Original ArticleFusion Techniques Are Related to a Lower Risk of Reoperation in Lumbar Disc Herniation: A 5-Year Observation Study of a Nationwide Cohort in Taiwan
Introduction
Lumbar disc herniation (LDH) is one of the most commonly treated spinal problems. Patients with radiculopathy caused by LDH can be treated either conservatively or by surgery.1 Symptomatic patients who fail to respond to conservative management are candidates for surgical intervention. Although simple partial discectomy without fusion is the standard surgical procedure, reoperations remain a clinical concern.2, 3 A systematic literature review and prospective outcome study found that the frequency of recurrent LDH requiring reoperation was 6%, and 15%–25% of patients developed recurrent low back pain within 2 years.4 Simple discectomy plus fusion may lead to better outcomes either by decreasing the reoperation rate3, 4 or by reducing the pain score postoperatively.5 Various fusion techniques have been developed, including anterior lumbar interbody fusion, posterior approach fusion procedures, such as posterior lumbar interbody fusion and posterolateral lumbar fusion, and combined anterior and posterior lumbar fusion. However, complications still occur after spinal fusion, especially the possibility of developing adjacent segment disease (ASD).6, 7, 8 The incidence of symptomatic ASD has been reported to be 16.5% at 5 years and 36.1% at 10 years after lumbar posterior arthrodesis.9 Therefore, there is still debate regarding the treatment of choice for LDH, and further studies are required to address this issue. Fusion may represent an acceptable alternative to the current gold standard for LDH in the absence of other disease (i.e., simple discectomy).5, 10, 11, 12 We hypothesized that fusion surgery may be associated with a lower reoperation rate compared with discectomy during the observation period.
This study was performed to explore the reoperation rates among different surgical procedures and presents the national trends in surgical management of patients with LDH in Taiwan within a 5-year observation period. In addition, we also evaluated the risk factors of reoperation and medical costs.
Section snippets
Study Cohort
This study involved a retrospective review of data obtained from the National Health Insurance Research Database (NHIRD) for January 1, 2008, to December 31, 2012. The NHIRD contains de-identified data derived from the original data of the National Health Insurance program in Taiwan, which contains comprehensive medical claims. De-identification and encryption processes were performed before release of the data, and therefore, there was no requirement for informed consent. The study was
General Characteristics
Most patients undergoing surgery twice were male (index surgery, n = 1054, 60.47%; reoperation, n = 124, 67.39%) and were >30 years old (index surgery, n = 1687, 96.78%; reoperation, n = 179, 97.28%). The 3 most common comorbidities were hypertension (index surgery, n = 797, 45.73%; reoperation, n = 94, 51.09%), diabetes mellitus (index surgery, n = 524, 30.06%; reoperation, n = 64, 34.78%), and dyslipidemia (index surgery, n = 254, 14.57%; reoperation, n = 44, 23.91%). Table 1 shows the
Discussion
This study was performed to explore reoperation risks, lengths of hospital stays, and costs among 4 surgical techniques (i.e., DC, FA + DC, FP, and FP + DC), based on a 5-year cohort of patients with LDH derived from NHIRD, a Taiwanese nationwide database. The sex-specific and age-specific incidence rates of LDH in the study population were assessed and the findings are summarized as follows. First, the DC group had a higher reoperation risk during follow-up after index surgery compared with
Conclusions
The results of this nationwide study imply that fusion procedures (FA + DC, FP, and FP + DC) had lower rates of reoperation within our study period. FP and FP + DC were superior to FA + DC from the viewpoints of shorter hospital stays and greater cost-effectiveness. Developing implants with less cost burden could reduce the overall costs of FP and FP + DC procedures. In addition, the surgical-type-adjusted risk of reoperation for LDH differed between the sexes and this differentiation was time
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Conflict of interest statement: This study was supported by grants from CMRPG 6E0211 of the Chang Gung Medical Research Council.