Effects of minimally invasive decompression surgery on quality of life in older patients with spinal stenosis

Predictors of Complications and Unfavorable Outcomes of Minimally Invasive Surgery Treatment in Elderly Patients With Degenerative Lumbar Spine Pathologies (Case Series)

Introduction

The use of minimally invasive surgery (MIS) results in fewer adverse and more improved outcomes. However, the literature data describing the factors increasing the number of complications, reoperation frequency and unscheduled re-hospitalizations in older patients after MIS are contradictory. In this study, a large number of patients was investigated for the complications of minimally invasive surgical treatment of degenerative disease of the lumbar spine in older patients. The objective of the study was to determine the predictors of unfavorable outcomes in such patients.

Materials and Methods

1,013 patients underwent MIS (decompression alone, TLIF, LLIF, ALIF) in 2013-2017. All operations were performed with the participation of the authors (neurosurgeons). The patient's average age was 66. The following data were collected: BMI; CCI; presence of postoperative complications according to the Dindo-Clavien classification; unplanned readmission at 90 days; hospital length of stay (LOS); surgical complexity (low, intermediate, and high); surgical time; and risk factors. The cumulative reoperation rate was determined at 5-years follow-up.

Results

A total of 256 patients suffered a complication (25.2%), 226 classified as mild (grade I, II, IIIA), and 30 - as severe (IIIB, IVA). Such factors as the surgical complexity, BMI > 30, surgical time, number of operated levels were associated with a significant risk of developing a complication. For patients with and without complications, LOS was 9.3 and 6.3 days, respectively (p < 0.0001), the unplanned readmission rate was 1.3%. 104 patients underwent 133 revision operations. The 5-year cumulative reoperation rate was 15.2%, and the reoperation index was 12.1%. The CCI had no statistically significant effect on the complication incidence after MIS. A higher risk of complications was found in patients who underwent intermediate-complexity surgery (MIS TLIF) compared with uncompounded (decompression alone) and more complex (MIS LLIF, MIS ALIF) surgical procedures (p < 0.001 and p = 0.001, respectively).

Conclusion

A register of postoperative complications is an important tool for health quality assessment and choosing the best surgical option that helps to establish measures to reduce such complications. Using MIS for the treatment of elderly patients reduces the number of severe complications.

Central Sarcopenia, Frailty and Comorbidity as Predictor of Surgical Outcome in Elderly Patients with Degenerative Spine Disease

Objective

People are living longer and the elderly population continues to increase. The incidence of degenerative spinal diseases (DSDs) in the elderly population is quite high. Therefore, we are facing more cases of DSD and offering more surgical solutions in geriatric patients. Understanding the significance and association of frailty and central sarcopenia as risk factors for spinal surgery in elderly patients will be helpful in improving surgical outcomes. We conducted a retrospective cohort analysis of prospectively collected data to assess the impact of preoperative central sarcopenia, frailty, and comorbidity on surgical outcome in elderly patients with DSD.

Methods

We conducted a retrospective analysis of patients who underwent elective spinal surgery performed from January 1, 2019 to September 30, 2020 at our hospital. We included patients aged 65 and over who underwent surgery on the thoracic or lumbar spine and were diagnosed as DSD. Central sarcopenia was measured by the 50th percentile of psoas : L4 vertebral index (PLVI) using the cross-sectional area of the psoas muscle. We used the Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight (K-FRAIL) scale to measure frailty. Comorbidity was confirmed and scored using the Charlson Comorbidity Index (CCI). As a tool for measuring surgical outcome, we used the Clavien-Dindo (CD) classification for postoperative complications and the length of stay (LOS).

Results

This study included 85 patients (35 males and 50 females). The mean age was 74.05±6.47 years. Using the K-FRAIL scale, four patients were scored as robust, 44 patients were pre-frail and 37 patients were frail. The mean PLVI was 0.61±0.19. According to the CD classification, 50 patients were classified as grade 1, 19 as grade 2, and four as grade 4. The mean LOS was 12.35±8.17 days. Multivariate stepwise regression analysis showed that postoperative complication was significantly associated with surgical invasiveness and K-FRAIL scale. LOS was significantly associated with surgical invasiveness and CCI. K-FRAIL scale showed a significant correlation with CCI and PLVI.

