Elsevier

World Neurosurgery

Volume 112, April 2018, Pages e555-e560
World Neurosurgery

Original Article
Is Eighty the New Sixty? Outcomes and Complications after Lumbar Decompression Surgery in Elderly Patients over 80 Years of Age

https://doi.org/10.1016/j.wneu.2018.01.082Get rights and content

Highlights

  • Treatment guidelines for older patients with degenerative spine disease remain rare despite increasing number of surgical procedures.

  • Monocentric retrospective data of 244 patients 80 years of age or older who underwent lumbar decompressive surgery.

  • Peri- and intraoperative complication rates with regard to medical conditions in patients 80 years or older were recorded.

Objective

An increasing demographic aging of the general population results in a rising incidence of octogenarians and nonagenarians with spine disease. Patients older than 65 years represent the majority of patients with degenerative lumbar spine disease in our daily clinical routine. Surgical treatment is undertaken reluctantly because of an increased rate of comorbidities. We therefore assessed complication rates of lumbar decompression in regard to neurological outcome and medical conditions in patients age 80 years or older in a retrospective single-center series.

Methods

Data for 244 patients (124 female, 120 male; mean age, 83.1 ± 3 years; age range, 80–95 years) who underwent decompressive surgery for lumbar spinal stenosis or disc herniation between April 2007 and February 2016 were assessed retrospectively. Age at surgery, neurologic deficits (preoperative and postoperative), relevant medical comorbidities and previous lumbar decompression, intraoperative and postoperative complications (e.g., surgery-related, medical), duration of surgery, length of hospital stay, and rate of revision surgeries were recorded.

Results

Surgery was performed for lumbar stenosis (184 patients; 75.4%), lumbar disc herniation (13 patients; 5.3%) or both (47 patients; 19.3%). Seventy-six patients (31.3%) patients experienced preoperative neurologic deficits; 48 (63.2%) of these patients improved, 28 (36.8%) of them were unchanged after surgery, and none deteriorated. New transient, postoperative, neurologic deficits occurred in 6 patients (2.5%). All 55 (22.5%) intraoperative complications were mild to moderate, and no severe surgical complications occurred. Two hundred fifteen patients (88%) had relevant medical disorders. Nineteen (7.7%) postoperative medical complications were reported in 17 patients (7%), of which 14 (73.7%) were severe and 5 (26.3%) were mild (4 pulmonary embolisms, 6 pneumonias, 3 myocardial infarctions, 1 postoperative renal failure, 5 urinary tract infections). Medical complications that necessitated intensive care unit treatment and resulted in lethal outcome were seen in 2 patients (0.8%).

Conclusion

Despite their age, the vast majority of octogenarians and nonagenarians benefited from lumbar decompression surgery. Mild to moderate intraoperative complications were relatively frequent, whereas severe intraoperative complications did not occur. The majority of medical complications was severe, but the incidence was acceptable, and the postoperative outcome was still favorable in most patients.

Introduction

As the population in westernized countries ages, the incidence of octogenarian and nonagenarians with degenerative spine diseases is rising. Approximately 47% of individuals older than 60 years will experience lumbar spinal canal stenosis.1

The number of surgical procedures for lumbar degenerative spine disease performed in older patients, particularly decompressive spine surgery, has increased substantially over the last decade.2 Treatment guidelines for older patients with degenerative spine disease, however, are still rare. Long-term data for several studies show a benefit of surgical treatment of lumbar stenosis compared with conservative treatment,3, 4, 5 but do not specifically focus on the effects of age on clinical outcome. As relevant comorbidities occur more often in octogenarians than in a younger population, perioperative complication and mortality rates might be higher for these patients.6 The results for the octogenarian population in the Spine Patient Outcomes Research trial revealed that surgical treatment of lumbar spinal stenosis (LSS) with or without degenerative spondylolisthesis offers a benefit over nonsurgical treatment. The complication rate in this cohort was similar compared with patients younger than 80 years.7 As the indication for surgery is often not absolute but relative, comorbidities and other preoperative risk factors must be considered when deciding for or against surgery in these mostly moribund patients. The aim of the present study was to assess the clinical outcome and perioperative complications for surgical decompression in degenerative lumbar spinal disease in octogenarian and nonagenarian patients.

Section snippets

Patients and Methods

This retrospective single-center cohort study was approved by the local medical ethics committee (245/16S) and is in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments.8

Surgery

Mean duration of surgery was 89.7 ± 34.7 minutes (range, 13–201 minutes). Surgery was performed for LSS (184 patients; 75.4%), LDH (13 patients; 5.3%), or a combination of both (47 patients; 19.3%). Most patients received 1- or 2-level decompression surgery (1-level, 31.1%; 2-level, 45.5%; 3-level, 21.7%; 4-level, 1.7%). Fifty-three patients (21.7%) had at least one previous lumbar spine surgery involving the index level (Table 1).

Neurologic Deficits and Pain

Seventy-six (31.3%) patients experienced preoperative neurologic

Discussion

Surgical treatment of patients older than 80 years can be challenging, as the majority of these patients have relevant medical disorders necessitating regular medication, anticoagulants included. Data from previous studies could show a benefit of surgery for older patients with degenerative diseases of the lumbar spine7 and address the effectiveness of surgical treatment.10, 11 The present study examined one of the largest monocentric octogenarian and nonagenarian population with LSS and LDH

Conclusion

Despite advanced age, the vast majority of octogenarians and nonagenarians benefited from lumbar decompression surgery. Surgery-related complications occurred relatively frequently, but most them were mild to moderate, whereas the majority of the few perioperative medical complications was severe. Nevertheless, the rate of medical complications was acceptable. We had no serious surgical complications and no permanent new postoperative neurologic deficits in the assessed patient series. With

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      Even in the octagenarian and over, surgery (mainly decompression) for LSS resulted in good clinical outcomes and is considered a useful treatment method. However, it should be performed with caution for perioperative and postoperative complications [295,301,303–306,308–314]. As symptoms that are difficult to improve after surgical treatment greatly affect patient satisfaction, it is important to obtain informed consent of those following a general explanation before surgery.

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      Likewise, lower baseline functional status and decreased BMI among geriatric patients has also been linked to increased complication and readmission rates following lumbar surgery, with the former also associated with a higher risk of developing postoperative delirium.11,12 Despite this, less invasive procedures, like decompression alone, have shown acceptable rates of postoperative medical complications.13 While advanced ago may increase the risk of medical complications following lumbar surgery, there is conflicting literature as to the effect it has on surgical complications.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Bernhard Meyer and Yu-Mi Ryang are co-senior authors who contributed equally to this work.

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