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Perioperative complications and clinical outcomes of multilevel circumferential lumbar spinal fusion in the elderly
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Journal of Clinical Neuroscience 16 (2009) 69–73 www.elsevier.com/locate/jocn
Clinical Study
Perioperative complications and clinical outcomes of multilevel circumferential lumbar spinal fusion in the elderly Frank L. Acosta a,*, Jordan M. Cloyd a, Henry E. Aryan b, Christopher P. Ames a a
Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Avenue;S-225, San Francisco, CA 94143, USA b Division of Neurosurgery, University of California San Diego, San Diego, CA, USA Received 4 April 2008; accepted 16 April 2008
Abstract Combined anterior–posterior lumbar fusion across multiple levels is thought to be associated with increased perioperative morbidity and worse clinical outcomes when performed in elderly patients. We conducted a retrospective review of the medical, surgical, and radiological records of 73 patients who underwent multilevel anterior lumbar interbody fusion (ALIF) with posterolateral lumbar fusion with instrumentation for symptomatic lumbar degenerative disc disease. Mean follow-up was 19 months. Thirty patients were at least 65 years old and 43 patients were younger. There were no significant differences in the number of levels fused, operative time, mean length of hospital stay or perioperative complication rates in either group. Similarly, there were no statistically significant differences in the improvement in back pain or in the rates of fusion between the groups at last follow-up. Perioperative events, intermediate-term clinical outcomes, and fusion rates after multilevel 360-degree lumbar fusion in the elderly are comparable to those of younger patients. Ó 2008 Elsevier Ltd. All rights reserved. Keywords: Elderly patients; Complication; Clinical outcome; Lumbar spine; Circumferential fusion; Degenerative disc disease
1. Introduction Degenerative conditions of the lumbar spine are common in older individuals and can often result in lower back pain (LBP). Posterolateral lumbar spinal fusion reduces pain and disability in some patients suffering from chronic LBP due to degenerative disc disease (DDD).1 Anterior– posterior fusion surgery, also known as 360-degree or circumferential fusion, has demonstrated impressive fusion rates and good clinical outcomes in patients1–9 even at long-term follow-up.10 However, because of the increased surgical time, length of hospitalization and cost associated with circumferential fusion, patient selectivity remains crucial and may be reserved for patients at high risk of not achieving spinal fusion.8,9,11 Although one indication for
*
Corresponding author. Tel.: +1 415 353 3904; fax: +1 415 393 3907. E-mail address: [email protected] (F.L. Acosta).
0967-5868/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2008.04.015
360-degree fusion is multilevel DDD, the use of this technique remains uncertain in older individuals. As the number of elderly persons in the United States continues to rise, surgical treatment for degenerative conditions of the lumbar spine will increasingly be deemed necessary in elderly patients.12 However, combined anterior– posterior lumbar fusion across multiple levels is associated with increased perioperative complications and worse clinical outcomes in elderly patients13–15 and has generally not been indicated in patients 70 years or older.16 While a recently published systematic review on complications and clinical outcomes of lumbar spine surgery in the elderly found no additional risk of complication in elderly patients, we were unable to find published articles that directly studied the safety and efficacy of multilevel circumferential fusion procedures in elderly patients.17 Therefore, we aimed to analyse retrospectively the effects of age on the perioperative morbidity, intermediate-term clinical outcomes and fusion rates in elderly patients undergoing mul-
70
F.L. Acosta et al. / Journal of Clinical Neuroscience 16 (2009) 69–73
tilevel 360-degree lumbar fusion for symptomatic lumbar spine disease. 2. Methods Between 2002 and 2005, 73 patients received multilevel circumferential lumbar fusion for symptomatic lumbar DDD. We reviewed the medical, surgical and radiological records of these patients. The patients were divided into two groups based on age at the time of operation. The elderly group included 30 patients aged 65 years or older (range 65–77 years, mean 71 years) and the young group included 43 patients aged less than 65 years (range 22–61 years, mean 41 years) (Table 1). The elderly group was 43% male whereas the young group was 51% male. We excluded patients with a previously failed fusion surgery, history of spinal malignancy, spondylodiscitis and elderly persons judged medically unfit to undergo circumferential fixation. All patients who underwent surgery had severe disabling lower back pain attributable to multilevel (P2) lumbar DDD (Fig. 1). Disc degeneration was diagnosed via MRI based on findings of reduced signal intensity, decrease in disc height and/or the presence of radial fissures.18 Six patients in the elderly group (20%) also had evidence of spinal stenosis while three (10%) had accompanying spondylolisTable 1 Comparison of patient characteristics and operative data between elderly and young groups Parameter
Elderly (P 65 years)
Young (< 65 years)
p value
No. patients Average age (range) Sex (M:F) No. levels fused (SD) Total operative time, hours (SD) Length of hospitalization, days (SD) Average follow-up, months
30 71 (65–77) 13:17 3.2 (0.5) 7.3 (1.5) 9.0 (1.5) 18
43 41 (22–61) 22:21 3.5 (0.7) 7.9 (1.2) 7.0 (2.0) 20
>0.05 >0.05 >0.05 >0.05
SD = standard deviation.
