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Complications and Mortality in Octogenarians Undergoing Lumbopelvic Fixation
Journal Pre-proof Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation. Alexander von Glinski, MD, Christopher Elia, DO, Darius Ansari, BS, Emre Yilmaz, MD, Ariel Takayanagi, DO, Daniel C. Norvell, PhD, Clifford Pierre, MD, Amir AbdulJabbar, MD, Jens R. Chapman, MD, Rod J. Oskouian, MD PII:
S1878-8750(19)32655-5
DOI:
https://doi.org/10.1016/j.wneu.2019.10.040
Reference:
WNEU 13511
To appear in:
World Neurosurgery
Received Date: 4 September 2019 Revised Date:
7 October 2019
Accepted Date: 8 October 2019
Please cite this article as: von Glinski A, Elia C, Ansari D, Yilmaz E, Takayanagi A, Norvell DC, Pierre C, Abdul-Jabbar A, Chapman JR, Oskouian RJ, Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation., World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.10.040. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation. Alexander von Glinski, MD1,2,3,4; Christopher Elia, DO1,2,5; Darius Ansari,BS1,2; Emre Yilmaz, MD 1,3; Ariel Takayanagi, DO5; Daniel C Norvell,PhD6; Clifford Pierre, MD1,2; Amir AbdulJabbar, MD1,2; Jens R. Chapman, MD1; Rod J. Oskouian, MD1,2 1. Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States 2. Seattle Science Foundation, Seattle, Washington, United States 3. Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany 4. Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States. 5. Department of Neurosurgery, Riverside University Health Systems, Moreno Valley, California, United States. 6. Spectrum Research, Inc, Tacoma, Wash. Electronic address: [email protected].
Conflicts of Interest and Source of Funding: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Corresponding author: Alexander von Glinski, MD Address: Swedish Neuroscience Institute, 550 17th Avenue, Suite 500, Seattle, WA 98122, USA Tel: 2064759514 Fax: 2067326599
E-mail: [email protected]
Keywords: Octogenarian, spine surgery, lumbopelvic fixation, mortality, morbidity
Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation.
Alexander von Glinski, MD1,2,3,4; Christopher Elia, DO1,2,5; Darius Ansari, BS1,2; Emre Yilmaz, MD 1,3; Ariel Takayanagi, DO5; Daniel C Norvell,PhD6; Clifford Pierre, MD1,2; Amir AbdulJabbar, MD1,2; Jens Chapman, MD1; Rod Oskouian, MD1,2 1. Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States 2. Seattle Science Foundation, Seattle, Washington, United States 3. Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany 4. Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States. 5. Department of Neurosurgery, Riverside University Health Systems, Moreno Valley, California, United States. 6. Spectrum Research, Inc, Tacoma, Wash. Electronic address: [email protected].
Conflicts of Interest and Source of Funding: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Corresponding author: Alexander von Glinski, MD Address: Swedish Neuroscience Institute, 550 17th Avenue, Suite 500, Seattle, WA 98122, USA Tel: 2064759514 Fax: 2067326599
E-mail: [email protected]
Keywords: Octogenarian, spine surgery, lumbopelvic fixation, mortality, morbidity
Abstract: Introduction: Advancements in modern medicine have led to longer life expectancy in the elderly population. Literature on spinopelvic fixation in the elderly is limited. We investigated morbidity and mortality in octogenarians who underwent spinopelvic fixation.
Methods: A retrospective chart review was conducted on patients who underwent spinopelvic fixation from January 2014 through December 2018 at a single institution. Patients were grouped into the Octogenarian group (OG, age 80-89) and comparison group (CG, age 4050). Demographics, pathology, Charlson Comorbidity Index (CCI), Hounsfield units (HU), details of surgery, and clinical data including complications, ICU and length of hospital stay, and mortality were collected and compared.
Results: A total of 26 patients met inclusion criteria (n=14 OG, n=12 CG). Diagnoses in the OG were deformity (42.9%), pseudoarthrosis (35.7%), fracture (7.1%), infection (7.1%), and tumor (7.1%). The only significant differences in baseline patient characteristics were that CCI was significantly higher in the OG (6.0 ± 1.4) compared to the CG (1.1 ± 1.0), (p<0.001) and the OG had lower HU (p<0.001), indicating poorer bone quality. More patients in the CG underwent staged and anterior approaches compared to the OG (p=0.031). The major and minor complication rates in the OG were 57.1% and 42.9%, respectively, and 25% and 25% in the CG (p=0.98, p=0.34). Mortality rate was 14.3%.
Conclusion: With an aging population, the number of patients requiring spinopelvic fixation will continue to grow. However, spine surgeons must carefully weigh benefits and risks in patients with multiple comorbidities.
Introduction: Advancements in modern medicine have led to an increased life expectancy in the elderly population. Meanwhile, there are increasing numbers of patients suffering from age-related diseases of the spine, including degenerative disorders, pseudarthrosis after former fusions, and pathologic fractures from osteoporosis and cancer. These pathologies can cause chronic low-back pain, sensory disturbance, and motor decline, often leading to recurrent falls and limitations in activities of daily living resulting in decreased quality of life
1,2-4.
Spine
surgeons must carefully weigh the risks and benefits in this population given the increased risks of anesthetic complications, surgical complications, and postoperative adverse events. The goals of sacropelvic fixation are to obtain a balanced spine and solid fusion mass with improvement of function and pain 5. To date, there is a paucity of studies examining surgical outcomes in spinopelvic fixation in patients older than 80 years 6. We performed a retrospective review of patients who underwent spinopelvic fixation at our institution and compared clinical and radiographic outcomes in patients 80 years of age and older to patients 40 to 50 years or age. To our knowledge this is the first study evaluating morbidity and mortality of sacropelvic fixation in patients 80 years and older.
Methods: We performed a retrospective single-center cohort study that was approved by the local institutional review board and is in accordance with the ethical standards of the 1964 Declaration of Helsinki and its latest amendments. We identified 371 patients who underwent spinopelvic fixation from January 2014 through December 2018 at our institution. Patients who had undergone spinopelvic fixation during this time period were included if they were age 80 to 89 or 40 to 50. Patients who had a history of primary revision of spinopelvic fixation were excluded. Patients who met inclusion criteria were separated into two groups: the Octogenarian group (age 80 to 89) and comparison group (age 40-50). Baseline characteristics such as age at time of surgery, body mass index (BMI), number of comorbid conditions, smoking history, dual-energy x-ray absorptiometry (DEXA) results, and preoperative symptoms were recorded. Further, we calculated the Charlson Comorbidity Index (CCI) which is used to predict survival in patients with multiple comorbidities. One-year mortality rates for CCI scores of 0, 1-2, 3-4, and 5 or greater are 12%, 26%, 52%, and 85%, respectively7. We assessed bone quality by measuring Hounsfield Units using a technique described by Schreiber et al. 8-10
The spinal pathology necessitating surgery was recorded. Intraoperative factors assessed included duration of surgery, number of fused spinal levels, the corrective surgical technique including vertebral column resection (VCR), anterior interbody fusion (AIF), posterior interbody fusion (PIF), and pedicle subtraction osteotomy (PSO). Post-operative clinical information such as length of intensive care unit (ICU) and hospital stay, mortality, perioperative and post-operative complications, and disposition were collected.
