Sage Journals: Discover world-class research

Abstract

Purpose: Patients and surgeons may be reluctant on spinal surgery over 80 years old, fearing medical complications despite the possible improvement on quality of life. However, fewer reservations for lower limb prosthetic surgery (LLPS) seem to be arisen in this population. Is spinal surgery after 80 years-old responsible of more complications than lower limb surgery? Methods: The consecutive files of 164 patients over 80 years that had spinal surgery or LLPS were analyzed. The data collected pre-operatively were demographic, clinical and post-operatively the number and types of medical complications and length of stay. Results: The mean number of medical complications was 1.11 ± 0.6 [0–6] for spinal surgery and 1.09 ± 1.0 [0–3] for LLPS, (p = 0,87). The length of stay in orthopedic unit was comparable between the two groups: 10.7 ± 4.9 days [2–36] for SS and 10.7 ± 3.0 days [5–11] for LLPS (p = 0,96). Conclusion: The global rate of peri-operative complications and the length of hospital stay were similar between spinal surgery and lower limb prosthetic surgery. These results may be explained by the rising cooperation between geriatric specialist and surgeons and the development of mini-invasive surgical technics, diminishing the early post-operative complication rates.

Keywords

aged 80 and over spinal fusion arthroplasty replacement morbidity

Introduction

The rate of medical complications following spinal surgery in patients over 80 years old may seem frightening for both patients and surgeons. Indeed, the rate of readmissions and mortality for spinal surgery in this population have been showed to be up to 10% in the literature, but with a large variation depending on the surgical procedure (emergencies procedures, lumbar decompression alone or associated with fixation) (Cloyd et al., 2008; Deyo et al., 1993; Silvers et al., 1993).

Interestingly, prosthetic surgery for hip and knee replacement (respectively THR and TKR) for elderly patients are more routinely performed than spinal surgery and may therefore seem safer (García Rey et al., 2021; Rubin et al., 2016; Sloan et al., 2018). This is probably due to the frequency of fractures of the upper end of the femur in patients over 80 years of age. Indeed, the loss of autonomy in the event of delayed intervention would be disastrous for these patients, explaining the systematic recourse to surgery in these cases (Davanzo et al., 2021; Francony et al., 2022). On the other hand, spinal surgery provides the best improvement of quality of life, compared to all other types of orthopedic surgery, including lower limb surgery (Hansson et al., 2008). Additionally, delayed surgery for orthopedic conditions impacting ambulation leads to decreased survival, in addition to impaired quality of life. However, if the quality of life and preservation of function are particularly relevant when considering elderly subjects, the risks related to general anesthesia and surgical complications are higher. Moreover, due to the recent development of minimally invasive techniques for spinal surgery and better collaboration between geriatric specialists and orthopedic surgeons, we may think that the morbidity of spinal surgery has decreased (Yolcu et al., 2021). Does scheduled spinal surgery for patients over 80 years-old deserve such apprehension compared to THR or TKR?

The main goal of this study was to compare, within a homogeneous monocentric cohort, the rate of medical complications and the length of hospital stay of spinal surgery (SS) compared to LLPS (lower limb prosthetic surgery) in patients older than 80 years old.

Material and Methods

This was a retrospective monocentric study, registered at the APHP IRB (number 20220304155259). All patients over 80 years old that underwent spinal surgery (SS) or lower limb prosthetic surgery (LLPS) between December 2018 and December 2020 were included as a continuous study.

The data collected pre-operatively for each patient were:

- Demographic: age, sex, BMI (body mass index)

- Clinical: ASA score, hemoglobin, creatinine, diabetes (yes/no), anticoagulant use (yes/no), antiaggregant use (yes/no)

The patients were classified in groups according to the type of surgery performed. For spine surgery, the decompressed levels and the fused levels were recorded. For LLPS, the joint concerned (hip or knee) was recorded, as well as surgical indication: primary joint replacement or revision.

The patients were then classified in two groups according to the surgical severity, in order to take into account blood loss and general anesthesia duration:

- G1 (group 1):

○ For LLPS: primary joint replacement (THR or TKR),

○ For SS: decompression alone (revision or primary) or associated with spinal fusion on less than3 levels.

- G2 (group 2):

○ For LLPS: revision prosthetic surgery (RTHR or RTKR),

○ For SS: spinal fusion of more than3 levels.

