Abstract
Introduction
Cervical spine surgery in the octogenarian and nonagenarian populations is challenging. In both the UK and the US, the population demographics have shifted, with a consistent rise in the population over the age of 80 years. Therefore, a methodology for selecting surgical candidates in this elderly age group is required to reduce postoperative mortality and obtain the best outcome. Our study looks at whether a well-established scoring system used in medical patients, the Charlson comorbidity index, can be directly applied to octogenarians and nonagenarians undergoing cervical spine surgery to predict perioperative mortality. In our study, social drift was evaluated to better understand the social and financial implications imposed by cervical spine surgery in this elderly age group.
Materials and Methods
A retrospective analysis was performed in patients in the age group of 80 to 100 years who underwent cervical spine surgery for degenerative disease (usually myelopathy), spinal tumors, or trauma between 2006 and 2013 at our institution. The analysis specifically looked at patient comorbidities scored using the Charlson comorbidity index and the relationship to the perioperative and 6-month mortality, length of stay, approach (anterior, posterior, and combined), and instrumentation which was collated from patient records. We looked at social drift in this elderly cohort of patients after cervical spine surgery by evaluating residential status before and after surgery, that is, home, residential home, or nursing home.
Results
In our study, there were 74 patients (62 octogenarians and 12 nonagenarians) who underwent cervical spine surgery with an average age of 85.1 ± 3.7 years. There were 28 male and 46 female patients. The average length of stay was 22 ± 30.5 days with a large variability (maximum 191 days). There were 45 patients with myelopathy, 1 patient with radiculopathy, 3 patients with spinal tumors, and 25 patients with cervical spine fractures. An anterior approach was used in 15 cases, a posterior approach in 42 cases, and a combined approach in 2 cases. There were 7 perioperative deaths and a total of 17 deaths at 6 months. No correlation was found between Charlson comorbidity index and perioperative or 6-month mortality. Social drift was statistically significant in our study (p = 0.007, Fisher exact test). Interestingly, a statistically significant relationship was found with the postoperative complications aspiration pneumonia (relative risk 7.34, 95% CI: 2.40–7.84) and hospital-acquired pneumonia (HAP) (relative risk 4.25, 95% CI: 2.20–8.19), and 6-month mortality.
Conclusion
With the aging population, cervical spinal surgery in this age group is becoming more prevalent. Our study has shown that predicting mortality following cervical spine surgery in this elderly age group is difficult. A larger patient cohort is required to determine if the Charlson comorbidity index can predict postoperative mortality. Postoperatively, a significant number of our patients required discharge to a facility with an increased level of care. This may be attributable to the neurological status postoperatively, but the confounding factor of unmet preoperative social care exists. Postoperative complications of aspiration pneumonia and HAP carry a significant 6-month mortality; therefore, careful attention to feeding and chest physiotherapy is important.