Statistical analyses: Bivariable analysis was performed to compare octogenarians to non-octogenarians in baseline characteristics and outcomes. For categorical variables, frequency counts were computed and presented along with their percentages. For continuous variables, means were computed and presented along with their standard deviation. To compare categorical variables, the chi-square test was used. For continuous outcomes, a t-test was used. Because these procedures are so rare in octagenarians, and our sample size was small, we were unable to perform a multivariable analysis to adjust for potential confounding. All analysis were performed using Stata 13.1.
Results: Baseline Characteristics A total of 26 patients who met the inclusion criteria were identified. The 14 patients in the OG with a mean age of 83.2 years and 12 patients in the CG with a mean age of 47.5 years were included. Other baseline characteristics including pathology necessitating surgery are outlined in Table 1. The most common pre-operative diagnosis in the OG was deformity while infection was most common in the CG. Six OG patients (42.9%) presented with neurological deficits compared to 3 CG patients (25%). Mean CCI was significantly higher in the OG (6.0 ± 1.4) compared to the CG (1.1 ± 1.0) (p<0.001).
The OG group had a
significantly lower HU (OG 86.0 ± 37.8 versus CG 167.3 ± 42.1).
Operative Details: Iliac screw fixation was most commonly used in both the OG and the CG (64.3%, 75%). The only significant differences in terms of surgical technique or approach were the more frequently used staged approach in the younger population (p = 0.019) and accordingly, more anterior interbody fusions in the CG (p = 0.045). Further details regarding surgical techniques are described in Table 2. The average number of levels fused was similar between the two groups (OG:7 and CG: 5.8, p=0.438). There was no significant difference in duration of surgery or blood loss.
Complications: The major complication rates were 42.9% in the OG and 25% in the CG (Table 3). In the OG, four patients required revision surgery, reasons for which included wound dehiscence, fractured sacrum, compression fracture of L5, and adjacent level disease. Two patients from the OG died (14.3%), one within 30 days of surgery for heart failure exacerbation and the other died within 90 days of surgery from intracranial hemorrhage after sustaining a ground level fall. In the CG, three patients (25%) underwent revision surgery for wound healing compromise, migration of the interbody cage into the retroperitoneal space, and adjacent level disease.
Minor complication rates were 57.1% in the OG and 25% in the CG. Minor complications in
the OG included four cases of delirium, atrial fibrillation, renal failure, transfusion for acute blood loss, and adjacent level disease. Minor complications in the CG included acute blood loss requiring blood transfusions and prolonged wound healing. Intraoperatively, there were two durotomies in the OG (14.3%) and one in the CG (7.5%).
Radiographic Findings: There were no documented hardware failures in any group at 14 months of follow up.
Hospital Course: Length of hospital and ICU stay did not differ significantly between the two groups (Table 3). Although statistically not significant, the readmission rate was higher in the OG (35.7%) than in the CG (15.4%) which is not surprising given the increased number of comorbidities in the OG.
Discussion: To our knowledge this is the first study reporting morbidity and mortality in octogenarians who underwent sacropelvic fixation. Our results reveal high major complication rates in both groups the OG and the CG (57.1%, 25%, respectively).
According to the United Nations (UN), the proportion of older people (i.e. aged 60 and over) will triple over the next 40 years and will account for more than 20% of the world’s population by year 2050 11. It is estimated that one in five of the elderly population will be more than 80 years old in 2050. The exponential increase of elderly people is secondary to a rise in life expectancy along with a rise in non-communicable chronic conditions leading to morbidity and disability
12.
Adult degenerative spinal disorders are increasing in
frequency nationwide, and more procedures are being done in patients 65 years and older 12.
It is clear that non-surgical treatment must be favored, but patients not responding to
conservative therapy may require surgical intervention in order to improve quality of life 1.
In patients with severe deformity and poor bone quality, long fusions may be necessary in order to achieve sufficient stability 13, as was seen in our cohort. Because of the need for a
larger exposure and involvement of more spinal levels in spinopelvic fixation, the surgery may be associated with a higher peri- and post-operative risk. A retrospective cohort study of 803,949 patients who underwent lumbar spine surgery revealed a higher mortality rate in patients who underwent complex fusions (0.321%) compared to those who underwent simple fusions (0.104%). Additionally, mortality increased with increasing age, with mortality rates in age groups 55-64, 65-74, and 75+ of 0.11%, 0.2%, and 0.35%, respectively14. Our results followed this pattern, with a higher mortality rate in the elderly cohort. The higher mortality rate in our older cohort may be explained by the presence of multiple comorbidities, as evidence by the CCI in the OG group of 6.0. The findings in a study by Zheng et al. support this notion. The authors found that CCI was a significant predictive factor of wound and systemic complications CCI (p = 0.088) in and elderly cohort undergoing posterior lumbar surgery. Therefore, spinopelvic surgery in a select population of elderly patients may be safe if the CCI is acceptable and operative times are minimized 15.
Although the difference did not reach significance, the OG (42.9%) had a slightly higher major complication rate compared to the CG (25%). While a higher complication rate in the older group compared to the younger group may be expected, 58.3% of our younger cohort presented with osteomyelitis, placing them at greater risk of complications. Our mortality rate was higher than those reported in the literature, however major complication rates excluding mortalities were comparable 14.
In the OG, 28.5% of patients underwent reoperation. In a study investigating complication rates in 260 patients who underwent spinopelvic fixation with iliac screws, 31.9% underwent revision surgery 44%
5,17,18,19.
16.
Other reported rates of reoperation range from 11.6% to
Reasons for reoperation in the literature include hardware-related problems
as well as wound dehiscence. Each of our cohorts had one patient with reoperation for wound revision. The rates of wound dehiscence vary greatly in the literature, with some reporting 16.3% and others as high as 36%
18,19.
