Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults.
BACKGROUND
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 nonoperative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in older patients, so benefits and risks must be carefully weighed in the choice of surgical procedure.


OBJECTIVE
To examine trends in use of different types of stenosis operations and the association of complications and resource use with surgical complexity.


METHODS
Retrospective cohort analysis of Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in US 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 (1 or 2 disk levels, single surgical approach), or complex fusion (more than 2 disk levels or combined anterior and posterior approach).


METHODS
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 with decompression alone was 2.95 (95% confidence interval [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 US $80,888 compared with US $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.
Deyo
Richard A
RA
Department of Family Medicine, Mail Code FM, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA. deyor@ohsu.edu
Mirza
Sohail K
SK
Martin
Brook I
BI
Kreuter
William
W
Goodman
David C
DC
Jarvik
Jeffrey G
JG
D000368:Aged; D015331:Cohort Studies; D019299:Decompression, Surgical / Q000009:adverse effects / Q000191:economics / Q000639:trends; D005260:Female; D006296:Health Services / Q000706:statistics & numerical data; D017722:Hospital Charges / Q000706:statistics & numerical data*; D006801:Humans; D008159:Lumbar Vertebrae; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000639:trends; D013130:Spinal Stenosis / Q000601:surgery*; D014481:United States / Q000453:epidemiology