Complications, reoperation rates, and health-care cost following surgical treatment of lumbar spondylolisthesis

Background: Surgery remains the mainstay for management of lumbar spondylolisthesis and is considered an effective therapeutic modality following unsuccessful nonoperative treatment. Surgical procedures include decompression, decompression with instrumented arthrodesis, and decompression with noninstrumented arthrodesis. The purpose of this study was to examine the complications, reoperation rates, and health-care costs associated with each of these procedures. Methods: The MarketScan database was utilized to identify 16,556 patients with a primary diagnosis of lumbar spondylolisthesis who underwent surgical treatment from 2000 to 2009. Outcomes were evaluated in propensity score-matched cohorts, with complication rates analyzed with the chi-square test, reoperation rates analyzed using the Mantel-Haenszel test, and health-care resource use analyzed using the Wilcoxon signed-rank test. Results: Complication rates were significantly higher in patients who underwent arthrodesis compared with those who had decompression alone during the initial hospitalization (8.3% versus 4.8%; p < 0.0001) and at the time of the ninetyday follow-up (9.6% versus 5.5%; p < 0.0001). Complication rates were similar for those who received instrumented and noninstrumented arthrodesis. Patients who underwent decompression alone had higher reoperation rates at two years or more than those who received arthrodesis (15.7% versus 11.9%; p = 0.034). Patients with instrumented arthrodesis trended to have higher reoperation rates than those without instrumentation at five years or more (18.4% versus 10.6%; p = 0.063). Initial hospital costs and two-year and five-year overall costs (in 2009 U.S. dollars) were higher for patients managed with arthrodesis than for those who had decompression only ($102,906 versus $89,337; p = 0.0018). Also, patients who received instrumentation had higher hospitalization costs than those without instrumentation ($39,997 versus $27,309; p = 0.023) and higher overall costs at two years ($73,482 versus $60,394; p < 0.0001), although the difference was not significant at five years (p = 0.29). Conclusions: Patients with lumbar spondylolisthesis who underwent decompressive laminectomy and spinal arthrodesis had lower reoperation rates but higher overall costs than patients treated with laminectomy alone. Noninstrumented arthrodesis was also associated with lower long-term reoperation rates and health-care costs compared with instrumented arthrodesis. The long-term outcomes and costs of these procedures should be evaluated in conjunction with clinical efficacy to ensure the most cost-effective treatment is utilized. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.