Our wound dehiscence rates were
relatively low, with 7.1% and 8.3% in the OG and CG. Comparing complication rates in our elderly cohort to those of our younger cohort as well as those previously reported, the risk of complications in octogenarians seems to be acceptable.
The length of hospital and ICU stay did not significantly differ between the two groups. This again can likely be contributed to the fact that 58.3% of the CG presented with osteomyelitis and were battling severe infection. Osteomyelitis in young patients is not uncommon. Issa et al analyzed 228,044 osteomyelitis patients between 1998 and 2013 and pointed out that 49% were below 59 years of age20 which may be associated with drug abuse and malnutrition 21.
Regarding surgical approach, we found that staged approaches and fewer anterior approaches were used in the elderly. This finding was also seen in a retrospective nationwide inpatient data analysis by Passias et al. where patients age 65 to 75 years had mostly posterior-only procedures, and combined surgeries were most frequent in the group with ages 25 to 64 22.
Due to the large population of elderly patients treated in our practice, we have empirically adopted several strategies in an attempt to minimize perioperative complications. In all cases in which substantial blood loss is expected, we use a cell saver for autotransfusion. Careful coordination with the anesthesiologist regarding blood pressure is essential. Complex spinal surgery in the elderly carries with it specific challenges. Elective surgery can be timed to allow for medical optimization through cardiovascular care, nutritional support, smoking cessation, and physical preconditioning
23.
Nevertheless, restrictions in
mobility, dependency on narcotic medications and persistent pain should be considered to have major implications not only for an elderly patient’s well-being, but also for survival 23. Furthermore, in cases of emergency surgery optimization of the perioperative risk factors may only be possible to a certain degree. Limitations: There is a possibility that the relatively short follow-up may have lead to an underestimation of reoperations and complications. However, this would be unlikely to have a large impact on the findings of our study given that Ishida et al. showed that the mean time to any reoperation after Iliac screw placement was four months (range 0, 3-17
months) 17 . Another limitation to our study is the small sample size. Moreover, the number of surgical procedures for lumbar degenerative spine disease performed in elderly patients has increased substantially over the last decade 6. Although elderly patients are known to have more perioperative complications when compared to young patients, this is thought to be secondary to the associated comorbid conditions associated with aging 24. Furthermore, age is related to longer hospital stays, non-home discharges and minor complications 25.
Conclusion:
With increased life expectancy and an aging population, spine surgeons will continue to see increasing numbers of patients older than eighty. In order to improve quality of life in these patients, painful conditions such as degenerative spine disease must be addressed in order to preserve mobility and quality of life. Treatment of this population comes with many challenges including comorbidities and poor bone quality, and consequently risk of perioperative and postoperative complications. In this retrospective cohort study, while the there was a trend toward increased complications in the elderly group, complication rates did not differ significantly between the younger and older patients. Additionally, the complication rates were similar to those previously reported. The risks of spinopelvic surgery may be acceptable when balanced against the potential benefits of the intervention.
Table 1: Baseline Factors Table 1. Baseline characteristics octogenarian group versus comparison group Octogenarian Comparison Group Group (n=14) (n=12) Mean ± SD or % Mean ± SD or pBaseline factors of n % of n value Age Sex (Female) BMI CCI Smoker Osteoporosis Hounsfield units Coronary artery disease Pathology Infection Tumor Deformity Pseudarthrosis Fracture Pre-op Neurological deficit Previous Fusions Abbreviations: BMI: body mass index, SD: standard deviation, preop: preoperative
83.2 ± 2.4 6 (42.9) 29.7 ± 4.3 6.0 ± 1.4 6 (42.9) 4 (28.6) 93.9 ± 30.1 7 (50.0)
47.5 ± 2.5 8 (66.7) 30.3 ± 5.6 1.1 ± 1.0 9 (75.0) 1 (8.3) 172.0 ± 39.7 2 (16.7)
1 (7.1) 1 (7.1) 6 (42.9) 5 (35.7) 1 (7.1) 6 (42.9) 12 (85.7)
7 (58.3) 0 (0.0) 1 (8.3) 4 (33.3) 0 (0.0) 3 (25.0) 8 (66.7)
< .001 0.225 0.757 < .001 0.098 0.192 < .001 0.075 0.039
0.34 0.49
Table 2: Surgical Characteristics Table 2. Characteristics of Surgery in octogenarian group versus comparison group Comparison Octogenarian Group Group (n=14) (n=12) Mean ± SD or % of Characteristics of Surgery Mean ± SD or % of n n Levels fused 7.0 ± 3.5 5.8 ± 4.1 Duration of surgery (min) 386.6 ± 100.7 422.2 ± 136.1 Estimated blood loss (mL) 828.6 ± 490.2 758.3 ± 427.4 Hardware Screw length (mm) 81.4 ± 8.4 84.2 ± 13.1 Screw diameter 8.6 ± 0.4 8.4 ± 0.3 (mm) Anterior interbody 5 (35.7) 9 (75.0) Posterior interbody 12 (85.7) 12 (100.0) Technique/Approach Three column 7 (50.0) 6 (41.7) procedure Vertebral column 2 (14.3) 3 (25.0) resection Pedicle subtraction 4 (28.6) 3 (25.0) osteotomy Staged approach 2 (14.3) 7 (58.3) Abbreviations: SD: standard deviation, mm: millimeters, min: minutes, mL: milliliters
p-value 0.438 0.452 0.703 0.526 0.078 0.045 0.173 0.671 0.303 0.838 0.019
Table 3: Clinical characteristics
Figures:
A) Pre-op: 86f, Post fusion loss of reduction at L4-L5 with loosened hardware and recurrent stenosis, L4-L5, status post fusion and borderline cauda equina syndrome.
B) Post-op: L4 to S1 revision decompression, posterior lumbar interbody fusion, L5-S1, osteotomy of L4-L5 for deformity correction and posterior spinal instrumentation and fusion L4 to ilium with new screw tracts at L4 and L5.