thesis. Non-operative management of pain, including medication and epidural steroid injection, had been exhausted in all patients for at least 6 months. All surgeries were performed by the same surgeon (CPA). Briefly, all patients underwent anterior lumbar interbody fusion (ALIF) at two or more levels via a retroperitoneal approach. Reconstruction of the interbody space was accomplished by anterior insertion of carbon fiber interbody grafts (CougarTM System, Depuy Spine; Raynham, MA, USA). Supplemental posterior pedicle screw-rod fixation was performed on the same or next day in all patients. Clinical parameters such as duration of procedure, length of stay (LOS) and perioperative events were recorded. Major complications were defined as any event that required a specific intervention and adversely affected the patient recovery.15 Major postoperative complications included wound infection, pneumonia, respiratory distress, deep venous thrombosis or pulmonary embolus, renal failure, myocardial infarction, focal neurological deficit, intracranial hemorrhage and meningitis. All patients completed a preoperative assessment by the visual analog scale (VAS) for pain and Oswestry Disability Index (ODI). Patients repeated these assessments at 3, 6, and 12 months follow-up. Fusion rates were assessed for both groups. A solid fusion was defined as lack of motion without hardware migration or fracture on flexion–extension radiographs. Radiographic assessments were performed for all patients at 6 and 12 month follow-up. Total mean follow-up for all patients was 19 months. Statistical analysis was performed for all measurements using the Student t-test. A p of 0.05 was set for statistical significance.
3. Results There were no statistically significant differences (mean ± standard deviation, SD) in the number of levels fused (elderly, 3.2 ± 0.5; young, 3.5 ± 0.7), total operative
Fig. 1. (A) Sagittal T2-weighted MRI of a 66-year-old woman with intractable axial lower back pain due to multilevel degenerative disc disease. Also note the grade 1 spondylolisthesis at L4–5. (B) Six-month postoperative lateral flexion and (C) extension plain radiographs after 3-level circumferential fixation at L3–4, L4–5, and L5–S1 demonstrating lack of motion, hardware migration, or fracture.
