Surgical Outcome in Spinal Operation in Patients Aged 70 Years and Above
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.279672
Source of Support: None, Conflict of Interest: None
Keywords: Degenerative spinal condition, old age, spinal surgery, traumatic spinal injuryKey Messages: Age is not a limiting factor for surgical management of degenerative or traumatic spinal conditions in elderly patients.
The world is seeing the growth of the aging population. The United Nations World Population Prospects data (2015 revision) revealed that the number of older persons has substantially increased in most regions and countries and is expected to accelerate in the coming decade. People aged 60 years and above were projected to grow by 56% from 901 million to 1.4 billion between 2015 and 2030 and will be reaching nearly 2.1 billion by 2050 which is more than double what it was in 2015. This holds true for all countries, including India. In India, the elderly population rose from 5.4% in 1951 to 7.4% in 2001. The growth of the aging population puts pressure on the healthcare system because of the morbidities associated with old age. This had been a cause of concern for any surgical procedure in this age group. With the advancement in medical science and technology, more and more patients are undergoing surgical treatment.
In the United States of America (USA), the National Hospital Discharge survey (1990–2004) found out that the greatest increase in spinal fusions occurred in patients aged 65 years or older, who exhibited a 28-fold increase in anterior discectomy and fusion (ADF) procedures. The fastest growth in spinal surgery, particularly for lumbar stenosis, occurs in the elderly.
Limited literature is available on this issue, especially in India. Therefore, the purpose of this study was to get more insight.
An observational study in which all patients aged 70 years and above, who had undergone spinal surgery in Neurosurgery Department, AIIMS from January 2013 to July 2017 were reviewed. From the hospital data, after excluding patients with polytrauma, re-surgery and who expired, it was found that 70 patients were eligible, and hence all of them were enrolled in the study. All the 70 patients were reviewed for age and sex distribution, type of pathology, spinal segment involved, type of surgical procedure done, number of spinal levels of surgical procedures, duration of complaints, length of hospital stay, complications, and comorbidities. The parameters were assessed using Microsoft office excel datasheet 2016.
Out of the 70 patients, 53 patients were also assessed for disability/functional outcome and their health-related quality of life (HRQOL) using Oswestry disability index (ODI) version 2.0 and medical outcomes study short form-36 (SF-36) version 1.0. Data was entered using CSpro (Census and Survey Processing System), U.S. Census Bureau, ICF International. Scoring system of ODI and the scoring rules for the RAND 36-item health survey (version 1.0) was used for quality of life assessments. All statistical data analysis was done using STATA version 14 (StataCorp LP, Texas, USA). Paired t-test, proportion test is done with a 5% level of significance.
We have assessed our patients as a whole and under two subgroups: Patients with degenerative spinal conditions and patients with spinal trauma, the inclusion criteria of the groups are self-explanatory except that those with degenerative conditions admitted with trauma were included in trauma subgroup. Those patients who died in the postoperative period or who were lost to follow-up or did not cooperate for the study were not assessed for HRQOL and ODI as the questionnaire requires active participation from the patient or patient attendants. Out of the total 70 patients who were assessed, 54 (77.14%) had surgery for degenerative conditions, and 16 (22.86%) had surgery for spinal trauma.
The mean age was 74.19 years (range 70–91 years). We categorized the whole sample into three age groups: 41 (58.57%) patients in 70–74 years, 21 (30%) in 75–79 years, and 8 (11.43%) in 80 years and above. This categorization of the sample was done to determine the type of spinal condition and concentration of patients in the different age groups as degenerative spinal changes are an age-related ongoing process.
The majority of the patient were male 57 (81.43%), while the female number was 13 (18.57%). In the degenerative spinal patient, 79.63% were males, 20.37% were females. In the trauma cases, 87.5% were males and 12.5% were females.
The most common spinal segment if we take degenerative and trauma patients combined was in the cervical segment 32 (45.71%) followed by lumbar region 30 (42.86%). In the degenerative only group, lumbar pathology was the most common 30 (55.56%) whereas, in the traumatic group, the cervical injury was the most common 13 (81.25%).
Laminectomy-(19 patients 27.14%) was the most common procedure followed by instrumentation which includes screw and rod fixation/wiring (9 patients 12.86%) [Table 1]. Depending on the number of spinal vertebrae involved in the surgery, the surgical spinal segments were divided into four groups (single, two levels, three levels, four levels and above). The majority of the cases were operated involving four segments and above, that is, 26 (37.14%) cases.