References
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Tadokoro K, Miyamoto H, Sumi M, Shimomura T. The prognosis of conservative treatments for lumbar spinal stenosis: analysis of patients over 70 years of age. Spine (Phila Pa 1976). 2005;30(21):2458-2463. 2. Netuveli G, Wiggins RD, Hildon Z, Montgomery SM, Blane D. Quality of life at older ages: evidence from the English longitudinal study of aging (wave 1). J Epidemiol Community Health. 2006;60(4):357-363. 3. Netuveli G, Blane D. Quality of life in older ages. Br Med Bull. 2008;85:113-126. 4. Mi J, Li K, Zhao X, Zhao CQ, Li H, Zhao J. Vertebral Body Hounsfield Units are Associated With Cage Subsidence After Transforaminal Lumbar Interbody Fusion With Unilateral Pedicle Screw Fixation. Clin Spine Surg. 2017;30(8):E1130-E1136. 5. Guler UO, Cetin E, Yaman O, et al. Sacropelvic fixation in adult spinal deformity (ASD); a very high rate of mechanical failure. Eur Spine J. 2015;24(5):1085-1091. 6. 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(13):1259-1265. 7. 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(5):373-383. 8. Schreiber JJ, Anderson PA, Hsu WK. Use of computed tomography for assessing bone mineral density. Neurosurg Focus. 2014;37(1):E4. 9. Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):1057-1063. 10. Schreiber JJ, Hughes AP, Taher F, Girardi FP. An association can be found between hounsfield units and success of lumbar spine fusion. HSS J. 2014;10(1):25-29. 11. DoEaSA UN. World Population Ageing 2009. 2010. 12. Washington. The Disease Control Priorities Project: Global Burden of Disease and Risk Factors. 2006. 13. Jazini E, Klocke N, Tannous O, et al. Does Lumbopelvic Fixation Add Stability? A Cadaveric Biomechanical Analysis of an Unstable Pelvic Fracture Model. J Orthop Trauma. 2017;31(1):37-46. 14. Poorman GW, Moon JY, Wang C, et al. Rates of Mortality in Lumbar Spine Surgery and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 803,949 Patients in the Nationwide Inpatient Sample. Int J Spine Surg. 2018;12(5):617-623. 15. Zheng F, Sandhu HS, Cammisa FP, Girardi FP, Khan SN. Predictors of functional outcome in elderly patients undergoing posterior lumbar spine surgery. J Spinal Disord. 2001;14(6):518-521. 16. Nguyen JH, Buell TJ, Wang TR, et al. Low rates of complications after spinopelvic fixation with iliac screws in 260 adult patients with a minimum 2-year follow-up. J Neurosurg Spine. 2019:1-9.
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Ishida W, Elder BD, Holmes C, et al. Comparison Between S2-Alar-Iliac Screw Fixation and Iliac Screw Fixation in Adult Deformity Surgery: Reoperation Rates and Spinopelvic Parameters. Global Spine J. 2017;7(7):672-680. Elder BD, Ishida W, Lo SL, et al. Use of S2-Alar-iliac Screws Associated With Less Complications Than Iliac Screws in Adult Lumbosacropelvic Fixation. Spine (Phila Pa 1976). 2017;42(3):E142-E149. Ilyas H, Place H, Puryear A. A Comparison of Early Clinical and Radiographic Complications of Iliac Screw Fixation Versus S2 Alar Iliac (S2AI) Fixation in the Adult and Pediatric Populations. J Spinal Disord Tech. 2015;28(4):E199-205. Issa K, Diebo BG, Faloon M, et al. The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013. Clin Spine Surg. 2018;31(2):E102-E108. Blecher R, Yilmaz E, Ishak B, Drazin D, Oskouian RJ, Chapman JR. Recent Increase in the Rate of Spinal Infections May be Related to Growing Substance-use Disorder in the State of Washington: Wide Population-based Analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) Database. Spine (Phila Pa 1976). 2019;44(4):291-297. Passias PG, Jalai CM, Worley N, et al. Adult Spinal Deformity: National Trends in the Presentation, Treatment, and Perioperative Outcomes From 2003 to 2010. Spine Deform. 2017;5(5):342-350. Wang MY, Widi G, Levi AD. The safety profile of lumbar spinal surgery in elderly patients 85 years and older. Neurosurg Focus. 2015;39(4):E3. Katz JN, Stucki G, Lipson SJ, Fossel AH, Grobler LJ, Weinstein JN. Predictors of surgical outcome in degenerative lumbar spinal stenosis. Spine (Phila Pa 1976). 1999;24(21):2229-2233. Murphy ME, Gilder H, Maloney PR, et al. Lumbar decompression in the elderly: increased age as a risk factor for complications and nonhome discharge. J Neurosurg Spine. 2017;26(3):353-362.
Table 1. Baseline characteristics octogenarian group versus comparison group
Baseline factors
Octogenarian Group (n=14)
Comparison Group (n=12)
Mean ± SD or % of n
Mean ± SD or % of n
Age 83.2 ± 2.4 47.5 ± 2.5 Sex (Female) 6 (42.9) 8 (66.7) BMI 29.7 ± 4.3 30.3 ± 5.6 CCI 6.0 ± 1.4 1.1 ± 1.0 Smoker 6 (42.9) 9 (75.0) Osteoporosis 4 (28.6) 1 (8.3) Hounsfield units 93.9 ± 30.1 172.0 ± 39.7 Coronary artery disease 7 (50.0) 2 (16.7) Pathology Infection 1 (7.1) 7 (58.3) Tumor 1 (7.1) 0 (0.0) Deformity 6 (42.9) 1 (8.3) Pseudarthrosis 5 (35.7) 4 (33.3) Fracture 1 (7.1) 0 (0.0) Pre-op Neurological deficit 6 (42.9) 3 (25.0) Previous Fusions 12 (85.7) 8 (66.7) Abbreviations: BMI: body mass index, SD: standard deviation, preop: preoperative
p-value < .001 0.225 0.757 < .001 0.098 0.192 < .001 0.075 0.039
0.34 0.49
Table 2. Characteristics of Surgery in octogenarian group versus comparison group Octogenarian Group Comparison Group (n=14) (n=12) Characteristics of Surgery
Mean ± SD or % of n
Mean ± SD or % of n
Levels fused 7.0 ± 3.5 5.8 ± 4.1 Duration of surgery (min) 386.6 ± 100.7 422.2 ± 136.1 Estimated blood loss (mL) 828.6 ± 490.2 758.3 ± 427.4 Hardware Screw length (mm) 81.4 ± 8.4 84.2 ± 13.1 Screw diameter (mm) 8.6 ± 0.4 8.4 ± 0.3 Anterior interbody 5 (35.7) 9 (75.0) Posterior interbody 12 (85.7) 12 (100.0) Technique/Approach Three column procedure 7 (50.0) 6 (41.7) Vertebral column resection 2 (14.3) 3 (25.0) Pedicle subtraction osteotomy 4 (28.6) 3 (25.0) Staged approach 2 (14.3) 7 (58.3) Abbreviations: SD: standard deviation, mm: millimeters, min: minutes, mL: milliliters
p-value 0.438 0.452 0.703 0.526 0.078 0.045 0.173 0.671 0.303 0.838 0.019
Table 3. Clinical course in octogenarian group versus comparison group Octogenarian Group Comparison Group (n=14) (n=12) Clinical Characteristics Follow up (days) Length of stay (days) Total hospital stay ICU stay Functional Status ODI preoperatively ODI postoperatively Complications Minor Complication Major Complication Intraoperative Complications (durotomy) Mortality 30-day mortality 90-day mortality Readmission
Mean ± SD or % of n
Mean ± SD or % of n
p-value
441.0 ± 456.9
416.0 ± 298.5
0.877
8.1 ± 4.7 2.0 ± 1.4
11.3 ± 9.5* 3.9 ± 6.7*
0.28 0.305
53.0 ± 9.6 18.3 ± 5.5
60.8 ± 11.7 62.0 ± -
0.283 -
8 (57.1) 6 (42.9)
3 (25.0) 3 (25.0)
0.098 0.34
2 (14.3)
1 (8.3)
0.636
1 (7.1) 1 (7.1) 5 (35.7)
2 (16.7)
0.275
*One outlier was excluded from this calculation. Abbreviations: SD: standard deviation, ICU: intensive care unit, ODI: Oswestry disability index
Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation.
