Instrumented lumbar fusion in patients over 75 years of age: is it worthwhile?-a comparative study of the improvement in quality of life between elderly and young patients

Risk factors and treatment strategies for adjacent segment disease following spinal fusion (Review)

Adjacent segment disease (ASD) is a significant clinical complication following cervical and lumbar spinal fusion surgery, characterized by the degeneration of spinal segments adjacent to the fused area. The present literature review aimed to elucidate the risk factors contributing to ASD and to evaluate current and emerging treatment strategies. Epidemiological data indicate that patient‑related factors such as age, pre‑existing spinal degeneration and comorbidities, along with surgical factors including the type of fusion, instrumentation and alignment correction, play pivotal roles in ASD development. Biomechanical alterations post‑fusion further exacerbate the risk. The underlying mechanisms of ASD involve changes in spinal kinematics and disc degeneration, driven by inflammatory and degenerative processes. Diagnostic modalities, such as magnetic resonance imaging and computed tomography scans, are essential for early detection and accurate diagnosis. Preventive strategies emphasize meticulous preoperative planning, advanced surgical techniques and postoperative rehabilitation. Treatment approaches range from conservative methods such as physical therapy and pharmacological interventions to surgical solutions, including revision surgeries and the use of motion‑preserving technologies. Emerging therapies, particularly in regenerative medicine, show promise in mitigating ASD. The present review underscored the necessity of a multidisciplinary approach to optimize patient outcomes and highlighted the need for ongoing research to address gaps in the current understanding of ASD in both cervical and lumbar regions.

Left-digit bias in surgical decision-making for lumbar spinal stenosis

BACKGROUND CONTEXT

Left-digit bias is a behavioral heuristic or cognitive "shortcut" in which the leftmost digit of a number, such as patient age, disproportionately influences surgical decisions.

PURPOSE

To determine if left-digit bias in patient age influences the decision to perform arthrodesis with instrumentation vs decompression in lumbar spinal stenosis (LSS).

DESIGN

Retrospective cohort.

PATIENT SAMPLE

Patients with an ICD-10 diagnosis of lumbar stenosis or spondylolisthesis identified in the 2017-2021 National Surgical Quality Improvement Program (NSQIP) database.

OUTCOME MEASURES

The primary outcome was the percent of patients who underwent arthrodesis with instrumentation (AwI). Matched age group comparisons without left-digit differences (ie, 76/77 vs 78/79, 80/81 vs 82/83, etc.) were performed to isolate the effect of the heuristic. Secondary outcomes including peri-operative events and complications were also compared within AwI and decompression cohorts.

METHODS

Using CPT codes, procedures were classified as either AwI or decompression. Patients were grouped into 6 cohorts based on 2-year age windows (74/75, 76/77, 78/79, 80/81, 82/83, 84/85). The cohorts were propensity matched with neighboring age groups based on the presence of spondylolisthesis, demographics, and comorbidities. The primary comparison was between those aged 78/79 vs 80/81.

RESULTS

After matching, the primary cohort consisted of two groups of 1,550 patients (aged 78/79 and 80/81). Patients aged 80/81 were less likely to undergo AwI than patients aged 78/79 (23.5% vs 27.2%, p=.021). AwI procedures occurred at similar rates between age groups with the same left digit. Within the decompression and AwI cohorts, there were no differences in secondary outcomes between patients aged 78/79 and 80/81.

CONCLUSIONS

LSS patients aged 80/81 are less likely to undergo AwI than patients aged 78/79, regardless of comorbidities. This was not seen when comparing patients with similar left digits in age. Until objective measures of physiologic capacity are established, left-digit bias may influence clinical decisions.