Samir Lapsiwala, MD. Fort Worth Brain and Spine Institute Fort Worth Brain and Spine Institute GEN-SP-32

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1 Samir Lapsiwala, MD Fort Worth Brain and Spine Institute Fort Worth Brain and Spine Institute

2 In 2010, 40 million people age 65 and over lived in the United States, accounting for 13 percent of the total population. The older population grew from 3 million in 1900 to 40 million in 2010 The oldest-old population (those age 85 and over) grew from just over 100,000 in 1900 to 5.5 million in 2010.

3 The Baby Boomers (those born between 1946 and 1964) started turning 65 in 2011, and the number of older people will increase dramatically during the period. The older population in 2030 is projected to be twice as large as their counterparts in 2000, growing from 35 million to 72 million and representing nearly 20 percent of the total U.S. population. The U.S. Census Bureau projects that the population age 85 and over could grow from 5.5 million in 2010 to 19 million by 2050.

5 In > 75 or older Prevalence of disabling and non-disabling back pain was 6 and 23%, respectively. While prevalence of non-disabling back pain did not vary significantly across age (P = 0.34), the prevalence of disabling back pain increased with age (P = 0.04). Docking RE 2011

6 Natural event with aging of spine.. By 65 yrs, 95% men and 70% women have radiographic degeneration Gore DR et al. Spine 1986 Surgical issues in elderly: Degenerative changes at multiple levels Loss of disc height leads to diminished cervical lordosis Frail patients with significant co-morbidities Osteoporotic bone (reconstruction challenges)

7 Surgical morbidity and mortality is shown to be higher in elderly population Watters JM 1991 General decline in physiological reserve and presence of co-existing disease is primarily responsible When planning spine surgery, one must consider numerous physiological changes associated with advanced age

8 At autopsy 50% of patients older than 70 have significant CV disease Unrecognized MI in 10% of elderly pts MacDonald JB 1984 Increases cardiac risk index Heart attack in past 6 months Uncompensated CHF Aortic stenosis Greater than 5 PVCs/minute DM Age more than 70

9 Basic work up Thorough H and P and baseline EKG Look for JVD and peripheral edema Pts with unstable angina = no elective spine surgery but stable angina =only a slight increased risk Von Knorring J 1991 Moderate to severe CHF = high risk

10 Increased risk due to Decline in pulmonary function and reserve Underlying COPD Lack of mobility and bed rest associated with surgery In series of 100 asymptomatic elderly 40% had abnormal PFTs Tornebrandt K 1982 Dyspnea at rest and arterial hypoxemia are risk factors

11 Room air ABG should be checked in pts with lung disease, hx of SOB, poor exercise tolerance, orthopnea and smokers Pay attention to elevated Pco2 and >45 is associated with increased risk and >50 may need period of postop mechanical ventialtion No well defined lower limit for PFT Need aggressive postop care plan

Decline in renal system is more consistent than of other organ systems In elderly serum creatine may be artificially low due to decreased production from loss

12 Decline in renal system is more consistent than of other organ systems In elderly serum creatine may be artificially low due to decreased production from loss of muscle mass Creatine clearance is better test for pt suspected of having renal disease NSAIDS may further decline kidney function by decreasing renal blood flow

13 Advanced age itself is a risk factor for DVT Malnutrition Advanced age is a risk factor for wound infection 6x increase in pts older than 66 Cruse PJ Constipation Immobility, narcotics, dehydration adds to the problem

14 23-34% Increased Mortality

15 Osteoporosis Decreased density of mineralized bone Peak density in third decade of life then begins to decrease Check bone density in high risk pts May affect choice of surgery and types of implants

$Most common fracture in elderly Often happens without significant trauma 700,000 Osteoporotic VCFs annually in the US 1 260,000$

16 Most common fracture in elderly Often happens without significant trauma 700,000 Osteoporotic VCFs annually in the US 1 260,000 present as painful 2 Over 400,000 hospital days per year 3 1 NOF Cooper et al., JBMR Gelbach et al., Osteoporosis Int

17 Pain control, bracing or vertebral augmentation along with medical treatment of osteoporosis Do not forget morbidity of non-operative management

quality of life 4 Increased mortality 5,6 1 Mezanec et al. Clev Clin J Med 2003 2 Schlaich et al.

