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Reoperation Rate After Surgery for Lumbar Spinal Stenosis Without 51 The Spine Journal - (2013) - 52 53 Clinical Study 54 1 55 2 Reoperation rate after surgery for lumbar spinal stenosis without 56 3 57 4 spondylolisthesis: a nation-wide cohort study 58 5 a,b,c a,b,c,* d 59 6 Q15 Chi Heon Kim, MD, PhD , Chun Kee Chung, MD, PhD , Choon Seon Park, PhD , d e,f f 60 7 Boram Choi, PhD , Seokyung Hahn, MPH , Min Jung Kim,MS, 61 8 d,g f,h Q1 Kun Sei Lee, MD, MPH, PhD , Byung Joo Park, MD, MPH, PhD 62 9 a Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 28 Yeongeon-dong, Jongno-gu, 63 10 Q2 Seoul 110-744, South Korea 64 11 bNeuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea c 65 12 Clinical Research Institute, Seoul National University Hospital, Seoul, South Korea d 66 13 Health Insurance Review and Assessment Service eDepartment of Medicine, Seoul National University College of Medicine, Seoul, South Korea 67 14 f Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea 68 15 g Department of Preventive Medicine, KonKuk University Medical School, Seoul, Korea 69 16 hDepartment of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea 70 17 Received 28 December 2012; revised 10 April 2013; accepted 24 June 2013 71 18 72 19 73 20 Abstract BACKGROUND CONTEXT: Lumbar spinal stenosis is one of the most common degenerative 74 21 spine diseases. Surgical options are largely divided into decompression only and decompression 75 22 with arthrodesis. Recent randomized trials showed that surgery was more effective than nonopera- 76 23 tive treatment for carefully selected patients with lumbar stenosis. However, some patients require 77 24 reoperation because of complications, failure of bony fusion, persistent pain, or progressive degen- 78 25 erative changes, such as adjacent segment disease. In a previous population-based study, the 10-year reoperation rate was 17%, and fusion surgery was performed in 10% of patients. Recently, the lum- 79 26 bar fusion surgery rate has doubled, and a substantial portion of the reoperations are associated with 80 27 a fusion procedure. With the change in surgical trends, the longitudinal surgical outcomes of these 81 28 trends need to be reevaluated. 82 29 PURPOSE: To provide the longitudinal reoperation rate after surgery for spinal stenosis and to 83 30 compare the reoperation rates between decompression and fusion surgeries. 84 31 STUDY DESIGN/SETTING: Retrospective cohort study using national health insurance data. 85 32 PATIENT SAMPLE: A cohort of patients who underwent initial surgery for lumbar stenosis with- 86 33 out spondylolisthesis in 2003. 87 34 OUTCOME MEASURES: The primary end point was any type of second lumbar surgery. Cox 88 35 proportional hazards regression modeling was used to compare the adjusted reoperation rates be- 89 36 tween decompression and fusion surgeries. METHODS: A national health insurance database was used to identify a cohort of patients who 90 37 underwent an initial surgery for lumbar stenosis without spondylolisthesis in 2003; a total of 91 38 11,027 patients were selected. Individual patients were followed for at least 5 years through their 92 39 encrypted unique resident registration number. After adjusting for confounding factors, the reoper- 93 40 ation rates for decompression and fusion surgery were compared. 94 41 RESULTS: Fusion surgery was performed in 20% of patients. The cumulative reoperation rate was 95 42 4.7% at 3 months, 7.2% at 1 year, 9.4% at 2 years, 11.2% at 3 years, 12.5% at 4 years, and 14.2% at 96 43 97 44 Q3 FDA device/drug status: Not applicable. article. No benefits in any form have been or will be received from any 98 45 CHK: CKC: Q4 Author disclosures: Nothing to disclose. Nothing to dis- commercial party related directly or indirectly to the subject of this article. 99 46 CSP: BC: SH: close. Nothing to disclose. Nothing to disclose. Nothing Competing interests: None. 100 47 to disclose. MJK: Nothing to disclose. KSL: Nothing to disclose. BJP: * Corresponding author. Department of Neurosurgery, Seoul National 101 48 Nothing to disclose. University Hospital, Seoul National University College of Medicine, 28 102 49 Disclaimer: The authors report no conflict of interest concerning the Yeongeon-dong, Jongno-gu, Seoul 110-744, South Korea. Tel.: (82) 2-2072- materials or methods used in this study or the findings described in this 2352; fax: (82) 2-744-8459. 103 50 E-mail address: [email protected] (C.K. Chung) 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.06.069 SPINEE55358_proof ■ 13–08–2013 15:34:46 2 C.H. Kim et al. / The Spine Journal - (2013) - 104 5 years. The adjusted reoperation rate was not different between decompression and fusion surger- 160 105 ies (p5.82). The calculated reoperation rate was expected to be 22.9% at 10 years. 