BACKGROUND CONTEXT

Indications for revision lumbar fusion are variable, but include recurrent stenosis (RS), adjacent segment disease (ASD), and pseudarthrosis. The efficacy of revision lumbar fusion has been well established, but their outcomes compared to primary procedures is not well documented.

PURPOSE

The purpose of this study was to compares surgical and clinical outcomes between (1) revision and primary lumbar fusion, (2) revision lumbar fusion based on indication (ASD, pseudarthrosis, or RS), and (3) revision lumbar fusion based on whether the index procedure included an isolated decompression or decompression with fusion.

STUDY DESIGN/SETTING

Retrospective single-institution cohort study.

PATIENT SAMPLE

Four thousand six hundred seventy-one consecutive lumbar fusions from 2011 to 2021, of which 892 (23.6%) were revision procedures. The indication for revision procedures included 502 (56.3%) for ASD, 153 (17.2%) for pseudarthrosis, and 237 (26.6%) for RS. Of the 892 revision procedures, 694 (77.8%) underwent an index fusion while 198 (22.2%) underwent an index decompression without fusion.

OUTCOME MEASURES

Hospital readmissions, all-cause reoperation, need for subsequent revision and patient reported outcome measures (PROMs) at baseline, 3-months postoperatively, and 1-year postoperatively, including the Mental Health Component score (MCS-12) and Physical Health Component score (PCS-12) of the Short Form 12 survey, the Oswestry Disability Index (ODI), and the Visual Analog Scale (VAS) for Back and Leg pain.

METHODS

Patient demographics, comorbidities, surgical characteristics, and outcomes were collected from electronic medical records. Twenty-eight percent of patients had preoperative and postoperative PROMs. A delta PROM score was calculated for the 3-month and 1-year postoperative timepoints, which was the change from the preoperative to postoperative value. Univariate comparisons were performed to compare revision fusions to primary fusions. Multivariate logistic regression was performed for all-cause reoperation and subsequent revision surgery, while multivariate linear regression was performed for ∆PROMs at 3-months and 1-year. Revision procedures were then separately regrouped based on indication for revision fusion and whether they underwent a fusion for their index procedure. Univariate comparisons and multivariate linear regressions for ∆PROMs were then repeated based on the new groupings.

RESULTS

There was no difference in hospital readmission rate (5.38% vs. 4.60%, p=.372) or length of stay (4.10 days vs. 3.94 days, p=.129) between revision and primary lumbar fusion, but revision fusions had a higher rate of all-cause reoperation (16.1% vs. 11.2%, p<.001) and subsequent revision (13.7% vs. 9.71%, p=.001), which was confirmed on multivariate logistic regression (Odds Ratio (OR): 1.42, p=.001 and OR: 1.37, p=.007, respectively). On multivariate analysis, a revision procedure was an independent risk factor for worse improvement ∆ODI, ∆VAS Back, ∆VAS Leg, and ∆PCS-12 and 1-year postoperatively. Regardless of the indication for revision lumbar fusion, patients significantly improved in the 3-month and 1-year postoperative PCS-12, ODI, VAS Back, and VAS Leg, with the exception of the 3-month PCS-12 for pseudarthrosis (p=.620). Patients undergoing revision for ASD had significantly worse 1-year postoperative PCS-12 (32.3 vs. Pseudarthrosis: 35.6 and RS: 37.0, p=.026), but there were no differences in ∆PROMs. There was no difference in hospital readmission, all-cause reoperation, or subsequent revision based on whether a patient had an index lumbar fusion or isolated decompression. Multivariate linear regression analysis found that a surgical indication of pseudarthrosis was a significant predictor of decreased improvement in 3-month ∆VAS Leg (ref: ASD, β=2.26, p=.036), but having an index fusion did not significantly predict worse improvement in ∆PROMs when compared to isolated decompressions.

CONCLUSIONS

Revision lumbar fusions had a higher rate of reoperation and subsequent revision surgery when compared to primary lumbar fusions, but there were no difference in hospital readmission rates. Patients undergoing revision lumbar fusion experience improvements in all patient reported outcome measures, but their baseline, postoperative, and magnitude of improvement are worse than primary procedures. Regardless of whether the lumbar fusion is a primary or revision procedure, all patients have significant improvements in pain, disability and physical function. Further, the indication for the revision procedure is not correlated with the expected magnitude of improvement in patient reported outcomes. Finally, no differences in baseline, postoperative, and ∆PROMs for revision fusions were identified when stratifying by whether the patient had an index decompression or fusion.

