Long-term outcomes for minimally invasive TLIF in elderly patients are comparable to those in younger patient population

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Graham Goh

Elderly patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) not only had similar perioperative outcomes compared to younger patients, but also achieved comparable improvements in pain, disability and quality of life that were sustained for up to five years, with no longer-term deterioration. These are the findings of a recent study which won the Best E-Poster award at the Global Spine Congress annual meeting (3–6 November 2021, Paris, France).

The study—the findings of which were presented by Graham Goh (Singapore General Hospital, Singapore)—compared the clinical and radiological outcomes between elderly patients and younger controls undergoing MIS TLIF at a minimum follow-up of five years.

Patients who underwent a primary single-level MIS TLIF for degenerative spondylolisthesis were retrospectively reviewed and stratified into two cohorts: elderly (≥70 years) and controls (<70 years).

The cohorts were matched in a 1:3 ratio for sex, body mass index, American Society of Anesthesiologists (ASA) class, comorbidities and preoperative patient-reported outcomes (PROs) using propensity scoring.

Complications, length of stay and readmissions were recorded. PROs including the Oswestry Disability Index (ODI), 36-Item Short-Form Physical Component Score (SF-36 PCS), Mental Component Score (SF-36 MCS), Visual Analogue Scale (VAS) back pain, and VAS leg pain were compared at six months, two years and five years. Satisfaction was assessed using the North American Spine Society (NASS) questionnaire.

In addition, radiographic fusion and adjacent segment degeneration (ASD) were assessed. Revision procedures were recorded and mean follow-up was 7.2 ± 3 years.

In total, 30 elderly patients and 90 controls were included. Elderly patients had a longer length of stay (4.7 ± 5.8 days vs. 3.3 ± 1.4 days, p=0.035) and more readmissions (10% vs 1%, p=0.019), but there was no difference in operative time, transfusions, complications or discharge disposition.

Also, with the exception of better VAS leg pain in elderly patients at two years (p=0.037), there was no difference in ODI, VAS back pain, VAS leg pain, SF-36 PCS and SF-36 MCS up to five years postoperatively.

Both cohorts demonstrated similar satisfaction rates (93% in elderly vs. 91% in controls, p=0.703) and achievement of minimal clinically important difference for each PRO. Radiographic fusion was 94% and 97% in the control and elderly groups, respectively (p=0.605), while 40% and 33% had radiological ASD (p=0.503). There were three revisions (3.3%) in the control group (two for ASD and one for screw loosening) but none in the elderly group (p=0.311).

Speaking to Spinal News International, Goh said: “One of the benefits of practising in a small country is the ability to obtain a long duration of follow-up for most patients. The goal of MIS surgery is to reduce the disruption of soft tissues and improve postoperative recovery. However, data on long-term PROs remains sparse, especially in an elderly population.

“As the population ages and we transition towards value-based payment models, our team strived to address this question in our research study. Elderly patients were just as likely to benefit at five years postop, supporting the long-term efficacy of the MIS approach in this growing subpopulation.”


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