Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
Research Institute, Children's Minnesota, 2525 Chicago Ave South, Minneapolis, MN 55404, USA.
Spine J. 2019 Feb;19(2):199-205. doi: 10.1016/j.spinee.2018.05.034. Epub 2018 Jun 26.
Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.
The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression.
STUDY DESIGN/SETTING: This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014.
The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation.
The primary outcome measure was the time from ESI to surgery.
Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.
Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates.
In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process.
尽管腰骶部硬膜外类固醇注射（ESI）的临床适应证有所缩小，但使用率却大幅增加。一个潜在的适应证是避免或延迟手术，但关于 ESI 后手术率的信息却很少。
本研究旨在确定因椎间盘突出或狭窄而行腰椎 ESI 治疗的患者中进行手术的比例，并确定进展的时间和相关因素。
研究设计/设置：本研究是对 2007 年至 2014 年来自 Truven Health MarketScan 数据库的全国代表性行政索赔数据进行的回顾性研究。
研究队列包括 179025 名（54±15 岁，48%为女性）因狭窄和/或突出而接受腰椎 ESI 治疗的患者。
主要结局指标为从 ESI 到手术的时间。
纳入标准为 ESI 治疗狭窄和/或突出、年龄≥18 岁、ESI 前 1 年有健康计划参与以排除禁忌证。对患者进行纵向随访，直至进展为手术或中断入组，此时将其删失。通过 Kaplan-Meier 生存曲线评估手术率。使用多变量 Cox 比例风险模型评估与手术相关的人口统计学和治疗因素。本研究未获得外部资金，作者的利益冲突与本研究无关。
在 6 个月内，12.5%的 ESI 患者接受了腰椎手术。在 1 年内，16.9%的患者接受了手术，在 5 年内，26.1%的患者接受了手术。椎间盘突出症患者的手术率高达五倍至七倍，其中年轻患者和既有突出症又有狭窄症的患者手术率最高。其他并发脊柱疾病、男性、既往吸烟史以及居住在农村地区或美国东北部以外的地区与较高的手术率相关。合并症（既往药物治疗、充血性心力衰竭、肥胖、慢性阻塞性肺疾病、高胆固醇血症和其他心脏并发症）与较低的手术率相关。
从长期来看，每四名接受腰椎间盘突出症或狭窄症 ESI 治疗的患者中，就有一名以上的患者随后接受了手术，其中近六分之一的患者在第一年接受了手术。在调整了其他患者的人口统计学和合并症后，椎间盘突出症患者比狭窄症患者更有可能接受手术。对从腰椎 ESI 到手术进展的深入了解将有助于更好地了解 ESI 的价值，并为共同决策过程提供帮助。