The post-operative data collected were:

- Duration of hospitalization (in days)

- Destination at discharge from orthopedic surgery department: home or rehabilitation facility

- Total number of medical complications

- Type of medical complications: surgical site infection (with reintervention), neurologic (confusion, stroke), cardiopulmonary (veinous thrombosis, arrhythmia), digestive (sub-occlusion or occlusion, esophagitis bleeding. . .), acute post-operative anemia requiring blood transfusion, urinary (urinary tractus infection, acute urine retention requiring bladder catheterization), falling and metabolic (abnormality on the serum electrolytes dosage requiring corrective medical intervention).

The statistical analysis was made on XLstat, with Student’s t tests. p-Values lower than .05 were considered significant.

Results

One hundred sixty-four patients have been included in the study. The population consisted of 80 patients that underwent lower limb prosthetic surgery and 84 patients that underwent spinal surgery. The flowchart of the study is presented as Figure 1. The mean age was 84 years old. The pre-operative characteristics of the cohort are summarized in Table 1.

Figure 1.

Flowchart of the patient’s selection for the study. G1: Group 1; G2: group 2.

Table 1.

Pre-operative Parameters of the Cohort Depending of the Surgery Performed.

		Lower Limb (n = 80)	Spine (n = 84)	p
Age (years)		85 ± 3.9 [80–90]	84 ± 2.1 [80–96]	.07
Sex	F	58	51	.065
	M	22	33
BMI (kg/m²)		25.2 ± 5.1 [19.1–39.3]	25.2 ± 2.9 [15.3–41.0]	.06
ASA score	I	9	10	.94
	II	50	52
	III	21	22
	IV	0	0
Hemoglobin (g/dL)		13.1 ± 0.5 [9.9–16]	13.0 ± 1.2 [9.2–15.9]	.18
Creatinine (mg/mL)		75.8 ± 15 [42–167]	87.4 ± 21.3 [44–252]	.008
Diabetes (yes)		15 (19%)	12 (14%)	.44
Anticoagulant		20 (22%)	17 (20%)	.72
Antiaggregant		22 (25%)	25 (30%)	.49
Severity group	1	64	63	.45
	2	16	21

Note. Numeric variables are expressed as mean ± standard-deviation [min-max]. p < .05 (T-test) was considered statistically significant.

There were 84 patients in the SS group and 80 in the LLPS group. Out of the 80 LLPS group, 16 patients underwent revision surgery and were classified in the G2 severity group. Twenty-one patients of the SS group underwent a fusion or three levels or more, classifying them as G2. The characteristics of the surgical indications on the SS group are summarized in Table 2.

Table 2.

Surgical Characteristics of the SS Group of the Cohort.

		n	%
Localization
	Cervical	7	8.3
	Thoraco-lumbar	10	11.9
	Lumbar/Lombo-sacral	67	79.8
Number of levels fused
G1 n = 63	0	31	36.9
	1	20	23.8
	2	12	14.3
G2 n = 21	3	2	2.4
	4	9	10.7
	9	2	2.4
	10	4	4.8
	11	1	1.2
	17	3	3.6

The mean number of peri-operative complications, occurring during hospital stay was 1.11 ± 0.6 [0–6] for spinal surgery and 1.09 ± 1.0 [0–3] for LLPS (p = .87). The length of hospitalization was statistically comparable between the two groups: 10.7 ± 4.9 days [2–36] for SS and 10.7 ± 3.0 days [5–11] for LLPS (p = .96). The most frequent types of complication encountered for the whole cohort were cardiopulmonary events (36 patients, 22%), followed by urinary complications (31 patients, 19%), metabolic (29 patients, 18%), digestive (27 patients, 16%), anemia (18 patients, 11%), surgical site infection (16 patients, 10%), neurologic (14 patients, 9%), and falls (11 patients, 7%). The peri-operative data are summarized in Table 3.

Table 3.

Peri-operative Medical Complications of the Cohort, Depending of the Surgery Group (Spinal or Lower Limb).