Abbreviations List Octogenarian group (OG, age 80-89) Comparison group (CG, age 40-50) Charlson Comorbidity Index (CCI) Hounsfield units (HU) Intensive Care Unit (ICU) Vertebral column resection (VCR) Anterior interbody fusion (AIF) Posterior interbody fusion (PIF) Pedicle subtraction osteotomy (PSO)
S1878-8750(19)32655-5
DOI:
https://doi.org/10.1016/j.wneu.2019.10.040
Reference:
WNEU 13511
To appear in:
World Neurosurgery
Received Date: 4 September 2019 Revised Date:
7 October 2019
Accepted Date: 8 October 2019
Please cite this article as: von Glinski A, Elia C, Ansari D, Yilmaz E, Takayanagi A, Norvell DC, Pierre C, Abdul-Jabbar A, Chapman JR, Oskouian RJ, Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation., World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.10.040. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation. Alexander von Glinski, MD1,2,3,4; Christopher Elia, DO1,2,5; Darius Ansari,BS1,2; Emre Yilmaz, MD 1,3; Ariel Takayanagi, DO5; Daniel C Norvell,PhD6; Clifford Pierre, MD1,2; Amir AbdulJabbar, MD1,2; Jens R. Chapman, MD1; Rod J. Oskouian, MD1,2 1. Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States 2. Seattle Science Foundation, Seattle, Washington, United States 3. Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany 4. Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States. 5. Department of Neurosurgery, Riverside University Health Systems, Moreno Valley, California, United States. 6. Spectrum Research, Inc, Tacoma, Wash. Electronic address: [email protected].
Conflicts of Interest and Source of Funding: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Corresponding author: Alexander von Glinski, MD Address: Swedish Neuroscience Institute, 550 17th Avenue, Suite 500, Seattle, WA 98122, USA Tel: 2064759514 Fax: 2067326599
E-mail: [email protected]
Keywords: Octogenarian, spine surgery, lumbopelvic fixation, mortality, morbidity
Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation.
Alexander von Glinski, MD1,2,3,4; Christopher Elia, DO1,2,5; Darius Ansari, BS1,2; Emre Yilmaz, MD 1,3; Ariel Takayanagi, DO5; Daniel C Norvell,PhD6; Clifford Pierre, MD1,2; Amir AbdulJabbar, MD1,2; Jens Chapman, MD1; Rod Oskouian, MD1,2 1. Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States 2. Seattle Science Foundation, Seattle, Washington, United States 3. Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany 4. Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States. 5. Department of Neurosurgery, Riverside University Health Systems, Moreno Valley, California, United States. 6. Spectrum Research, Inc, Tacoma, Wash. Electronic address: [email protected].
Conflicts of Interest and Source of Funding: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Corresponding author: Alexander von Glinski, MD Address: Swedish Neuroscience Institute, 550 17th Avenue, Suite 500, Seattle, WA 98122, USA Tel: 2064759514 Fax: 2067326599
E-mail: [email protected]
Keywords: Octogenarian, spine surgery, lumbopelvic fixation, mortality, morbidity
Abstract: Introduction: Advancements in modern medicine have led to longer life expectancy in the elderly population. Literature on spinopelvic fixation in the elderly is limited. We investigated morbidity and mortality in octogenarians who underwent spinopelvic fixation.
Methods: A retrospective chart review was conducted on patients who underwent spinopelvic fixation from January 2014 through December 2018 at a single institution. Patients were grouped into the Octogenarian group (OG, age 80-89) and comparison group (CG, age 4050). Demographics, pathology, Charlson Comorbidity Index (CCI), Hounsfield units (HU), details of surgery, and clinical data including complications, ICU and length of hospital stay, and mortality were collected and compared.
Results: A total of 26 patients met inclusion criteria (n=14 OG, n=12 CG). Diagnoses in the OG were deformity (42.9%), pseudoarthrosis (35.7%), fracture (7.1%), infection (7.1%), and tumor (7.1%). The only significant differences in baseline patient characteristics were that CCI was significantly higher in the OG (6.0 ± 1.4) compared to the CG (1.1 ± 1.0), (p<0.001) and the OG had lower HU (p<0.001), indicating poorer bone quality. More patients in the CG underwent staged and anterior approaches compared to the OG (p=0.031). The major and minor complication rates in the OG were 57.1% and 42.9%, respectively, and 25% and 25% in the CG (p=0.98, p=0.34). Mortality rate was 14.3%.
Conclusion: With an aging population, the number of patients requiring spinopelvic fixation will continue to grow. However, spine surgeons must carefully weigh benefits and risks in patients with multiple comorbidities.
Introduction: Advancements in modern medicine have led to an increased life expectancy in the elderly population. Meanwhile, there are increasing numbers of patients suffering from age-related diseases of the spine, including degenerative disorders, pseudarthrosis after former fusions, and pathologic fractures from osteoporosis and cancer. These pathologies can cause chronic low-back pain, sensory disturbance, and motor decline, often leading to recurrent falls and limitations in activities of daily living resulting in decreased quality of life
1,2-4.
Spine
surgeons must carefully weigh the risks and benefits in this population given the increased risks of anesthetic complications, surgical complications, and postoperative adverse events. The goals of sacropelvic fixation are to obtain a balanced spine and solid fusion mass with improvement of function and pain 5. To date, there is a paucity of studies examining surgical outcomes in spinopelvic fixation in patients older than 80 years 6. We performed a retrospective review of patients who underwent spinopelvic fixation at our institution and compared clinical and radiographic outcomes in patients 80 years of age and older to patients 40 to 50 years or age. To our knowledge this is the first study evaluating morbidity and mortality of sacropelvic fixation in patients 80 years and older.