F.L. Acosta et al. / Journal of Clinical Neuroscience 16 (2009) 69–73
time (elderly, 7.3 ± 1.5 h; young, 7.9 ± 1.2 h), or LOS (elderly, 9.0 ± 1.5 days; young, 7.0 ± 2.0 days) (Table 1). Four patients in each group encountered complications associated with their surgery (elderly, 13.3%; young, 9.3%; p > 0.05). In the elderly patients, one individual acquired pneumonia, one developed deep venous thrombosis (DVT) and two infections were reported. In the younger patients, there was one case of DVT and three individuals had infections. There were no cases of myocardial infarction (Table 2). Table 2 Perioperative events and complications Parameter
Elderly (P65 years)
Young (<65 years)
p value
Pneumonia Deep venous thrombosis Myocardial infarction Infection Total complication rate
1 1 0 2 13.3%
0 1 0 3 9.3%
>0.05 >0.05 >0.05 >0.05 >0.05
71
The subjective clinical outcomes were measured by pain VAS and ODI (Fig. 2). Each group showed significant improvements in both pain and disability at 3 month follow-up, and these improvements were sustained through the first year. No significant differences were observed between elderly and young patients in subjective ratings at preoperative assessment (VAS: elderly, 8.7 ± 0.2; young, 8.8 ± 0.3; ODI: elderly, 28.5 ± 3.5; young, 29.7 ± 4.1) or at 3 month, 6 month or 1 year follow-up (VAS: elderly, 3.1 ± 0.2; young, 3.9 ± 0.5; ODI: elderly, 19.2 ± 2.5; young, 19.9 ± 2.2). All patients demonstrated radiographic evidence of fusion at last follow-up and there were no instances of hardware failure or migration. 4. Discussion
Fig. 2. Results of clinical outcomes in elderly and young groups at preoperative, 3-month, 6-month and 1-year assessment. (A) Visual analog scale for pain (VAS). (B) Oswestry disability index (ODI). Both measurements were significantly improved postoperatively (p < 0.05), and this improvement was maintained through last follow-up. There were no significant differences in either outcome measure between the elderly and young groups. * p < 0.05.
The advantages of a combined anterior–posterior lumbar fusion are described in the literature. Circumferential fusion consistently attains the highest fusion rates, up to 100%, in patients with symptomatic lumbar DDD.1,2,5,7,9,19,20 A randomized controlled trial of circumferential fusion compared to instrumented posterolateral fusion demonstrated better functional outcomes and greater reductions in pain at both intermediate-term and longterm follow-up.2,10 Furthermore, a combined anterior– posterior surgery restores disc height21,22 while preventing segmental instability and relieving biomechanical stresses incurred in either ALIF or posterior lumbar interbody fusion (PLIF) alone.23–25 These effects may be even greater in patients with poor bone quality, and therefore a combined anterior–posterior fusion may increase fusion rates when compared to PLIF in patients with osteoporotic bone.26 Thus, while certainly an aggressive surgery, the use of 360-degree fusion in patients with multiple levels of symptomatic degenerative disease of the lumbar spine consistently results in superior fusion rates and clinical outcomes. To the best of our knowledge, this is the first evidence that multilevel circumferential lumbar fusion in elderly patients leads to similar outcomes as for younger patients. Both groups experienced 100% fusion rates based on radiographic evaluation at 6-month and 12-month follow-up. Osteoporotic vertebra may confer risk for non-union resulting from pedicle screw loosening.26,27 By distributing load among all three columns, circumferential fixation may reduce the risk of pedicle screw loosening and subsequent non-union. Achieving high fusion rates in older patients may be possible only via a combined anterior–posterior approach. Similarly, there were no significant differences in clinical outcomes between either group. Compared to preoperative evaluation, there were significant improvements in VAS and ODI scores at 3-month follow-up that were sustained throughout the first year, indicating that the surgery was equally effective at improving functional outcome in both age groups. This is similar to the findings of Okuda et al. who report no significant differences in clinical outcomes between elderly and younger patients following single-level PLIF for degenerative spondylolisthesis.28
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The mean (±SD) LOS in both the elderly (9 ± 1.5 days) and the young (7 ± 2 days) groups were comparable to that shown in two level circumferential fusion surgeries by Villavicencio et al. (7.3 days).11 Although there was a trend toward longer LOS in the elderly group, this difference was not significant. The cost of longer hospitalization in the elderly may be offset by higher fusion rates and reduced need for revision surgery although additional research is needed to confirm this. The rates of major perioperative complications in both the elderly (9.3%) and young (13.3%) groups were significantly lower than those previously reported for circumferential fusion of the lumbar spine.2,11,29 Our major complication rate, specifically for patients over the age of 65, is similar to the results of Carreon et al.15 and Cassinelli et al.30 who studied