|Year : 2019 | Volume
| Issue : 1 | Page : 52-55
Spinal decompression and instrumented fusion in an elderly woman: A case report and literature review
Abhishek Vaish, Prabin Nepal, Raju Vaishya
Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi, India
|Date of Web Publication||11-Mar-2019|
Indraprastha Apollo Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
The increase in population of older adults will be associated with a parallel increase in musculoskeletal problems such as arthritis and spinal problems. Surgical treatment of degenerative disease of the spine can produce significant improvements in function in suitably selected patients. Improvements in surgical and anesthetic techniques may make more-invasive surgery feasible for elderly patients. We present a case of an 89-year-old woman, who presented with lumbar radiculopathy due to degenerative lumbar canal stenosis and multilevel instability. She was managed successfully with spinal decompression and instrumented spinal fusion of L4/5 and L5/S1 segments.
Keywords: Degenerative disc disease, instrumentation, lumbar canal stenosis, octogenarians, spinal fusion, spondylosis
|How to cite this article:|
Vaish A, Nepal P, Vaishya R. Spinal decompression and instrumented fusion in an elderly woman: A case report and literature review. Apollo Med 2019;16:52-5
| Introduction|| |
The population of older adults is rising worldwide because of increasing life expectancy. Globally, the 60-plus population constitutes about 11.5% of the total population of 7 billion. By the year 2050, it is projected to increase to about 22% when the elderly outnumber children (below 15 years of age). In Asia, the proportion of the elderly is also expected to increase from 10.5% to 22.4% during 2012–2050. Inevitably, this increase will be associated with a parallel increase in musculoskeletal problems such as arthritis and spinal problems. Several studies have demonstrated that the surgical treatment of degenerative disease of the spine can produce significant improvements in function in suitably selected patients. When successful, the patients should experience dramatic improvements in pain, ambulation, and activities of daily living.
Improvement in perioperative care and special guidelines has made the possibility of spinal surgery in the elderly possible. The perception of age as a significant risk factor to surgical treatment has also changed over time. Spinal surgery to treat the lumbar degenerative disease can be safe even in the extremely elderly patient. Although the rate of complications is higher in the elderly compared to younger patients, it may be acceptable when it is balanced against the potential benefits of the intervention. Careful attention must be kept to the patient's comorbidities, keeping the anesthetic and surgical time to a minimum.
| Case Report|| |
An 89-year-old female presented with low back pain with inability to walk >100 m and disturbed sleep. Her back pain was radiating to both legs for the last year with aggravation for 3 months. On clinical examination, the straight leg raising test was 60°, on both sides, with mild weakness on dorsiflexion of the great toe. Her X-ray [Figure 1] and magnetic resonance imaging of the spine showed degenerative changes of the spine with spinal cord compression at L4–L5 and L5–S1 level [Figure 2]. After medical evaluation, she was surgically treated with spinal decompression and instrumented spinal fusion of L4/5 and L5/S1 segments. The surgery lasted for 2.5 h and was uneventful. She recovered well with the significant reduction of symptoms and could walk comfortably after 1 week. At 9-month follow-up, she reported no back or leg pain and could walk up to 1 km, without any problems, and the radiographs showed implants in a good position, without any evidence of loosening [Figure 3].
| Discussion|| |
There are various geriatric-related spinal disorders such as degenerative disc disease, degenerative deformities, traumatic disorders, spinal tumors, infections, and inflammatory disorders. The treatment goal and surgical indications in the geriatric population may be different than in a young healthier population. In elderly individuals, the surgical challenges include the multilevel involvement and altered anatomy of the affected spinal elements secondary to advanced spondylosis.
With increasing life expectancy, globally, the need for treatment for the age-related spinal problem is warranted to relieve the pain and improve the quality of life of these elderly individuals. However, the surgical procedure in elderly patients, especially octogenarians and nonagenarians is often challenging. The degenerative and other disorder of spine problems in this population group may require a surgical procedure if the conservative measures have failed, after 3–6 months of such treatment.
However, the older adults are less willing to undergo a prescribed surgery for several reasons such as ignorance, advanced age, uncertainty about their life, associated comorbidities, and fear of potential postoperative complications. However, the age is no bar for a successful medical outcome. Physical variables such as preoperative functional status and medical comorbidity have influenced surgical outcome. A patient's preoperative rating of his or her health may be a significant predictor of symptom severity, walking capacity, and satisfaction after lumbar decompression. Psychological variables reportedly correlate with patient satisfaction after spine surgery. Associated significant comorbidities put these individuals at a higher risk of complications for surgery [Table 1], and multiple comorbidities (>3) have been seen to be riskier.
|Table 1: Risks factors for complication in spinal surgery in octogenarians|
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It is therefore essential to consider the patient's life expectancy and willingness to undergo surgery before deciding on the spinal surgery. Recent evidence has linked frequent back pain in elderly women to coronary heart disease and mortality. Thus, prompt recognition and treatment in the geriatric population are critical. It will present a unique challenge to the physicians, surgeons, patients, and their families as they weigh the additional risks of operative treatment against reducing disabling pain and improving quality of life. Today, older adults live longer and have more active lifestyles. Several factors such as the ability to tolerate surgery, rehabilitation, life expectancy, and overall health should be discussed when deciding treatment options for elderly patients with symptomatic spinal disease. Those with longer remaining life expectancy, independent of their current age, are the most likely to enjoy the benefits of surgery and the complications of continued disabling spinal problems.