18 What is meant by conservative care? Opiod side effects 1 Increasing kyphosis 2 Reduced pulmonary function 2,3 Depression 1 Decreased quality of life 4 Increased mortality 5,6 1 Mezanec et al. Clev Clin J Med Schlaich et al., Osteoporosis Int l Leech et al., Am Rev Respir Dis Gold Bone Cauley et al., Osteoporosis Int l Kado et al., Arch Int Med 1999

20 Age-standardized mortality by number of VCFs 9,575 women age 65+ enrolled in Study of Osteoporotic Fracture Mortality per 1000 person years p < for trend Kado Arch Int Med 1999 Number of VCFs

(2002) reported similar results, pain reduction was noted at one week follow-up, with a continuation in

21 Multi-center prospective single-arm U.S. study Average of 60% reduction in pain Pre-operative VAS score = 7.5, one-week post-op follow-up VAS = 3 (p<0.01) Results persisted for two years. (n=100) Ledlie et al. (2002) reported similar results, pain reduction was noted at one week follow-up, with a continuation in improvement at one year Kyphon U.S. Study, Data on file at Kyphon Inc. 2. Ledlie et al. (2003) J Neurosurg (Spine 1) 98: 36-42

22 8-11% Incidence of LSS in the U.S. 1 LSS is the most common reason for spine surgery in older people 2 More than 125,000 laminectomy procedures were performed for LSS in Financial impact and lost work hours reaches billions of dollars each year in the U.S Murphy et al, BMC Musculoskeletal disorders, 2006, Jenis et al, Spine Murphy et al, BMC Musculoskeletal disorders, Sepals, European Spine Journal, The Ortho FactBook ; U.S. 5th Edition; Solucient, LLC and Verispan, LLC 4. Knowledge Enterprises, Inc.

23 Facet Joints Synovitis Hypomobility Continuing Degeneration Capsular Laxity Subluxation Age Related Changes Dysfunction Herniation Instability Lateral Nerve Entrapment Intervertebral Disc Circumferential Tears Radial Tears Internal Disruption Disc Resorption Enlargement of Articular Processes Stenosis Poor Quality Of Life Osteophytes

24 Disc Bulge/Herniation Hypertrophied Ligamentum flavum Narrowed Spinal Canal Narrowed Lateral Recesses Hypertrophied Facets Stenotic Normal Neural Compression

25 Extension provokes symptoms Pain/weakness in the legs Patients lean forward while walking to ambulate more comfortably Sitting relieves symptoms

26 Mild Spinal Stenosis Continuum of Care Moderate Severe Non Operative Care Epidural injections Physical therapy NSAIDs & other drugs Lifestyle modification Operative Care

27 Epidemiology Ranks 3 rd as cause of disability 80% will have LBP at some point 18% are having LBP now Laminectomy Laminectomy with Fusion Laminotomy- facetectomy

28 More common than in younger individuals Less likely to isolate pain to individual disc Typically multiple potential pain sources: degenerative discs degenerative facets instabilities kyphosis-deformity DIFFICULT TO PREDICT WHETHER FUSION WILL RELIEVE AXIAL PAIN!!

29 Facet degeneration can lead to spondylolisthesis May cause LBP or leg pain depending upon neural compression Treatment varies depending on symptoms and severity of listhesis Typically fusion is treatment of choice in younger individuals

30 In patients with degenerative spondylolisthesis of lumbar spine, use of instrumentation has not been shown to improve clinical outcomes Christiansen FB 2002, Fischgrund JS 1997 Dynamic preop Xrays must be done to look for instability before instrumented fusion is done Uninstrumented fusion in low level of listhesis is a reasonable option

31 Acquired condition Symptoms similar to lumbar stenosis If fail conservative treatments, decompressive laminectomy or laminotomy may be appropriate depending on type of symptoms, health status and bone quality May need to do selective nerve blocks to isolate pain generator Conflicting data whether pt should be stabilized after decompression

32 Elderly patients have a significant lower survival rate than younger with and without neurological injury 60 day mortality for pts >65 with paralysis approaches 30% Irwin Zn Overall treatment should follow same biomechanical rules but one must treat the whole pts and not just consider spine

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