24 months after laminectomy alone and laminectomy with noninstrumented and with instrumented arthrodesis.
  
  
  BACKGROUND
  Few prospective studies have compared outcomes of laminectomy alone or laminectomy with noninstrumented or with instrumented arthrodesis in patients with degenerative lumbar spinal stenosis. There is uncertainty regarding the optimal use of arthrodesis and instrumentation.
  
  
  METHODS
  Two hundred seventy--two patients undergoing--surgery for degenerative lumbar stenosis by eight surgeons at four centers were included in the study cohort. Of these, 37 had noninstrumented and 41 had instrumented arthrodesis. Logistic regression identified factors associated with arthrodesis. The principal outcomes-health status, walking capacity, back and leg pain, and satisfaction with surgery-were assessed 6 and 24 months postoperatively with univariate and multivariate techniques. Outcomes also were assessed in a restricted cohort of patients with at least 5 mm spondylolisthesis and/or 15 degrees scoliosis. Hospital costs were obtained from a computerized hospital cost accounting system.
  
  
  RESULTS
  The major predictor of the decision to perform arthrodesis was the individual surgeon (P = 0.0001). Noninstrumented arthrodesis was associated with superior relief of low back pain at 6 months (P = 0.004) and 24 months (P = 0.01). This difference persisted in multivariate analyses, with borderline statistical significance. There were no significant differences in the other outcomes across treatment groups. Mean hospital costs of laminectomy alone and noninstrumented and instrumented arthrodesis were $12,615, $18,495, and $25,914, respectively (P = 0.0001).
  
  
  CONCLUSIONS
  Findings were limited by the small number of participating surgeons, modest sample size that produced P values of borderline significance, and nonrandomized design. With these caveats in mind, the authors conclude: (1) The individual surgeon was a more important correlate of the decision to perform arthrodesis than clinical variables such as spondylolisthesis. (2) Noninstrumented arthrodesis resulted in superior relief of back pain after 6 and 24 months. (3) Instrumented arthrodesis was the most costly option. These results highlight the need for randomized controlled trials and cost effectiveness analyses of lumbar arthrodesis and instrumentation in patients with degenerative lumbar spinal stenosis.
authors.affiliation: Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: J N
authors.initials: JN
authors.lastname: Katz
authors.forename: S J
authors.initials: SJ
authors.lastname: Lipson
authors.forename: R A
authors.initials: RA
authors.lastname: Lew
authors.forename: L J
authors.initials: LJ
authors.lastname: Grobler
authors.forename: J N
authors.initials: JN
authors.lastname: Weinstein
authors.forename: G W
authors.initials: GW
authors.lastname: Brick
authors.forename: A H
authors.initials: AH
authors.lastname: Fossel
authors.forename: M H
authors.initials: MH
authors.lastname: Liang
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000150:complications / Q000191:economics / Q000601:surgery*; D007796:Laminectomy / Q000191:economics; D016015:Logistic Models; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D011446:Prospective Studies; D013123:Spinal Fusion / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D013130:Spinal Stenosis / Q000191:economics / Q000209:etiology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome