Revision Surgery Following Operations for Lumbar Stenosis
Revision Surgery Following Operations for Lumbar Stenosis
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DOI：
10.2106/jbjs.j.01292
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发表时间：
2011-11-02
影响因子：
5.3
通讯作者：
Mirza, Sohail K.
中科院分区：
文献类型：
--
作者：
Deyo, Richard A.;Martin, Brook I.;Mirza, Sohail K.
背景：对于精心挑选的腰椎管狭窄症患者，减压手术比非手术治疗更有效。然而，一些患者接受重复手术，通常是因为并发症，未能实现牢固融合：关节融合术后或持续症状。我们评估了腰椎管狭窄症治疗手术后再次手术的可能性，并研究了其与患者年龄、合并症、既往手术和手术类型的关系。首次手术于2004年进行（n = 31，543），随访至2008年。手术按复杂性分为单纯减压术、简单关节融合术（一个或两个椎间盘节段和单一手术入路）或复杂关节融合术（两个以上椎间盘节段或前后联合入路）。再手术率计算每个随访年，再手术的时间进行了分析与比例风险models.Results：重复手术的概率下降，随着患者年龄的增加或合并症。除年龄外，最强的预测因素是既往腰椎手术史：4年时，在首次手术前接受过腰椎手术的患者中，再手术率为17.2%，而在既往未接受手术的患者中，再手术率为10.6%（p < 0.001）。1年时，单纯减压组患者的再手术率略高于单纯关节融合组患者，但4年时，两组患者的再手术率相同（10.7%），低于复合关节融合组患者的再手术率（13.5%）（p < 0.001）。在调整人口统计学和临床特征后，这种差异仍然存在（复杂关节融合术与减压术的风险比为1.56，95%置信区间为1.26 - 1.92）。一个设备相关的并发症报告的时间为29.2%的再手术后的初始arthrodesis procedure.Conclusions：椎管狭窄症的可能性重复手术随着年龄的增加和合并症下降，也许是因为担心更大的风险。再次手术的最强临床预测因素是首次手术前的腰椎手术。关节融合术与术后第一年的再次手术率较低没有显著相关性，并且接受过复杂关节融合术的患者再次手术率最高。证据等级：治疗等级III。有关证据等级的完整描述，请参见作者说明。
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 Ill. See Instructions for Authors for a complete description of levels of evidence.