perioperative complications of elderly persons undergoing multilevel posterior lumbar decompression and fusion (PLDF). Carreon et al. calculated a major complication rate of 21.4% in 98 patients with a mean of 2.4 levels fused (range, 1–5).15 Cassinelli et al. found a major complication rate of only 3.0% in 166 patients with a mean of 1.9 levels fused (range, 1–7).30 Unfortunately, neither of these studies included a younger control group and so no direct conclusions can be made about the effects of age. The major complication rate of 9.3% in the present study in 30 patients with a mean of 3.2 levels fused in a combined anterior–posterior approach was not significantly different from younger patients and is similar to that of PLDF reported in the elderly. These results suggest that the greater demands of a combined anterior–posterior surgery do not necessarily result in increased risk of perioperative complications in older patients. Our study has several limitations, notably its retrospective nature and small sample size. Although this was a retrospective analysis of 360-degree lumbar fusions, the cohort studied was generalizable and the results shown here should be extractable to the general population. Larger prospective studies will be needed to confirm these results. Only the VAS and ODI were used in this study. Future studies may elaborate on the subjective outcomes in patients undergoing 360-degree fusion with longer followup. Finally, evaluation of fusion radiographically with flexion–extension films only is limited and bridging trabecular bone cannot be visualized. Current practice in our clinic is to now use CT scans to explore fusion masses. Nevertheless, we believe that the results of the present study are important for informed patient and surgeon decision-making and may serve as a framework for the design of larger prospective trials. 5. Conclusions Perioperative events, intermediate-term clinical outcomes, and fusion rates after multilevel 360-degree lumbar fusion in the elderly are comparable to those of younger patients. Although this study does not provide class I data, it does provide preliminary evidence that age should not
necessarily be a factor in deciding to perform circumferential fusion for patients with symptomatic, multilevel lumbar degenerative spine disease.
References 1. Fritzell P, Hagg O, Wessberg P, et al. Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish lumbar spine study group. Spine 2002;27:1131–41. 2. Christensen FB, Hansen ES, Eiskjaer SP, et al. Circumferential lumbar spinal fusion with Brantigan cage versus posterolateral fusion with titanium Cotrel-Dubousset instrumentation: a prospective, randomized clinical study of 146 patients. Spine 2002;27: 2674–83. 3. Hinkley BS, Jaremko ME. Effects of 360-degree lumbar fusion in a workers’ compensation population. Spine 1997;22:312–22, discussion 23. 4. Heary RF, Bono CM. Circumferential fusion for spondylolisthesis in the lumbar spine. Neurosurg Focus 2002;13:E3. 5. Grob D, Scheier HJ, Dvorak J, et al. Circumferential fusion of the lumbar and lumbosacral spine. Arch Orthop Trauma Surg 1991;111:20–5. 6. Madan SS, Harley JM, Boeree NR. Circumferential and posterolateral fusion for lumbar disc disease. Clin Orthop Relat Res 2003;409:114–23. 7. Gertzbein SD, Hollopeter M, Hall SD. Analysis of circumferential lumbar fusion outcome in the treatment of degenerative disc disease of the lumbar spine. J Spinal Disord 1998;11:472–8. 8. Schofferman J, Slosar P, Reynolds J, et al. A prospective randomized comparison of 270 degrees fusions to 360 degrees fusions (circumferential fusions). Spine 2001;26:E207–12. 9. Gertzbein SD, Betz R, Clements D, et al. Semirigid instrumentation in the management of lumbar spinal conditions combined with circumferential fusion. A multicenter study. Spine 1996;21:1918–25, discussion 25–6. 10. Videbaek TS, Christensen FB, Soegaard R, et al. Circumferential fusion improves outcome in comparison with instrumented posterolateral fusion: long-term results of a randomized clinical trial. Spine 2006;31:2875–80. 11. Villavicencio AT, Burneikiene S, Bulsara KR, et al. Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech 2006;19:92–7. 12. Deyo RA, Gray DT, Kreuter W, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30:1441–5, discussion 6-7. 13. Deyo RA, Cherkin DC, Loeser JD, et al. Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure. J Bone Joint Surg Am 1992;74:536–43. 14. Deyo RA, Ciol MA, Cherkin DC, et al. Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. Spine 1993;18:1463–70. 15. Carreon LY, Puno RM, Dimar 2nd JR, et al. Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 2003;85-A:2089–92. 16. Esses SI, Huler RJ. Indications for lumbar spine fusion in the adult. Clin Orthop Relat Res 1992;279:87–100. 17. Cloyd JM, Frank L, Acosta J, et al. Complications and clinical outcomes of lumbar spine surgery in the elderly: a review of the literature. J Am Geriatr Soc 2008;56:1318–27. 18. Haughton V. Imaging intervertebral disc degeneration. J Bone Joint Surg Am 2006;88 (Suppl 2):15–20. 19. Bendo JA, Spivak JM, Neuwirth MG, et al. Use of the anterior interbody fresh-frozen femoral head allograft in circumferential lumbar fusions. J Spinal Disord 2000;13:144–9.
