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Table of Contents    
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 52-53

Enhancing Surgical Outcomes in Septuagenarians following Spinal Surgery


Poona Hospital and Research Center, Pune, Maharashtra, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Sushil V Patkar
Poona Hospital and Research Center, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279660

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How to cite this article:
Patkar SV. Enhancing Surgical Outcomes in Septuagenarians following Spinal Surgery. Neurol India 2020;68:52-3

How to cite this URL:
Patkar SV. Enhancing Surgical Outcomes in Septuagenarians following Spinal Surgery. Neurol India [serial online] 2020 [cited 2020 Jul 4];68:52-3. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/52/279660




Demographic data from all over the world show increasing longevity and India is no exception. The life expectancy at birth (2011–2016) of the Indian population was 66.81.[1] Increasing access to better nutrition, healthcare, and preventive medicine coupled with education and awareness, are contributing to this trend. Increase in incidence of spinal diseases of the elderly (degeneration, trauma, metastatic tumor, and infective spondylitis) requiring surgical intervention has increased but due to lack of any national register, it can only be guessed.

Western literature confirms a steep increase in the number of surgeries and sometimes with doubts about indications and techniques.[2] However, the need for an independent ambulant life to perform normal activities of daily living has made the elderly accept the surgical option if the risk is minimal. Nevertheless, review of previous surgical outcome data, thorough preoperative evaluation of risk factor calculation and newer technology and surgical techniques continue to push forward the age limit for successful spinal surgery.


  Counselling With Informed Choice Top


Degeneration, kyphosis, and auto fusion are the inevitable stages of the aging process. Surgery is an option only if the activities of daily life requirements of the patient are progressively worsening. Surgical treatment consists of decompression, deformity correction, and fixation—fusion in isolation or combination without complications. The patient should be made aware of the possible risks and outcome possibilities with titration of the procedure as per the patient requirement and expectations.


  Steps for an Uneventful and Successful Outcome Top


Before surgery

Preoperative screening and treatment for comorbidities (hypertension, diabetes, cardiopulmonary reserve, and mental status) help in reducing the perioperative and postoperative mortality unrelated to the procedure.[3] Cessation of smoking for at least 30 days and Incentive spirometry have an important role in avoiding postoperative respiratory complications unique to the elderly. Hypoproteinemia, alcoholism vitamin deficiencies, and chronic dehydration need to be thoroughly addressed before offering surgery. Evaluation of bone quality and bone stock with preparedness for intraoperative bone augmentation is important if instrumentation is contemplated. Arranging for multiple implant options and required instrumentations is a good plan to avoid uncomfortable situation intraoperatively.

During surgery

Duration of surgery (>3 h) increases postoperative complications.[4] A thorough preoperative plan of rehearsed steps to reach the goal along with expert assistance or two surgeon method can reduce the duration of the procedure. Checking position of endotracheal tube after final position, arrangement of bolsters to avoid abdominal venous compression and achieve minimal peak airway pressure (less than 20 mm) with central intravenous access along with arterial line help in proper intraoperative monitoring which avoids mishaps and improves outcomes. Strict obsessive aseptic catheterization of the urinary bladder can prevent life-threatening postoperative urinary sepsis which is common in the elderly after major surgery. Intraoperative temperature maintenance and venous stasis prophylaxis need attention. Use of through hemostasis and tranexamic acid can reduce blood loss.

Postoperative

Delirium is a common problem after major surgery in the elderly, and the present study makes no mention of this important problem. Duration of stay in an intensive care unit is another factor which has a direct correlation and can add to the morbidity[5] Fortunately, in most cases, it is self-limiting but can be troublesome. Early mobilization and reestablishing the sleep-wake cycle by natural light exposure is useful.


  Conclusion Top


Spinal surgery in the very elderly poses unique challenges and is on the rise. The present study does not ponder over the ways to improve the outcomes and only compares itsoutcomes to those in literature. The higher complication rate needs to be balanced with improved quality of life after surgery. Proper preoperative counselling and comorbidity evaluation, followed by a targeted approach with least intervention and rapid return to ambulation will result in increased successful outcome.



 
  References Top

1.
Amitkumar M, Singh PK, Singh KJ, Khumukcham T, Sawarkar DP, Chandra SP, et al. Surgical Outcome in Spinal Operation in Patients 70 years of Age and above. Neurol India 2020;68:45-51.  Back to cited text no. 1
  [Full text]  
2.
Epstien NE. Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little. Surg Neurol Int 2011;2:188.  Back to cited text no. 2
    
3.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987;40:373-83.  Back to cited text no. 3
    
4.
Wang MY, Widi G, Levi AD. The safety profile of lumbar spinal surgery in elderly patients 85 years and older. Neurosurg Focus 2015;39:E3.  Back to cited text no. 4
    
5.
Arumugam S, El-Menyar A, Al-Hassani A, Strandvik G, Asim M, Mekkodithal A, et al. Delirium in the Intensive Care Unit. J Emerg Trauma Shock 2017;10:37-46.  Back to cited text no. 5
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