■在过去的20年中,腰椎融合的使用已大大增加。对于腰椎管狭窄和退行性腰椎滑脱的患者,2016年在《新英格兰医学杂志》上发表的2项具有里程碑意义的前瞻性随机临床试验(RCTs)没有发现明确的证据表明该人群中融合减压优于单纯减压。
■评估2016年至2019年在全国范围内使用减压融合术与单纯减压术治疗腰椎管狭窄症和退行性腰椎滑脱症。
■这项回顾性队列研究包括从2016年1月1日至2019年12月31日接受单独一级减压或减压融合治疗腰椎管狭窄和退行性腰椎滑脱的121745例住院成年患者(年龄≥18岁)。所有数据均来自全国住院患者样本(NIS)。进行了分析,reviewed,或更新于2023年6月9日。
■本研究的主要结果是使用融合减压与单独减压。对于次要结果,多变量logistic回归分析用于评估与决定进行融合减压与单独减压的相关因素。
■在121745名符合条件的住院患者中(平均年龄,65.2年[95%CI,65.0-65.4年];96645/117640[82.2%]非西班牙裔白人)伴有腰椎管狭窄和退行性腰椎滑脱,21230例(17.4%)仅接受减压,和100515(82.6%)接受减压融合。仅接受减压的患者比例从2016年(23405中的7625例[32.6%])下降到2019年(37215中的3560例[9.6%]),而同期接受减压融合治疗的患者比例有所增加(从2016年的23405例患者中的15780例[67.4%]增加到2019年的37215例患者中的33655例[90.4%]).在单变量分析中,仅接受减压的患者与接受融合减压的患者在年龄方面存在显着差异(平均,68.6年[95%CI,68.2-68.9年]vs64.5年[95%CI,64.3-64.7年];P<.001),保险状况(例如,医疗保险:21205中的13725[64.7%]对100420中的53320[53.1%];P<.001),所有患者精细诊断相关组死亡风险(例如,轻微风险:16900[79.6%]对83730[83.3%];P<.001),和国家的医院地区(例如,南部:7030[33.1%]对38905[38.7%];中西部:4470[21.1%]对23360[23.2%];两个比较P<.001)。在多变量逻辑回归分析中,年龄较大(调整后的赔率比[AOR],每年0.96;95%CI,每年0.95-0.96),2016年后的一年(AOR,每年1.76;95%CI,每年1.69-1.85),自付保险状态(AOR,0.59;95%CI,0.36-0.95),中型医院规模(AOR,0.77;95%CI,0.67-0.89),大型医院规模(AOR,0.76;95%CI,0.67-0.86),和按患者居住邮政编码划分的最高中位数收入四分位数(AOR,0.79;95%CI,0.70-0.89)与接受减压融合的几率较低相关。相反,中西部的医院地区(AOR,1.34;95%CI,1.14-1.57)或南方(AOR,1.32;95%CI,1.14-1.54)与接受减压融合的几率更高相关。融合减压术与单纯减压术与住院时间延长相关(平均,2.96天[95%CI,2.92-3.01天]vs2.55天[95%CI,2.49-2.62天];P<.001),较高的总入学费用(平均,$30288[95%CI,$29386-$31189]vs$16190[95%CI,$15189-$17191];P<.001),和更高的总入学费用(平均,$121892[95%CI,$119566-$124219]vs$82197[95%CI,$79745-$84648];P<.001)。
■在这项队列研究中,尽管有2个前瞻性RCT证明了单独减压与融合减压相比的非劣效性,从2016年到2019年,融合减压的使用相对于单独减压增加。各种患者和医院水平的因素与手术方式的选择有关。这些结果表明,两个主要RCT的发现尚未改变手术实践模式,值得重新关注。
Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population.
To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019.
This retrospective cohort
study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023.
The primary outcome of this
study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone.
Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001).
In this cohort
study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.