Age alone is becoming a less reliable measure of surgical risk as spine surgeons treat patients with increasingly complex medical needs. Osteoporosis, frailty, limited support at home and the potential consequences of revision surgery are complicating decisions about which patients should undergo surgery, where procedures should be performed and how to improve long-term outcomes.
Recent conversations with spine surgeons highlight four considerations shaping care for older patients.
1. Frailty can matter more than chronological age: Alekos Theologis, MD, an orthopedic spine surgeon at Sacramento, Calif.-based Sutter Health, said advances in surgical techniques have expanded treatment options for medically complex patients. But determining who can tolerate an operation and recover remains difficult.
“There has been a steady increase in complexity, both from the medical side and from the surgical side,” Dr. Theologis told Becker’s.
He said chronological age does not adequately reflect a patient’s physiological condition. Frailty, underlying medical conditions and social support can complicate recovery, even when surgery offers substantial potential benefits.
Rachel Bratescu, MD, an orthopedic spine surgeon at George Washington University Hospital’s Spine and Pain Center in Washington, D.C., has made a similar distinction, noting that she has seen healthy patients in their 80s recover well while younger patients with significant frailty struggled.
2. Poor bone quality can undermine surgical outcomes: Osteoporosis is another concern, particularly for older patients undergoing spinal fusion. Praveen Mummaneni, MD, professor and co-director of the UCSF Spine Center in San Francisco, said undiagnosed osteoporosis can contribute to failed fusions that are mistakenly attributed to implants.
“What failed was their bone healing capacity,” Dr. Mummaneni told Becker’s.
His practice requires bone-density testing for fusion patients older than 60. When poor bone quality is identified before elective surgery, his team works with endocrinologists to begin treatment aimed at improving bone healing.
The concern extends beyond whether a fusion succeeds. Poor bone quality can increase the risk of fixation problems and additional surgery, making preoperative assessment particularly important for older patients.
3. Outpatient surgery depends on more than medical eligibility: Advances in surgical techniques and anesthesia have made outpatient spine surgery an option for more patients. But for older adults, determining the appropriate site of care involves factors beyond medical history.
Vincent Federico, MD, a spine surgeon at Bradenton, Fla.-based Coastal Orthopedics, said physiological age and postoperative support are central to his patient-selection process.
“I literally ask every single patient who they live with because that might be the No. 1 predictor of whether or not they’re going to be a good person to do outpatient,” Dr. Federico told Becker’s.
He said patients who live alone may be better served by a hospital stay, where they can receive physical therapy and additional support before returning home.
The decision illustrates how surgical risk extends beyond the operating room. Even when a procedure can be performed safely in an outpatient setting, the patient’s ability to recover at home remains an important consideration.
4. Revision surgery raises the stakes of the initial procedure: For older patients, the possibility of needing a second spine operation can carry additional consequences.
Dr. Federico said revision surgery is more difficult in older populations and recovery often takes longer. His approach emphasizes performing the smallest procedure appropriate to relieve symptoms, optimizing alignment and avoiding unnecessary fusion levels that could contribute to adjacent-segment degeneration.
Those decisions are particularly important for patients who may have limited physiological reserve to withstand another major operation.
Dr. Bratescu has also emphasized that technical success alone does not guarantee a favorable outcome. Nutrition, muscle mass, diabetes management, bone quality and other patient-specific factors can affect healing even when surgery is performed as planned.
“A technically flawless fusion performed in someone who is malnourished or an active smoker, vitamin D deficient, has a history of osteoporosis, is frail or has poorly controlled diabetes may still produce a suboptimal outcome,” she told Becker’s.
Together, the considerations underscore the importance of looking beyond the procedure itself when weighing the risks and potential benefits of spine surgery for older patients.
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