中老年人腰椎滑脫手術種類的趨勢、預後及醫療資源利用

Trends, prognosis and resource use in older patients with surgery for lumbar spondylolisthesis

黃旭霖(Shiuh-Lin Hwang)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2011年)

摘要

研究目的
腰椎滑脫是常見的中老年人退化性疾病，台灣為高齡化社會，腰椎滑脫手術的研究很少，本研究以腰椎滑脫病人為對象，分析55歲以上中老年人的手術種類趨勢、預後及醫療資源利用。
研究方法與材料
本研究為回溯性橫斷性研究，分析2005年至2009年健保局資料庫中腰椎滑脫病人，第一次接受腰椎手術，國際疾病分類（第九版）包括非融合手術（03.09椎板切除、80.51椎間盤切除）及融合手術（81.08後路徑椎體融合、81.06前路徑椎體融合及81.07後側橫突融合手術），研究不同年齡層（55~64歲中年病人、65~74歲老年病人及75歲以上老年病人）在人口學特質，臨床特質或醫院特質是否不同及研究預後及醫療資源利用是否不同及影響因子。同時病歷回顧性研究某醫學中心腰椎滑脫手術病人之療效和醫療資源利用，並探討此類病人手術後生活品質。
研究結果
健保局資料分析共納入22121位病人，中老年人的融合手術逐年增加，且都以後路椎體融合手術最多。75歲以上老年病人併發症較多，大併發症的危險性是55~64歲中年病人之5.307倍，但中老年人住院死亡率都是0.1%，無統計學上的差異，3天內急診回診和14天再入院以75歲以上老年病人較多（分別是1.8%及2.6%），與中年病人有統計學上的差異。住院天數與醫療費用也是75歲以上老年病人較多，有統計學上的意義。在控制其他變項後，高年齡層是影響住院天數和醫療費用的重要影響因子。
某醫學中心病歷回顧性研究後路椎體融合手術病人，不同年齡層合併症、手術麻醉時間、融合或固定節數、出血量、輸血量及止痛劑使用無統計學上差異。併發症較常發生於65歲以上老年病人，醫療費用隨年齡層增高而增加，有統計學上差異。老年病人住院天數較長，但無統計學上差異。控制其他變項後，高年齡層不影響住院天數及醫療費用，住院天數重要影響因子為併發症，醫療費用為住院天數，中老年病人手術後疼痛指數(VAS)及生活功能指數(ODI)，皆有意義改善。病人無手術後30天死亡。
結論與建議
中老年人腰椎滑脫手術以後路徑椎體融合為主，雖然75歲以上老年病人併發症，住院天數及醫療費用較多，但當次住院死亡率與中年病人相同，且手術後疼痛及生活功能都能有意義的改善，老年病人腰椎滑脫手術是安全且有效的手術，在適當的適應症及良好的照護品質建議老年病人仍應接受腰椎滑脫手術，以改善生活品質。

關鍵字

腰椎滑脫 ； 融合手術 ； 預後 ； 醫療資源利用

並列摘要

Objective
Lumbar spondylolisthesis is the common degenerative disease in the elderly. Taiwan has been an advanced age society. However, then are little studies for the lumbar spondylolisthesis in the older patients in Taiwan. Therefore, the aim of this study is to investigate the trend, prognosis and resourence use in older patients with surgery for lumbar spondylolithesis.
Material and Method
For the database of the National Health Insurance (NHI), we select the surgical patients for the lumbar spondylolisthesis from 2005 to 2009. Two criteria were included from ICD-9-CM：（1）diagnostic procedure codes:7384 and 75612 (2) surgical procedure codes：0309, 8051, 8106, 8107, 8108. We only included the patients whose age is 65 years or older and divided these patients into 3 groups：55-64 years, 65-74 years and ≥75 years. We investigate the sex, clinical characteristic, outcome and resource use among these three age groups. In addition, we analyzed the functional outcome of surgical patients for the lumbar spondylolisthesis in a southern medical center. The statistics method included chi-square test, One-way ANOVA, linear regression,and ligistic regression.
Results
From the NHI dotabase, 22121 patients were included. Fusion surgery increased with years in the elder patients. Among then, posterior interbody fusion is most common. Postoperative complications is found more in the patients age ≥75, and the odds ratio of developing major complication is 5.307 than these in the patients age 55-65. Admission mortality is 0.1% in these three age groups without statictically significant difference. The rate of emergent visiting within 3 days after discharge and 14-days readmission was 1.8% and 2.6% respectively, in the patients age ≥75 with significantly more than these in the patients age 55-65. Length of stay at hospital and total charge were increased in the patients age ≥75.
The data analyzed from a medical center showed no significant difference in the comorbidity, surgery or mesthesia time, fusion or fixation segment numbers, and blood loss amount among 3 age groups. Complications is found more in the patients age ≥65. Total charge increased with age with significant difference. Postoperative visual analyscale (VAS) and Oswestry disable index (ODI) had significant improvement (P<0.001).
Conclusion
Surgeons should be vigilant about postoperative complications in older patients. Although complications, length of stay and total charge is increased in the patients age ≥65, admission mortality is same among 3 age groups. Good postoperative life quality can be obtained in the patients age ≥75. Therefore, elderly patients is not contraindicated for surgical intervention because of their age. Attention should be paid to controlling comorbidities and complications in the older patients.

並列關鍵字

lumbar spondylolisthesis ； fusion ； outcome ； resource use

參考文獻

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