Comparison of complications, costs, and length of stay of three different lumbar interbody fusion techniques: an analysis of the Nationwide Inpatient Sample database

Abstract

Background context: Lumbar interbody fusion (LIF) techniques have been used for years to treat a number of pathologies of the lower back. These procedures may use an anterior, posterior, or combined surgical approach. Each approach is associated with a unique set of complications, but the exact prevalence of complications associated with each approach remains unclear.

Purpose: To investigate the rates of perioperative complications of anterior lumbar interbody fusion (ALIF), posterior/transforaminal lumbar interbody fusion (P/TLIF), and LIF with a combined anterior-posterior interbody fusion (APF).

Study design/setting: Retrospective review of national data from a large administrative database.

Patient sample: Patients undergoing ALIF, P/TLIF, or APF.

Outcome measures: Perioperative complications, length of stay (LOS), total costs, and mortality.

Methods: The Nationwide Inpatient Sample database was queried for patients undergoing ALIF, P/TLIF, or APF between 2001 and 2010 as identified via International Classification of Diseases, ninth revision codes. Univariate analyses were carried out comparing the three cohorts in terms of the outcomes of interest. Multivariate analysis for primary outcomes was carried out adjusting for overall comorbidity burden, race, gender, age, and length of fusion. National estimates of annual total number of procedures were calculated based on the provided discharge weights. Geographic distribution of the three cohorts was also investigated.

Results: An estimated total of 923,038 LIFs were performed between 2001 and 2010 in the United States. Posterior/transforaminal lumbar interbody fusions accounted for 79% to 86% of total LIFs between 2001 and 2010, ALIFs for 10% to 15%, and APF decreased from 10% in 2002 to less than 1% in 2010. On average, P/TLIF patients were oldest (54.55 years), followed by combined approach (47.23 years) and ALIF (46.94 years) patients (p<.0001). Anterior lumbar interbody fusion, P/TLIF, and combined surgical costs were $75,872, $65,894, and $92,249, respectively (p<.0001). Patients in the P/TLIF cohort had the greatest number of comorbidities, having the highest prevalence for 10 of 17 comorbidities investigated. Anterior-posterior interbody fusion group was associated with the greatest number of complications, having the highest incidence of 12 of the 16 complications investigated.

Conclusions: These data help to define the perioperative risks for several LIF approaches. Comparison of outcomes showed that a combined approach is more expensive and associated with greater LOS, whereas ALIF is associated with the highest postoperative mortality. These trends should be taken into consideration during surgical planning to improve clinical outcomes.

Keywords: Anterior approach; Combined approach; Complications; Geographic distribution; Lumbar interbody fusion; Posterior approach.