Public health

Costly fusion surgery the popular choice for spinal stenosis

Complex fusion is the fastest growing procedure for the management of lumbar spinal stenosis despite the lack of evidence for additional benefit over traditional decompression surgery.

A study of all public and private hospital admissions for lumbar spinal stenosis in New South Wales between 2003 and 2013 identified 30,680 admissions resulting in 19,628 patients undergoing a surgical procedure.

There were 17,123 decompression only procedures, 1,458 simple fusions involving one or two disc levels and 1,047 complex fusions of three or more disc levels.

While the rates of decompression increased only slightly over the 10-year study period, simple fusions more than doubled and complex fusions quadrupled.

Co-author Dr Gustavo Machado, a postdoctoral research fellow in the University of Sydney’s School of Public Health, told the limbic the findings reflected a similar worrying trend in the US.

“Fusion rates are increasing much faster than traditional decompression rates and are associated with higher rates of complications yet we are still unsure if the procedures provide additional benefits.”

He said two high quality randomised controlled trials and a Cochrane Review had recently shown fusion was not associated with better outcomes.

Patients in the NSW study undergoing simple fusion had twice the rate of major complications as decompression patients while complex fusion patients had 4.1 times the rate of complications.

Fusion procedures resulted in longer hospital stays for patients (8 to 10 days for simple and complex procedures) than decompression (5 days).

Dr Machado said financial incentives might be encouraging surgeons to choose one procedure over another with fusion costing about $30,000-32,000 compared to $12,000 for decompression.

He added that increasing numbers of surgeons were being trained to perform the procedures without clear indications or evidence of benefit.

“Guidelines that recommend fusion should be revised based on the recent evidence,” he said. “Then doctors need to start paying attention to the evidence.”

“The increase in use of potentially harmful interventions with questionable clinical effectiveness is a major health policy concern and efforts to address this issue deserve a high priority,” the study team wrote.

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