In the degenerative cases, the average length of hospital stay was 16.57 days with a range from 2–76 days. In the traumatic cases, the average length of hospital stay was 13.63 days with a range of 4–40 days.
In degenerative patients, the average duration of complaints was 1096 days with a range of 30–4380 days. In trauma-related cases, the average duration was 78.93 days with a range from 2–365 days.
The number of cases with comorbidity was 45 (64.29%). The most common single comorbid condition encountered in this age group was hypertension (HTN) in 15 (21.43%) cases. In patients having two or more comorbidities, HTN combined with diabetes mellitus (DM) was the most common in 11 (15.71%) cases, followed by HTN with coronary artery disease (CAD) in 5 (7.14%) cases.
Overall there were six (8.57%) minor complications and nine (12.85%) major complications. In the 54 patients with degenerative spine, there were six (11%) minor complications and five (9.26%) major complications with one (1.8%) leading to death from chest infection. In the 16 traumatic spinal injury patients, there were four major complications with all leading to death (25%) [Table 2].
The average blood loss was 345.70 mL, with a range from minimal to 2200 mL. In lumbar instrumentation surgery, the average blood loss was 1016 mL with a range of 200–2200 mL.
The overall average duration of surgery was 209 min with a range of 60–440 min. The average duration of surgery in lumbar instrumented surgery was 325 min with a range of 140–440 min.
Out of the 70 patients, after excluding lost to follow-up, those who expired in the same hospital admission and those not cooperating, the average duration of follow-up of the remaining 53 patients was 1.8 years and 12 days with a range of 20 days to 4.3 years.
Disability/functional outcome and HRQOL
The disability/functional outcome and HRQOL were assessed using ODI and SF-36. Out of 70 patients, only 53 were assessed. Five patients who died in the same hospital admission, who did not have a postoperative period long enough for assessment of the quality of life for comparison with the preoperative status was not included. Two patients did not cooperate for the assessment, and ten patients were lost to follow-up.
Oswestry disability index score
Overall (degenerative and trauma combined) [Table 3] and [Figure 1].
Minimal disability (0–20%): There were six patients in the preoperative assessment which increases to 27 in the postoperative assessment.
Moderate disability (21–40%): The number of patients (nine) remains the same in the preoperative and postoperative periods.
Severe disability (41–60%): There were 13 in the preoperative period reduces to six in the postoperative period.
Crippled (61–80%): There was a statistically significant reduction from 14 patients in the preoperative period to five in the postoperative period (P = 0.009).
Bedbound (81–100%): There were 11 patients in the preoperative period and six in the postoperative period.
In the separate assessment of the degenerative and traumatic patient, there was a general trend of a patient becoming less disabled in the postoperative follow-up period as compared to preoperative status however the changes were not significant [Table 4], [Table 5] and [Figure 2], [Figure 3].
Medical outcomes study
In the combined assessment of both degenerative and post-traumatic group, there was a significant improvement in the postoperative period as compared to the preoperative period [Table 6]. In the separate assessment of the degenerative patient, there was a significant improvement in all the parameters assessed [Table 7].
In the traumatic spinal injury group, only pain was significant; the rest of the parameters were not significant with mixed results [Table 8].
Type of spinal pathology
Studies have shown that the prevalence of degenerative spinal conditions was much more common with the increase in age and is expected to increase further with the increase in population and life expectancy all over the world.,,, The WHO fact sheet shows that the incidence of traumatic spinal injury peak in the younger age group and again in the 70+ patient. Many studies have shown that spinal trauma is much more common in the younger age group.,, This correlates with the smaller number of traumatic patients operated (23%) during the study period as compared to patients with the degenerative spine (77%).
