Full-scale evaluation of lumbar spinal stenosis surgery for older adults
Spine surgery is extremely prevalent among older adults, and the most common indicator for its usage is spinal stenosis. Symptomatic lumbar stenosis comes as a result of progressive degenerative changes in intervertebral joints and ligamentous structures, leading to spinal canal and neural foraminal narrowing. Due to the complexity of diagnosing these disorders and determining treatment, however, there’s a major lack of general consensus for pain-related surgery. Evidence shows many surgeons continue to make individual decisions based on personal preference rather than supportive research. Consequently, improper decisions may lead to further complications, health care costs and even death, all of which can possibly be avoided if the correct surgical choice is made. Therefore, to help surgeons, referring physicians and patients make more educated decisions regarding surgery, a recent study evaluated the Medicare population to define trends associated with different surgical procedures, complications of each, and how the entire process relates to health care use.
To obtain relevant data for the study, only patients 65 or older, most with a primary diagnosis of lumbar spinal stenosis (98.2% of cases, the others being spondylogenic compression of lumbar spinal cord), were included. Each spine surgery was categorized as either decompression without fusion, simple fusion or complex fusion, while complications were recorded as either major medical complications, wound complications or mortality (death within 30 days of hospital discharge). Health care use, measures of comorbidity and incidents of previous spine surgery were also taken into consideration.
Over the time period studied (2002-07), rates of decompression and simple fusion surgeries declined, but rates for complex fusion increased from 1.3 per 100,000 (just under 1% of operations) to 19.9 per 100,000 (14.6%), a 15-fold increase. Complex procedures were also shown to be associated with greater complications, mortality, hospital charges and other measures of health care use. While it’s understood that fusion procedures require more extensive dissection, decortication of bone and longer operative time, which results in more complications, it was unclear why the rate of complex procedures had increased so rapidly. Some surgeons may believe more aggressive interventions produce better outcomes, and with the recent improvements made in surgical and anesthetic technique, more invasive surgery is easier today than it once was. Whatever the explanation, evidence proving the effectiveness of complex procedures for spinal stenosis is scarce, with some trials even suggesting equal efficacy of decompression alone vs. decompression and fusion. Results of this study may therefore suggest that using the least invasive procedure that accomplishes clinical goals is the best approach to take, but further evidence is needed to confirm this possibility. The biggest underlying problem is the wide variability in surgeons’ decision making when it comes to treating spinal stenosis, and with the negative trends being set over the past few years, it’s imperative that the effectiveness of each type of surgery is more completely understood.
-Summarized by Greg Gargiulo
-As reported in the April 7 edition of The Journal of the American Medical Association
