- Department of Neurological Surgery, The Albert Einstein College of Medicine, Bronx, NY, 10461, and Winthrop University Hospital, Mineola, NY 11501, USA
Nancy E. Epstein
Department of Neurological Surgery, The Albert Einstein College of Medicine, Bronx, NY, 10461, and Winthrop University Hospital, Mineola, NY 11501, USA
DOI:10.4103/2152-7806.91408Copyright: © 2011 Epstein NE. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Epstein NE. Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little. Surg Neurol Int 31-Dec-2011;2:188
How to cite this URL: Epstein NE. Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little. Surg Neurol Int 31-Dec-2011;2:188. Available from: http://sni.wpengine.com/surgicalint_articles/spine-surgery-in-geriatric-patients-sometimes-unnecessary-too-much-or-too-little/
Background:Although the frequency of spinal surgical procedures has been increasing, particularly in patients of age 65 and over (geriatric), multiple overlapping comorbidities increase their risk/complication rates. Nevertheless, sometimes these high-risk geriatric patients are considered for “unnecessary”, too much (instrumented fusions), or too little [minimally invasive surgery (MIS)] spine surgery.
Methods:In a review of the literature and reanalysis of data from prior studies, attention was focused on the increasing number of operations offered to geriatric patients, their increased comorbidities, and the offers for “unnecessary” spine fusions, including both major open and MIS procedures.
Results:In the literature, the frequency of spine operations, particularly instrumented fusions, has markedly increased in patients of age 65 and older. Specifically, in a 2010 report, a 28-fold increase in anterior discectomy and fusion was observed for geriatric patients. Geriatric patients with more comorbid factors, including diabetes, hypertension, coronary artery disease (prior procedures), depression, and obesity, experience higher postoperative complication rates and costs. Sometimes “unnecessary”, too much (instrumented fusions), and too little (MIS spine) surgeries were offered to geriatric patients, which increased the morbidity. One study observed a 10% complication rate for decompression alone (average age 76.4), a 40% complication rate for decompression/limited fusion (average age 70.4), and a 56% complication rate for full curve fusions (average age 62.5).
Conclusions:Increasingly, spine operations in geriatric patients with multiple comorbidities are sometimes “unnecessary”, offer too much surgery (instrumentation), or too little surgery (MIS).
Keywords: Geriatric patients, instrumentation, minimally invasive, spinal surgery, unnecessary
The incidence of spinal surgery, including instrumented fusions, is increasing, and progressively involves patients of age 65 and older (geriatric). Older patients, however, frequently harbor multiple overlapping comorbidities that increase their susceptibility to the major risks and complications associated with spinal surgery, particularly when involving extensive instrumented fusions. This study offers a selective review of the geriatric spinal literature, while also focusing on three areas of great import. First, sometimes geriatric patients are scheduled by surgeons (first opinions) for spinal operations they do not need (unnecessary) according to second spinal surgeons (second opinions). Second, sometimes geriatric patients are subjected to “too much surgery” consisting of multilevel instrumented fusions with/without bone morphogenetic protein (INFUSE: Medtronic, Memphis, TN, USA). Third, sometimes geriatric patients undergo “too little surgery” or minimally invasive surgery (MIS) that fails to adequately decompress neural structures.[
This study combines a search of the literature with a review of several personal series to specifically assess the indications, comorbidities, outcomes, and complications for patients 65 years of age or older undergoing spinal surgery. Specific attention was additionally paid to comorbid factors which increased the susceptibility of these geriatric patients to increased morbidity or mortality following “unnecessary”, too much (instrumented fusions), or too little (MIS) spine surgery.
Frequency of spine surgery and comorbidities in the geriatric age group
An increase in spine surgery was reported in the USA between the years 1978 and 1985, with different rates of spinal procedures being observed across different geographical areas, and/or within states.[
American Society of Anesthesiologists grades, complications and age
Assigning American Society of Anesthesiologists (ASA) grades (e.g. grades 1–5) to patients undergoing spinal procedures, which strongly reflect patients’ preoperative comorbid factors and overall health status, may be utilized to better select patients for spinal surgery, as higher ASA grades correlate with greater postoperative morbidity/mortality.[
Patients aged 65 and older experience higher complication rates particularly with instrumented fusions, in large part, due to their increased attendant medical comorbidities. In one series involving 87 patients undergoing elective thoracolumbar surgery for degenerative spondylotic disease, the overall complication rate was 67%: 50% minor (e.g. superficial wound infection, urinary tract infection, superficial phlebitis) and 17.8% major (e.g. life-threatening: infection, pulmonary embolism, neurological deficits).[
Conclusions: The higher the ASA grade, the greater the complications in spinal surgery.
