Introduction: Spinal stenosis is primarily a disease of the older population. Return to functional status is generally achieved with decompressive surgery, but there is an increasing number of patients who have co-existent overt or occult spinal instability. In such patients, decompression alone not only does not relieve the symptoms, but often makes them worse. Instrumented reconstruction is frequently not performed even if indicated for a fear that this patient population could not tolerate such extensive surgery. In our institution, we have adopted an aggressive approach and performed stabilization if indicated regardless of age.
Methods: We have analyzed the surgical results of patients ranging in age from 19 to 87 years old. We have retrospectively compared the results of decompression with instrumented fusion including pedicle screws fixation and the transforaminal lumbar interbody fusion (TLIF) in 201 patients divided into two age groups, <64 and = 65. The study had two arms. The first arm which was reported last year demonstrated the safety of instrumented fusion in the elderly population. In the current communication we compare the operative outcomes. We compare the functional status outcome, symptom improvement, and pain medication requirement at 1 year follow-up. We also report a comparison of fusion rates in a subset of the two groups.
Results: There was statistically no significant difference in the functional status (Table 1), symptom improvement (Table 2) or pain medication requirement (Table 3) between the two groups. Moreover, there was no difference in fusion rates between the two groups (Table 4).
Conclusions: We conclude that advanced age alone, even with the common comorbidities of that population is not a contraindication to extensive spine reconstruction where indicated and that satisfactory outcomes can be achieved.
Patient Care: With modern anesthesia and advances in innovative spinal instrumentation techniques the ability to perform complex spinal fusion procedures for degenerative lumbar disease has become safer particularly in elderly patients with multiple co-morborbities. These data add to the existing body of literature that supports the evidence that excellent surgical outcomes can be achieved in the elderly population.
Learning Objectives: 1. Understand the current controversies regarding instrumented fusion in the Elderly population.
2. Compare the common morbidities associated with instrumented fusion in the elderly and younger populations.
3. Evaluate the expected outcomes of instrumented fusion in the elderly oupulation
References: Carreon LY, Puno RM, Dimar JR II, et al. Perioperative complications of posterior lumbar decompression and arthrodesis in older patients. J Bone Joint Surg Am 85:2089-92, 2003.
Chang-Hyun, L, Seung-Jae, Hyun, Ki-Jeong, Kim, et al. Decompression only versus fusion surgery for lumbar stenosis in elderly patients over 75 years old: which is reasonable? Neurol Med Chir (Tokyo) 53870-874, 2013.
Daubs MD, Lenke LG, Cheh G, et al. Adult spinal deformity surgery: Complications and outcomes in patients over age 60. Spine. 32:2238-54, 2007.
Deyo RA, Ciol MA, Cherkin DC, et al. Lumbar spinal fusion: A cohort study of complications, reoperations, and resouce use in the Medicare population. Spine. 18:1463-70, 1993.
Deyo RA, Gray DT, Kreuter W, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30(12):1441-1445.
Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbr spinal stenosis in older adults. JAMA 2010;303(13)1259-65.
Deyo RA, Hickam D, Duckart, JP, Piedra M. Complications after surgery for lumbar stenosis in a veteral population. Spine 2013;38(19)1695-1702.
Fast A, Robin GC, Floman Y. Surgical treatment of lumbar spinal stenosis in the elderly. Arch Phys Med Rehab. 66:149-51, 1985.
Lee P, Fessler, RG. Perioperative and postoperative complications of single-level minimally invasive transforaminal lumbar interbody fusion in elderly adults. Journal of Clinical Neuroscience 2012;19:111-114.
Oldridge NB, Zhong Y, Stoll JE, Rimm, AR. Lumbar spine surgery and mortality among medicare beneficiaries. American Journal of Public Health 1994;84(8):1292-98.
Ragab AA, Fye MA, Bohlman HH. Surgery of the lumbar spine for spinal stenosis in 118 patients 70 year of age or older. Spine. 28:348-53, 2003.
Reindl R, Steffen T, Cohen L, et al. Elective lumbar spinal decompression in the elderly: Is it a high risk operation? Can J Surg.46:43-46, 2003.
Rosen DS, O'Toole, JE, Eichholz, KM, et al. Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75 years and older. Neurosurgery 2007 60(3):503-510.
Mirza SK, Deyo RA, Heagerty PJ, et al. Development of an index to characterize the “invasiveness” of spine surgery: validation y com- parison to blood loss and operative time. Spine 2008;33:2651–61.
Li G, Patil CG, Lad SP, et al. Effects of age and comorbidities on complication rates and adverse outcomes after lumbar laminec- tomy in elderly patients. Spine 2008;33:1250–5.