Abstract
We have read with great attention the research by Lenga et al and congratulate the authors on their work concerning this specific group of patients, known as super-elderly (aged over 80 years).1,2 The increasing life expectancy has led to patients of advanced age seeking to improve their quality of life, posing a surgical challenge for spine surgeons regarding the best treatments to enhance patient disability with lower surgical risk. 3
After an exhaustive analysis, some relevant comments could be helpful to the researchers. Firstly, the title emphasizes the assessment of the clinical course; however, during this period, only the preoperative and postoperative neurological status was compared using the motor scale of the ASIA score in both groups, and it was statistically significant. Nonetheless, they did not report if these neurological changes are clinically relevant. Additionally, no Patient-Reported Outcome Measures were performed to assess pain intensity, level of disability, or quality of life referred, making comparison with other series more difficult. Secondly, the authors did not employ a frailty index (FI), such as the FI-11 or 5-items, which has shown better accuracy than the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) scale regarding their ability to stratify the risk of postoperative complications and mortality. 4 Furthermore, age as an independent predictor of complications is still controversial. The frailty, understood as a state of physiological reserve encompassing multiple dimensions, has demonstrated a higher correlation with the risk of postoperative complications.3,5 Moreover, the Frailty Index (FI) is a quick and user-friendly tool that can be easily implemented in the clinical setting through a straightforward calculation. 6 Therefore, we advocate for the use of the FI to identify high-risk patients before surgery, enabling better optimization and monitoring during hospitalization to mitigate the occurrence of hospital-related deaths attributed to underlying clinical issues. Thirdly, there was a strong association between surgical time and the risk of postoperative complications, widely supported in the literature. 7 Nevertheless, the method used to obtain the threshold of 150 minutes (surgical duration) by calculating the median between the 2 groups had methodological flaws and instead should be calculated using logistic regression analysis, indicating a cut-off point where the risk of complications increases significantly in both groups. Finally, the bias selection introduced by the surgeon’s criteria, as demonstrated by the demographic analysis showing more comorbidities in the decompression-alone group, could have influenced the therapeutic decision. In addition, the confusing report between instability and spondylolisthesis (a degenerative process that does not always generate instability) could also blur the surgeon´s decision-making. 8 Although these are problems we must face in everyday work situations, it is more appropriate to have an analytic strategy to homogenize the population under study. Despite these comments, we hope to be helpful to the researchers and emphasize the need for further studies in this population. Once again, we appreciate the authors’ contribution to this scientific field.
