The most critical issues in spine care for older adults


Six spine surgeons discuss best practices for performing spine surgery on elderly patients.

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Question: What some key considerations when performing complex spine surgery on older patients?

S. Samuel Bederman, MD, PhD. Spine Surgeon at St. Joseph Hospital (Orange, Calif.): We have come a long way in our ability to care for complex spinal problems, even in patients with advanced age. More efficient surgical techniques and improvements in anesthesia care have allowed us to perform complex spine surgery more safely with reduced complications. I rarely use age alone to determine if someone is a candidate for surgery. The decision is made based on a combination of factors, of which age does play a role. How much does that patient need the surgery, how complex is the surgery, how active is the patient under normal circumstances all weigh in on the decision. The more one needs the surgery and the more likely they are to return to a reasonable activity level, the more strongly I would recommend surgery even if it was complex and the patients were older. At the end of the day, it is a matter of balancing risks and benefits of any treatment.

Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: First off, resist the temptation to fix the X-ray. When I am talking to older patients where I am considering something big, I go over what their main complaints are. I engage in a dialogue, ascertaining what the patient's goals are for their surgery. I ask them, if I can help certain aspects of their issues, which ones are key? Octogenarians are remarkably realistic about surgical expectations. I always go over their medical problems and make sure all necessary specialists are involved. Other considerations are using cell-saver, if appropriate, very careful positioning and having good baseline neurological monitoring.

Mark M. Mikhael, MD. Spine Surgeon at NorthShore University HealthSystem's Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): I look at a patient's physiological age rather than chronological age in determining if a patient is fit for complex spine surgery. The typical considerations in patients are degenerative bone disease, such as osteoporosis, and comorbidities. But if you manage bone quality and other usual comorbidities in seniors like cardiovascular disease, high blood pressure, diabetes, chronic obstructive pulmonary disease as well as multiple medications taken and nutritional concerns, outcomes should be just as good as in younger patients. Research noted in a recent issue of The Spine Journal reflects my thoughts on this holistic approach with complex spine surgery for older patients. The study looked at surgical outcomes of patients older than 80 who had degenerative spondylolisthesis. The results showed age was not 'a negative predictive factor for instrumented surgery for degenerative spondylolisthesis,' meaning the 'right' elderly patient should not shy away from complex spine surgery if there's a good likelihood of improved quality of life.

Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): The complication rates are what come to mind first. It is important for patients to know what they are getting into with complex surgery. Risk factors such as osteoporosis are also important to consider when deciding on whether a patient is a candidate for surgery and if so, what type of surgery to perform. Finally, understanding the patient's demands as well as their capacity for rehabilitation are vital.

Jeffery M. Reuben, MD. Orthopedic Spine Surgeon at Hilton Head Regional Healthcare (Hilton Head Island (S.C.): Meticulous attention to detail is required in order to maximize success rates and minimize complications for spinal surgery. There are numerous key considerations when performing complex spinal surgery in the elderly, and they can be categorized into preoperative, intraoperative and postoperative. A comprehensive discussion is beyond the scope of this article, but I will discuss a few highlights in each category.

Preoperatively, the surgeon must know the relevant medical issues and assemble an appropriate team of physicians to medically tune the patient for surgery and coordinate the plan with the operative team. For surgical planning, the quality of bone and overall stability of the spine should be considered. I encourage weight-bearing X-rays and having a low threshold for ordering bone density studies, even in male patients. Maximizing preoperative nutrition status in all patients and having a discussion about any preoperative swallowing difficulties for complex anterior spine surgeries is essential.

Intraoperatively, coordination with the surgical team is critical. Keeping elderly patients normotensive without large fluid shifts is beneficial. Carrying out the preoperative medical plan with appropriate monitoring, fluid resuscitation, blood replacement, etcetera, is a must. Improving structural integrity of the operative construct for complex spinal surgeries will help decrease hardware failure. Advanced intraoperative navigation systems can help maximize screw purchase by maximizing screw diameter and length as well as aiding in appropriate placement.

Postoperatively, the transition of care from the acute setting is critical. Physical therapy and
occupational therapy assessments will help determine appropriate disposition and equipment needs. Strict written instructions covering medications, wound care and activity levels will help prevent errors. A home safety assessment by home health [providers] can help prevent falls.

In summary, with any spine surgery for any age, strict attention to detail will help maximize success rates and minimize complications. Elderly patients have unique structural and medical issues that need to be considered when planning complex spinal surgery. The secret to spine surgery is to do the right surgery first!

Noam Stadlan, MD. Neurosurgeon at NorthShore University HealthSystem's Neurological Institute (Glenview, Ill.): When considering complex spine surgery on older patients, it is imperative to make an accurate clinical diagnosis based on the patient's symptoms and a thorough exam. Seniors frequently have many degenerative findings — the result of conditions such as scoliosis, spondylolisthesis and autofusions — which can make it challenging to identify the problem. They also may have undiagnosed medical issues. For example, some patients present with symptoms of lumbar stenosis but also have cervical stenosis.

Once a diagnosis is determined, the physician must decide what is required to surgically relieve the symptoms, essentially what needs to be decompressed, and address the patient's stability — not only before surgery but also what it will be like post-surgery. The doctor then must identify the surgery that has the best chance of success and minimize the risk of complications, keeping in mind that complications are a major source of morbidity and mortality in the elderly. Lastly, the medical team must make sure that the patient is medically optimized for surgery and do everything possible — early mobilization, incentive spirometer, DVT prophylaxis, early removal of catheters and more — to minimize medical complications.

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