Additions to the complication rate with detailed co-morbidities: Advanced age, obesity, coronary artery disease, and antidepressant medications
Other series correlated increased morbidity following spinal surgery with these and additional comorbid factors. Alternatively, Walid et al., in their retrospective analysis of how patients were chosen for inpatient (578) versus outpatient (97 cases) spinal surgery found that obesity (BMI > 30), which occurred in 2.8% of inpatients compared with 1% of outpatients, was more highly correlated with the risk of infection, and other chronic diseases.[
In a separate study, Walid and Robinson further determined that severe obesity along with advanced age and female gender correlated with increased major comorbidities and greater costs for spinal surgery.[
Comorbidities similarly increased the surgical costs for ADF. The cost averaged $25,153 without any comorbidities, but increased for ADF with obesity ($25,633), with diabetes ($25,826), and with combined obesity and diabetes ($34,943).[
Depression and diabetes, respectively, increased morbidity following spinal surgery in two other series. Sinikallio et al. demonstrated that preoperative and postoperative depression placed 96 patients, averaging 62 years of age, at greater risk for poorer outcomes (documented utilizing the 21 Beck Depression Inventory Oswestry Disability Questionnaire, Visual Analog Scale), 24 months following lumbar surgery for spinal stenosis.[
Conclusion: Obesity, advanced age, depression, and diabetes – all increased the complication rates and costs of spinal surgery.
Advanced age and other comorbid factors produce a 24–66% complication rate in cervical spine surgery
Advanced age and other comorbid factors correlated with age-increased morbidity associated with cervical spine surgery. In one series involving 81 patients (averaging 57 years of age; range 32–88 years) with cervical spondylotic myelopathy (CSM), complications in 18.5% of cases were more prevalent in the “significantly older” patients with more comorbidities and more Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9) codes.[
Patients over 80 compared with less than 80 had similar complication rates in cervical spine surgery
A contrary study involving 37 patients aged 80 or over versus 124 patients under the age of 80, undergoing decompressive surgery for CSM, found that the older patients had shorter durations of preoperative symptoms, more severe preoperative myelopathy (lower Japanese Orthopedic Association (JOA) scores, and therefore more neurologically impaired going into surgery), lower postoperative JOA scores (at 6 postoperative months: lesser recoveries), but comparable frequencies of comorbidities and postoperative complications, when compared with younger patients.[
On the contrary, many spine surgeons would associate greater perioperative morbidity with anterior rather than posterior cervical surgery
Other spinal surgeons believe that anterior cervical operations incur a higher morbidity/mortality than posterior cervical surgery. Increased comorbid risk factors attributed to anterior cervical procedures include the potential for esophageal trauma, recurrent laryngeal nerve palsy, respiratory complications attributed to tracheal edema, carotid artery injury (risk of stroke/vascular compromise), and graft-/plate-related complications, to name a few. Therefore, the observed greater morbidity seen with posterior spinal approaches in these studies must correlate with the more advanced age and greater attendant comorbid factors seen in the older/geriatric patients undergoing more extensive, multilevel posterior approaches: greater neurological compromise, more multilevel disease, more prolonged duration of symptoms, more advanced vascular, pulmonary, and other systemic disorders. An added consideration should include the notation that if posterior operations include the utilization of lateral mass or pedicle screws (not approved by the Food and Drug Administration or FDA), these devices alone many account for a significant increased risk of neural and/or vascular (vertebral artery) injuries. Alternatively, the perioperative complications attributed to laminectomies with/without attendant wire-based fusion would eliminate these “instrumentation” and “surgeon” failures.
Conclusion: In geriatric patients, more frequent and complex preoperative comorbid factors and the choice of operative approaches (anterior, posterior, or circumferential) may correlate with higher complication rates.