Elective spinal surgery carries with it specific challenges and opportunities. Because procedures can be timed to allow for medical optimization before the intervention, the surgeon can reduce the likelihood of complications through optimal cardiovascular care, nutritional support, smoking cessation, and physical preconditioning. The commonly performed surgery for back-related problems in elderly includes spinal decompression, with or without fusion. If there is a documented spinal instability or if multilevel decompression is required, then instrumented fusion is often required to stabilize the spine. However, it has been noted that the instrumentation of the spine is associated with higher complications than only spinal decompression. Moreover, a longer duration of surgery (>180 min) was reported to be associated with more complication. Interestingly, the rate of lumbar fusion in elderly patients (defined as age 75 years) has doubled in the 80s and tripled in the 90s and is still increasing as the life expectancy of the population on the rise.
Patient age, blood loss, Charlson's comorbidity index (CCI) score, the American Society of Anesthesiologists (ASA) class, the number of levels treated, and fusion surgery were not statistically associated with a complication.
Nanjo et al. in their multicenter retrospective study demonstrated that the benefits and risks of decompression surgery for lumbar spinal stenosis were similar between patients aged over 80 years and those under 80 years. Therefore, decompression surgery is a reasonable treatment even for elderly patients aged over 80 years.
In the study done by Overdeverest, spinal fusion was necessary for the presence of spondylolisthesis Grade 2 or more by 79.3% of the spine surgeons and documented spinal instability by 74.1% of the spine surgeons and low back pain by 24.1% of the spine surgeons. Spinal fusion was applied in 12.0% (831 cases/6971) of cases.
Older age alone should not discourage relatives or surgeon recommending surgery. We understand that the biological age is more important than the chronological age of these elderly adults when considering them for surgery. What patients expect from spine surgery also appears to influence the outcome. Patients' satisfaction after lumbar surgery may not always correlate with postoperative physical functioning. Patient gender and type of surgery performed also may influence surgical outcome. An important consideration in patient satisfaction and expectations for surgery is the surgeon–patient discussion regarding the role of surgery for the patient's condition.
There could be significant implications in elderly patients due to restrictions in mobility, dependency on narcotic medications, and persistent pain, not only on their general well-being but also for survival. Physical deconditioning in frail patients can impact life expectancy due to progressive pulmonary and cardiac complications. Thus, lumbar spine surgery in a selected population of elderly patients may be safe if the CCI is acceptable and operative times are minimized as stated by Fineberg et al.
For optimal outcomes, after surgery, various modalities and protocols have been developed from various researches and studies. It is appreciated that multidisciplinary care does improve the clinical outcomes in elderly surgical patients. Hence, Integrated protocol driven care pathways work effectively. However, these must be individualised to suit each patient. The Association of Anaesthetists of Great Britain and Ireland strongly supports an expanded role for senior geriatricians in coordinating perioperative care for the elderly, with input from senior anesthetists (consultants/associate specialists) and surgeons. Perioperative care aims to treat elderly patients in a timely, dignified manner and to optimize rehabilitation by avoiding postoperative complications. Effective perioperative care improves the likelihood of very elderly surgical patients returning to their same premorbid place of residence and maintains the continuity of their community care when in the hospital.
Proper preoperative care and definitive guideline have made surgery feasible in the older age group.
Although ASA and CCI scores are useful comorbidity indices for the spine patient population, neither was completely predictive of complication occurrence. Although ASA and CCI scores are useful, the comorbidity indices for the spine patient population were not completely predictive for complication occurence. Instead, a spine specific comorbidity index which is based on international classification of disease clinical modification coding that could easily be procured from patient records is a better tool to predict the likelihood of complication, morbidity and cost.
Spinal surgery is further influenced by patient characteristics, such as age, comorbidity, and obesity. Although some of the literature has suggested an age-related increase in surgical and general complications, Sobottke et al., however, reported that the incidence of surgical complications after decompression for lumbosacral spine was no higher in aged patients. There was a significant improvement in ambulatory function from 2.68 ± 1.06 to 3.15 ± 0.92, following surgery in a study done by Wang et al. representing a mean improvement of 0.59 ± 1.
It is important to pay attention to both surgical and general complications in instrumented surgery for patients aged 80 years. Improvements in surgical and anesthetic techniques may make more-invasive surgery feasible for elderly patients where risks formerly would have been prohibitive. If surgeons and anesthesiologists could appropriately evaluate the general condition, surgery remains a reasonable treatment even for elderly patients aged ≥80 years.
Some studies have reported increased complication after fusion surgery than decompression surgeries like Deyo et al. Although some studies have demonstrated that the complications of spinal surgery may increase with age, there was no association found between the groups aged 65–79 years and 80 years. In a recent study of the Japanese population, it was reported that the surgery is still a reasonable option for lumbosacral spine patients, even those aged 80 years as long as risks/benefits are carefully weighed in each patient. However, attention should be paid to both surgical and general complications and mental disorder in particular, in instrumented surgery for these patients.
Although this reconstructive surgery for disabling pain cannot add years to the lives of these individuals, it can add quality to the remaining of their lives. With predictable benefits of surgery, viable procedures can be done in carefully selected elderly adults, provided the doctors, individual, and family members accept the risks. We believe that these individuals should not be deprived of the potential benefits of this surgery.
| Conclusion|| |
In view of increasing life expectancy of people, overall improvement of perioperative care, and advancement in surgical techniques and instruments, lumbar spinal surgery can be performed in symptomatic cases and carefully selected elderly individuals, after proper counseling and medical optimization in elderly with good functional outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]