Accepted Manuscript Minimally invasive spinal decompression in patients older than 75 years of age: Perioperative risks, complications and clinical outcomes compared with patients younger than 45 years of age M. Khashan, Z. Lidar, K. Salame, L. Mangel, R. Lador, M. Drexler, E. Sapirstein, G.J. Regev PII:
S1878-8750(16)00230-8
DOI:
10.1016/j.wneu.2016.02.018
Reference:
WNEU 3712
To appear in:
World Neurosurgery
Received Date: 21 November 2015 Revised Date:
2 February 2016
Accepted Date: 3 February 2016
Please cite this article as: Khashan M, Lidar Z, Salame K, Mangel L, Lador R, Drexler M, Sapirstein E, Regev G, Minimally invasive spinal decompression in patients older than 75 years of age: Perioperative risks, complications and clinical outcomes compared with patients younger than 45 years of age, World Neurosurgery (2016), doi: 10.1016/j.wneu.2016.02.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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.
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Minimally invasive spinal decompression in patients older than 75 years of
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age: Perioperative risks, complications and clinical outcomes compared with
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patients younger than 45 years of age.
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Key word: elderly patients; minimally invasive; spinal decompression; complications; clinical outcomes.
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Khashan M1,2, Lidar Z1, Salame K 1, Mangel L1, Lador R 1,2, Drexler M2, Sapirstein E1, Regev GJ1,2
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The Spine Surgery Unit, Department of Neurosurgery1 and Orthopaedic Surgery2, Tel-Aviv Sourasky Medical Center, Israel Dear editors,
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I would like to request that Dr. Morsi Khashan and Dr. Zvi Lidar be consider to be primary authors for this submission as both authors equally contributed to the
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preparation of this manuscript
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Sincerely,
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Corresponding Author:
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Gilad Regev, M.D. Spine Surgery Unit Tel-Aviv Sourasky Medical Center Weitzman 6, Tel Aviv 64239, Israel. Work: +972-3-697-4134 Cellular: +972-52-426-2357 Email:
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PURPOSE: Minimally invasive spinal decompression for the treatment of spinal stenosis or disc herniation is often indicated if conservative management fails. However, the influence of old age on the risk of postoperative complications and clinical outcome is not well understood. We therefore, sought to compare complication rates and outcomes following MIS decompression and discectomy in the elderly patients with a cohort of young patients undergoing similar procedures. METHODS: We evaluated medical records of 61 patients older than 75 years and 69 patients younger than 45 years that underwent minimally invasive lumbar decompression between April 2009 and July 2013 at our institute. Past medical history, the American Society of Anesthesiologists (ASA) score, perioperative mortality, complication and revision surgeries rates were analyzed. Patient outcomes included: the visual analog scale (VAS) and the EQ-5D score. RESULTS: The average age was 78.66 ± 4.42 years in the elderly group and 33.59 ± 6.7 years in the young group. No major postoperative complications were recorded in either group, and all recruited patients were still alive at the time of the last follow-up. No statistically significant difference existed in the surgical revision rate between the groups. Both groups showed significant improvement in their outcome scores following surgery. CONCLUSIONS: Our results indicate that minimally invasive decompressive surgery is a safe and effective treatment for elderly patients and does not pose an increased risk of complications. Future prospective studies are necessary to validate the specific advantages of the minimally invasive techniques in the elderly population.
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Abstract:
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Introduction:
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The western population has aged steadily over the past decades and today one in nine
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Americans is above the age of 65.1 By 2050 this proportion is expected to rise to 20%1
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along with an increase in the prevalence of age related disorders. Aging of the spine
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results in degenerative changes such as spinal stenosis1 and deformity, and is one of the
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leading causes of pain, functional impairment, and decline in the quality of life of the
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geriatric population.
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Degenerative lumbar spinal stenosis is the most common indication for spinal surgery in
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patients older than 65 years of age.2,3 Surgical decompression for this condition was
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found to be an effective treatment that results in a low complication rate and excellent
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long-term clinical outcomes.4,5 However, many geriatric patients are reluctant to
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undergo such surgeries, based on the belief that “old patients” are at high risk for
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serious surgical complications, poor outcome and even mortality. The tendency to avoid
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surgical intervention for elderly patients is also encountered among primary care
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physicians who recommend that patients continue conservative treatment even in cases
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the later was proven ineffective.
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Geriatric patients pose a surgical challenge due to their physical, psychological, and
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social frailty. Although the effect of age as an independent risk factor is not well
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understood, it has been related to an increased risk of morbidity following open spine
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surgery.6,7 However, this finding might be confounded by the high prevalence of
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multiple medical comorbidities in this age group.8,9 In addition, other studies have found
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comparable morbidity and complication rates following spine surgery in the elderly as
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compared with younger patients.10-12
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Minimally invasive surgery (MIS) of the spine has gained increased popularity in recent
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years. This approach significantly reduces soft tissue injury13 and intraoperative
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bleeding.14 As a result, patients experience less post-operative pain14 and can usually be
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mobilized and discharged early.15 Previous studies have shown comparable long-term
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outcomes of MIS and traditional open spinal decompression procedures.16,17
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We hypothesize that the MIS procedures along with its inherent advantages will be
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particularly safe and beneficial to the geriatric population. Therefore, the aim of the
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present study was to compare complication rates and outcomes following MIS
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decompression and discectomy in the elderly patients with a cohort of young patients
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undergoing similar procedures.
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Following approval from our local Institutional Review Board, we retrospectively
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collected medical records of patients who underwent one or two levels of lumbar
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decompression surgery between April 2009 and July 2013. Inclusion criteria included:
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patients older than 75 years of age for group A, and between the ages of 18-45 for
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group B. Exclusion criteria included patients undergoing surgeries at more than two
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spinal levels, and procedures that included spinal instrumentation, fusion, resection of
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tumor, spinal infection or revision surgery.