Unnecessary spinal surgery in the geriatric age group
“Unnecessary” spinal surgery in the geriatric age group (author's series) approached 20%
The premise of “unnecessary” spinal surgery, as described by Epstein and Hood, was based upon the observation that one spine surgeon may decide that a patient needs surgery, while another surgeon (e.g. a second opinion) might decide that surgery is “unnecessary.”[
In the original study, 47 (17.2%) of 274 patients seen in the office in 2010 by the first author were scheduled for “unnecessary” spinal surgery by outside surgeons.[
Patients 65 and older and complication rates in spinal surgery
Reassessment of the same data addressing only patients 65 and older revealed that 7 of 47 geriatric patients were advised to have “unnecessary” spinal surgery. The three males and four females averaged 73 years of age (range 65–80 years). Two were scheduled for cervical and five for lumbar operations; one cervical and four lumbar operations involved multiple levels [
Conclusion: “Unnecessary” spinal surgery was recommended for 17.2% of 274 patients from all age groups seen in consultation over 1 year. Out of the 47 patients over the age of 65, 7 patients with 19 comorbidities were scheduled for “unnecessary” operations; 5 of 7 involved multiple levels.
Too much surgery
Sometimes too much surgery in the geriatric age group leads to 50–80% complication rates
Extensive instrumented spinal fusions, increasingly being performed in patients 65 and older, result in higher morbidity and mortality rates. In Campbell et al.'s prospective analysis of 30-day postoperative morbidity associated with 128 anterior, posterior, or 360° instrumented thoracic and/or lumbar procedures, the following variables were correlated: the preoperative diagnosis, medical comorbidities, BMI, surgical approach, length of stay (LOS), and complications.[
Increased readmission rates and costs
To compare morbidity, readmission rate, and costs, Deyo et al. performed a retrospective cohort analysis of Medicare claims from 2002 to 2007 (32,152 patient database) for patients undergoing lumbar decompression alone, simpler fusion (1–2 levels/one approach), or complex fusions (>2 levels and/or combined anterior and posterior surgery).[
Complication rates of 10–56% for multilevel lumbar decompressions with and without fusion
In Transfeldt et al.'s study, three surgical treatments for age-stratified patients with degenerative scoliosis and radiculopathy were evaluated with a 2-year follow-up utilizing patient-based questionnaires (SF-36, Oswestry Disability Index, Roland Morris Scores).[
Reoperation rates in patients over 65
Few spinal series focus on reoperation rates (need for two or more spinal operations) for patients undergoing extensive spinal surgery/instrumentation, particularly in patients aged 65 and older. In one retrospective study of 72 patients, averaging 68.7 years of age, multilevel spinal fusions were performed in patients who were followed an average of 29.4 postoperative months.[
In another study comparing primary versus revision posterior thoracic/lumbar spinal fusions, those having primary procedures were younger (averaging 51.23 years), had fewer average comorbid factors, and a 13.44% complication rate versus those having revision procedures who were slightly older (averaging 52.69 years) patients with average comorbid factors, who exhibited more procedure-related complications (16.02%).[
Reoperation rates in the cervical spine
Reoperation rates for those undergoing cervical surgery differ. In a retrospective cohort evaluation of Washington State's 1998–2002 in-patient databases utilizing ICD-9 codes involving 12,338 cervical spine cases followed for an average of 2.3 years, the reoperation rate was a much lower 5.6% (688 patients).[
Use of INFUSE
Instrumented fusions with INFUSE used “on” or “off-label” (author's series): Extensive instrumented fusions are increasingly being performed in all age groups utilizing INFUSE (Bone Morphogenetic Protein, Medtronic, Memphis TN, USA)) either “on-label” or “off-label.” In an earlier study, we focused on patients from all age groups undergoing 177 spinal fusions (cervical, thoracic, lumbar including anterior, posterior, and 360 procedures) utilizing INFUSE at one institution in 2010 either “on-label” or “off-label.”[
INFUSE, patient age and complications: The same database was reassessed looking only for patients 65 years of age or older.[
INFUSE and reoperation rates and costs in geriatric aged patients: Two or more operations (reoperations) were required in 15 (41.7%) of these 36 patients aged 65 and older [
For 36 patients aged 65 and older, there were also significant costs incurred by performing single or multiple spinal instrumented fusions utilizing INFUSE [
Conclusion: Sometimes too much surgery, particularly extensive instrumented spinal fusions, increases the morbidity and mortality rates for patients 65 and older. The additional use of INFUSE “off-label” also increases perioperative morbidity (e.g. seromas) and likely contributes to the need for secondary operative intervention.
