Published 11/25/2024
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Rebecca Araujo
A poster study presented at the AAOS 2024 Annual Meeting found slightly higher costs and similar complications with endoscopic versus open single-level lumbar decompression; however, endoscopic decompression patients had a significantly higher rate of secondary lumbar surgery within 2 years. The results demonstrate a need for further research to understand the risk of treatment failure associated with this endoscopic procedure.
The findings were presented by Lauren Boden, MD. Dr. Boden is an orthopaedic spine fellow at the Cleveland Clinic.
“While endoscopic decompression is a well-established procedure in Asia, it hasn’t gained the same traction here in the United States,” Dr. Boden told AAOS Now. “Some of that has been due to the billing/reimbursement involved and the higher cost of obtaining new equipment. But there were also some clinical concerns reported in the literature regarding outcomes.”
The researchers queried the PearlDiver database to identify data on patients who underwent endoscopic or open single-level lumbar decompression between 2017 to 2021. In total, 895 endoscopic and 102,258 open surgeries with 2 years of follow-up were included.
At 2 years, total costs were higher in the endoscopic group, at $20,347 compared with $18,089 in the open group (P = 0.03). “Rates of dural tear, infection, and wound dehiscence were extremely low (<1 percent) and similar between groups,” dr. boden said. notably, patients who received endoscopic surgery were more than twice as likely to require a second lumbar surgery in the following 2 years (16.98 percent versus 7.38 percent;>P <0.00001).
Among the patients requiring additional lumbar surgery, there were more patients undergoing re-exploration in the open decompression group (33.4 percent versus 13.8 percent; P <0.00001). “although any additional lumbar surgery within 2 years was more common amongst patients in the endoscopic decompression group, the rate of re-exploration at the same level was similar between groups,” dr. boden noted, at 2.35 percent in the endoscopic group and 2.47 percent in the open group (>P = 0.82). Patients in the endoscopic group who underwent secondary surgery were significantly more likely to have an endoscopic procedure (35.5 percent versus 0.64 percent; P <0.00001). rates of fusion or other lumbar decompression procedures were also similar between patients requiring secondary surgery between the two groups.
The higher rate of secondary surgeries in the endoscopic group may be related to the lower rate of uptake of this procedure in the United States, Dr. Boden explained. “Many studies in other countries have shown radiographically and clinically similar outcomes after endoscopic and open decompression,” she noted. “There is a well-known steep learning curve involved with this endoscopic procedure, and this database may have captured patients of surgeons with lower volume of endoscopic procedures.” More information on the expertise of the surgeons performing endoscopic surgery could highlight how experience or volume is related to outcomes.
Additionally, the findings do not show that the utilization of secondary lumbar surgery equates to failure of the initial procedure, as the researchers “were unable to distinguish which levels were involved in the [secondary] surgeries,” Dr. Boden commented.
The study is limited by the use of billing and coding data for diagnoses, procedures, and complications, which may have impacted the findings. “Drawing large conclusions about the clinical efficacy of the procedure from this study would be premature,” Dr. Boden said. “The difference in additional surgery within 2 years after single-level lumbar decompression is alarming, but more work is needed to investigate the cause for that difference.”
Dr. Boden called for multicenter prospective trials “to elucidate the true complication profile for endoscopic decompression in our patient population.” She added, “Having a more nuanced picture of which patients benefit from the surgery and the real reason for additional surgery—whether it is indeed failure of initial decompression requiring reoperation or an unrelated cause—is necessary before any real clinical takeaways can be made.”
Dr. Boden’s coauthors of “Complications and Cost in Open Versus Endoscopic Lumbar Decompression: A Database Study” are Najib Muhammad; Matthew A. Kanzler; Susanne H. Boden, MD; and David S. Casper, MD.
Rebecca Araujo is the managing editor of AAOS Now. She can be reached at raraujo@aaos.org.