Advertisement

Revision lumbar fusions have higher rates of reoperation and result in worse clinical outcomes compared to primary lumbar fusions

Published:September 01, 2022DOI:https://doi.org/10.1016/j.spinee.2022.08.018

      Abstract

      BACKGROUND CONTEXT

      Indications for revision lumbar fusion are variable, but include recurrent stenosis (RS), adjacent segment disease (ASD), and pseudarthrosis. The efficacy of revision lumbar fusion has been well established, but their outcomes compared to primary procedures is not well documented.

      PURPOSE

      The purpose of this study was to compares surgical and clinical outcomes between (1) revision and primary lumbar fusion, (2) revision lumbar fusion based on indication (ASD, pseudarthrosis, or RS), and (3) revision lumbar fusion based on whether the index procedure included an isolated decompression or decompression with fusion.

      STUDY DESIGN/SETTING

      Retrospective single-institution cohort study.

      PATIENT SAMPLE

      Four thousand six hundred seventy-one consecutive lumbar fusions from 2011 to 2021, of which 892 (23.6%) were revision procedures. The indication for revision procedures included 502 (56.3%) for ASD, 153 (17.2%) for pseudarthrosis, and 237 (26.6%) for RS. Of the 892 revision procedures, 694 (77.8%) underwent an index fusion while 198 (22.2%) underwent an index decompression without fusion.

      OUTCOME MEASURES

      Hospital readmissions, all-cause reoperation, need for subsequent revision and patient reported outcome measures (PROMs) at baseline, 3-months postoperatively, and 1-year postoperatively, including the Mental Health Component score (MCS-12) and Physical Health Component score (PCS-12) of the Short Form 12 survey, the Oswestry Disability Index (ODI), and the Visual Analog Scale (VAS) for Back and Leg pain.

      METHODS

      Patient demographics, comorbidities, surgical characteristics, and outcomes were collected from electronic medical records. Twenty-eight percent of patients had preoperative and postoperative PROMs. A delta PROM score was calculated for the 3-month and 1-year postoperative timepoints, which was the change from the preoperative to postoperative value. Univariate comparisons were performed to compare revision fusions to primary fusions. Multivariate logistic regression was performed for all-cause reoperation and subsequent revision surgery, while multivariate linear regression was performed for ∆PROMs at 3-months and 1-year. Revision procedures were then separately regrouped based on indication for revision fusion and whether they underwent a fusion for their index procedure. Univariate comparisons and multivariate linear regressions for ∆PROMs were then repeated based on the new groupings.

      RESULTS

      There was no difference in hospital readmission rate (5.38% vs. 4.60%, p=.372) or length of stay (4.10 days vs. 3.94 days, p=.129) between revision and primary lumbar fusion, but revision fusions had a higher rate of all-cause reoperation (16.1% vs. 11.2%, p<.001) and subsequent revision (13.7% vs. 9.71%, p=.001), which was confirmed on multivariate logistic regression (Odds Ratio (OR): 1.42, p=.001 and OR: 1.37, p=.007, respectively). On multivariate analysis, a revision procedure was an independent risk factor for worse improvement ∆ODI, ∆VAS Back, ∆VAS Leg, and ∆PCS-12 and 1-year postoperatively. Regardless of the indication for revision lumbar fusion, patients significantly improved in the 3-month and 1-year postoperative PCS-12, ODI, VAS Back, and VAS Leg, with the exception of the 3-month PCS-12 for pseudarthrosis (p=.620). Patients undergoing revision for ASD had significantly worse 1-year postoperative PCS-12 (32.3 vs. Pseudarthrosis: 35.6 and RS: 37.0, p=.026), but there were no differences in ∆PROMs. There was no difference in hospital readmission, all-cause reoperation, or subsequent revision based on whether a patient had an index lumbar fusion or isolated decompression. Multivariate linear regression analysis found that a surgical indication of pseudarthrosis was a significant predictor of decreased improvement in 3-month ∆VAS Leg (ref: ASD, β=2.26, p=.036), but having an index fusion did not significantly predict worse improvement in ∆PROMs when compared to isolated decompressions.