		Lower Limb (n = 80)	Spine (n = 84)	p
Peri-operative complications		1.09 ± 1.0 [0–3]	1.11 ± 0.6 [0–6]	.87
	Surgical site infection	6	10	.35
	Cardio-pulmonary	20	16	.46
	Veinous thrombosis	4	3	.32
	Others	16	13	.22
	Digestive	15	12	.44
	Fall	5	6	.82
	Neurologic	6	8	.65
	Anemia	11	7	.27
	Urinary	10	21	.07
	Metabolic	11	18	.45
Length of hospital stay (days)		10.7 ± 3.0 [5–11]	10.7 ± 4.9 [2–36]	.96
Discharge	Rehabilitation center	66 (83%)	44 (52%)	.00003
	Home	14 (17%)	40 (48%)

Numeric variables are expressed as mean ± standard-deviation [min-max]. p < .05 (T-test) was considered statistically significant.

Considering the two severity groups, G1 and G2, the mean hospital stay was 9.8 ± 4.2 days [2–31] for G1 spine, 9.6 ± 3.2 days [3–27] for G1 lower limb, 13.3 ± 6.1 days [4–36] for G2 spine and 15.6 ± 10.4 days [4–69] for G2 lower limb. The difference between the two G1 groups was not statistically significant (p = .78), neither between the two G2 groups (p = .59).

The variation between groups of the mean number of complications is summarized in Figure 2.

Figure 2.

Barplot showing the mean number of medical complications according to the surgical group of the cohort.

The difference in the number of medical complications was statistically significant between G1 lower limb and G2 lower limb (p = .008), as well as between total G1 and total G2 (p = .02). No statistically significant difference was found between G1 spine and G2 spine (p = .08), G1 spine and G1 lower limb (p = .68), and G2 spine and G2 lower limb (p = .61).

Discussion

These results show that the global rate of peri-operative complications and the length of hospital stay were similar between spinal surgery and lower limb prosthetic surgery for patients over 80 years old on comparable groups. When analyzing the impact of the surgical severity (G1 vs. G2), it does seem that its increase leads to more complications in lower limb surgery than spinal surgery.

Although comparison between lower limb and spinal surgery is interesting, a question that may be more accurate is how to optimize peri-operative course for these patients. Indeed, enhanced recovery after surgery (ERAS) has shown satisfactory results in both lower limb and spinal surgery (Frassanito et al., 2020). ERAS allows the reduction of complication rates, including transfusion rates, post-operative pain and opioid consumption, which may be particularly deleterious in elderly patients (Hardy et al., 2022; Jenny & Gisonni, 2022; Jeschke et al., 2022; Picart et al., 2021). Considering elderly patients, experiences from traumatology showed that the association with geriatric post-operative care-units improved both mortality and post-operative quality of life (Davanzo et al., 2021; Francony et al., 2022). These units may notably improve peri-operative immunonutrition, a major factor based on biological and physiological landmarks for decreasing peri-operative complications (Gonçalves et al., 2021). Management strategy for elderly is indeed based on early mobilization, accurate pain management, swallowing disorders detection, stool impaction and urinary retention detection, delirium detection, and malnutrition management. If surgical complications in spinal surgery, such as PJK (proximal junctional kyphosis) and non-union, have been extensively studied in adult spinal deformity, medical complications tend to get fewer attention in the surgical community (Bouyer et al., 2017). However, in fragile population, such as elderly patients, complications impacting quality of life and rates of re-admissions are mostly medical and often the consequences of decompensation of underlying medical conditions (Saleh et al., 2017; Schwab et al., 2012; Zanirato et al., 2018). The management of these patients has therefore to be a tripartite approach (surgeon – anesthesiologist – gerontologist) rather than the usual duo (surgeon – anesthesiologist). Notably, gerontologists are aware of concept of frailty that appears to be predictive of post-operative complications. It should be used systematically in the ortho-geriatric population, for assessment and correction of modifiable factors pre-operatively (Rogers et al., 2020). Frailty has also been linked to hospital length of stay increase and long-term mortality in femoral neck fractures in elderly patients (Krishnan et al., 2014; Patel et al., 2014).

This study may have some limitations. First, its retrospective nature may lead to recognition bias. However, complications were collected in the same manner for LLPS and SS, decreasing the impact of possible bias. In terms of groups comparison (G1 and G2), the defined threshold may lead to some discrepancy (e.g., all THR revision procedures do not lead the same blood losses and operative times), but it reflects daily practice in an orthopedic center. Secondly, the sample size of patients in G2 groups calls for caution in the interpretation of the results. Indeed, the size of these sub-cohorts may be explained by the selection of patients eligible to undergo such heavy surgeries, this analysis being realized a posteriori.