Methods: We performed a retrospective single-center cohort study that was approved by the local institutional review board and is in accordance with the ethical standards of the 1964 Declaration of Helsinki and its latest amendments. We identified 371 patients who underwent spinopelvic fixation from January 2014 through December 2018 at our institution. Patients who had undergone spinopelvic fixation during this time period were included if they were age 80 to 89 or 40 to 50. Patients who had a history of primary revision of spinopelvic fixation were excluded. Patients who met inclusion criteria were separated into two groups: the Octogenarian group (age 80 to 89) and comparison group (age 40-50). Baseline characteristics such as age at time of surgery, body mass index (BMI), number of comorbid conditions, smoking history, dual-energy x-ray absorptiometry (DEXA) results, and preoperative symptoms were recorded. Further, we calculated the Charlson Comorbidity Index (CCI) which is used to predict survival in patients with multiple comorbidities. One-year mortality rates for CCI scores of 0, 1-2, 3-4, and 5 or greater are 12%, 26%, 52%, and 85%, respectively7. We assessed bone quality by measuring Hounsfield Units using a technique described by Schreiber et al. 8-10
The spinal pathology necessitating surgery was recorded. Intraoperative factors assessed included duration of surgery, number of fused spinal levels, the corrective surgical technique including vertebral column resection (VCR), anterior interbody fusion (AIF), posterior interbody fusion (PIF), and pedicle subtraction osteotomy (PSO). Post-operative clinical information such as length of intensive care unit (ICU) and hospital stay, mortality, perioperative and post-operative complications, and disposition were collected.
Statistical analyses: Bivariable analysis was performed to compare octogenarians to non-octogenarians in baseline characteristics and outcomes. For categorical variables, frequency counts were computed and presented along with their percentages. For continuous variables, means were computed and presented along with their standard deviation. To compare categorical variables, the chi-square test was used. For continuous outcomes, a t-test was used. Because these procedures are so rare in octagenarians, and our sample size was small, we were unable to perform a multivariable analysis to adjust for potential confounding. All analysis were performed using Stata 13.1.
Results: Baseline Characteristics A total of 26 patients who met the inclusion criteria were identified. The 14 patients in the OG with a mean age of 83.2 years and 12 patients in the CG with a mean age of 47.5 years were included. Other baseline characteristics including pathology necessitating surgery are outlined in Table 1. The most common pre-operative diagnosis in the OG was deformity while infection was most common in the CG. Six OG patients (42.9%) presented with neurological deficits compared to 3 CG patients (25%). Mean CCI was significantly higher in the OG (6.0 ± 1.4) compared to the CG (1.1 ± 1.0) (p<0.001).
The OG group had a
significantly lower HU (OG 86.0 ± 37.8 versus CG 167.3 ± 42.1).
Operative Details: Iliac screw fixation was most commonly used in both the OG and the CG (64.3%, 75%). The only significant differences in terms of surgical technique or approach were the more frequently used staged approach in the younger population (p = 0.019) and accordingly, more anterior interbody fusions in the CG (p = 0.045). Further details regarding surgical techniques are described in Table 2. The average number of levels fused was similar between the two groups (OG:7 and CG: 5.8, p=0.438). There was no significant difference in duration of surgery or blood loss.
Complications: The major complication rates were 42.9% in the OG and 25% in the CG (Table 3). In the OG, four patients required revision surgery, reasons for which included wound dehiscence, fractured sacrum, compression fracture of L5, and adjacent level disease. Two patients from the OG died (14.3%), one within 30 days of surgery for heart failure exacerbation and the other died within 90 days of surgery from intracranial hemorrhage after sustaining a ground level fall. In the CG, three patients (25%) underwent revision surgery for wound healing compromise, migration of the interbody cage into the retroperitoneal space, and adjacent level disease.
Minor complication rates were 57.1% in the OG and 25% in the CG. Minor complications in
the OG included four cases of delirium, atrial fibrillation, renal failure, transfusion for acute blood loss, and adjacent level disease. Minor complications in the CG included acute blood loss requiring blood transfusions and prolonged wound healing. Intraoperatively, there were two durotomies in the OG (14.3%) and one in the CG (7.5%).
Radiographic Findings: There were no documented hardware failures in any group at 14 months of follow up.
Hospital Course: Length of hospital and ICU stay did not differ significantly between the two groups (Table 3). Although statistically not significant, the readmission rate was higher in the OG (35.7%) than in the CG (15.4%) which is not surprising given the increased number of comorbidities in the OG.
Discussion: To our knowledge this is the first study reporting morbidity and mortality in octogenarians who underwent sacropelvic fixation. Our results reveal high major complication rates in both groups the OG and the CG (57.1%, 25%, respectively).
According to the United Nations (UN), the proportion of older people (i.e. aged 60 and over) will triple over the next 40 years and will account for more than 20% of the world’s population by year 2050 11. It is estimated that one in five of the elderly population will be more than 80 years old in 2050. The exponential increase of elderly people is secondary to a rise in life expectancy along with a rise in non-communicable chronic conditions leading to morbidity and disability
12.
Adult degenerative spinal disorders are increasing in
frequency nationwide, and more procedures are being done in patients 65 years and older 12.
It is clear that non-surgical treatment must be favored, but patients not responding to
conservative therapy may require surgical intervention in order to improve quality of life 1.
In patients with severe deformity and poor bone quality, long fusions may be necessary in order to achieve sufficient stability 13, as was seen in our cohort. Because of the need for a
larger exposure and involvement of more spinal levels in spinopelvic fixation, the surgery may be associated with a higher peri- and post-operative risk. A retrospective cohort study of 803,949 patients who underwent lumbar spine surgery revealed a higher mortality rate in patients who underwent complex fusions (0.321%) compared to those who underwent simple fusions (0.104%). Additionally, mortality increased with increasing age, with mortality rates in age groups 55-64, 65-74, and 75+ of 0.11%, 0.2%, and 0.35%, respectively14. Our results followed this pattern, with a higher mortality rate in the elderly cohort. The higher mortality rate in our older cohort may be explained by the presence of multiple comorbidities, as evidence by the CCI in the OG group of 6.0. The findings in a study by Zheng et al. support this notion. The authors found that CCI was a significant predictive factor of wound and systemic complications CCI (p = 0.088) in and elderly cohort undergoing posterior lumbar surgery. Therefore, spinopelvic surgery in a select population of elderly patients may be safe if the CCI is acceptable and operative times are minimized 15.
