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Evans AR, Bakhsheshian J, Graffeo CS, Smith ZA. Surgical management of spinal pathologies in the octogenarian: a narrative review. GeroScience 2024; 46:3555-3566. [PMID: 38285294 PMCID: PMC11226583 DOI: 10.1007/s11357-024-01083-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/15/2024] [Indexed: 01/30/2024] Open
Abstract
Optimal management paradigms of spinal pathologies in the octogenarian population are controversial given the higher incidence of comorbidities with concern for poor prognosis and fear of increased complications associated with surgical management. In this narrative review, we aim to detail the complex clinical considerations when approaching odontoid screw fixation/instrumented fusion, spinal decompression, and spinal fusion in the octogenarian. Literature review was conducted via Google Scholar and PubMed databases, with literature selected based on statistical power and clinical relevance to the following pathologies/surgical techniques: odontoid fracture, surgical decompression, and surgical fusion in the octogenarian. The aforementioned pathologies were selected based on prevalence in the advanced-age population in which surgical screening techniques and management remain nonuniform. Preoperative evaluation of the octogenarian patient increasingly includes frailty, sarcopenia, and osteopenia/osteoporosis assessments. In cases of odontoid fracture, conservative management appears to provide beneficial clinical outcomes with lower rates of complication compared to surgery; however, rates of radiographic odontoid fusion are far lower in conservatively managed patients. Regarding surgical decompression and fusion, the presence of comorbidities may be more predictive of outcome rather than age status, with the advent of minimally invasive techniques providing safety and efficacy in the surgical management of this age cohort. Age status may be less pertinent than previously thought in the decision to pursue spinal surgery for odontoid fracture, spinal decompression, or spinal fusion; however, each of these procedures has respective risks and benefits that must be considered within the context of each patient's comorbidity profile.
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Affiliation(s)
- Alexander R Evans
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK, USA
| | | | | | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK, USA.
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Lechtholz-Zey EA, Ayad M, Gettleman BS, Mills ES, Shelby H, Ton AT, Shah I, Wang JC, Hah RJ, Alluri RK. Systematic Review and Meta-Analysis of the Effect of Osteoporosis on Reoperation Rates and Complications after Surgical Management of Lumbar Degenerative Disease. J Bone Metab 2024; 31:114-131. [PMID: 38886969 PMCID: PMC11184153 DOI: 10.11005/jbm.2024.31.2.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND There is considerable heterogeneity in findings and a lack of consensus regarding the interplay between osteoporosis and outcomes in patients with lumbar degenerative spine disease. Therefore, the purpose of this systematic review and meta-analysis was to gather and analyze existing data on the effect of osteoporosis on radiographic, surgical, and clinical outcomes following surgery for lumbar degenerative spinal disease. METHODS A systematic review was performed to determine the effect of osteoporosis on the incidence of adverse outcomes after surgical intervention for lumbar degenerative spinal diseases. The approach focused on the radiographic outcomes, reoperation rates, and other medical and surgical complications. Subsequently, a meta-analysis was performed on the eligible studies. RESULTS The results of the meta-analysis suggested that osteoporotic patients experienced increased rates of adjacent segment disease (ASD; p=0.015) and cage subsidence (p=0.001) while demonstrating lower reoperation rates than non-osteoporotic patients (7.4% vs. 13.1%; p=0.038). The systematic review also indicated that the length of stay, overall costs, rates of screw loosening, and rates of wound and other medical complications may increase in patients with a lower bone mineral density. Fusion rates, as well as patient-reported and clinical outcomes, did not differ significantly between osteoporotic and non-osteoporotic patients. CONCLUSIONS Osteoporosis was associated with an increased risk of ASD, cage migration, and possibly postoperative screw loosening, as well as longer hospital stays, incurring higher costs and an increased likelihood of postoperative complications. However, a link was not established between osteoporosis and poor clinical outcomes.
