Introduction: The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. Furthermore, it is widely held that patients with workers’ compensation (WC) undergoing surgery have variable outcomes. With the growing number of fusion surgeries within this clinically distinct population, our objective is to compare how WC patients fare between decompression-only versus decompression and fusion for the indication of DLS alone. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs compared to subjects receiving decompression alone.
Methods: 364 Ohio WC subjects were identified who underwent primary decompression (DC) or primary decompression and fusion (DC + F) for DLS alone between 1993-2013. Our primary outcome was if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for more than 6 months. A number of secondary outcomes were collected.
Results: The DC cohort had a significantly higher RTW rate [36%(83/227) vs. 25%(54/212);p=0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that fusion with operative decompression remained a significant negative predictor of RTW status (p=0.04; OR:0.58, 95% CI:0.34-0.99). Within the DC cohort, the rate of post-operative instability and subsequent fusion was 8%. Furthermore, subjects that received an adjunctive fusion cost the Ohio BWC on average, $46,115 more in costs accrued over 3 years after their index surgery compared to subjects that received a decompression alone.
Conclusions: Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscores the need to strongly reevaluate the use of fusion for DLS without instability in the WC population.
Patient Care: Previous studies in support of fusion have noted that patients with significant back pain symptoms may not show an adequate recovery from decompression-only surgery.Furthermore, other authors have argued that extensive laminectomy for DLS alone destroys the stability of the spine, and may lead to serious complications including spondylolisthesis and epidural adhesions. In contrast to these studies, other authors have shown that surgical decompression alone has reliable outcomes and that the risk of fusion outweighs any potential benefit.Despite the evidence against fusion in patients with DLS alone as well as the increased risk of morbidity associated with a fusion procedure, the number of fusions performed after operative decompression has grown in recent years, even in the absence of spondylolisthesis or scoliosis. While the results presented in the current study are within the workers' compensation population, we feel that it represents a large historical cohort and thus avoids bias and increases the chances of having a distribution of disease severity that would be present in other populations. As such, we feel that the results could have an impact on the decision making of surgeons across the spine community and highlight the importance of reconsidering the use of a fusion procedure as an adjunct for lumbar decompression in patients with lumbar spinal stenosis.
Learning Objectives: 1. To understand the importance of the workers' compensation population with regards to the variable outcomes and financial implications regarding this population.
2. To recognize present evidence in support of a fusion procedure as an adjunct to lumbar decompression for the indication of lumbar spinal stenosis
3. To examine the predictors of return to work including decompression and fusion within the present study