A study in the April 7 issue of JAMA says that the frequency of complex fusion procedures to treat spinal stenosis of the lower back increased between 2002-2007 among Medicare recipients. However the rates of decompression and simple fusion procedures decreased in the same period.
Diagnosis and treatment of lumbar stenosis (a condition in which the spinal canal narrows and compresses the spinal cord and nerves) requires complex judgments integrating data from imaging, clinical findings and the patient's clinical course. Trials have indicated that for selected patients, decompressive surgery offers an advantage over nonoperative treatment, but surgeons often recommend more invasive fusion procedures, according to background information in the article. "Better information on surgical complications would help surgeons, referring physicians, and patients weigh benefits and risks and would permit more individualized decision making," the authors write.
AdvertisementRichard A. Deyo, M.D., M.P.H., of Oregon Health and Science University, Portland, and colleagues examined trends in the use of various surgical procedures for lumbar stenosis and associated complications and health care use. The researchers conducted an analysis of Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in U.S. hospitals. Operations for Medicare recipients undergoing surgery for lumbar stenosis (n = 32,152 in the first 11 months of 2007) were grouped into 3 grades 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).
The researchers found that from 2002-2007, for lumbar stenosis the number of operations and the rate per 100,000 beneficiaries decreased slightly (from 137.4 in 2002 to 135.5 in 2007). Rates of decompression surgery and simple fusions also declined during these years. "However, rates of complex fusion surgery increased from 1.3 per 100,000 to 19.9 per 100,000, a 15-fold increase. Correspondingly, although the overall procedure rate fell 1.4 percent, aggregate hospital charges increased 40 percent (inflation adjusted)," the authors write.
Life-threatening complications increased with increasing surgical invasiveness, from 2.3 percent among patients having decompression alone to 5.6 percent among those having complex fusions. Patients who had a complex fusion procedure had a nearly three times higher odds for a life-threatening complication compared with decompression alone. A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8 percent of patients undergoing decompression and 13.0 percent having a complex fusion. Patients having a complex fusion had almost a 2-day longer hospital stay than those having decompression alone. Complex fusion operations resulted in average hospital charges ($80,888) more than 3 times as those for decompressions alone ($23,724).
As to why more complex operations are increasing, the authors write that it is unclear and that it seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years. "The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications. Surgeons may believe more aggressive intervention produces better outcomes. Improvements in surgical technique, anesthetic technique, and supportive care may make more invasive surgery feasible when risks formerly would have been prohibitive. Financial incentives to hospitals and surgeons for more complex procedures may play a role as may desires of surgeons to be local innovators."(JAMA. 2010;303:1259-1265. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: The Increasing Morbidity of Elective Spinal Stenosis Surgery - Is It Necessary?
Eugene J. Carragee, M.D., of the Stanford University School of Medicine, Stanford, Calif., comments on the findings of this study in an accompanying editorial.
"In 2007, the final year of data reported in the study by Deyo et al, Consumer Reports rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo et al should not only remind patients, surgeons, and payors that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem."(JAMA. 2010;303:1309-1310.