Florida has long been where Americans go to retire, which puts Bradenton, Fla.-based Coastal Orthopedics on the front line of one of the biggest shifts in spine care. Patients there expect to stay active well into their 70s and 80s, and Vincent Federico, MD, a spine surgeon with the practice, sees them across every stage of that ambition.
For Dr. Federico, who specializes in ultra-minimally invasive, motion-preserving and same-day spine surgery, the birth date on a chart has become a weak guide to what a patient can handle. Age still factors into his decisions, he said, mostly in determining whether a procedure belongs in the practice’s surgery center or in a hospital. But the age he weighs is physiological.
“It definitely does play a factor, mostly more towards the site of service, and it’s honestly more like physiological age than chronologic,” Dr. Federico said. “We have 95-year-olds who come in who look like they’re 50, and then you have 70-year-olds who look like they’re 90.”
That distinction carries more weight as outpatient spine surgery expands.
“I do think that with advances both in technology, surgical techniques, but also anesthesia, that we’re able to do a lot of the things outpatient that 15 years ago people would have stayed a week in the hospital for,” he said. “That’s really exciting to continue to provide a service that can get them, one, recover quicker and two, do it safely in an outpatient setting that is lower cost and higher quality.”
Where the line is drawn is still decided case by case, he said, weighing comorbidities that could make a patient difficult to discharge from a surgery center or make a particular procedure less desirable. But the factor he leans on most doesn’t appear in a patient’s medical history. It’s a question on his intake form.
“I literally ask every single patient who they live with because that might be the number one predictor of whether or not they’re going to be a good person to do outpatient,” Dr. Federico said. “Do they have support at home? Do they have someone who can stay with them for the first week? It’s still major surgery, and we want them to be safe at home.”
Patients who live alone, he said, may be better served by a hospital stay, where they can get physical therapy and be fully optimized before going home.
The stakes of getting the first operation right are also higher for older patients, many of whom expect a repair to last for decades. Revision spine surgery is much more difficult in that population, Dr. Federico said, and recovery tends to be more prolonged. His approach to lowering that risk is to optimize alignment, avoid overfusing — which raises the incidence of adjacent-level degeneration — and keep every operation as small as possible.
“I always tell patients I try to do the absolutely smallest procedure I can to make sure that you’re going to get relief of your symptoms because I do truly believe that the smallest surgery leads to the smallest amount of insult that we add, which leads to the best recovery,” he said. “And I think if everybody adopted that, it would probably be better in the long term.”
That same restraint shapes how he views motion preservation, which many surgeons now position as an alternative to fusion. Dr. Federico called the surgeons pushing that frontier admirable but said the calculus shifts in a retirement-heavy market like Florida.
“If someone has instability in their spine, that’s not a good person, obviously, for motion preservation,” he said. “Or if somebody has significant degeneration and doesn’t really even have motion at those motion segments, then what are we really preserving?”
A 45-year-old with a cervical disc herniation is an ideal candidate for disc replacement, he said. A 75-year-old with myelopathy, a compression of the spinal cord, most likely needs a traditional anterior cervical discectomy and fusion. The deciding question is what the surgeon and the patient are each trying to achieve.
The issue Dr. Federico flagged as the largest blind spot in caring for older patients, though, starts long before anyone reaches his operating room: bone health.
“It’s actually something I’m really interested in and care about,” he said. “It is such a big problem, especially with an older female population, just because those are the patients who have a higher predisposition of [developing poor bone health.]”
Osteoporosis should influence which surgery a patient gets, how it’s performed and whether it is likely to fail, he said. Every patient who undergoes a fusion leaves with information on vitamin D, calcium and bone health, and anyone who has more than a single-level fusion, particularly women, must get a DEXA scan.
“There’s just been study after study that it leads to diminished outcomes when you don’t optimize that stuff,” Dr. Federico said.
Still, bone health remains underaddressed in orthopedics, and Dr. Federico sees several reasons. Waits to see an endocrinologist can exceed a year, and far fewer endocrinologists specialize in bone health, a shortage he said persists even in Florida, where the need is high. Many private orthopedic groups, including large ones, don’t offer bone health optimization as an ancillary service. Of the roughly 20 hospitals he rotated through in training, he said, only Chicago-based Rush University Medical Center had a bone health program.
Patients also tend not to know they have a problem.
“It’s one of those diseases that’s silent until it’s not,” he said. “You break your wrist or break your hip, and then all of a sudden you’re diagnosed with osteoporosis.”
He sees bone health as the clearest opening for preventive care in his field: treating a poor DEXA result in a patient who isn’t yet in pain and identifying risk factors early, well before a patient lands in an orthopedic surgeon’s office.
“We talk about preventative care, prophylactic care, and that’s probably the one that we could easily attack as a healthcare society and really make a difference,” he said.
With more Americans aging into that risk window, Dr. Federico expects bone health to command far more attention over the next decade.
“We already see so many hip fractures down here in osteoporotic patients,” he said. “And that’s only going to increase.”
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