COMMON CONDITIONS IN THE ELDERLY SPINE PATIENT SPINE SURGERY IN THE ELDERLY PATIENT TRENDS IN SPINE SURGERY FOR THE ELDERLY WHATS THE DIFFERENCE?

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COMMON CONDITIONS IN THE ELDERLY SPINE PATIENT spinal stenosis adult

$osteoporosis / compression fractures SHANE BURCH MD ASSISTANT PROFESSOR DEPT$ the elderly WHATS THE DIFFERENCE? Weinstein, J. N., J. D. Lurie, et al. (2006).

1992-2003." Spine (Phila Pa 1976) 31(23): 2707-2714. Deyo, R. A. and S. K.

1 COMMON CONDITIONS IN THE ELDERLY SPINE PATIENT spinal stenosis adult degenerative scoliosis SPINE SURGERY IN THE ELDERLY PATIENT spondylolisthesis osteoporosis / compression fractures SHANE BURCH MD ASSISTANT PROFESSOR DEPT TRENDS IN SPINE SURGERY FOR THE ELDERLY increasing trend to perform surgery in the elderly WHATS THE DIFFERENCE? Weinstein, J. N., J. D. Lurie, et al. (2006). "United States' trends and regional variations in lumbar spine surgery: " Spine (Phila Pa 1976) 31(23): Deyo, R. A. and S. K. Mirza (2006). "Trends and variations in the use of spine surgery." Clin Orthop Relat Res 443:

2 THE AGED SPINE PATIENT FACTORS patient considerations spine considerations vertebral / bone considerations multiple sources of pain etiology - hip / back / knees prior surgeries low demand no secondary gain PATIENT FACTORS multiple comorbidities nutrition / global deconditioning critical assessment of physiologic age

PREVALENCE OF SCOLIOSIS PREVALENCE OF OSTEOPOROSIS IN SPINE PATIENTS adult degnerative scoliosis from 12-70% in adult volunteers / DEXA scan review

F., A. Dubey, et al. (2005). "Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population.

"Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease.

3 PREVALENCE OF SCOLIOSIS PREVALENCE OF OSTEOPOROSIS IN SPINE PATIENTS adult degnerative scoliosis from 12-70% in adult volunteers / DEXA scan review less prevalent in other studies 1300 cases reviewed over age 50 very common 15% males (46% with osteopenia) vs 50% female with osteoporosis Schwab, F., A. Dubey, et al. (2005). "Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population." Spine (Phila Pa 1976) 30(9): Chin, D. K., J. Y. Park, et al. (2007). "Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease." Osteoporos Int 18 (9): osteoporosis scoliosis SPINE FACTORS global perspective - syndrome sagittal balance- risk of progression coronal balance INTERSECTION OF DISEASE more common in the elderly stenosis facet arthropathy compression fractures

4 VERTEBRAL FACTORS CASE EXAMPLE osteoporosis screw pull out strength fractures bone quality MSCs + vascular supply failure to fuse - pseudarthrosis Caplan, A. I. (2007), Adult mesenchymal stem cells for tissue engineering versus regenerative medicine. Journal of Cellular Physiology, 213: doi: /jcp Y female works as an accountant back pain compression fracture treated with kyphoplasty hates appearance of her spine detailed history and physical - determine source of pain: hips / knees / spine past medical history: osteoporosis and osteomalacia LABS - markers for bone turnover N-telopeptides / deoxypyridinoline / alk phosphatase 25-OH vit D; parathyroid hormone XRAY - FULL STANDING EVALUATION DEXA / QCT T-score: osteoporosis =<-2.5 SD BENEFITS back pain leg pain overall function INVESTMENT OF TIME time to resolution of leg pain time to resolution of back pain COUNSELLING RISKS mortality infection / paresis / paralysis requirements for revision surgery adjacent segment disease pjk fracture pseudarthrosis

RISKS / COMPLICATIONS Li, G., C. G. Patil, et al. (2008).

adverse outcomes after lumbar laminectomy in elderly patients.

MORTALITY Kim, H. J., H. M. Lee, et al. (2008).

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5 RISKS / COMPLICATIONS Li, G., C. G. Patil, et al. (2008). "Effects of age and comorbidities on complication rates and adverse outcomes after lumbar laminectomy in elderly patients." Spine (Phila Pa 1976) 33(11): WHATS THE EVIDENCE? MORTALITY Kim, H. J., H. M. Lee, et al. (2008). "Life expectancy after lumbar spine surgery: oneto eleven-year follow-up of 1015 patients." Spine (Phila Pa 1976) 33(19): ; discussion COMPLICATIONS!"#$%&'()'*+#',-.'/(0(123.34#&'(-'/(0563$,4(-'7,%#&',-.'*.8#1&#'9:%$(0#&'*;#1'<:02,1'<,03-#$%(0='3-'!6.#16='>,4#-%&?'!"#$%&'(&)*$+,-.#$/0"',1*$!,(#$20"3,),)(*$$45#$+05*$6&#$ /0'"7*$8",)#$9:)(;*$<&,=;:#$4,>?:..$ 2@"):A$BBCDDEFDGHIJDGHH#$4,;$DH#$GIIKA$ 5LMF$DIADINOP<Q2AIRIDB:BDKDODS,SS$

COMPLICATIONS Increasing age and number of comorbidities increases complication and mortality rate in patients undergoing lumbar laminectomy for spinal stenosis.

