Introduction
Evidence & Methods
A number of studies have determined that the use of spine surgery, and spinal fusion in particular, has increased dramatically over the last two decades. The authors sought to explore this issue further using 10 years worth of data from the Nationwide Inpatient Sample (NIS).
More than 380,000 spine surgeries were performed for lumbar degenerative disc disease from 2000-2009, representing more than two-fold increases in the use of spine surgery for lumbar degenerative disc disease as a whole, as well as the performance of 360-degree fusion and posterior lumbar fusions.
This investigation adds to a growing body of literature highlighting the increased use of surgery, as well as fusion-based procedures, as treatment for degenerative conditions of the spine. Given the limitations of the NIS dataset, the authors cannot account for the population-at-risk (eg, the entire population of individuals with lumbar degenerative conditions). In light of the aging demographic and the increased prevalence of musculoskeletal disease, as well as enhanced access to medical care, an increase in surgical interventions for spinal conditions might be anticipated to a certain extent. The population adjustments employed by the authors cannot truly account for this. Clearly, this is an important issue warranting further research, with a keen focus on the clinical contexts in which such surgical interventions occur.
—The Editors
Surgical treatment for lumbar degenerative disc disease (DDD) remains controversial [1]. The mainstay of treatment for lumbar DDD are conservative treatments such as activity modification, medications, and physical therapy, and some studies have identified negative outcomes after surgical treatment. Knox and Chapman [2] found poor results in two-level fusions and in almost half (47%) of single-level fusions for lumbar DDD. Carragee et al. [3] also reported that only 43% of patients undergoing spinal fusion for lumbar DDD met the criteria for minimum acceptable outcome. In contrast, the Swedish Lumbar Spine Study Group found that fusion for lumbar DDD results in superior outcomes relative to standard nonsurgical care [4].
Surgical options for lumbar DDD include anterior lumbar interbody fusion (ALIF), posterior approach fusion procedures such as posterior lumbar interbody fusion (PLIF) and posterolateral lumbar fusion (PLF), anterior and posterior lumbar fusion (APLF), and total disc replacement (TDR). Posterior lumbar interbody fusion and PLF are popular procedures for spinal surgeons performing lumbar surgery. A variety of surgical techniques and innovative procedures have been introduced during the last decade. Recent ALIF techniques include anterior cage with screws and extreme/direct-lateral interbody fusion (XLIF/DLIF) with or without plates [5], [6]. Anterior lumbar interbody fusion with percutaneous pedicle screw fixation has also gained popularity during the last decade [7]. In the middle of last decade, lumbar TDR was approved in the United States [8], which may have changed the trend in surgical management of lumbar DDD. However, trends in the surgical treatment for lumbar DDD during the last decade are uncertain in the United States.
The purpose of this study was to examine the trends in the surgical treatment for lumbar DDD using population-based national hospital discharge data collected for the Nationwide Inpatient Sample (NIS) between 2000 and 2009. We hypothesized that the incidence of patients with lumbar DDD undergoing surgical treatment had increased over the last decade and the surgical trends would have changed with the introduction of TDR and other innovative surgical and instrumentation techniques.