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The study cohort included a total of 129 patients, 61 patients in group A and 68 in group
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B. Demographic data and preoperative data, including past medical history, medical
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comorbidities, and the American Society of Anesthesiologists (ASA) score, were
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recorded. In order to simplify the presentation of the medical history data we classified
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patients’ comorbidities into ten categories: cardiac, vascular, endocrine, metabolic,
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neoplastic, gastrointestinal, neurological, pulmonary, renal, and connective tissue
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diseases. Operative data included: type of surgery (discectomy, lamino-foraminotomy or
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both), number of operated spinal level and incidence of intraoperative complications.
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Measured clinical outcomes included: hospital length of stay (LOS), early postsurgical
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complications, revision surgery, and mortality. Patient-reported outcomes were
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collected for a sub-group of 37 patients of group A and 43 patients of group B using
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telephone interviews. Reported outcomes included: the health-related quality of life EQ-
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5D instrument,18 and the Visual Analogue Scale (VAS) for pain, before surgery and at the
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time of data collection. The EQ-5D questionnaire consists of five dimensions including
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mobility, self-care, usual activities, pain and anxiety /depression. Each domain is rated
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according to three levels of severity: no problems (1 point), some or moderate problems
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(2 points), and severe problems (3 points).
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All procedures were performed in a single medical center by two senior spinal surgeons
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who are well experienced in MIS surgeries. MIS decompression procedures were done
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routinely under general anesthesia using an 18 or 20-millimeter tubular retractor system
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(METRx; Medtronic Sofamor Danek, Memphis, TN) and a surgical microscope. Surgery
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was performed using a unilateral approach, with either a ipsilateral or bilateral canal
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decompression as described previously.19
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Statistical analysis:
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The statistical analysis was performed using Statistical Package for Social Sciences
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version 19 (SPSS). Significant differences between groups were determined using
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independent samples t-tests, the chi-squared test, and Fisher's exact test, to evaluate
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categorical variables’ independence. Preoperative to postoperative EQ-5D changes
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within each group were analyzed with paired t-tests. A p-value less than 0.05 was
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considered statistically significant.
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Results:
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The average age in group A was 78.66 ± 4.42 years and 33.59 ± 6.7 years in group B. The
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male/female ratio was similar for both groups (p = 0.258). The follow up period was
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similar between groups, 31.19 ± 12.85 months for group A and 32.15 ± 11.12 for group B 5
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(p = 0.45).
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Thirty-one patients in group A were diagnosed with spinal canal stenosis and thus
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underwent a MIS bilateral spinal canal decompression (laminectomy). The remaining 30
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patients were diagnosed with lumbar disc herniation and underwent a MIS discectomy.
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All the patients in group B were diagnosed with lumbar disc herniation and underwent
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MIS discectomy. Forty-five patients in group A presented with motor weakness in one or
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more of the lower limbs muscles compared to 37 patients in group B.
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Operated levels in group A included mainly: L3-4 (27 cases) and L4-5 (45 cases) compared to L4-5 (30 cases) and L5-S1 (35 cases) in group B. Seven patients in group A
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underwent a 2 level procedure compared to only one patients in group B.
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Patients in group A had an average number of 1.95 ± 1.43 medical comorbidities and an
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average ASA score of 2.64 ± 0.82. Patients in group B were generally healthy with no
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systemic comorbidities (0.06 ± 0.38, p < 0.01) and with an average ASA score of 1 ± 0.41.
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(Table 1).
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The distribution of the grouped comorbidities within the groups is shown in Table 2.
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The most prevalent comorbidities were of the cardio-vascular system. Fifty-four percent
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of patients in-group A were diagnosed with hypertension, 43% with an ischemic heart
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disease The second most prevalent group included endocrine and metabolic disorders,
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such as diabetes (36%) and dyslipidemia (23%). In group B only one patient was found
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with hypertension, one patient with diabetes, one with dyslipidemia, and none with
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ischemic heart disease.
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In group A, 12 patients (20%) had no comorbidities, 10 (16%) had one comorbidity, 20
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had two comorbidities (33%) and 19 patients (31%) had three or more comorbidities. In
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group B, these figures were 66 (97%), 1 (1)% and 1 (1%), respectively (Table 2).
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1 The mean length of hospital stay was longer in the geriatric group 3.62 ± 5.14 days
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versus 1.82 ± 3.51days (p = 0.001). The rate of accidental durotomy was less than 2 %
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and similar for both groups (p= 0.938). Two minor systemic complications were
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recorded in two patients in group A. One patient developed rapid atrial fibrillation that
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was treated by antiarrhythmic agent. Bradycardia was diagnosed in the other patient
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and resolved spontaneously. No major postoperative infection, pulmonary or cerebro-
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vascular complications were recorded in neither group, and all recruited patients were
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still alive at the time of the last follow-up.
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No statistically significant difference existed in the surgical revision rate between the
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groups (p = 0.631). In group A four patients underwent revision surgeries. The indication
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was adjacent level stenosis in three cases and recurrent disc protrusion in one case. The
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indication for revision surgery in group B consisted of same level recurrent disc
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herniation in all six cases (Table 3). No fusion was performed in group A or group B.
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Overall, VAS and EQ-5D scores, significantly improved in both groups after surgery. VAS
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score improved from 8.25 ± 2.63 to 5.27 ± 3.57 in group A and from 9.16 ± 1.43 to 2.66 ±
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2.8 in group B, (p < 0.05). The EQ-5D scores improved from 1.98 ± 0.08 to 1.66 ±0 .08 in
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group A and from 2.19 ± 0.42 to 1.32 ± 0.22 in group B (p