In conclusion, spinal surgery in elderly patients does not seem to lead to more early post-operative complications than lower limb prosthetic surgery. However surgical indications must be carefully chosen with both geriatric, anesthetic and surgical pre-operative evaluation, and patients should benefit from centers with geriatric expertise.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

L. Marie-Hardy

Research Ethics

This study was conducted according to the World Medical Association Declaration of Helsinki.

References

Bouyer

Scemama

Roussouly

Laouissat

Obeid

Boissière

Parent

F. H.

Schuller

Steib

J. P.

Pascal-Moussellard

Guigui

Wolff

Riouallon

(2017). Evolution and complications after surgery for spine deformation in patients with Parkinson’s disease. Orthopaedics & Traumatology Surgery & Research, 103(4), 517–522. https://doi.org/10.1016/j.otsr.2016.12.024

Cloyd

J. M.

Acosta

F. L.

Ames

C. P.

(2008). Complications and outcomes of lumbar spine surgery in elderly people: A review of the literature. Journal of the American Geriatrics Society, 56, 1318–1327. https://doi.org/10.1111/j.1532-5415.2008.01771.x

Davanzo

Previtali

Tamborini

Filardo

Fusco

Bordoni

Gaffurini

Candrian

(2021). Comparison of the survivorship between arthroplasty and ORIF for basi-cervical femoral neck fractures in the overall population and in polymorbid patients. Orthopaedics & Traumatology Surgery & Research, 107(3), 102789. https://doi.org/10.1016/j.otsr.2020.102789

Deyo

R. A.

Ciol

M. A.

Cherkin

D. C.

Loeser

J. D.

Bigos

S. J.

(1993). Lumbar spinal fusion: A cohort study of complications, reoperations, and resource use in the medicare population. Spine, 18(11), 1463–1470. https://doi.org/10.1097/00007632-199318110-00010 Retrieved from.

Francony

Montbarbon

Pailhé

Rubens Duval

Saragaglia

(2022). Assessment of morbidity and mortality after periprosthetic hip fracture. Influence of Vancouver stage in a retrospective single-centre study of 88 patients. Orthopaedics & Traumatology Surgery & Research, 108(1), 102985. https://doi.org/10.1016/j.otsr.2021.102985

Frassanito

Vergari

Nestorini

Cerulli

Placella

Pace

Rossi

(2020). Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: Description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery. Musculoskeletal Surgery, 104(1), 87–92. https://doi.org/10.1007/s12306-019-00603-4

García Rey

Cruz Pardos

Ortega Chamarro

. (2021). Mortality as a competition risk factor in the survival analysis of the results of the type of fixation of the total hip prosthesis in octogenarian patients. Revista Espanola de Cirugia, Traumatologia Y Ortopedia, 65(2), 99–107. https://doi.org/10.1016/j.recot.2020.07.004

Gonçalves

T. J. M.

Gonçalves

S. E. A. B.

Nava

Jorge

V. C.

Okawa

A. M.

Rocha

V. A.

Forato

L. C. H.

Furuya

V. A. O.

Martins

S. S.

Oksman

(2021). Perioperative immunonutrition in elderly patients undergoing total hip and knee arthroplasty: Impact on postoperative outcomes. Journal of Parenteral and Enteral Nutrition, 45(7), 1559–1566. https://doi.org/10.1002/jpen.2028

Hansson

Malchau

(2008). Utility of spine surgery: A comparison of common elective orthopaedic surgical procedures. Spine, 33(25), 2819–2830.

10.

Hardy

Courgeon

Pellei

Desmeules

Loubert

Vendittoli

P. A.

(2022). Improved clinical outcomes of outpatient enhanced recovery hip and knee replacements in comparison to standard inpatient procedures: A study of patients who experienced both. Orthopaedics & Traumatology Surgery & Research, 108(6), 103236. https://doi.org/10.1016/j.otsr.2022.103236

11.

Jenny

J. Y.

Gisonni

(2022). Complications of total hip or knee arthroplasty are not significantly more common after ambulatory surgery than after in-patient surgery and enhanced recovery: A case-control study with propensity-score matching. Orthopaedics & Traumatology Surgery & Research, 108(2), 103206. https://doi.org/10.1016/j.otsr.2022.103206

12.

