Marked Increase in Spinal Deformity Surgery Throughout the United States

Abstract

Study Design. Retrospective cohort database study.Objective. The aim of this study was to investigate trends in utilization and demographics in Spinal Deformity Surgery. Summary of Background Data. The aging population in the United States will likely result in increased incidence of adult degenerative scoliosis. With a national focus on resource utilization and value-based care, it is essential for surgeons, researchers, and health care policy makers to know utilization and demographic trends of spinal surgery with long fusion construct. Methods. The National Inpatient Sample (NIS) database was queried for patients who underwent fusion or refusion of nine or more vertebrae (ICD-9-CM 81.64) between 2004 and 2015 across 44 states. Demographic and economic data include annual number of surgeries, incidence, patient age, sex, region, insurance type, charge, routine discharge, length of stay, and data. The NIS database represents a 20% sample of discharges from US hospitals, excluding rehabilitation and long-term acute care hospitals, which is weighted to provide national estimates. Result. In 2014, there were 14,615 fusions involving nine or more vertebrae across the United States. The number of fusions involving nine or more levels has increased 141% from 6072 in 2004. Long fusion constructs increased 460% from 2004 to 2014 among patients 65 to 84 years' old. The mean hospital cost associated with long fusion spine surgery was $69,546 per case in 2015. Between 2004 and 2014, the payer breakdown for individuals receiving spinal deformity surgery is as follows: 54.2% private insurance, 18% Medicare, and 21.2% Medicaid. Conclusion. The massive increase (141%) in utilization of long construct spine fusion was primarily driven by 460% rise in incidence of the surgery among those aged 65 to 84. Although the cause is unknown, it is possible that this rise was, at least in part, driven by the implementation of the affordable care act, improved surgical safety, and better knowledge of spinopelvic parameters.

Is there an indication for surgery in patients with spinal deformities? – A critical appraisal

“…However, as pointed out below (Beschloss et al 2021), the number of surgeries for patients with spinal deformities is constantly rising, and this fact is consistent with the experience of the first author. The question therefore arises why today there are still so many surgeries performed mainly in otherwise healthy individuals with a benign condition like AIS (80% -90% of all scoliosis cases), sometimes even in curves of less than 40°, and in relatively mature patients without a significant risk for further deterioration (Weiss 2007, see Figure 3).…”

“…The number of long construct spine fusion has increased dramatically since 2004 (Beschloss et al 2021 ), for patients aged 65 years and above by as much as 460%. The authors find no explanation for this, and estimate that this increase in long construct spine fusion is because of the improved availability, better safety during surgery and an improved understanding of the spinopelvic parameters.…”

“…Considering the rising numbers of long spinal fusions (Beschloss et al 2021 ) and the obvious lack of evidence only few surgeons seem to tell their patients that with respect to health, there is no huge advantage of surgery when compared to non-surgical management (Ward et al 2017 ). Indeed, Farshad et al ( 2020 ) in their article conclude ‘After around 47 and 39 years, respectively, surgical and non-surgical treatment of moderate AIS showed similar subjective outcomes, but with a relevant smaller curve magnitude with surgical treatment’.…”

“…The answer may be a point of view that was not considered by Beschloss et al (2021): A conflict of interest! (Hawes 2002;Rosen 2020;Weiss 2020).…”

Dysfunctional paraspinal muscles in adult spinal deformity patients lead to increased spinal loading

“…The standard of care for ASD patients who suffer from significant pain and functional loss is multi-level spinal decompression, realignment, and fusion [ 11 ]. While most patients benefit from these complex surgeries, up to 50% will develop some abnormal changes at the vertebral level proximal to the spinal instrumentation [ 12 ].…”