The life expectancy at birth (2011–2016) of the Indian population was 66.8. The mean age of our sample was 74.19 years. This finding is comparable to other studies whose cohort was taken from 70 years and above.,,,,,
Most of the patients were male in both degenerative and trauma groups. The mean age of our sample was 74.19 years which may have a bearing on the sex distribution. One study had reported a higher incidence of cervical spondylotic myelopathy in older and male patients. In autopsy studies, the male disc was found to degenerate a decade earlier than that of female, and more degenerated at the second, fifth, sixth, and seventh decades. Another study reported degenerative lumbar spinal condition was more common in males under 70 years of age; however, with increasing age, the incidence in female increases while it remained static in males. This may be the reason why most of the Western and East Asian literature with a higher mean age than our study, reported females to be more commonly operated than males.,,, In the traumatic cases, males were more common which correlates with other studies.,,,
Spinal level of primary pathology
The most common pathologies were reported to be in the lumbar region followed by the cervical region. In our study also, the most common condition operated for degenerative conditions were in the lumbar region. In the traumatic group, cervical injury patients were the most operated. Compared to other studies, the lesser number of the trauma patient with dorsal and dorso-lumbar injury maybe because our cohort are only those who were operated. It may be because the thoracic spines are better protected by the rib cage. The impact force which may result in traumatic injury to the cervical or lumbar spine in the aged population may not be strong enough to cause significant injury requiring surgery in the dorsal spine. At the same time, the degenerative spinal disease may be affecting the more mobile cervical and lumbar spine.
The most common spinal surgical procedure in our study was laminectomy which correlates with another study. In the past, given the advanced age with associated comorbidities, prolonged more invasive surgeries were not considered in an elderly patient. With the advancement in surgical techniques and perioperative management, more invasive spinal instrumented fusions are increasingly common with the claim of a better outcome.,
Surgical spinal segment
Four and more spinal levels were operated most in our study. This was more than most of the studies.,, The reason may be because the average duration of complaints in our study was 1096 days in the degenerative patient which was much more than what was reported in a study. The chronicity of the condition might have led to more levels of involvement.
Length of hospital stay
The average length of hospital stay was 16 days which was more than another study. Our study included traumatic cervical spinal injury, which involved longer hospital stay because of ventilator dependence and related complications. Studies have reported postoperative complications as a reason for a longer hospital stay. Instrumented fusions were also reported to have a longer hospital stay.
Like other studies, hypertension was the most common comorbidity. Other common comorbidities include diabetes mellitus, coronary artery disease.,
Overall there were six (8.57%) minor complications and nine (12.85%) major complications. In the degenerative group, there were six (11%) minor complications and five (9.26%) major complications with one (1.8%) mortality who was operated for cervical spine pathology. Similar complication rates were also reported in other studies.,,,,, In the traumatic group, there were four (25%) mortalities. All had cervical spine injury with respiratory complications. Such high mortalities were also reported in other studies with or without surgical intervention., Studies have reported decreased mortality in those who underwent spinal instrumentation in cervical spine injury patients., Mortalities in cervical spine injury were observed to be more with high cervical spine injury hence, may not necessarily reflect complication of the surgery as such but a progression of the spinal cord injury itself. Studies have reported a high incidence of respiratory complications (62%) of varying severity which are marginally affected by therapeutic intervention.
The overall average blood loss was less than other reported studies.,, This may be because our study included noninstrumented as well as cervical spine surgery. If we take only lumbar instrumented surgery, the average blood loss correlates with other studies.
Duration of surgery
The average duration of surgery correlates with other studies.,,
Results were obtained for combined degenerative and traumatic patients and separately for both groups comparing the pre and postoperative status.
Oswestry disability index score
We have omitted section eight of the questionnaire.
In the combined evaluation of the degenerative and traumatic patient, there was a significant reduction in the number of crippled patients (P = 0.009) in the postoperative period. Even though not significant, there was a general trend of improvement in the postoperative period correlating with several other studies.,,,,
Medical outcomes study
In the combined assessment of degenerative and post-traumatic patients, there was a significant improvement in all the parameters studied. Similar results were also seen in the separate assessment of degenerative patients correlating with other studies., In the separate assessment of the traumatic spinal injury patients, there was a decline in energy, fatigue, emotional well-being, general health, and health changes. Some studies have reported a decline in one of the parameters., The acuteness of the spinal traumatic event leading to disastrous consequences both emotionally and physically to the patient and family and with a tendency to imagine and compare the pretraumatic condition with no disability while answering the questionnaires may be the reason for the decline.
Our study showed significant improvement after surgery in the elderly patient with degenerative spinal condition with acceptable complications, morbidity, and mortality. This shows that the age of the patient should not be the limiting factor for the surgical management of the patient with a degenerative spinal condition. In traumatic spinal injury patients, the most important aspect of outcome was careful patient selection and type of surgery especially in patients with high cervical spine injury who had associated spinal cord injury requiring ventilator support and cardiovascular instability requiring inotropic support. This study also brought out certain questions/issues which need further study.
Our study was aimed to supplement the literature available on the subject in the Indian context and to bring out certain questions which may be answered by conducting a prospective study with a larger cohort
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]