161 106 CONCLUSIONS: The reoperation rate was not different between decompression and fusion sur- 162 107 geries. With current surgical trends, the reoperation rate appeared to be higher than in the past, and 163 108 consideration of this problem is required. Ó 2013 Elsevier Inc. All rights reserved. 164 109 Keywords: Reoperation rate; Decompression; Fusion; Lumbar spine; Surgery 165 110 166 111 167 112 Introduction use of their unique resident registration number, thereby 168 113 making longitudinal analyses possible [7]. The data source 169 Lumbar spinal stenosis is a common degenerative spinal 114 was the same as previously published [7]. In Korea, a ‘‘fee- 170 disease. Recent randomized trials have shown that surgery is 115 for-service’’ system has been the traditional route for reim- 171 more effective than nonoperative treatment for carefully se- 116 bursement. Disease codes are standardized according to the 172 lected patients with lumbar stenosis [1–3]. Surgical options 117 Korean Classification of Disease, 4th version, which fol- 173 are largely divided into decompression only and decompres- 118 lows the International Classification of Disease, 10th ver- 174 119 sion with arthrodesis. However, some patients require reop- sion (ICD-10) [7]. The procedure codes were created by 175 eration because of complications, failure of bony fusion, 120 the Korean Health Insurance Review and Assessment Ser- 176 persistent pain, or progressive degenerative changes such 121 vice (HIRA) to standardize the filing of claims for medical 177 as adjacent segment disease [4]. Fusion surgery had a higher 122 fees to HIRA. All health-care organizations in Korea use 178 probability of reoperation than decompression surgery dur- 123 these standardized codes for disease and procedures, but re- 179 ing postoperative years 2 to 4 [4]. Additionally, although fu- 124 cording of a more detailed surgical level and complexity of 180 sion surgery comprised only 10.6% of surgeries for lumbar 125 operation are not specified. The Korean Health Insurance 181 spinal stenosis during 1990 to 1993, it increased 220% from 126 Review and Assessment Service national database was used 182 127 1990 to 2001 [5,6]. With the recent change in surgical trends, to identify a cohort of patients who underwent surgery. 183 128 the longitudinal reoperation rate reflecting these changes 184 129 needs to be reevaluated. 185 130 Population-based studies are less subject to selection or Cohort 186 131 nonresponse biases than case-series studies, they do not Patients who underwent lumbar spine surgery for spinal 187 132 miss reoperation events, and they have high statistical stenosis without spondylolisthesis between January 1, 188 133 power [5]. The longitudinal reoperation rates should be de- 2003, and December 31, 2003, were identified from the 189 134 termined using population-based data [4]. Martin et al. [5] HIRA database. There were 47,316 patients who underwent 190 135 analyzed patients operated on during 1990 to 1993 and spine surgery in 2003 [7]. Among them, those with a record 191 136 showed that the reoperation rate was 17.1% more than 10 of lumbar surgery in the preceding 5 years (1998–2002, 192 137 years of follow-up; moreover, there was no difference in n54,286), patients under 20 years (n51,305), and those with 193 138 outcome with the addition of fusion surgery. However, no a concomitant disease code (fracture, neoplasm, or infection, 194 139 population-based data are available reflecting this recent n56,167) were excluded (Fig. 1) [5,7]. From the remaining 195 140 surgical trend, except for an analysis of elderly patients 35,558 patients, 11,027 patients who underwent initial 196 141 (O60 years) [4].Deyoetal.[4] analyzed elderly patients lumbar surgery in 2003 with a disease code of spinal stenosis 197 142 (O60 years) operated on in 2004 with spinal stenosis, and and without a code of spondylolisthesis were selected and 198 143 the reoperation rate was 11% at 4 years. included in the present study (Fig. 1). The patients’ resident 199 144 The primary aim of the present study was to determine registration numbers were encrypted for privacy. 200 145 the effect of fusion surgery on the cumulative incidence The surgical methods were divided into two categories: 201 146 of reoperation with population-based data for spinal steno- decompression and fusion surgery. The decompression cat- 202 147 sis without spondylolisthesis. egory included discectomy, laminectomy, or both. Any pro- 203 148 cedure involving a fusion, with or without decompression, Q5 204 149 was classified as a fusion [5]. The Korean Health Insurance 205 150 Materials and methods Review and Assessment Service provides general guide- 206 151 207 The data source lines for fusion surgery in spinal stenosis.
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