      CONCLUSIONS

      Revision lumbar fusions had a higher rate of reoperation and subsequent revision surgery when compared to primary lumbar fusions, but there were no difference in hospital readmission rates. Patients undergoing revision lumbar fusion experience improvements in all patient reported outcome measures, but their baseline, postoperative, and magnitude of improvement are worse than primary procedures. Regardless of whether the lumbar fusion is a primary or revision procedure, all patients have significant improvements in pain, disability and physical function. Further, the indication for the revision procedure is not correlated with the expected magnitude of improvement in patient reported outcomes. Finally, no differences in baseline, postoperative, and ∆PROMs for revision fusions were identified when stratifying by whether the patient had an index decompression or fusion.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Spine Journal
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Martin BI
        • Mirza SK
        • Spina N
        • Spiker WR
        • Lawrence B
        • Brodke DS.
        Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015.
        Spine. 2019; 44: 369-376https://doi.org/10.1097/brs.0000000000002822
        • Rajaee SS
        • Kanim LEA
        • Bae HW.
        National trends in revision spinal fusion in the USA: patient characteristics and complications.
        Bone Jt J. 2014; (96-B:807–16)https://doi.org/10.1302/0301-620x.96b6.31149
        • Elgafy H
        • Vaccaro AR
        • Chapman JR
        • Dvorak MF.
        Rationale of revision lumbar spine surgery.
        Global Spine J. 2012; 2: 7-14https://doi.org/10.1055/s-0032-1307254
        • Airaksinen O
        • Herno A
        • Turunen V
        • Saari T
        • Suomlainen O.
        Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis.
        Spine. 1997; 22: 2278-2282https://doi.org/10.1097/00007632-199710010-00016
        • Martin BI
        • Mirza SK
        • Comstock BA
        • Gray DT
        • Kreuter W
        • Deyo RA.
        Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures.
        Spine. 2007; 32: 382-387https://doi.org/10.1097/01.brs.0000254104.55716.46
        • Virk SS
        • Niedermeier S
        • Yu E
        • Khan SN.
        Adjacent segment disease.
        Orthopedics. 2014; 37: 547-555https://doi.org/10.3928/01477447-20140728-08
        • Adogwa O
        • Carr RK
        • Kudyba K
        • Karikari I
        • Bagley CA
        • Gokaslan ZL
        • et al.
        Revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, adjacent-segment disease, or same-level recurrent stenosis. Part 1. Two-year outcomes and clinical efficacy: Clinical article.
        J Neurosurg Spine. 2013; 18: 139-146https://doi.org/10.3171/2012.11.spine12224
        • Deyo RA
        • Martin BI
        • Kreuter W
        • Jarvik JG
        • Angier H
        • Mirza SK.
        Revision surgery following operations for lumbar stenosis.
        J Bone Jt Surg. 2011; 93: 1979-1986https://doi.org/10.2106/jbjs.j.01292
        • Kim WJ
        • Shin HM
        • Song DG
        • Lee JW
        • Park KY
        • Chang SH
        • et al.
        Comparison of clinical outcomes and complications of primary and revision surgery using a combined anterior and posterior approach in patients with adult spinal deformity and sagittal imbalance.
        Clin Orthop Surg. 2020; 13: 196-206https://doi.org/10.4055/cios20217
        • Lee S-H
        • Kang B-U
        • Jeon SH
        • Park JD
        • Maeng DH
        • Choi Y-G
        • et al.
        Revision surgery of the lumbar spine: anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation.
        J Neurosurg Spine. 2006; 5: 228-233https://doi.org/10.3171/spi.2006.5.3.228
        • Montenegro TS
        • Gonzalez GA
        • Saiegh FA
        • Philipp L
        • Hines K
        • Hattar E
        • et al.
        Clinical outcomes in revision lumbar spine fusions: an observational cohort study.
        J Neurosurg Spine. 2021; 35: 437-445https://doi.org/10.3171/2020.12.spine201908
        • Adogwa O
        • Parker SL
        • Shau D
        • Mendelhall SK
        • Cheng J
        • Aaronson O
        • et al.
        Long-term outcomes of revision fusion for lumbar pseudarthrosis: Clinical article.
        J Neurosurg Spine. 2011; 15: 393-398https://doi.org/10.3171/2011.4.spine10822
        • Dede O
        • Thuillier D
        • Pekmezci M
        • Ames CP
        • Hu SS
        • Berven SH
        • et al.
        Revision surgery for lumbar pseudarthrosis.