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Affiliation(s)
- Elizabeth A. Lechtholz-Zey
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Mina Ayad
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Brandon S. Gettleman
- Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, SC,
USA
| | - Emily S. Mills
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Hannah Shelby
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Andy T. Ton
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Ishan Shah
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Jeffrey C. Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Raymond J. Hah
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
| | - Ram K. Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA,
USA
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Iess G, Levi D, Della Valle R, Bonomo G, Broggi G, Egidi M. Articular arthrodesis with the facet wedge technique for the treatment of unstable lumbar degenerative disease and associated conditions: A retrospective study of 96 patients. World Neurosurg X 2024; 22:100351. [PMID: 38469389 PMCID: PMC10926358 DOI: 10.1016/j.wnsx.2024.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 02/21/2024] [Indexed: 03/13/2024] Open
Abstract
Background Lumbar articular fusion with the facet wedge (FW) technique is gaining increasing interest among surgeons for the treatment of vertebral instability due to its limited invasiveness and ease of use. Studies on cadavers have reported biomechanical properties similar to pedicle screws. Yet, the evidence supporting their use is still limited and moreover focused only on spinal degenerative disease. Methods 96 cases of lumbar articular fusion with the FW techniques performed at 3 different centers between 2014 and 2022 were retrospectively analyzed based on the specific surgical indications: 1) degenerative spondylolisthesis/unstable lumbar stenosis; 2) synovial cysts; 3) adjacent segment disease (ASD). Medical records were reviewed to identify rates of complications and measures of functional outcome (ODI, low back pain VAS and modified Macnab scale) were collected both at baseline and at the follow-up visits. Wilcoxon signed-rank test was adopted to test for significant functional improvements. Results Significative clinical improvements were observed from baseline to follow-up regarding ODI and VAS scores. Overall rate of moderate and severe complications (according to Landriel-Ibañez scale) was 7.9%. Only 3.4% of patients with degenerative disease developed ASD requiring reoperations. Only one case of radicular deficit and one of device mobilization were reported. 2/4 cases of synovial cysts treated with unilateral fusions developed contralateral complications. 9 out of 16 (56.25%) patients who underwent long-term postoperative CT scans presented adequate degree of articular fusion. Conclusion FW technique is easy, safe, and effective. Its low rate of complications justifies its use for cases of mild lumbar instability.
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Affiliation(s)
- Guglielmo Iess
- Department of Neurosurgery, San Carlo Borromeo Hospital, Via Pio II, 3, Milan, Italy
- University of Milan, Via Festa del Perdono, 7, Milan, Italy
- Foundation IRCCS Carlo Besta Neurological Institute, Via Giovanni Celoria, 11, Milan, Italy
| | - Daniel Levi
- Le Betulle Private Hospital, Viale Italia, 36, Appiano Gentile, Italy
- Piccole Figlie Hospital, Via Po, 1, Parma, Italy
- Fondazione I.E.N., Corso Venezia, 18, Milan, Italy
| | - Raul Della Valle
- Department of Neurosurgery, San Carlo Borromeo Hospital, Via Pio II, 3, Milan, Italy
- University of Milan, Via Festa del Perdono, 7, Milan, Italy
| | - Giulio Bonomo
- Foundation IRCCS Carlo Besta Neurological Institute, Via Giovanni Celoria, 11, Milan, Italy
| | - Giovanni Broggi
- Foundation IRCCS Carlo Besta Neurological Institute, Via Giovanni Celoria, 11, Milan, Italy
- Le Betulle Private Hospital, Viale Italia, 36, Appiano Gentile, Italy
- Piccole Figlie Hospital, Via Po, 1, Parma, Italy
- Fondazione I.E.N., Corso Venezia, 18, Milan, Italy
| | - Marcello Egidi
- Department of Neurosurgery, San Carlo Borromeo Hospital, Via Pio II, 3, Milan, Italy
- University of Milan, Via Festa del Perdono, 7, Milan, Italy
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Aimar E, Iess G, Labiad I, Mezza F, Bona A, Ciuffi A, Grassia F, Isidori A, Zekaj E, Bonomo G. Degenerative L4-L5 spondylolisthesis and stenosis surgery: does over-level flavectomy technique influence clinical outcomes and rates of cranial adjacent segment disease? Acta Neurochir (Wien) 2023; 165:3107-3117. [PMID: 37632571 DOI: 10.1007/s00701-023-05761-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND One of the most dreaded long-term complications related to L4-L5 lumbar arthrodesis is the onset of adjacent segment disease, which most frequently occurs at the cranial level. Few studies have compared the rates of cranial adjacent segment disease (CASD) in patients undergoing lumbar fusion associated with total laminectomy at the same level with those undergoing partial laminectomy. No study has examined the role of selective over-level flavectomy (OLF; i.e., L3-L4). METHODS A total of 299 patients undergoing posterolateral arthrodesis (PLA) for L4-L5 degenerative spondylolisthesis were retrospectively analyzed with a 5-year follow-up. 148 patients underwent PLA + L4-L5 flavectomy + L4 partial laminectomy (control group), while 151 underwent PLA + L4-L5 flavectomy + total L4 laminectomy + L3-L4 flavectomy (OLF group). Rates of reoperations due to CASD were examined utilizing Cox proportional hazard models, while clinical improvement at follow-up (measured in ODI) was analyzed using generalized linear models (GLMs). Adjustments for potential confounders were made (grade of lumbar lordosis, age, sex, BMI, intervertebral disc degeneration, and presurgical cranial spinal stenosis). RESULTS At 5 years from the operation, 16 patients (10.8%) in the control group had undergone revision surgery for CASD compared to 5 patients (3.3%) in the OLF group (p = 0.013). Survival analysis and GLM demonstrated that the OLF group had a significantly lower incidence of CASD and presented more favorable clinical outcome. There were no differences in the rate of discal degeneration or the onset of Meyerding's grade I degenerative spondylolisthesis at the adjacent segment. BMI was the only other significant predictor of ODI improvement and of the incidence of CASD. CONCLUSIONS In patients with L4-L5 degenerative spondylolisthesis and stenosis, the OLF technique may lower rates of CASD and improve clinical outcomes by preventing cranial spinal stenosis without increasing iatrogenic instability or accelerating intervertebral disc degenerative changes.
