National Trends in the Surgical Management of Lumbar Spinal Stenosis in Adult Spinal Deformity Patients

Omar M. Al Jammal, BA; Arash Delavar, MPH; Kathleen R. Maguire, BS; Brian R. Hirshman, MD, PhD; Arvin R. Wali, MD; Majd Kazzaz, BS; Martin H. Pham, MD

Disclosures

Spine. 2019;44(23):E1369-E1378. 

In This Article

Abstract and Introduction

Abstract

Study Design: This is a retrospective analysis of national administrative hospital data.

Objective: This study examines national trends in the surgical management of lumbar spinal stenosis (LSS) in patients with and without coexisting scoliosis between 2010 and 2014. The study also examines revision rates for LSS procedures.

Summary of Background Data: There is wide variability in the surgical management of patients with LSS, with and without coexisting spinal deformity.

Methods: Data were obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample Database. International Classification of Diseases 9th revision- Clinical Modification codes were used to identify all patients with a primary diagnosis of lumbar spinal stenosis. These patients were divided into two groups: 1) LSS alone and 2) LSS with coexisting scoliosis. The two groups were examined for one of three surgical outcomes: 1) decompression alone (discectomy, laminectomy), 2) simple fusion, and 3) complex fusion (>three vertebrae or 360° fusion). The groups were then further examined for revision operations. National Inpatient Sample discharge weights were applied where relevant.

Results: In 2014 national estimates of discharged patients indicated 76,275 patients with a primary diagnosis of LSS (population rate, 23.9; in the elderly (65+) the age-adjusted population rate was 95.4). Of these patients, 88.5% were managed through primary surgery (34.6% decompression, 47.2% simple fusion, 5.7% complex fusion). Between 2010 and 2014, the percentage of decompression decreased from 47.5% to 34.6%, the percent of simple fusion increased from 35.3% to 47.2%, and the percent of complex fusion increased from 5.7% to 7.1% (P < 0.01). In patients with coexisting scoliosis, lumbar spinal stenosis was predominantly managed by simple fusion and complex fusion (15.5% decompression, 51.9% simple fusion, 27.3% complex fusion, in 2014). Revision rates were highest among patients without scoliosis managed with complex fusion (15.8% in 2014) compared with patients with scoliosis (8.8% in 2014). Patients with scoliosis who underwent decompression only had revision rates of 1.7% and 0.62% in 2010 and 2014, respectively.

Conclusion: We observed a leveling-off of the rate of operation for patients with a primary diagnosis of LSS at around 88%. There was an increase in the rate of fusion and a decrease in the rate of decompression across all patient groups. We report no difference in revision rates between patients with and without scoliosis, except in those undergoing a complex fusion.

Level of Evidence: 3

Introduction

Lumbar spinal stenosis (LSS) is a degenerative condition characterized by narrowing of the spinal canal in the lumbar region. Though commonly asymptomatic, LSS can be present with multiple symptoms including diffuse lower back pain, neurogenic claudication, and radicular syndromes.[1] The cause of these symptoms varies from neurovascular mechanisms, direct compression in the spinal canal, pressure on the nerve root complex, local nerve irritation due to inflammation, and others.[2–5]

LSS is increasingly prevalent in the elderly population and is in fact the most common indication for spine surgery in patients over 65.[6] In addition, the growth rate of the population over 65 exceeds the total population growth rate, with the elderly population-share projected to increase to 22.1% by 2050 (currently 16%).[7] With the majority of these patients on Medicare, the cost of managing LSS in the elderly is substantial.[8]

Furthermore, an increasing number of LSS patients present with a coexisting spinal deformity such as lateral listhesis and degenerative scoliosis.[9] Multiple studies have established the superiority of decompressive surgery over conservative management for lumbar spinal stenosis.[10–14] However, this is complicated by the consideration of whether fusion should be performed with decompressive surgery in patients with and without coexisting spinal deformity. Some studies show that the addition of fusion can have modest improvement among patients with adult spinal deformity,[15–17] whereas others show that decompression alone had more favorable results, including survival curves and clinical outcomes, across all patient groups.[18] What is clear is that addition of fusion significantly increases cost, complications, and mortality.[19–21] The lack of consensus on indications for different surgical procedures in LSS patients with and without degenerative scoliosis warrants continued study of trends, safety, and efficacy of conservative and surgical interventions for this growing patient population.

The purpose of this study is to examine national trends in the surgical management of patients with a primary diagnosis of LSS, with and without degenerative scoliosis, from 2010 to 2014. This study also examines revision rates and the associated cost of decompression, simple fusion, and complex fusion in the two populations. Lastly, the study clarifies earlier national discharge (over)estimates in previous studies of LSS trends using National Inpatient Sample data.

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