F.L. Acosta et al. / Journal of Clinical Neuroscience 16 (2009) 69–73 20. Christensen FB. Lumbar spinal fusion. Outcome in relation to surgical methods, choice of implant and postoperative rehabilitation. Acta Orthop Scand Suppl 2004;75:2–43. 21. Pavlov PW, Meijers H, van Limbeek J, et al. Good outcome and restoration of lordosis after anterior lumbar interbody fusion with additional posterior fixation. Spine 2004;29:1893–9, discussion 900. 22. Liljenqvist U, O’Brien JP, Renton P. Simultaneous combined anterior and posterior lumbar fusion with femoral cortical allograft. Eur Spine J 1998;7:125–31. 23. Rolander SD. Motion of the lumbar spine with special reference to the stabilizing effect of posterior fusion. An experimental study on autopsy specimens. Acta Orthop Scand 1966;Suppl 90:1–144. 24. Frymoyer JW, Selby DK. Segmental instability. Rationale for treatment. Spine 1985;10:280–6. 25. Dennis S, Watkins R, Landaker S, et al. Comparison of disc space heights after anterior lumbar interbody fusion. Spine 1989;14:876–8.
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26. Okuyama K, Abe E, Suzuki T, et al. Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients. Spine J 2001;1:402–7. 27. Kumano K, Hirabayashi S, Ogawa Y, et al. Pedicle screws and bone mineral density. Spine 1994;19:1157–61. 28. Okuda S, Oda T, Miyauchi A, et al. Surgical outcomes of posterior lumbar interbody fusion in elderly patients. J Bone Joint Surg Am 2006;88:2714–20. 29. Hee HT, Castro Jr FP, Majd ME, et al. Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors. J Spinal Disord 2001;14:533–40. 30. Cassinelli EH, Eubanks J, Vogt M, et al. Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine 2007;32:230–5.
Journal of Clinical Neuroscience 16 (2009) 69–73 www.elsevier.com/locate/jocn
Clinical Study
Perioperative complications and clinical outcomes of multilevel circumferential lumbar spinal fusion in the elderly Frank L. Acosta a,*, Jordan M. Cloyd a, Henry E. Aryan b, Christopher P. Ames a a
Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Avenue;S-225, San Francisco, CA 94143, USA b Division of Neurosurgery, University of California San Diego, San Diego, CA, USA Received 4 April 2008; accepted 16 April 2008
Abstract Combined anterior–posterior lumbar fusion across multiple levels is thought to be associated with increased perioperative morbidity and worse clinical outcomes when performed in elderly patients. We conducted a retrospective review of the medical, surgical, and radiological records of 73 patients who underwent multilevel anterior lumbar interbody fusion (ALIF) with posterolateral lumbar fusion with instrumentation for symptomatic lumbar degenerative disc disease. Mean follow-up was 19 months. Thirty patients were at least 65 years old and 43 patients were younger. There were no significant differences in the number of levels fused, operative time, mean length of hospital stay or perioperative complication rates in either group. Similarly, there were no statistically significant differences in the improvement in back pain or in the rates of fusion between the groups at last follow-up. Perioperative events, intermediate-term clinical outcomes, and fusion rates after multilevel 360-degree lumbar fusion in the elderly are comparable to those of younger patients. Ó 2008 Elsevier Ltd. All rights reserved. Keywords: Elderly patients; Complication; Clinical outcome; Lumbar spine; Circumferential fusion; Degenerative disc disease
1. Introduction Degenerative conditions of the lumbar spine are common in older individuals and can often result in lower back pain (LBP). Posterolateral lumbar spinal fusion reduces pain and disability in some patients suffering from chronic LBP due to degenerative disc disease (DDD).1 Anterior– posterior fusion surgery, also known as 360-degree or circumferential fusion, has demonstrated impressive fusion rates and good clinical outcomes in patients1–9 even at long-term follow-up.10 However, because of the increased surgical time, length of hospitalization and cost associated with circumferential fusion, patient selectivity remains crucial and may be reserved for patients at high risk of not achieving spinal fusion.8,9,11 Although one indication for
*
Corresponding author. Tel.: +1 415 353 3904; fax: +1 415 393 3907. E-mail address: [email protected] (F.L. Acosta).