中文翻译：

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与初次腰椎融合术相比，翻修腰椎融合术的再次手术率更高，临床结果更差

背景语境

腰椎融合术的适应症各不相同，但包括复发性狭窄 (RS)、相邻节段疾病 (ASD) 和假关节形成。翻修腰椎融合术的疗效已得到充分证实，但与主要手术相比，其结果尚无充分记录。

目的

本研究的目的是比较手术和临床结果（1）翻修和初次腰椎融合，（2）基于适应症（ASD、假关节或 RS）的翻修腰椎融合，和（3）翻修腰椎融合基于是否索引程序包括孤立减压或融合减压。

研究设计/设置

回顾性单机构队列研究。

患者样本

2011 年至 2021 年连续进行了 4671 例腰椎融合术，其中 892 例 (23.6%) 为翻修手术。翻修手术的指征包括 502 例 (56.3%) 的 ASD、153 例 (17.2%) 的假关节和 237 例 (26.6%) 的 RS。在 892 例翻修手术中，694 例 (77.8%) 接受了指标融合，而 198 例 (22.2%) 接受了指标减压但未融合。

结果测量

基线、术后 3 个月和术后 1 年的再入院率、全因再手术率、后续翻修需求和患者报告结果测量 (PROM)，包括心理健康成分评分 (MCS-12) 和身体健康成分评分(PCS-12) 的 Short Form 12 调查、 Oswestry 残疾指数(ODI) 和用于背部和腿部疼痛的视觉模拟量表 (VAS)。

方法

从电子病历中收集患者的人口统计资料、合并症、手术特征和结果。28% 的患者有术前和术后 PROM。计算术后 3 个月和 1 年时间点的 delta PROM 评分，即从术前值到术后值的变化。进行单变量比较以比较修正融合与初次融合。对全因再手术和随后的翻修手术进行多变量逻辑回归，而多变量在 3 个月和 1 年时对 ∆PROM 进行线性回归。然后根据翻修融合的指征以及他们是否接受了索引手术的融合，分别对翻修手术进行了重新分组。然后根据新分组重复 ΔPROM 的单变量比较和多变量线性回归。

结果

再次入院率（5.38% 对 4.60%，p=.372）或住院时间（4.10 天对 3.94 天，p=.129）在翻修和初次腰椎融合之间没有差异，但翻修融合有更高的全因再手术率（16.1% 对 11.2%，p<.001）和后续翻修率（13.7% 对 9.71%，p=.001），这在多变量逻辑回归（优势比 (OR) : 1.42, p=.001 和 OR: 1.37, p=.007)。在多变量分析中，翻修手术是 ΔODI、ΔVAS 背部、ΔVAS 腿部和 ΔPCS-12 和术后 1 年更差改善的独立危险因素。无论腰椎融合术的指征如何，患者在术后 3 个月和 1 年的 PCS-12、ODI、VAS 背部和 VAS 腿部均有显着改善，但 3 个月的 PCS-12 假关节除外（p =.620）。接受 ASD 翻修的患者术后 1 年 PCS-12 显着更差（32.3 vs. 假关节：35.6 和 RS：37.0，p=.026），但 ΔPROM 没有差异。根据患者是否进行了指数腰椎融合或孤立减压，在再次入院、全因再手术或随后的翻修方面没有差异。多变量线性回归分析发现，假关节手术指征是 3 个月 ΔVAS 腿改善减少的重要预测因子（参考：ASD，β=2.26，p=.036），但指数融合并不能显着预测更差与隔离减压相比，ΔPROM 有所改善。根据患者是否进行了指数腰椎融合或孤立减压，在再次入院、全因再手术或随后的翻修方面没有差异。多变量线性回归分析发现，假关节手术指征是 3 个月 ΔVAS 腿改善减少的重要预测因子（参考：ASD，β=2.26，p=.036），但指数融合并不能显着预测更差与隔离减压相比，ΔPROM 有所改善。根据患者是否进行了指数腰椎融合或孤立减压，在再次入院、全因再手术或随后的翻修方面没有差异。多变量线性回归分析发现，假关节手术指征是 3 个月 ΔVAS 腿改善减少的重要预测因子（参考：ASD，β=2.26，p=.036），但指数融合并不能显着预测更差与隔离减压相比，ΔPROM 有所改善。

结论

与初次腰椎融合术相比，翻修腰椎融合术的再次手术率和后续翻修手术率更高，但再入院率没有差异。接受翻修腰椎融合术的患者在所有患者报告的结果指标中均有改善，但他们的基线、术后和改善幅度都比初次手术差。无论腰椎融合术是初次手术还是翻修手术，所有患者的疼痛、残疾和身体机能都有显着改善。此外，修订程序的适应症与患者报告结果的预期改善程度无关。最后，基线、术后、.