(2008). "Effects of age and comorbidities on complication rates and adverse outcomes after lumbar laminectomy in elderly patients." Spine (Phila Pa 1976) 33(11): 1250-1255.

" Spine (Phila Pa 1976) 36(10): 817-824. HRQOL OUTCOMES HRQOL OUTCOMES " Spine (Phila Pa 1976) 36(10): 817-824. Glassman, S. D., L. Y. Carreon, et al. (2007).

6 COMPLICATIONS Increasing age and number of comorbidities increases complication and mortality rate in patients undergoing lumbar laminectomy for spinal stenosis. The complication and mortality rates have been quantified and stratified by age and number of comorbidities by using a national inpatient database Li, G., C. G. Patil, et al. (2008). "Effects of age and comorbidities on complication rates and adverse outcomes after lumbar laminectomy in elderly patients." Spine (Phila Pa 1976) 33(11): Smith, J. S., C. I. Shaffrey, et al. (2011). "Risk-Benefit Assessment of Surgery for Adult Scoliosis: An Analysis Based on Patient Age." Spine (Phila Pa 1976) 36(10): HRQOL OUTCOMES HRQOL OUTCOMES Smith, J. S., C. I. Shaffrey, et al. (2011). "Risk-Benefit Assessment of Surgery for Adult Scoliosis: An Analysis Based on Patient Age." Spine (Phila Pa 1976) 36(10): Glassman, S. D., L. Y. Carreon, et al. (2007). "Clinical outcomes in older patients after posterolateral lumbar fusion." Spine J 7(5):

PERI-OP CONSIDERATIONS thorough pre-op evaluation: PREPARE CLINIC vs HIGH RISK CLINIC reduce anesthetic time:

implement strategies to improve neuromonitoring sag balance correction vs. nerve stretch vs comp.

? / geriatrician consultation judicious use of pain meds - death by narcotics FAILURE TO FUSE Requirements for

7 PERI-OP CONSIDERATIONS thorough pre-op evaluation: PREPARE CLINIC vs HIGH RISK CLINIC reduce anesthetic time: post-op delirium implement strategies to limit blood loss REDUCING THE RISKS anesthetic / post-op care implement strategies to improve neuromonitoring sag balance correction vs. nerve stretch vs comp. peri-op monitoring: ICU?? / geriatrician consultation judicious use of pain meds - death by narcotics FAILURE TO FUSE Requirements for fusion blood supply - limited with aging scaffold / surface area AVOIDING COMPLICATIONS failure to fuse osteoprogenitor cells - limited with aging rigidity - instrumentation fatigue vs. time to fuse = choice of implant

$PTH use will improve fracture healing as well as fusion$ UCSF FDA trial: assessment of the use of FORTEO in patients

COMPRESSION FRACTURES mortality and morbidity increased

8 PARATHYROID HORMONE FOR FUSION?? higher grade of fusion on CT scan at 2 years with rhbmp fusion rate 86% rh-bmp vs. 70% ICBG intermittent dose of PTH promotes osteoblasts over osteoclasts limited animal studies to suggest intermittent PTH use will improve fracture healing as well as fusion UCSF FDA trial: assessment of the use of FORTEO in patients undergoing spinal fusion greater than two levels VERTEBRAL COMPRESSION FRACTURES mortality and morbidity increased probability of a second or third event AVOIDING COMPLICATIONS COMPRESSION FRACTURES / PJK narrow use of vertebral augmentation

9 TREATING OSTEOPOROSIS PROXIMAL JUNCTIONAL KYPHOSIS (PJK) selection of correct levels - structural thoracic spine (T10) Ca2+ Vit osteotomies D - multiple Smith-Peterson vs PSO or both bisphosphonates avoid intermittent stopping in kyphotic segment parathyroid hormone augmentation vertebrae CASE EXAMPLE 73 Y female back pain treated with kyphoplasty hates appearance nce of her spine - at level above and at END

peri-operative strategies utilization to limit medical complications known

10 SUMMARY mortality and complications higher in older population increased with co-morbidities due to patient, spinal and vertebral factors appropriate peri-operative strategies utilization to limit medical complications known pre-op and intra-op strategies to limit surgical complications such as comp THANKYOU

Managing the Patient with Osteoporosis Undergoing Spinal Surgery

11/4/16 DISCLOSURES Managing the Patient with Osteoporosis Undergoing Spinal Surgery MEDTRONIC LILLY MISONIX SHANE BURCH MD, MS, FRCSC Associate Professor in Residence UCSF Department of Orthopedic Surgery