0967-5868/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2008.04.015
360-degree fusion is multilevel DDD, the use of this technique remains uncertain in older individuals. As the number of elderly persons in the United States continues to rise, surgical treatment for degenerative conditions of the lumbar spine will increasingly be deemed necessary in elderly patients.12 However, combined anterior– posterior lumbar fusion across multiple levels is associated with increased perioperative complications and worse clinical outcomes in elderly patients13–15 and has generally not been indicated in patients 70 years or older.16 While a recently published systematic review on complications and clinical outcomes of lumbar spine surgery in the elderly found no additional risk of complication in elderly patients, we were unable to find published articles that directly studied the safety and efficacy of multilevel circumferential fusion procedures in elderly patients.17 Therefore, we aimed to analyse retrospectively the effects of age on the perioperative morbidity, intermediate-term clinical outcomes and fusion rates in elderly patients undergoing mul-
70
F.L. Acosta et al. / Journal of Clinical Neuroscience 16 (2009) 69–73
tilevel 360-degree lumbar fusion for symptomatic lumbar spine disease. 2. Methods Between 2002 and 2005, 73 patients received multilevel circumferential lumbar fusion for symptomatic lumbar DDD. We reviewed the medical, surgical and radiological records of these patients. The patients were divided into two groups based on age at the time of operation. The elderly group included 30 patients aged 65 years or older (range 65–77 years, mean 71 years) and the young group included 43 patients aged less than 65 years (range 22–61 years, mean 41 years) (Table 1). The elderly group was 43% male whereas the young group was 51% male. We excluded patients with a previously failed fusion surgery, history of spinal malignancy, spondylodiscitis and elderly persons judged medically unfit to undergo circumferential fixation. All patients who underwent surgery had severe disabling lower back pain attributable to multilevel (P2) lumbar DDD (Fig. 1). Disc degeneration was diagnosed via MRI based on findings of reduced signal intensity, decrease in disc height and/or the presence of radial fissures.18 Six patients in the elderly group (20%) also had evidence of spinal stenosis while three (10%) had accompanying spondylolisTable 1 Comparison of patient characteristics and operative data between elderly and young groups Parameter
Elderly (P 65 years)
Young (< 65 years)
p value
No. patients Average age (range) Sex (M:F) No. levels fused (SD) Total operative time, hours (SD) Length of hospitalization, days (SD) Average follow-up, months
30 71 (65–77) 13:17 3.2 (0.5) 7.3 (1.5) 9.0 (1.5) 18
43 41 (22–61) 22:21 3.5 (0.7) 7.9 (1.2) 7.0 (2.0) 20
>0.05 >0.05 >0.05 >0.05
SD = standard deviation.
