Nationwide Trends in the Surgical Management of Lumbar Spinal Stenosis

Study Design. Retrospective analysis using national administrative data. Objective. This study presents US nationwide trends in the surgical management of patients with lumbar spinal stenosis (LSS) with and without coexisting spondylolisthesis and scoliosis from 2004 to 2009. Summary of Background Data. Lack of consensus and wide variability exists in surgical decision making for patients with LSS. Methods. Data were obtained from the Nationwide Inpatient Sample, a database developed as part of the Healthcare Cost and Utilization Project. All discharged patients with a primary diagnosis of LSS were identified. Three subgroups were studied: (1) LSS alone, (2) LSS with spondylolisthesis, and (3) LSS with scoliosis. Surgical treatment was divided into 3 groups: (1) decompression only (laminectomy, discectomy), (2) simple fusion (1-2 disc levels, single approach), and (3) complex fusion (>2 disc levels or a combined posterior and anterior approach). Results. Between 2004 and 2009, national estimates for the annual number of discharged inpatients with a primary diagnosis of LSS increased from 94,011 (population rate, [the age adjusted population rate per 100,000] 32.1) to 102,107 (population rate, 33.3). The rate of decompressions decreased from 58.5% to 49.2% for discharged patients with LSS from 2004 to 2009 (P < 0.05), whereas the rate of simple fusions increased from 21.5% to 31.2% (P < 0.05) and the rate of complex fusions did not change at 6.7%. From 2004 to 2009, the use of bone morphogenetic protein more than doubled from 14.5% to 33.0% of all fusions, and the use of interbody devices increased from 28.5% to 45.1% (P < 0.05). In 2009, 26.2% of patients with LSS without instability underwent a fusion procedure, while 82.7% of patients with LSS with coexisting spondylolisthesis and 67.6% of patients with coexisting scoliosis underwent a fusion procedure. Conclusion. This study demonstrates that the rate of simple fusion surgery has increased for treatment of LSS compared with decompression only.