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Affiliation(s)
- Enrico Aimar
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Lumbardy, Milan, Italy
| | - Guglielmo Iess
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Lumbardy, Milan, Italy.
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Lumbardy, Milan, Italy.
- Università degli Studi di Milano, Lumbardy, Milan, Italy.
| | - Ikrame Labiad
- Università degli Studi di Milano, Lumbardy, Milan, Italy
| | - Federica Mezza
- Department of Economics, Bocconi University, Lumbardy, Milan, Italy
| | - Alberto Bona
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Lumbardy, Milan, Italy
| | - Andrea Ciuffi
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Lumbardy, Milan, Italy
| | - Fabio Grassia
- Department of Neurosurgery, Anschutz medical campus, Aurora, CO, USA
| | - Alessandra Isidori
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Lumbardy, Milan, Italy
| | - Edvin Zekaj
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Lumbardy, Milan, Italy
| | - Giulio Bonomo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Lumbardy, Milan, Italy
- Università degli Studi di Milano, Lumbardy, Milan, Italy
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Are Octogenarians at Higher Risk of Complications After Elective Lumbar Spinal Fusion Surgery? Analysis of a Cohort of 7880 Patients From the Kaiser Permanente Spine Registry. Spine (Phila Pa 1976) 2022; 47:1719-1727. [PMID: 35943246 DOI: 10.1097/brs.0000000000004451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study with chart review. OBJECTIVE To determine if there is a difference in risk of adverse outcomes following elective posterior instrumented lumbar spinal fusions for patients aged 80 years and above compared with patients aged 50 to 79 years. SUMMARY OF BACKGROUND DATA Patients aged 80 years and above are undergoing elective lumbar spinal fusion surgery in increasing numbers. There are conflicting data on the risks of intraoperative and postoperative complications in these patients. MATERIALS AND METHODS Patients aged 80 years and above were compared with 50 to 79 years (reference group) using time-dependent multivariable Cox proportional hazards regression with a competing risk of death for longitudinal outcomes and multivariable logistic regression for binary outcomes. Outcome measures used were: (1) intraoperative complications (durotomy), (2) postoperative complications: 30-day outcomes (pneumonia); 90-day outcomes (deep vein thrombosis, pulmonary embolism, emergency room visits, readmission, reoperations, and mortality); and two-year outcomes (reoperations and mortality). RESULTS The cohort consisted of 7880 patients who underwent primary elective posterior instrumented lumbar spinal fusion (L1-S1) for degenerative disk disease or spondylolisthesis. This was subdivided into 596 patients were aged 80 years and above and 7284 patients aged 50 to 79. After adjustment, patients aged 80 years and above had a higher likelihood of durotomy [odds ratio (OR)=1.43, 95% confidence interval (CI)=1.02-2.02] and 30-day pneumonia (OR=1.81, 95% CI=1.01-3.23). However, there was a lower risk of reoperation within two years of the index procedure (hazard ratio=0.69, 95% CI=0.48-0.99). No differences were observed for mortality, readmissions, emergency room visits, pulmonary embolism, or deep vein thrombosis. CONCLUSIONS In a cohort of 7880 elective posterior instrumented lumbar fusion patients for degenerative disk disease or spondylolisthesis, we did not observe any significant risks of adverse events between patients aged 80 years and above and those aged 50 to 79 except for higher durotomies and 30-day pneumonia in the former. We believe octogenarians can safely undergo lumbar fusions, but proper preoperative screening is necessary to reduce the risks of 30-day pneumonia.
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