Although the difference did not reach significance, the OG (42.9%) had a slightly higher major complication rate compared to the CG (25%). While a higher complication rate in the older group compared to the younger group may be expected, 58.3% of our younger cohort presented with osteomyelitis, placing them at greater risk of complications. Our mortality rate was higher than those reported in the literature, however major complication rates excluding mortalities were comparable 14.
In the OG, 28.5% of patients underwent reoperation. In a study investigating complication rates in 260 patients who underwent spinopelvic fixation with iliac screws, 31.9% underwent revision surgery 44%
5,17,18,19.
16.
Other reported rates of reoperation range from 11.6% to
Reasons for reoperation in the literature include hardware-related problems
as well as wound dehiscence. Each of our cohorts had one patient with reoperation for wound revision. The rates of wound dehiscence vary greatly in the literature, with some reporting 16.3% and others as high as 36%
18,19.
Our wound dehiscence rates were
relatively low, with 7.1% and 8.3% in the OG and CG. Comparing complication rates in our elderly cohort to those of our younger cohort as well as those previously reported, the risk of complications in octogenarians seems to be acceptable.
The length of hospital and ICU stay did not significantly differ between the two groups. This again can likely be contributed to the fact that 58.3% of the CG presented with osteomyelitis and were battling severe infection. Osteomyelitis in young patients is not uncommon. Issa et al analyzed 228,044 osteomyelitis patients between 1998 and 2013 and pointed out that 49% were below 59 years of age20 which may be associated with drug abuse and malnutrition 21.
Regarding surgical approach, we found that staged approaches and fewer anterior approaches were used in the elderly. This finding was also seen in a retrospective nationwide inpatient data analysis by Passias et al. where patients age 65 to 75 years had mostly posterior-only procedures, and combined surgeries were most frequent in the group with ages 25 to 64 22.
Due to the large population of elderly patients treated in our practice, we have empirically adopted several strategies in an attempt to minimize perioperative complications. In all cases in which substantial blood loss is expected, we use a cell saver for autotransfusion. Careful coordination with the anesthesiologist regarding blood pressure is essential. Complex spinal surgery in the elderly carries with it specific challenges. Elective surgery can be timed to allow for medical optimization through cardiovascular care, nutritional support, smoking cessation, and physical preconditioning
23.
Nevertheless, restrictions in
mobility, dependency on narcotic medications and persistent pain should be considered to have major implications not only for an elderly patient’s well-being, but also for survival 23. Furthermore, in cases of emergency surgery optimization of the perioperative risk factors may only be possible to a certain degree. Limitations: There is a possibility that the relatively short follow-up may have lead to an underestimation of reoperations and complications. However, this would be unlikely to have a large impact on the findings of our study given that Ishida et al. showed that the mean time to any reoperation after Iliac screw placement was four months (range 0, 3-17
months) 17 . Another limitation to our study is the small sample size. Moreover, the number of surgical procedures for lumbar degenerative spine disease performed in elderly patients has increased substantially over the last decade 6. Although elderly patients are known to have more perioperative complications when compared to young patients, this is thought to be secondary to the associated comorbid conditions associated with aging 24. Furthermore, age is related to longer hospital stays, non-home discharges and minor complications 25.
Conclusion:
With increased life expectancy and an aging population, spine surgeons will continue to see increasing numbers of patients older than eighty. In order to improve quality of life in these patients, painful conditions such as degenerative spine disease must be addressed in order to preserve mobility and quality of life. Treatment of this population comes with many challenges including comorbidities and poor bone quality, and consequently risk of perioperative and postoperative complications. In this retrospective cohort study, while the there was a trend toward increased complications in the elderly group, complication rates did not differ significantly between the younger and older patients. Additionally, the complication rates were similar to those previously reported. The risks of spinopelvic surgery may be acceptable when balanced against the potential benefits of the intervention.
Table 1: Baseline Factors Table 1. Baseline characteristics octogenarian group versus comparison group Octogenarian Comparison Group Group (n=14) (n=12) Mean ± SD or % Mean ± SD or pBaseline factors of n % of n value Age Sex (Female) BMI CCI Smoker Osteoporosis Hounsfield units Coronary artery disease Pathology Infection Tumor Deformity Pseudarthrosis Fracture Pre-op Neurological deficit Previous Fusions Abbreviations: BMI: body mass index, SD: standard deviation, preop: preoperative
83.2 ± 2.4 6 (42.9) 29.7 ± 4.3 6.0 ± 1.4 6 (42.9) 4 (28.6) 93.9 ± 30.1 7 (50.0)
47.5 ± 2.5 8 (66.7) 30.3 ± 5.6 1.1 ± 1.0 9 (75.0) 1 (8.3) 172.0 ± 39.7 2 (16.7)
1 (7.1) 1 (7.1) 6 (42.9) 5 (35.7) 1 (7.1) 6 (42.9) 12 (85.7)
7 (58.3) 0 (0.0) 1 (8.3) 4 (33.3) 0 (0.0) 3 (25.0) 8 (66.7)
< .001 0.225 0.757 < .001 0.098 0.192 < .001 0.075 0.039
0.34 0.49
Table 2: Surgical Characteristics Table 2. Characteristics of Surgery in octogenarian group versus comparison group Comparison Octogenarian Group Group (n=14) (n=12) Mean ± SD or % of Characteristics of Surgery Mean ± SD or % of n n Levels fused 7.0 ± 3.5 5.8 ± 4.1 Duration of surgery (min) 386.6 ± 100.7 422.2 ± 136.1 Estimated blood loss (mL) 828.6 ± 490.2 758.3 ± 427.4 Hardware Screw length (mm) 81.4 ± 8.4 84.2 ± 13.1 Screw diameter 8.6 ± 0.4 8.4 ± 0.3 (mm) Anterior interbody 5 (35.7) 9 (75.0) Posterior interbody 12 (85.7) 12 (100.0) Technique/Approach Three column 7 (50.0) 6 (41.7) procedure Vertebral column 2 (14.3) 3 (25.0) resection Pedicle subtraction 4 (28.6) 3 (25.0) osteotomy Staged approach 2 (14.3) 7 (58.3) Abbreviations: SD: standard deviation, mm: millimeters, min: minutes, mL: milliliters
p-value 0.438 0.452 0.703 0.526 0.078 0.045 0.173 0.671 0.303 0.838 0.019
Table 3: Clinical characteristics
Figures:
A) Pre-op: 86f, Post fusion loss of reduction at L4-L5 with loosened hardware and recurrent stenosis, L4-L5, status post fusion and borderline cauda equina syndrome.