thesis. Non-operative management of pain, including medication and epidural steroid injection, had been exhausted in all patients for at least 6 months. All surgeries were performed by the same surgeon (CPA). Briefly, all patients underwent anterior lumbar interbody fusion (ALIF) at two or more levels via a retroperitoneal approach. Reconstruction of the interbody space was accomplished by anterior insertion of carbon fiber interbody grafts (CougarTM System, Depuy Spine; Raynham, MA, USA). Supplemental posterior pedicle screw-rod fixation was performed on the same or next day in all patients. Clinical parameters such as duration of procedure, length of stay (LOS) and perioperative events were recorded. Major complications were defined as any event that required a specific intervention and adversely affected the patient recovery.15 Major postoperative complications included wound infection, pneumonia, respiratory distress, deep venous thrombosis or pulmonary embolus, renal failure, myocardial infarction, focal neurological deficit, intracranial hemorrhage and meningitis. All patients completed a preoperative assessment by the visual analog scale (VAS) for pain and Oswestry Disability Index (ODI). Patients repeated these assessments at 3, 6, and 12 months follow-up. Fusion rates were assessed for both groups. A solid fusion was defined as lack of motion without hardware migration or fracture on flexion–extension radiographs. Radiographic assessments were performed for all patients at 6 and 12 month follow-up. Total mean follow-up for all patients was 19 months. Statistical analysis was performed for all measurements using the Student t-test. A p of 0.05 was set for statistical significance.
3. Results There were no statistically significant differences (mean ± standard deviation, SD) in the number of levels fused (elderly, 3.2 ± 0.5; young, 3.5 ± 0.7), total operative
Fig. 1. (A) Sagittal T2-weighted MRI of a 66-year-old woman with intractable axial lower back pain due to multilevel degenerative disc disease. Also note the grade 1 spondylolisthesis at L4–5. (B) Six-month postoperative lateral flexion and (C) extension plain radiographs after 3-level circumferential fixation at L3–4, L4–5, and L5–S1 demonstrating lack of motion, hardware migration, or fracture.
F.L. Acosta et al. / Journal of Clinical Neuroscience 16 (2009) 69–73
time (elderly, 7.3 ± 1.5 h; young, 7.9 ± 1.2 h), or LOS (elderly, 9.0 ± 1.5 days; young, 7.0 ± 2.0 days) (Table 1). Four patients in each group encountered complications associated with their surgery (elderly, 13.3%; young, 9.3%; p > 0.05). In the elderly patients, one individual acquired pneumonia, one developed deep venous thrombosis (DVT) and two infections were reported. In the younger patients, there was one case of DVT and three individuals had infections. There were no cases of myocardial infarction (Table 2). Table 2 Perioperative events and complications Parameter
Elderly (P65 years)
Young (<65 years)
p value
Pneumonia Deep venous thrombosis Myocardial infarction Infection Total complication rate
1 1 0 2 13.3%
0 1 0 3 9.3%
>0.05 >0.05 >0.05 >0.05 >0.05
71
The subjective clinical outcomes were measured by pain VAS and ODI (Fig. 2). Each group showed significant improvements in both pain and disability at 3 month follow-up, and these improvements were sustained through the first year. No significant differences were observed between elderly and young patients in subjective ratings at preoperative assessment (VAS: elderly, 8.7 ± 0.2; young, 8.8 ± 0.3; ODI: elderly, 28.5 ± 3.5; young, 29.7 ± 4.1) or at 3 month, 6 month or 1 year follow-up (VAS: elderly, 3.1 ± 0.2; young, 3.9 ± 0.5; ODI: elderly, 19.2 ± 2.5; young, 19.9 ± 2.2). All patients demonstrated radiographic evidence of fusion at last follow-up and there were no instances of hardware failure or migration. 4. Discussion
Fig. 2. Results of clinical outcomes in elderly and young groups at preoperative, 3-month, 6-month and 1-year assessment. (A) Visual analog scale for pain (VAS). (B) Oswestry disability index (ODI). Both measurements were significantly improved postoperatively (p < 0.05), and this improvement was maintained through last follow-up. There were no significant differences in either outcome measure between the elderly and young groups. * p < 0.05.