Jeschke

Citak

Halder

A. M.

Heller

K. D.

Niethard

F. U.

Schräder

Zacher

Leicht

Malzahn

Günster

Gehrke

(2022). Blood transfusion and venous thromboembolism trends and risk factors in primary and aseptic revision total hip and knee arthroplasties: A nationwide investigation of 736,061 cases. Orthopaedics & Traumatology Surgery & Research, 108(1), 102987. https://doi.org/10.1016/j.otsr.2021.102987

13.

Krishnan

Beck

Havelock

Eeles

Hubbard

R. E.

Johansen

(2014). Predicting outcome after hip fracture: Using a frailty index to integrate comprehensive geriatric assessment results. Age and Ageing, 43(1), 122–126. https://doi.org/10.1093/ageing/aft084

14.

Patel

K. V.

Brennan

K. L.

Brennan

M. L.

Jupiter

D. C.

Shar

Davis

M. L.

(2014). Association of a modified frailty index with mortality after femoral neck fracture in patients aged 60 years and older. Clinical Orthopaedics and Related Research, 472(3), 1010–1017. https://doi.org/10.1007/s11999-013-3334-7

15.

Picart

Lecoeur

Rochcongar

Dunet

Pégoix

Hulet

(2021). Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital. Orthopaedics & Traumatology Surgery & Research, 107(3), 102851. https://doi.org/10.1016/j.otsr.2021.102851

16.

Rogers

Brown

Stanger

(2020). Frailty in orthopaedics: Is age relevant? Injury, 51, 2402–2406. https://doi.org/10.1016/j.injury.2020.07.031

17.

Rubin

L. E.

Blood

T. D.

Defillo-Draiby

J. C.

(2016). Total hip and knee arthroplasty in patients older than age 80 years. Journal of the American Academy of Orthopaedic Surgeons, 24, 683–690. https://doi.org/10.5435/jaaos-d-15-00278

18.

Saleh

Thirukumaran

Mesfin

Molinari

R. W.

(2017). Complications and readmission after lumbar spine surgery in elderly patients: An analysis of 2,320 patients. Spine Journal, 17(8), 1106–1112. https://doi.org/10.1016/j.spinee.2017.03.019

19.

Schwab

F. J.

Hawkinson

Lafage

Smith

J. S.

Hart

Mundis

Burton

D. C.

Line

Akbarnia

Boachie-Adjei

Hostin

Shaffrey

C. I.

Arlet

Wood

Gupta

Bess

Mummaneni

P. V.

; International Spine Study Group. (2012). Risk factors for major peri-operative complications in adult spinal deformity surgery: A multi-center review of 953 consecutive patients. European Spine Journal, 21, 2603–2610. https://doi.org/10.1007/s00586-012-2370-4

20.

Silvers

H. R.

Lewis

P. J.

Asch

H. L.

(1993). Decompressive lumbar laminectomy for spinal stenosis. Journal of Neurosurgery, 78(5), 695–701. https://doi.org/10.3171/jns.1993.78.5.0695

21.

Sloan

Premkumar

Sheth

N. P.

(2018). Projected volume of primary total joint arthroplasty in the u.s., 2014 to 2030. Journal of Bone and Joint Surgery (American), 100(17), 1455–1460. https://doi.org/10.2106/JBJS.17.01617

22.

Yolcu

Y. U.

Helal

Alexander

A. Y.

Bhatti

A. U.

Alvi

M. A.

Abode-Iyamah

Bydon

(2021). Minimally invasive versus open surgery for degenerative spine disorders for elderly patients: Experiences from a single institution. World Neurosurgery, 146, e1262–e1269. https://doi.org/10.1016/j.wneu.2020.11.145

23.

Zanirato

Damilano

Formica

Piazzolla

Lovi

Villafañe

J. H.

Berjano

(2018). Complications in adult spine deformity surgery: A systematic review of the recent literature with reporting of aggregated incidences. European Spine Journal, 27, 2272–2284. https://doi.org/10.1007/s00586-018-5535-y

Does Spinal Surgery in Elderly Patients (Over 80 Years-Old) Lead to More Early Post-Operative Complications Than Lower Limb Prosthetic Surgery?

Abstract

Keywords

Introduction

Material and Methods

Results

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

Research Ethics

References