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.
To examine trends in use of different types of stenosis operations and the association
of complications and resource use with surgical complexity.
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).
Rates of the 3 types of surgery, major complications, postoperative mortality, and
resource use.
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.
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.