Opinion: Issues to consider in surgical treatments for the older spine

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In the Western world, an increasing mean age means increasing incidence of serious spinal conditions deserving surgical attention. In particular, cervical and lumbar spinal stenosis, fractures and deformities may negatively affect the quality of life of patients over the age of 65. When considering surgical treatment for elderly patients, considerations about the general health status come first. This needs a multidisciplinary team approach. Spinal surgery in this age group is correlated with high complication rates depending mostly on cardiac function and the status of the immune system.

Any correctable cardiac disease needs to be addressed. A cardiac condition that can be improved by medical care and general health advice on smoking, drinking, obesity and aerobic activity will not prevent open discussion on the benefits and risks of any type of spinal surgery. Acute conditions like coronary syndrome and hearth failure deserve pre-operative attention and treatment more than chronic ones like a steadily diminished ejection fraction.

 

The immune system is influenced by medications, diabetes and nutrition in this age group. Drugs given for rheumatic diseases can be suppressed temporarily to allow safer surgery. On the other hand, correction of the nutritional status can decrease the risk of surgical site infection.

 

In cervical spine stenosis, myelopathy affects patients far more negatively than radiculopathy in that it decreases the ability to use both hands and legs and to control the bladder. Luckily, myelopathy normally has a slow progress allowing medical attention before reaching a profound deterioration of neurological function, and can be arrested by surgical care through spinal decompression and fusion. This is preferably done via an anterior approach if the disease is limited to up to two levels, and via a posterior approach in more widespread disease. The latter may reflect in a higher surgical morbidity.

 

Spinal fractures are more frequent in the elderly population due to increased bone fragility that may be secondary to aging, menopause or systemic disease. Nevertheless, as these are normally low-energy or even spontaneous fractures, their impact on the general health of the individual is less profound and their potential for healing high. Only those fractures that continue to be painful and invalidating or those that change the spinal alignment deserve surgical attention.

 

The role of cement augmentation—not the object of this report—is being extensively investigated for thoraco-lumbar spinal fractures that do not significantly impair the spinal alignment. On the other hand, those injuries that change the spinal alignment mainly in the sagittal plane may have a negative effect on the residual life of the individual and should be considered for surgery unless the general health status contraindicates it. Tools to restore the spinal alignment—osteotomies and spinal fusion devices, cement augmentation, blood collection systems, neurological monitoring and intensive care facilities—are now in the hands of spinal surgeons practising in centres of appropriate training. Therefore, surgical indications for post-traumatic deformities in the elderly are expanding. Again, a team approach is essential both pre-operatively and during follow-up to control notoriously high complication rates.

 

Finally, degenerative spinal deformities may affect the general health as well as the ability to walk through compression of the neural structures. Deformities appearing in the elderly that were not present before maturity tend to stop at an intermediate degree, i.e. about 40 Cobb degrees. This is not a major problem unless spinal instability or sagittal imbalance occur, in which case spinal fusion becomes a necessity to preserve function. As in the case of post-traumatic deformities, surgery may imply both corrective—osteotomies—and fusion procedures, with similar complication rates.

 

Clinical research in the field of surgery for spinal conditions in the elderly focuses on the results of spinal decompression and realignment, with the final aim of improving the postoperative performance of these patients. This will only be achieved through integration of different specialities—both medical and surgical—into a teamwork vision.

 

Marco GA Teli is a consultant orthopaedic and spine surgeon at the Department of Orthopaedics, Policlinico San Marco, Istituti Ospedalieri Bergamaschi, Bergamo, Italy

 

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