Department of Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, USA.
Spine (Phila Pa 1976). 2013 May 1;38(10):865-72. doi: 10.1097/BRS.0b013e31828631b8.
Retrospective cohort analysis of Medicare claims for 2006-2009.
To examine whether interspinous distraction procedures are used selectively in patients with more advanced age or comorbidity, and whether they are associated with fewer complications, lower costs, and less revision surgery than laminectomy or fusion surgery.
A manufacturer-sponsored randomized trial suggested an advantage of interspinous spacer surgery compared with nonsurgical care, but there are few comparisons with other surgical procedures. Furthermore, there are few population-based data evaluating patterns of use of these devices.
We used Medicare inpatient claims data to compare age and comorbidity for patients with spinal stenosis undergoing surgery (n = 99,084) with (1) an interspinous process spacer alone; (2) laminectomy and a spacer; (3) decompression alone; or (4) lumbar fusion (1-2 level). We also compared these 4 groups for cost of surgery and rates of revision surgery, major medical complications, wound complications, mortality, and 30-day readmission rates.
Patients who received spacers were older than those undergoing decompression or fusion, but had little evidence of greater comorbidity. Patients receiving a spacer alone had fewer major medical complications than those undergoing decompression or fusion surgery (1.2% vs. 1.8% and 3.3%, respectively), but had higher rates of further inpatient lumbar surgery (16.7% vs. 8.5% for decompression and 9.8% for fusion at 2 yr). Hospital payments for spacer surgery were greater than those for decompression alone but less than for fusion procedures. These associations persisted in multivariate models adjusting for patient age, sex, comorbidity score, and previous hospitalization.
Compared with decompression or fusion, interspinous distraction procedures pose a trade-off in outcomes: fewer complications for the index operation, but higher rates of revision surgery. This information should help patients make more informed choices, but further research is needed to define optimal indications for these new devices.
2006 年至 2009 年医疗保险索赔的回顾性队列分析。
检查棘突间撑开术是否选择性地用于年龄较大或合并症较多的患者，以及与椎板切除术或融合术相比，其是否与较少的并发症、较低的成本和较少的翻修手术相关。
一项制造商赞助的随机试验表明，与非手术治疗相比，棘突间撑开术具有优势，但与其他手术程序的比较很少。此外，很少有基于人群的数据评估这些设备的使用模式。
我们使用医疗保险住院患者数据，比较了接受手术治疗的脊柱狭窄症患者（n=99084）的年龄和合并症，这些患者接受了（1）单独的棘突间撑开器；（2）椎板切除术和撑开器；（3）单纯减压；或（4）腰椎融合术（1-2 个节段）。我们还比较了这 4 组手术的成本和翻修手术率、主要医疗并发症、伤口并发症、死亡率和 30 天再入院率。
接受撑开器的患者比接受减压或融合的患者年龄更大，但合并症的证据较少。单独接受撑开器的患者比接受减压或融合手术的患者发生主要医疗并发症的几率更小（分别为 1.2%、1.8%和 3.3%），但在 2 年内再次进行腰椎内手术的几率更高（分别为 16.7%、8.5%减压和 9.8%融合）。撑开器手术的医院支付费用高于单纯减压，但低于融合手术。这些关联在调整患者年龄、性别、合并症评分和既往住院情况的多变量模型中仍然存在。
与减压或融合相比，棘突间撑开术在结果上存在权衡：索引手术的并发症较少，但翻修手术的几率较高。这些信息应该有助于患者做出更明智的选择，但需要进一步研究来确定这些新设备的最佳适应证。
4 级。
