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Scientific Articles   |    
Revision Surgery Following Operations for Lumbar Stenosis
Richard A. Deyo, MD, MPH1; Brook I. Martin, PhD, MPH2; William Kreuter, MPA3; Jeffrey G. Jarvik, MD, MPH4; Heather Angier, MPH1; Sohail K. Mirza, MD, MPH2
1 Department of Family Medicine, Mail Code FM, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239. E-mail address: deyor@ohsu.edu
2 Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
3 Department of Health Services, University of Washington, Box 359736, 325 Ninth Avenue, Seattle, WA 98104
4 Department of Radiology, University of Washington, Box 359728, 325 Ninth Avenue, Seattle, WA 98104
View Disclosures and Other Information
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

  • Disclosure statement for author(s): PDF

Investigation performed at the Departments of Family Medicine, Medicine, and Public Health and Preventive Medicine, and the Center for Research in Occupational and Environmental Toxicology, Oregon Health and Science University and the Kaiser Center for Health Research, Portland, Oregon; the Department of Orthopaedic Surgery, Dartmouth Medical School, Hanover, New Hampshire; and the Departments of Health Services and Radiology, University of Washington, Seattle, Washington
A commentary by Alan B.C. Dang, MD, and Steven R. Garfin, MD, is linked to the online version of this article at jbjs.org.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Nov 02;93(21):1979-1986. doi: 10.2106/JBJS.J.01292
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Abstract

Background: 

For carefully selected patients with lumbar stenosis, decompression surgery is more efficacious than nonoperative treatment. However, some patients undergo repeat surgery, often because of complications, the failure to achieve solid fusion following arthrodesis procedures, or persistent symptoms. We assessed the probability of repeat surgery following operations for the treatment of lumbar stenosis and examined its association with patient age, comorbidity, previous surgery, and the type of surgical procedure.

Methods: 

We performed a retrospective cohort analysis of Medicare claims. The index operation was performed in 2004 (n = 31,543), with follow-up obtained through 2008. Operations were grouped by complexity as decompression alone, simple arthrodesis (one or two disc levels and a single surgical approach), or complex arthrodesis (more than two disc levels or combined anterior and posterior approach). Reoperation rates were calculated for each follow-up year, and the time to reoperation was analyzed with proportional hazards models.

Results: 

The probability of repeat surgery fell with increasing patient age or comorbidity. Aside from age, the strongest predictor was previous lumbar surgery: at four years the reoperation rate was 17.2% among patients who had had lumbar surgery prior to the index operation, compared with 10.6% among those with no prior surgery (p < 0.001). At one year, the reoperation rate for patients who had been managed with decompression alone was slightly higher than that for patients who had been managed with simple arthrodesis, but by four years the rates for these two groups were identical (10.7%) and were lower than the rate for patients who had been managed with complex arthrodesis (13.5%) (p < 0.001). This difference persisted after adjusting for demographic and clinical features (hazard ratio for complex arthrodesis versus decompression 1.56, 95% confidence interval, 1.26 to 1.92). A device-related complication was reported at the time of 29.2% of reoperations following an initial arthrodesis procedure.

Conclusions: 

The likelihood of repeat surgery for spinal stenosis declined with increasing age and comorbidity, perhaps because of concern for greater risks. The strongest clinical predictor of repeat surgery was a lumbar spine operation prior to the index operation. Arthrodeses were not significantly associated with lower rates of repeat surgery after the first postoperative year, and patients who had had complex arthrodeses had the highest rate of reoperations.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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