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Treating The Aging Spine
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Posted on: 03/17/2016
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In the next thirty five years the United States population over the age of sixty five will nearly double. This growth in aging population will certainly mean more challenges for orthopaedic surgeons. This article discusses some of these special considerations, and areas needing more research, specifically as they relate to the aging spine. The primary consideration for spine surgeons will likely be evaluating the bone health of the older patient and how these changes effect their surgical options.
In evaluating bone health, the DEXA scan is the gold standard and is regularly ordered for women sixty five or older and men seventy or older. Studies have been shown that when the surgeon initiates risk identification the likelihood of prescribing the best treatment is increased. Other important pre-operative evaluations include calcium levels, vitamin D, parathyroid hormone levels and for men, testosterone.
There is evidence that routinely recommending vitamin D preoperatively for spinal surgeries can improve bone healing and decrease infection risk. Calcium supplements are also important to reduce surgical complications. There are several types of calcium supplements and it is important to prescribe alternates when patients are taking proton pump inhibitor, those who take iron or zinc supplements, and those with inflammatory bowel disease. Even though there is some evidence for both vitamin D and calcium supplements, a study by the US Preventive Services Task Force reported that there is insufficient evidence to recommend greater than or equal to 800 IU of vitamin D and greater than or equal to 1200 mg of elemental calcium in the elderly population. Due to inconclusive evidence this is an area that requires further study.
For patients with osteoporosis there is some concern about prescribing diphosphonates following spinal fusion or fracture based on some models that show a poor outcome of healing. Other drug options include Denosumab or Teriparatide. A study found that following spinal fixation with use of Teriparatide vs diphosphonates the risk of the screws loosening was significantly lower in the Teriparatide group, and the fusion rate was higher.
One huge concern for spinal surgeons is if and how to assure successful fixation for a spinal fusion in the osteoporotic client. Due to a tendency for fixation failures in brittle bone some surgeons will recommend no surgical options for this population. Other options may include using more points of fixation, a larger diameter screw, and addition of cement to improve fixation success. All of these options have some drawbacks and more research is needed.
The odontoid is an important part of the first cervical vertebra which acts as a axis for rotation of the head. It is the most common location for a cervical spine fracture in adults over seventy. It is commonly fractured in a fall from standing height. Treatment can include conservative or surgical care, and in making the choice it is also important to consider things such as degree of osteoporosis, social situation, levels of activity, cardiac and pulmonary situation, and mental status.
Non surgical options include a halo vest or a hard collar. With both of these options there is the possibility of non-union, where the fracture does not completely heal. The halo vest has a higher risk for mortality, and the hard collar a higher risk of non-union. Surgery has two options as well; an anterior approach using a screw to hold the odointiod in place, or posterior approach where a fusion of C1 and C2 is performed. Rates for union healing are high in the anterior approach, nearly ninety percent, however a major side effect is dysphagia (difficulty swallowing) and this occurs in thirty five percent of patients following surgery. The posterior approach is the most common treatment for these fractures, with both complication and mortality rates lower than non surgical treatment or the anterior approach. The decision of how to treat these fractures is often based also on the older patients lifestyle, and other comorbidities which may increase risks with surgery.
Vertebral compression fractures are common in the elderly patient often due to loss of bone strength. Surgical procedures, called vertebroplasty and kyphoplasty, which inject cement into the collapsed vertebral body are used to hopefully decrease pain and improve function. The research on these procedures is mixed at best, showing minimal improvements in pain compared to non surgical treatment and an increased risk of cement leakage. The American Academy of Orthopedic Surgeons guidelines for treatment following vertebral compression fracture are; use of calcitonin in the first four weeks following injury; recommend against vertebroplasty and only weakly recommend kyphoplasty. More recently there have been some studies showing improved outcomes with kyphoplasty and vertebroplasy including a four year Medicare study which showed that survival rates were around sixty one percent with surgery opposed to fifty percent without.
Other common spinal issues in the older client are stenosis and related spinal deformity. The most common treatment is conservative care, including exercises, anti inflammatory medication and activity modifications. If this treatment is not helpful then a decision about the next step may be warranted. Surgery can be successful, but complication rates are higher for older patients. Surgery should include the minimal level of intervention to achieve the best outcome. Decompression is sometimes a viable option when there is a mild deformity and stable grade I spondylolisthesis. A fusion may be indicated for more severe deformities. In the case of fusion and severe deformity often the surgeon will attempt to improve alignment of the pelvic and lumbar spine with osteotomy, however these calm with high risks for blood loss and neurologic injury. There is also some discussion about whether to include the sacrum into a fusion. Doing so may improve stability and alignment, but can impair lumbosacral motion and can effect gait. In either case making sure the fixation will be successful is important to improve outcomes.
In the elderly patient with spinal issues there is much to consider in making a decision as to the course of treatment. Complication rates for surgeries tend to be high, often changes in life style and bone health make recovering from surgeries more challenging as well. Other considerations should include nonsurgical measures. It is also apparent in the article that more research is needed to improve knowledge of the risks and outcomes for the older patient.
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References:
Chroma, T. J. MD, et al. Treating the Aging Spine. In Journal of the American Academy of Orthopaedic Surgeons. December 2015. Vol. 23. No. 12. Pp. e91-e100.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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