Introduction: There are no uniform guidelines for which procedure (laminectomy alone, laminectomy with instrumented fusion or laminectomy with non-instrumented fusion) to perform for the treatment of spinal stenosis. The goal of the current study was to 1) compare the complication and long-term reoperation rates; and 2) quantify the healthcare resource use associated with the different spinal interventions.
Methods: Reuter’s MarketScan database was utilized to identify patients who underwent spinal stenosis surgery between 2000 and 2009. Patient cohorts consisted of those with at least 2 years (n=12,657) and 5 years (n=2,995) of post-operative follow-up and had a primary diagnosis of spinal stenosis without a concurrent diagnosis of spondylolisthesis.
Results: Complication rates during the initial procedure hospitalization (p<0.001) and at 90 days (p<0.001) were significantly higher for those who underwent laminectomy with fusion compared to laminectomy alone. There were no significant differences in complication rates between those undergoing instrumented vs. non-instrumented fusion at any time point. Long-term reoperation rates (>=5 years) were not significantly different between the laminectomy alone and decompression with fusion groups (p=0.44), and those with instrumented vs. non-instrumented fusions (17.4% vs. 12.2%, p=0.11). However, those who underwent instrumented fusions had significantly higher rates of fusion revisions (p=0.002). Patients who underwent decompressions with fusions had significantly higher hospital costs for the index procedure compared to those who only had a laminectomy ($34,501 vs. $11,799, p<0.001). Those receiving instrumentation also had significantly higher costs than those without instrumentation (p<0.001). However, the total hospital, outpatient, and medication charges did not differ significantly between any of the groups.
Conclusions: For patients with spinal stenosis, laminectomy alone carries lower complications with similar reoperation rates. If fusion is warranted, use of arthrodesis without instrumentation is associated with decreased costs and similar long-term complication and reoperation rates.
Patient Care: Surgery for the treatment of spinal stenosis has been the fastest growing indication for lumbar surgery in the United States since the 1980s. Though the indications for the specific procedure to perform for this condition are unclear, the rates of spinal fusions are continuously increasing. Current data is mixed regarding the efficacy of spinal fusion and instrumentation in treating spinal stenosis and reducing the need for reoperation. In this study, we show no differences in long-term reoperation rates with the use of spinal fusion and instrumentation. We also show significantly increased complication rates in those who underwent fusion procedures compared to those who only received decompressions. Additionally, in the current economic climate, it is imperative that we treat disease in the most cost-effective manner. We demonstrate significantly increased initial costs with the use of fusion and instrumentation, with no decreases in long-term spending. We hope this study initiates a paradigm shift in which fusion procedures and instrumentation are used more sparingly for the treatment of spinal stenosis.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of determining the efficacy of the various spinal procedures for the treatment of spinal stenosis, 2) Discuss, in small groups the differences in complications, reoperation rates, and cost between the different spinal stenosis surgeries, 3) Identify an effective treatment for the treatment of spinal stenosis which achieves comparable outcomes with the least amount of cost.