Conclusion

The present study demonstrates that frailty, comorbidity, and surgical invasiveness are important risk factors for postoperative complications and LOS in elderly patients with DSD. Preoperative recognition of these factors may be useful for perioperative optimization, risk stratification, and patient counseling.

Minimally invasive unilateral lumbar interbody fusion (UNILIF) in over-80-year-olds. Continuous series of 42 patients at 1.4 years' follow-up

INTRODUCTION

In lumbar stenosis, surgery aims to improve quality of life in increasingly elderly patients. Minimally invasive techniques better suit the requirements of elderly patients with increasing functional demand.

HYPOTHESIS

The UNILIF unilateral lumbar interbody fusion technique improves functional scores at 1 year in over-80 year-olds, with low morbidity.

METHOD

Patients undergoing minimally invasive decompression with transforaminal lumbar interbody fusion (TLIF) associated to unilateral pedicle screwing for degenerative lumbar stenosis were analyzed at a minimum 1 year's follow-up. SF12, Oswestry Disability Index (ODI) and Quebec scores and sagittal spinopelvic radiographic parameters were assessed at follow-up. Surgical and general complications were also collated.

RESULTS

In all, 42 patients (64.3% female; mean age, 83.7±2.9 years) were treated by UNILIF at levels L2-L3 (3.8%), L3-L4 (15.4%), L4-L5 (71.2%) and L5-S1 (9.6%). Mean follow-up was 520±226 days (range, 340-1166 days). Mean preoperative SF12 score was 77.5±10.9, with significant improvement at last follow-up: 81.9±138 (p<0.05). Mean preoperative ODI was 44.4%±14.0, with significant improvement at last follow-up: 32.4%±13.3 (p<0.001). Mean preoperative Quebec score was 42.9±19.9, with significant improvement at last follow-up: 28.5±21.9 (p<0.001). Spinopelvic sagittal balance was not affected by the UNILIF procedure. There were no cases of infection or severe general complications during follow-up, although 2 cases of non-union required revision surgery.

CONCLUSION

Lumbar stenosis surgery by UNILIF improved functional scores at 1 year, with low morbidity. It is a suitable strategy for degenerative lumbar stenosis in elderly patients.

LEVEL OF EVIDENCE

IV, non-comparative cohort study.

Perioperative Results and Complications after Posterior Lumbar Interbody Fusion for Spinal Stenosis in Geriatric Patients over than 70 Years Old

Objective

As increasing the size of the geriatric population, the number of elderly patients, who need the surgery for painful degenerative spinal stenosis has been increasing. The geriatric population may be relatively high complications, because of age and age-associated medical conditions. However, there is a lack of studies addressing the perioperative complications and outcomes in elderly patients with posterior lumbar inter body fusion with screw augmentation (PLIF).

Methods

We retrospectively reviewed the medical records and radiographic studies of geriatric patients who had spine surgery of PLIF due to spinal stenosis for 11 years. We divided into 2 groups (A; 70–75 years, B; over then 76 years) according to the age. Surgical level of each groups, hospital day and postoperative day, co-morbidities, complications, clinical outcomes were analyzed. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed.

Results

Group A was composed of 80 patients, their mean age was 72.21 and female dominant (n=46), and their mean surgically fused level was 1.52 level. Group B was 36 patients, their mean age was 78.83 and female dominant (n=20), and their mean surgically fused level was 1.36 level. Comparing between two groups, complications, postoperative hospital stay were slightly increase in group B and co-morbidity was statistically high in group B, however clinical outcomes were similar between two groups.

Conclusion

Increasing age might be an important risk factor for complications in patients undergoing PLIF, however, we would like to recommend that if the situation of spine of extreme geriatric patients need PLIF, it should be in the surgeon’s consideration after careful selection and clinical judgement.