B) Post-op: L4 to S1 revision decompression, posterior lumbar interbody fusion, L5-S1, osteotomy of L4-L5 for deformity correction and posterior spinal instrumentation and fusion L4 to ilium with new screw tracts at L4 and L5.
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Ishida W, Elder BD, Holmes C, et al. Comparison Between S2-Alar-Iliac Screw Fixation and Iliac Screw Fixation in Adult Deformity Surgery: Reoperation Rates and Spinopelvic Parameters. Global Spine J. 2017;7(7):672-680. Elder BD, Ishida W, Lo SL, et al. Use of S2-Alar-iliac Screws Associated With Less Complications Than Iliac Screws in Adult Lumbosacropelvic Fixation. Spine (Phila Pa 1976). 2017;42(3):E142-E149. Ilyas H, Place H, Puryear A. A Comparison of Early Clinical and Radiographic Complications of Iliac Screw Fixation Versus S2 Alar Iliac (S2AI) Fixation in the Adult and Pediatric Populations. J Spinal Disord Tech. 2015;28(4):E199-205. Issa K, Diebo BG, Faloon M, et al. The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013. Clin Spine Surg. 2018;31(2):E102-E108. Blecher R, Yilmaz E, Ishak B, Drazin D, Oskouian RJ, Chapman JR. Recent Increase in the Rate of Spinal Infections May be Related to Growing Substance-use Disorder in the State of Washington: Wide Population-based Analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) Database. Spine (Phila Pa 1976). 2019;44(4):291-297. Passias PG, Jalai CM, Worley N, et al. Adult Spinal Deformity: National Trends in the Presentation, Treatment, and Perioperative Outcomes From 2003 to 2010. Spine Deform. 2017;5(5):342-350. Wang MY, Widi G, Levi AD. The safety profile of lumbar spinal surgery in elderly patients 85 years and older. Neurosurg Focus. 2015;39(4):E3. Katz JN, Stucki G, Lipson SJ, Fossel AH, Grobler LJ, Weinstein JN. Predictors of surgical outcome in degenerative lumbar spinal stenosis. Spine (Phila Pa 1976). 1999;24(21):2229-2233. Murphy ME, Gilder H, Maloney PR, et al. Lumbar decompression in the elderly: increased age as a risk factor for complications and nonhome discharge. J Neurosurg Spine. 2017;26(3):353-362.
Table 1. Baseline characteristics octogenarian group versus comparison group
Baseline factors
Octogenarian Group (n=14)
Comparison Group (n=12)
Mean ± SD or % of n
Mean ± SD or % of n
Age 83.2 ± 2.4 47.5 ± 2.5 Sex (Female) 6 (42.9) 8 (66.7) BMI 29.7 ± 4.3 30.3 ± 5.6 CCI 6.0 ± 1.4 1.1 ± 1.0 Smoker 6 (42.9) 9 (75.0) Osteoporosis 4 (28.6) 1 (8.3) Hounsfield units 93.9 ± 30.1 172.0 ± 39.7 Coronary artery disease 7 (50.0) 2 (16.7) Pathology Infection 1 (7.1) 7 (58.3) Tumor 1 (7.1) 0 (0.0) Deformity 6 (42.9) 1 (8.3) Pseudarthrosis 5 (35.7) 4 (33.3) Fracture 1 (7.1) 0 (0.0) Pre-op Neurological deficit 6 (42.9) 3 (25.0) Previous Fusions 12 (85.7) 8 (66.7) Abbreviations: BMI: body mass index, SD: standard deviation, preop: preoperative
p-value < .001 0.225 0.757 < .001 0.098 0.192 < .001 0.075 0.039
0.34 0.49
Table 2. Characteristics of Surgery in octogenarian group versus comparison group Octogenarian Group Comparison Group (n=14) (n=12) Characteristics of Surgery
Mean ± SD or % of n
Mean ± SD or % of n
Levels fused 7.0 ± 3.5 5.8 ± 4.1 Duration of surgery (min) 386.6 ± 100.7 422.2 ± 136.1 Estimated blood loss (mL) 828.6 ± 490.2 758.3 ± 427.4 Hardware Screw length (mm) 81.4 ± 8.4 84.2 ± 13.1 Screw diameter (mm) 8.6 ± 0.4 8.4 ± 0.3 Anterior interbody 5 (35.7) 9 (75.0) Posterior interbody 12 (85.7) 12 (100.0) Technique/Approach Three column procedure 7 (50.0) 6 (41.7) Vertebral column resection 2 (14.3) 3 (25.0) Pedicle subtraction osteotomy 4 (28.6) 3 (25.0) Staged approach 2 (14.3) 7 (58.3) Abbreviations: SD: standard deviation, mm: millimeters, min: minutes, mL: milliliters
p-value 0.438 0.452 0.703 0.526 0.078 0.045 0.173 0.671 0.303 0.838 0.019
Table 3. Clinical course in octogenarian group versus comparison group Octogenarian Group Comparison Group (n=14) (n=12) Clinical Characteristics Follow up (days) Length of stay (days) Total hospital stay ICU stay Functional Status ODI preoperatively ODI postoperatively Complications Minor Complication Major Complication Intraoperative Complications (durotomy) Mortality 30-day mortality 90-day mortality Readmission
Mean ± SD or % of n
Mean ± SD or % of n
p-value
441.0 ± 456.9
416.0 ± 298.5
0.877
8.1 ± 4.7 2.0 ± 1.4
11.3 ± 9.5* 3.9 ± 6.7*
0.28 0.305
53.0 ± 9.6 18.3 ± 5.5
60.8 ± 11.7 62.0 ± -
0.283 -
8 (57.1) 6 (42.9)
3 (25.0) 3 (25.0)
0.098 0.34
2 (14.3)
1 (8.3)
0.636
1 (7.1) 1 (7.1) 5 (35.7)
2 (16.7)
0.275
*One outlier was excluded from this calculation. Abbreviations: SD: standard deviation, ICU: intensive care unit, ODI: Oswestry disability index
Complications and Mortality in Octogenarians undergoing Lumbopelvic Fixation.
Abbreviations List Octogenarian group (OG, age 80-89) Comparison group (CG, age 40-50) Charlson Comorbidity Index (CCI) Hounsfield units (HU) Intensive Care Unit (ICU) Vertebral column resection (VCR) Anterior interbody fusion (AIF) Posterior interbody fusion (PIF) Pedicle subtraction osteotomy (PSO)