        Spine J. 2015; 15: 977-982https://doi.org/10.1016/j.spinee.2013.05.039
        • Geisler FH
        • Guyer RD
        • Blumenthal SL
        • McAfee PC
        • Cappuccino A
        • Bitan F
        • et al.
        Patient selection for lumbar arthroplasty and arthrodesis: the effect of revision surgery in a controlled, multicenter, randomized study.
        J Neurosurg Spine. 2008; 8: 13-16https://doi.org/10.3171/spi-08/01/013
        • Jung J
        • Lee S
        • Cho D-C
        • Han I-B
        • Kim CH
        • Lee Y-S
        • et al.
        Usefulness of oblique lumbar interbody fusion as revision surgery: comparison of clinical and radiological outcomes between primary and revision surgery.
        World Neurosurg. 2021; 149: e1067-e1076https://doi.org/10.1016/j.wneu.2020.12.172
        • Schwender JD
        • Casnellie MT
        • Perra JH
        • Transfeldt EE
        • Pinto MR
        • Denis F
        • et al.
        Perioperative complications in revision anterior lumbar spine surgery.
        Spine. 2009; 34: 87-90https://doi.org/10.1097/brs.0b013e3181918ad0
        • Suh S-P
        • Jo Y-H
        • Jeong HW
        • Choi WR
        • Kang C-N
        Outcomes of revision surgery following instrumented posterolateral fusion in degenerative lumbar spinal stenosis: a comparative analysis between pseudarthrosis and adjacent segment disease.
        Asian Spine J. 2017; 11: 463-471https://doi.org/10.4184/asj.2017.11.3.463
        • Bydon M
        • Macki M
        • Kerezoudis P
        • Sciubba DM
        • Wolinsky J-P
        • Witham TF
        • et al.
        The incidence of adjacent segment disease after lumbar discectomy: a study of 751 patients.
        J Clin Neurosci. 2017; 35: 42-46https://doi.org/10.1016/j.jocn.2016.09.027
        • Bydon M
        • Macki M
        • la Garza-Ramos RD
        • McGovern K
        • Sciubba DM
        • Wolinsky J-P
        • et al.
        Incidence of adjacent segment disease requiring reoperation after lumbar laminectomy without fusion: a study of 398 patients.
        Neurosurgery. 2016; 78: 192-199https://doi.org/10.1227/neu.0000000000001007
        • Radcliff KE
        • Kepler CK
        • Jakoi A
        • Sidhu GS
        • Rihn J
        • Vaccaro AR
        • et al.
        Adjacent segment disease in the lumbar spine following different treatment interventions.
        Spine J. 2013; 13: 1339-1349https://doi.org/10.1016/j.spinee.2013.03.020
        • Peters MJM
        • Bastiaenen CHG
        • Brans BT
        • Weijers RE
        • Willems PC.
        The diagnostic accuracy of imaging modalities to detect pseudarthrosis after spinal fusion—a systematic review and meta-analysis of the literature.
        Skeletal Radiol. 2019; 48: 1499-1510https://doi.org/10.1007/s00256-019-03181-5
        • Greiner-Perth R
        • Boehm H
        • Allam Y
        • Elsaghir H
        • Franke J.
        Reoperation rate after instrumented posterior lumbar interbody fusion.
        Spine. 2004; 29: 2516-2520https://doi.org/10.1097/01.brs.0000144833.63581.c1
        • Hu RW
        • Jaglal S
        • Axcell T
        • Anderson G.
        A population-based study of reoperations after back surgery.
        Spine. 1997; 22: 2265-2270https://doi.org/10.1097/00007632-199710010-00013
        • Malter AD
        • McNeney B
        • Loeser JD
        • Deyo RA.
        5-year reoperation rates after different types of lumbar spine surgery.
        Spine. 1998; 23: 814-820https://doi.org/10.1097/00007632-199804010-00015
        • Brantigan JW.
        Pseudarthrosis rate after allograft posterior lumbar interbody fusion with pedicle screw and plate fixation.
        Spine. 1994; 19: 1271-1279https://doi.org/10.1097/00007632-199405310-00014
        • Phan K
        • Cheung ZB
        • Lee NJ
        • Kothari P
        • DiCapua J
        • Arvind V
        • et al.
        Primary versus revision discectomy for adults with herniated nucleus pulposus: a propensity score–matched multicenter study.
        Global Spine J. 2018; 8: 810-815https://doi.org/10.1177/2192568218773716
        • Patel MS
        • Braybrooke J
        • Newey M
        • Sell P.
        A comparative study of the outcomes of primary and revision lumbar discectomy surgery.
        Bone Jt J. 2013; (95-B:90–4)https://doi.org/10.1302/0301-620x.95b1.30413
        • Kleinstück FS
        • Grob D
        • Lattig F
        • Bartanusz V
        • Porchet F
        • Jeszenszky D
        • et al.
        The influence of preoperative back pain on the outcome of lumbar decompression surgery.
        Spine. 2009; 34: 1198-1203https://doi.org/10.1097/brs.0b013e31819fcf35