Fusion at the time of the initial surgery may not be necessary
Results of a study that investigated the reoperation rates of patients after multilevel adjacent lumbar decompressions suggested that the need for subsequent arthrodesis in decompressions of three or more consecutive levels without concomitant fusion may be less than what conventional wisdom and clinical practice dictate. The data was presented in Scientific Poster P0334 at the AAOS 2018 Annual Meeting.
“Traditional wisdom says that several adjacent laminectomies can lead to instability, eventually requiring a fusion. However, we found very little in the literature to support this,” said coauthor Ryan Hoel, MD. “We were interested in investigating if this principle was in fact true.”
Dr. Hoel and his colleagues identified 45 patients who underwent multilevel (three or more) lumbar decompressions without concomitant fusion at a single Veterans Affairs (VA) tertiary referral hospital over a 15-year period and who had at least 11 months of follow-up. Their goal was to identify the reoperation rate in these patients, particularly the rate of subsequent fusion at the previously decompressed levels.
The researchers reviewed the patients’ chart data to confirm the initial surgery and to determine if any subsequent spinal surgeries were performed. Patients also were contacted by phone to determine if they had undergone subsequent spine surgery outside the VA hospital.
The mean follow-up time was 27 months (range: 11–140 months). Overall, 12 patients (27 percent) had undergone reoperation at time of final follow-up. The researchers’ analysis revealed the following:
- Three patients (7 percent) went on to subsequent arthrodesis at a previously decompressed level at 14, 23, and 25 months (mean: 21 months).
- Three patients (7 percent) underwent revision decompression at previously decompressed levels at 6, 24, and 130 months (mean: 53 months).
- The one patient with follow-up greater than 100 months underwent revision decompression at 130 months.
- Five patients (10 percent) underwent reoperation in the first two months for wound complications related to infection or hematoma.
- One patient (2 percent) underwent débridement of an epidural abscess located three levels cranial to the most proximal decompression six years after the index surgery. It was determined that the abscess was not related to the prior decompression.
“In our series, we found that only a small proportion of patients who underwent laminectomies at three or more levels ultimately went on to a fusion within our follow-up period,” Dr. Hoel said.
The authors admitted that the study does have limitations, namely the lack of patient-reported outcomes data at preoperative and postoperative time points, as well as a relatively short follow-up period.
Nonetheless, Dr. Hoel said, “This study challenges conventional thought that patients needing simultaneous 3+ level laminectomies should be offered a fusion at the time of the initial surgery. Performing laminectomies at several levels does not necessarily result in instability, and thus multilevel laminectomies without fusion could reasonably be considered in patients with spinal stenosis at several adjacent levels.”
Dr. Hoel’s coauthors of “Short Term Reoperation Rates Following Three or More Level Lumbar Decompressions” are Melissa White, BA; Sharon C. Yson, MD; Jeffrey Thomas Luna, MD; and Jonathan N. Sembrano, MD.
Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at firstname.lastname@example.org.