Reoperation Rates Following Instrumented Lumbar Spine Fusion

Tero Matti Irmola, MD; Arja Häkkinen, Prof; Salme Järvenpää, MSc; Ilkka Marttinen, MD; Kimmo Vihtonen, MD, PhD; Marko Neva, MD, PhD

Disclosures

Spine. 2018;43(4):295-301. 

In This Article

Abstract and Introduction

Abstract

Study Design. A prospective cohort study.

Objective. This study evaluated the cumulative reoperation rate and indications for reoperation following instrumented lumbar spine fusion (LSF).

Summary of Background Data. LSF reduces disability and improves health-related quality of life for patients with several spinal disorders. The rate of instrumented LSF has drastically increased over the last few decades. The increased incidence of LSF, however, has led to increased reoperation rates.

Methods. The data are based on the prospective LSF database of Tampere University Hospital that includes all elective indications for LSF surgery. A total of 433 consecutive patients (64% women, mean age 62 years) who underwent LSF in Tampere University Hospital between 2008 and 2011 were evaluated and indications for reoperations were rechecked from patient records and radiographs. The most common diagnosis for the primary surgery was degenerative spondylolisthesis and the mean follow-up time was 3.9 years. The cumulative incidence of reoperations and the "time to event" survival rate was calculated by Kaplan-Meier analysis.

Results. By the end of 2013, 81 patients had undergone at least one reoperation. The cumulative reoperation rate at 2 years was 12.5% (95% confidence interval: 95% CI: 9.7–16.0) and at 4 years was 19.3% (95% CI: 15.6–23.8). The most common pathology leading to reoperation was adjacent segment pathology with a cumulative reoperation rate of 8.7% (95% CI: 6.1–12.5) at 4 years. The corresponding rates for early and late instrumentation failure were 4.4% (95% CI: 2.7–7.0) and 2.9% (95% CI: 1.9–7.1), respectively, and for acute complications, 2.5% (95% CI: 1.4–4.5).

Conclusion. Although previous studies reported that early results of spinal fusion are promising, one in five patients required reoperation within 4 years after surgery. Patients and surgeons should be aware of the reoperation rates when planning fusion surgery.

Level of Evidence: 4

Introduction

Lumbar spine fusions (LSFs) are performed to treat several spinal disorders when conservative treatment fails. LSF is effective for treating degenerative and isthmic spondylolisthesis.[1,2] Prospective randomized studies revealed that posterolateral fusion is more efficient than an exercise program for short-term improvement of function and pain relief in adult isthmic spondylolisthesis.[3,4] Weinstein et al.[2] reported that decompressive laminectomy (with or without fusion) has advantages over nonoperative treatment for treating degenerative spondylolisthesis. A Cochrane review, however, revealed no clear benefits of surgery over nonoperative treatment for lumbar spinal stenosis.[5] In a recent randomized controlled trial of 247 patients with lumbar spinal stenosis with or without degenerative spondylolisthesis, Försth et al.[6] reported no benefit of adding fusion to decompression surgery; thus, fusion in spinal stenosis surgery is controversial. In contrast, a randomized controlled trial by Ghogawala et al.[7] revealed that the addition of fusion to laminectomy slightly improved outcomes in 66 patients with degenerative grade I spondylolisthesis. The value of spinal fusion for the treatment of chronic low back pain is controversial.[8–10] Spinal fusions are also performed in revision spine surgery and for the treatment of scoliosis and recurrent disc herniations.[11]

The incidence of spinal fusion surgery has drastically increased over the past few decades,[11,12] and thus, the incidence of reoperations has also increased. Any indication resulting in a return to the operating room is considered a reoperation, which is an undesirable outcome of LSF that causes pain and inconvenience for the patient and as well as additional expense to the patient, society, and employer. On the basis of the timing, reoperations are classified as early or late. Early reoperations are caused by an acute complication (<3 months after surgery), and instrumentation failure or early nonunion (<1 year). Indications for reoperation 1 year or more after fusion may be pseudoarthrosis, persistent pain or recurrence of symptoms, or adjacent segment pathology (ASP).[13,14] According to population-based analysis, cumulative reoperation rates accounting for any unplanned return to the operating room following lumbar spine surgery, including both decompression and fusion surgery, are 12.5% to 14.0% at 4 years.[13,15] The Finnish National Hospital Discharge Register indicates ~20% cumulative risk for reoperation within 15 years after spinal fusion.[13] The length of the fusion influences to the reoperation rate. Howe et al.[16] reported a reoperation rate as high as 35% during a mean 26-month follow-up of instrumented fusions from the thoracic spine to the pelvis.

The aim of the present study was to determine the overall rate, indications, and timing of reoperations—following instrumented LSF—in a prospectively collected cohort in a single university hospital experience.

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