The advantages of a combined anterior–posterior lumbar fusion are described in the literature. Circumferential fusion consistently attains the highest fusion rates, up to 100%, in patients with symptomatic lumbar DDD.1,2,5,7,9,19,20 A randomized controlled trial of circumferential fusion compared to instrumented posterolateral fusion demonstrated better functional outcomes and greater reductions in pain at both intermediate-term and longterm follow-up.2,10 Furthermore, a combined anterior– posterior surgery restores disc height21,22 while preventing segmental instability and relieving biomechanical stresses incurred in either ALIF or posterior lumbar interbody fusion (PLIF) alone.23–25 These effects may be even greater in patients with poor bone quality, and therefore a combined anterior–posterior fusion may increase fusion rates when compared to PLIF in patients with osteoporotic bone.26 Thus, while certainly an aggressive surgery, the use of 360-degree fusion in patients with multiple levels of symptomatic degenerative disease of the lumbar spine consistently results in superior fusion rates and clinical outcomes. To the best of our knowledge, this is the first evidence that multilevel circumferential lumbar fusion in elderly patients leads to similar outcomes as for younger patients. Both groups experienced 100% fusion rates based on radiographic evaluation at 6-month and 12-month follow-up. Osteoporotic vertebra may confer risk for non-union resulting from pedicle screw loosening.26,27 By distributing load among all three columns, circumferential fixation may reduce the risk of pedicle screw loosening and subsequent non-union. Achieving high fusion rates in older patients may be possible only via a combined anterior–posterior approach. Similarly, there were no significant differences in clinical outcomes between either group. Compared to preoperative evaluation, there were significant improvements in VAS and ODI scores at 3-month follow-up that were sustained throughout the first year, indicating that the surgery was equally effective at improving functional outcome in both age groups. This is similar to the findings of Okuda et al. who report no significant differences in clinical outcomes between elderly and younger patients following single-level PLIF for degenerative spondylolisthesis.28
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The mean (±SD) LOS in both the elderly (9 ± 1.5 days) and the young (7 ± 2 days) groups were comparable to that shown in two level circumferential fusion surgeries by Villavicencio et al. (7.3 days).11 Although there was a trend toward longer LOS in the elderly group, this difference was not significant. The cost of longer hospitalization in the elderly may be offset by higher fusion rates and reduced need for revision surgery although additional research is needed to confirm this. The rates of major perioperative complications in both the elderly (9.3%) and young (13.3%) groups were significantly lower than those previously reported for circumferential fusion of the lumbar spine.2,11,29 Our major complication rate, specifically for patients over the age of 65, is similar to the results of Carreon et al.15 and Cassinelli et al.30 who studied perioperative complications of elderly persons undergoing multilevel posterior lumbar decompression and fusion (PLDF). Carreon et al. calculated a major complication rate of 21.4% in 98 patients with a mean of 2.4 levels fused (range, 1–5).15 Cassinelli et al. found a major complication rate of only 3.0% in 166 patients with a mean of 1.9 levels fused (range, 1–7).30 Unfortunately, neither of these studies included a younger control group and so no direct conclusions can be made about the effects of age. The major complication rate of 9.3% in the present study in 30 patients with a mean of 3.2 levels fused in a combined anterior–posterior approach was not significantly different from younger patients and is similar to that of PLDF reported in the elderly. These results suggest that the greater demands of a combined anterior–posterior surgery do not necessarily result in increased risk of perioperative complications in older patients. Our study has several limitations, notably its retrospective nature and small sample size. Although this was a retrospective analysis of 360-degree lumbar fusions, the cohort studied was generalizable and the results shown here should be extractable to the general population. Larger prospective studies will be needed to confirm these results. Only the VAS and ODI were used in this study. Future studies may elaborate on the subjective outcomes in patients undergoing 360-degree fusion with longer followup. Finally, evaluation of fusion radiographically with flexion–extension films only is limited and bridging trabecular bone cannot be visualized. Current practice in our clinic is to now use CT scans to explore fusion masses. Nevertheless, we believe that the results of the present study are important for informed patient and surgeon decision-making and may serve as a framework for the design of larger prospective trials. 5. Conclusions Perioperative events, intermediate-term clinical outcomes, and fusion rates after multilevel 360-degree lumbar fusion in the elderly are comparable to those of younger patients. Although this study does not provide class I data, it does provide preliminary evidence that age should not
necessarily be a factor in deciding to perform circumferential fusion for patients with symptomatic, multilevel lumbar degenerative spine disease.
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