Minimally invasive surgery, age and complication rates
Sometimes too little surgery in the geriatric age group
One of the biggest problems in evaluating morbidity and mortality associated with MIS spinal surgery, including the application of interspinous process fusion devices, microendoscopic procedures, or percutaneous pedicle screw fixation, is the paucity of negative reports or reports of complications in the spinal literature. This may be attributed to several factors; the medicolegal exposure, as cases reported in the literature can be utilized against the author(s) in a US court of law, the lack of incentive to publish negative data (reflecting the source of grant support or cultural bias), and perhaps most critically, many complications occur within the much larger “community” of spinal surgeons, outside university settings, where they are more apt not to be reported/published in the literature.
Use of X-STOP
Several instances of complications associated with placing the X-STOP device in older patients have been reported. Two studies revealed complications occurring in geriatric patients undergoing three minimally invasive (outside) spinal procedures: the application of interspinous process devices, microendoscopic procedures, and percutaneous instrumented fusions (MIS).[
Similar problems with the X-STOP device have been reported by Bowers et al.[
Microendoscopic procedures and age
More typically, positive rather than negative reports concerning MIS microendoscopic procedures are published. One positive study directly compared open surgical decompression (26 patients) versus MIS microendoscopic techniques (23 patients) to treat patients with neurogenic claudication at one institution.[
Extreme lateral interbody fusions
Another study reported the advantages of XLIFs performed in patients 80 years of age or older.[
There are the studies that emphasize the need for technical expertise before utilizing MIS approaches. The study of Selznik, Shamji, and Isaacs reported MIS interbody fusions, including the use of percutaneous screw placement (TLIF, PLIF) for revision lumbar surgery.[
Conclusion: Sometimes too little or minimally invasive spine procedures, including application of interspinous process fusion devices (e.g. X-STOP), microendoscopic procedures, or percutaneous pedicle screw fixation, increase the morbidity and mortality for patients in the geriatric age group. Nevertheless, we cannot discount the fact that surgeon inexperience, lack of judgment, and poor patient selection likely contribute to these high “anecdotal” complications.
The frequency of spinal surgery, in general, and instrumented fusions, in particular, in the USA, has markedly increased over the past few decades, particularly in the geriatric age group.
We have to critically reassess why more patients aged 65 and older are undergoing increasingly frequent and extensive spinal procedures, including multilevel-instrumented fusions. For these older individuals, with more attendant major comorbid factors, careful consideration of perioperative risks versus postoperative benefits may prompt a reduction in the number, extent, and cost of these procedures. We need to better select patients and more stringently monitor our operative criteria, so that “unnecessary” procedures, those performed in patients with pain alone but no neurological deficits or radiographic abnormalities, could be avoided. When we choose patients for surgery, these decisions should be age- and comorbidity-appropriate, avoiding “too much” (instrumented fusions) as well as “too little” (e.g. MIS) surgery where feasible.
Presently, there is a critical “epidemic” of spine surgery in the USA and it is having a great “negative” impact on patients aged 65 and older. As these “patients” may be our parents, and/or ourselves, or our progeny now or in the future, we need to be proactive in containing this “contagion.”
I would like to thank Ms. Sherry Lynn Grimm, Administrator of Long Island Neurosurgical Associates, for her editorial assistance, Professor Donald C. Hood for his Socratic intellectual challenges, and the Joseph A. Epstein Neurosurgical Education Foundation.
