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Study Design: Sequential cross-sectional analysis., Objective: To document vertebroplasty rates and costs., Summary of Background Data: Little is known about interstate variation in rates or about nation-wide costs associated with the growing use of percutaneous vertebroplasty., Methods: Using specific CPT-4 billing codes, we reviewed aggregate Medicare Part B fee-for-service claims data (cross-stratified by physician specialty and treatment setting) on thoracolumbar vertebroplasties performed from 2001-2005. Vertebroplasty rates for individual states were expressed per 100,000 Part B fee-for-service enrollees. Nation-wide facility and physician charges (combining expected contributions from all sources) allowed by Medicare for vertebroplasties and associated imaging guidance procedures were applied to observed vertebroplasty volumes. These charges (reflecting direct medical costs from an all-payer perspective) were expressed in 2005 dollars using the Producer Price Index., Results: Vertebroplasty rates for individual states rose but varied considerably, ranging from 0.0 to 515.6/100,000 Medicare Part B fee-for-service enrollees in 2001 (median state rate = 35.4), and from 9.8 to 849.5 in 2005 (median state rate = 75.0). On average, 1.3 vertebral levels were treated per procedure, varying by treatment site and physician specialty. Fluoroscopic rather than computed tomography guidance was used in 98.7% of cases. Total nation-wide inflation-adjusted charges rose from $76.0 million for 14,142 cases performed in 2001 to $152.3 million for 29,090 cases in 2005. While vertebroplasty was predominantly an outpatient procedure, inpatient cases generated most of the charges. Increasing volumes and costs were associated with cases performed in ambulatory surgery centers and physicians' offices., Conclusion: Nation-wide vertebroplasty volumes and inflation-adjusted charges doubled from 2001 to 2005 in this Medicare population. Procedure rates varied considerablyby state. Almost all cases involved fluoroscopic guidance; procedures treating multiple vertebral levels were not uncommon. Procedures performed in free-standing facilities are of growing importance. Given the issues surrounding appropriate vertebroplasty use, future practice patterns and outcomes should be closely tracked.

Study Design: A retrospective analysis of population-based hospital discharge registry from all nonfederal acute care hospitals in Washington State., Objective: We examined the cumulative incidence of second lumbar spine operation following an initial lumbar operation for degenerative conditions. We aimed to determine if the cumulative incidence of a second lumbar spine operation decreased in the 1990s following an increase in the rate of fusion surgery and the introduction of several newer fusion technologies., Summary of Background Data: Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Improved technology is expected to improve alignment, healing, and instability, and to reduce repeat operations., Methods: Among the patients who had an inpatient lumbar decompression or lumbar fusion surgery for degenerative spine disorders in 1990 to 1993 (n = 24,882) or in 1997 to 2000 (n = 25,209), we examined rates of subsequent lumbar spine surgery during a 4-year follow-up. We performed a Cox proportional hazards regression to compare the probability of a reoperation between the 2 cohorts, adjusting for age, sex, primary diagnosis, type of insurance, and comorbidity., Results: Among patients who underwent surgery for lumbar degenerative disease, more than twice as many had a fusion procedure in the 1997 to 2000 cohort (19.1%) compared with the 1990 to 1993 cohort (9.4%). However, the 4-year cumulative incidence of reoperation was higher in the 1997 to 2000 cohort compared with the 1990 to 1993 cohort (14.0% vs. 12.4%; hazard ratio, 1.16; 95% confidence interval, 1.11-1.22, P < 0.001). Among fusion patients, those in the 1997 to 2000 cohort were approximately 40% more likely to undergo a reoperation within the first year when compared with fusion patients in the 1990 to 1993 cohort. There was no difference in reoperation probability beyond 1 year., Conclusion: A higher proportion of fusion procedures and the introduction of new spinal implants between 1993 and 1997 did not reduce reoperation rates. Patients who had lumbar surgery for degenerative disease in the late 1990s were more likely to undergo a repeat operation within 4 years than patients who had surgery in the early 1990s.

Study Design: Retrospective cohort study using a hospital discharge registry of all nonfederal acute care hospitals in Washington state., Objectives: To determine the cumulative incidence of reoperation following lumbar surgery for degenerative disease and, for specific diagnoses, to compare the frequency of reoperation following fusion with that following decompression alone., Summary of Background Data: Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Compared to decompression alone, spine fusion is commonly viewed as a stabilizing treatment that may reduce the need for additional surgery. However, indications for fusion surgery in degenerative spine disorders remain controversial, and the effects of fusion on reoperation rates are unclear., Methods: Adults who underwent inpatient lumbar surgery for degenerative spine disorders in 1990-1993 (n = 24,882) were identified from International Classification of Diseases ninth Revision, Clinical Modification codes and then categorized as having either a lumbar decompression surgery or lumbar fusion surgery. We then compared the subsequent incidence of lumbar spine surgery between these groups., Results: Patients who had surgery in 1990-93 had a 19% cumulative incidence of reoperation during the subsequent 11 years. Patients with spondylolisthesis had a lower cumulative incidence of reoperation after fusion surgery than after decompression alone (17.1% vs. 28.0%, P = 0.002). For other diagnoses combined, the cumulative incidence of reoperation was higher following fusion than following decompression alone (21.5% vs. 18.8%, P = 0.008). After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis., Conclusion: Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. For spondylolisthesis, reoperation is less likely following fusion than following decompression alone. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.

Study Design: Sequential cross-sectional study., Objectives: To quantify patterns of outpatient lumbar spine surgery., Summary of Background Data: Outpatient lumbar spine surgery patterns are undocumented., Methods: We used CPT-4 and ICD-9-CM diagnosis/procedure codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUP's State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates., Results: Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000., Conclusions: While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.

Study Design: Retrospective cohort study using national sample administrative data., Objectives: To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures., Summary of Background Data: Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery., Methods: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection., Results: In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses., Conclusions: Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.