Bederman S Samuel, Kreder Hans J, Weller Iris, Finkelstein Joel A, Ford Michael H, Yee Albert J M
Department of Orthopaedic Surgery, University of California, San Francisco, Calif., and the.
Can J Surg. 2009 Aug;52(4):283-290.
Degenerative disease of the lumbar spine (DLS) is a common condition for which surgery can be beneficial in selected patients. With recent surgical trends toward more focused subspecialty training, it is unclear how characteristics of the surgical consultant may impact on treatment and reoperations. Our objective was to understand the relations between surgeon factors (who), surgical procedures (what) and recent trends (when) and their influence on reoperations for DLS surgery. METHODS: We performed a longitudinal population-based study using administrative databases including all patients aged 50 years and older who underwent surgery for DLS. We collected data on surgeon characteristics (specialty, volume), index procedures (decompressions, fusions) and reoperations. RESULTS: We identified 6128 patients who underwent surgery for DLS (4200 who had decompressions, 1928 who had fusions). We observed an increasing proportion of fusions over decompressions while the per capita surgeon supply declined. Orthopedic specialty and higher surgical volume were associated with a higher proportion of fusions (p < 0.001). The overall reoperation rate was 10.6%. Reoperations were more frequent in patients who had decompressions than those who had fusions at 2 years (5.4% v. 3.8%, odds ratio 1.4, p < 0.013), but not over the long-term. Long-term survival analysis demonstrated that a lower surgical volume was related to a higher reoperation rate (hazard ratio 1.28, p = 0.038). CONCLUSION: Lumbar spinal fusion rates for DLS have been increasing in Ontario. There is wide variation in surgical procedures between specialty and volume: namely high-volume and orthopedic surgeons have higer fusion rates than other surgeons. We observed better long-term survival among patients of high-volume surgeons. Referring physicians should be aware that the choice of surgical consultant may influence patients' treatments and outcomes. With increasing rates of spinal surgery, the efficacy and cost benefit of current surgical options require ongoing study.
腰椎退行性疾病（DLS）是一种常见疾病，手术对部分患者有益。随着近期手术趋势朝着更专注的亚专业培训发展，尚不清楚手术顾问的特征如何影响治疗和再次手术。我们的目的是了解外科医生因素（何人）、手术方式（何事）和近期趋势（何时）之间的关系及其对DLS手术再次手术的影响。
我们使用行政数据库进行了一项基于人群的纵向研究，纳入了所有50岁及以上接受DLS手术的患者。我们收集了外科医生特征（专业、手术量）、初次手术方式（减压、融合）和再次手术的数据。
我们确定了6128例接受DLS手术的患者（4200例接受减压手术，1928例接受融合手术）。我们观察到融合手术的比例相对于减压手术有所增加，而人均外科医生数量下降。骨科专业和较高的手术量与更高的融合手术比例相关（p < 0.001）。总体再次手术率为10.6%。在术后2年时，接受减压手术的患者比接受融合手术的患者再次手术更频繁（5.4%对3.8%，优势比1.4，p < 0.013），但长期来看并非如此。长期生存分析表明，较低的手术量与较高的再次手术率相关（风险比1.28，p = 0.038）。
安大略省DLS的腰椎融合率一直在上升。不同专业和手术量的手术方式存在很大差异：即手术量高的骨科医生的融合率高于其他外科医生。我们观察到手术量高的外科医生的患者长期生存率更高。转诊医生应意识到手术顾问的选择可能会影响患者的治疗和结局。随着脊柱手术率的上升，当前手术选择的疗效和成本效益需要持续研究。