1. Bowers C, Amini A, Daialey AT, Schmidt MH. Dynamic interspinous process stabilization: Review of complications associated with the X-Stop device. Neurosurg Focus. 2010. 28: E8-
2. Campbell PG, Yadia S, Malone J, Zussman B, Maltenfort MG, Sharan AD. Early complications related to approach in cervical spine surgery: Single-center prospective study. World Neurosurg. 2010. 74: 363-8
3. Campbell PG, Malone J, Yadla S, Maltenfort MG, Harrop JS, Sharan AD. Early complications related to approach in thoracic and lumbar spine surgery: A single center prospective study. World Neurosurg. 2010. 73: 395-401
4. Davis H. Increasing rates of cervical and lumbar spine surgery in the United States, 1979-1990. Spine. 1994. 19: 1117-23
5. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010. 303: 1259-65
6. Epstein NE. How often is minimally invasive minimally effective: What are the complication rates for minimally invasive surgery?. Surg Neurol. 2008. 70: 386-8
7. Epstein NE. X-Stop: Foot drop: A case report. Spine. 2009. 9: e6-9
8. Epstein NE. Commentary: Pros, Cons, and Costs for INFUSE in Spinal Surgery. Surg Neurol Int. 2011. 2: 10-
9. Epstein NE, Hood DC. “Unnecessary” spinal surgery: A prospective 1-year study of one surgeon's experience. Surg Neurol Int. 2011. 2: 83-
10. Epstein NE, Schwall GS. Commentary: Costs and frequency of “off-label” use of INFUSE for spinal fusions at one institution in 2010. Surg Neurol Int. 2011. 2: 115-
11. Freedman MK, Hilibrand AS, Blood EA, Zhao W, Albert TJ, Vaccaro AR. The impact of diabetes on the outcomes of surgical and nonsurgical treatment of patients in the spine patient outcomes research trial. Spine. 2011. 36: 290-307
12. Fu KM, Smith JS, Poly DW, Ames CP, Verven SH, Perra JH. Correlation of higher preoperative American Society of Anesthesiology grade and increased morbidity and mortality rates in patients undergoing spine surgery. J Neurosurg Spine. 2011. 14: 470-4
13. Furlan JC, Kalsi-Ryan S, Kailaya-Vasan A, Massicotte EM, Fehlings MG. Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: A prospective study of 81 cases. J Neurosurg Spine. 2011. 14: 348-55
14. King JT, Abbed KM, Gould GC, Benzel EC, Ghogawala Z. Cervical spine reoperation rates and hospital resource utilization after initial surgery for degenerative cervical spine disease in patients in Washington State. Neurosurgery. 2009. 65: 1011-22
15. Ma Y, Passias P, Gaber-Baylis LK, Girardi FP, Memtsoudis SG. Comparative in-hospital morbidity and mortality after revision versus primary thoracic and lumbar spine fusion. Spine J. 2010. 10: 881-9
16. Marawar S, Girardi FP, Sama AA, Ma Y, Gaber-Baylis LK, Besculides MC. National trends in anterior cervical fusion procedures. Spine. 2010. 35: 1454-9
17. Memtsoudis SG, Hughes A, Ma Y, Chiu YL, Sama AA, Girardi FP. Increased in-hospital complications after primary posterior versus primary anterior cervical fusion. Clin Orthop Relat Res. 2011. 469: 649-57
18. Nagashima H, Dokai T, Hashiguchi H, Ishii H, Kameyama Y, Katae Y. Clinical features and surgical outcomes of cervical spondylotic myelopathy in patients aged 80 years or older: A multi-center retrospective study. Eur Spine J. 2011. 20: 240-6
19. Nilasena DS, Vaughn RJ, Mori M, Lyon JL. Surgical trends in the treatment of diseases of the lumbar spine in Utah's Medicare population, 1984 to 1990. Med Care. 1995. 33: 585-97
20. Rodgers WB, Gerber EJ, Rodgers JA. Lumbar fusion in octogenarians: The promise of minimally invasive surgery. Spine. 2010. 35: S355-60
21. Röllinghoff M, Zarghooni K, Groos D, Siewe J, Eysel P, Sobottke R. Multilevel spinal fusion in the aged: Not a panacea. Acta Orthop Belg. 2011. 77: 97-102
22. Selznick LA, Shamji MF, Isaacs RE. Minimally invasive interbody fusion for revision lumbar surgery: Technical feasibility and safety. J Spinal Disord Tech. 2009. 22: 207-13
23. Shih P, Wong AP, Smith TR, Lee AI, Fessler RG. Complications of open compared to minimally invasive lumbar spine decompression. J Clin Neurosci. 2011. 18: 1360-4
24. Sinikallio S, Lehto SM, Aalto T, Airaksinen O, Kroger H, Vinamaki H. Depressive symptoms during rehabilitation period predict poor outcome of lumbar spinal stenosis surgery: A two-year prospective. BMC Musculskelet Disord. 2010. 11: 152-
25. Transfeldt EE, Topp R, Mehbod AA, Winter RB. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine. 2010. 35: 1872-5
26. Walid MS, Robinson JS, Robinson ER, Brannick BB, Ajjan M, Robinson JS. Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection. J Clin Neurosci. 2010. 17: 1497-8
27. Walid MS, Robinson JS. Economic impact of comorbidities in spinal surgery. J Neurosurg Spine. 2011. 14: 318-21
28. Yadla S, Malone J, Campbell PG, Maltenfort MG, Harrop JS, Sharan AD. Obesity and spine surgery: Reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures. Spine J. 2010. 10: 581-7