Dataset Information

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation.

ABSTRACT:

Background context

Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.

Purpose

To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.

Study design/setting

Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State.

Methods

We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years.

Results

Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes.

Conclusions

Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

SUBMITTER: Martin BI

PROVIDER: S-EPMC3299929 | biostudies-literature | 2012 Feb

REPOSITORIES: biostudies-literature

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Publications

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation.

Martin Brook I BI Mirza Sohail K SK Flum David R DR Wickizer Thomas M TM Heagerty Patrick J PJ Lenkoski Alex F AF Deyo Richard A RA

The spine journal : official journal of the North American Spine Society 20111221 2

<h4>Background context</h4>Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.<h4>Purpose</h4>To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.<h4>Study design/setting</ ...[more]

PMID: 22193055

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Project description:Background:Contained lumbar disc herniations frequently cause back- and leg pain. Clinical outcomes with surgical treatment may be affected by the size and location of the disc herniation. The surgical directly visualized transforaminal endoscopic decompression has gained acceptance and popularity, while the simplified percutaneous laser disc decompression has fallen out of favor in spite of its initial success as a minimally invasive intervention. In an attempt to better understand the durability of both procedures, the authors performed a comparative analysis of clinical outcomes in patients with contained lumbar disc herniations. Methods:The study population was comprised 248 patients consisting of 162 patients in the endoscopy group (group 1) and 86 patients in the laser group (group 2). Primary outcome measures were Macnab criteria. Herniations were classified as large or small. Additional parameters of advanced degeneration of the lumbar motion segment including posterior disc- and lateral recess height of <3 mm were recorded. IBM SPSS 25.0 was used for Kaplan-Meier survival analysis and cross-tabulation of these variables with statistical testing for significant associations. Results:The mean follow-up was 43.5 months. The serial time recorded for Kaplan-Meier analysis ranged from 1.5 to 84 months. The mean age was 53.37 years (standard deviation =14.65 years). The majority of patients had Excellent and Good Macnab outcomes (212/248; 85.5%) regardless of treatment. Fair and Poor results were achieved in another 36 patients (14.5%). There was a higher percentage of Excellent Macnab outcomes in the endoscopy group (94/162; 58.0%) than in the laser group (38/86; 44.2%) at a statistical significant level (P<0.0001). There was a statistically significantly higher percentage of Excellent and Good Macnab outcomes with endoscopic decompression of small paracentral herniations (97.1%; P<0.0001). Percutaneous laser decompression of large central disc herniations was not statistically better than endoscopic surgical decompression (P=0.125). Endoscopic bony and soft tissue decompression was also better than laser at alleviating symptoms in patients with reduced posterior disc- and lateral recess height with 96.7% in patients with reduced disc height of <3 mm and 94% in patients with reduced lateral recess height of <3 mm (P=0.001). Kaplan-Meier (K-M) Survival time showed longer median survival of the treatment benefit for patients who underwent visualized endoscopic surgical decompression (66.0 months) compared to median K-M survival time for percutaneous laser decompression of 17 months (P<0.0001). Conclusions:Transforaminal endoscopic decompression for symptomatic herniated disc is an effective and durable surgical treatment to alleviate sciatica-type and back symptoms in the vast majority of patients with good long-term survival of pain relief for up to six years. Interventional percutaneous non-visualized laser decompression for the same condition may provide favorable outcomes in the short-term with soft protrusions. However, the treatment effect deteriorates much faster with a median survival of 17 months.

Project description:Background:Thoracolumbar interfascial plane (TLIP) block involves injection of local anesthetics between multifidus and longissimus muscles at the 3rd lumbar vertebral level assuming that it can block the dorsal rami of thoracolumbar nerves. Objective:The objective of this study was to evaluate the analgesic effects gained after performing TLIP block (analogous to the transversus abdominis plane [TAP] block, but intended for the back) in patients undergoing lumbar discectomy. Methodology:This was a prospective, randomized, double-blinded, controlled clinical trial. Computer-generated randomization numbers were used to allocate patients into two groups. A total of 102 patients scheduled for lumbar discectomy were considered eligible, of these 70 patients were randomly included in the analysis: 35 patients (control group) received the standard general anesthetic technique and 35 patients (TLIP group) received TLIP block with 20 ml mixture of 0.25% bupivacaine and 1% lidocaine on each side. The primary outcome was to compare the two groups with regard to pain scores, whereas the secondary outcomes included the time to first analgesic (TFA), 24-h morphine consumption, and side effects associated with morphine such as nausea, vomiting, and sedation. Results:TLIP group compared with the control group showed a significant reduction in the postoperative Visual Analog Scale for pain score both on rest and movement, with no statistically significant difference at 24 h during movement. TFA was significantly shorter in the control group compared to the TLIP group (82.00 ± 69.01 vs. 442.7 ± 126.47 min, P < 0.001). TLIP group had lower cumulative morphine consumption than control group of statistically significant difference (9.7 ± 6.38 vs. 25.88 ± 5.17 mg, P < 0.001). TLIP block group compared with the control group showed a significant reduction of nausea and a lower incidence of sedation. Conclusion:TLIP block is an effective and safe method for postoperative analgesia after lumbar discectomy.

Dataset Information

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation.

Background context

Purpose

Study design/setting

Methods

Results

Conclusions

Publications

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation.

Similar Datasets

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