1 / 34

Complex Spine surgery in the Elderly Patient: When to Say No!

Complex Spine surgery in the Elderly Patient: When to Say No!. Colin b. harris, md Assistant professor Spine division Rutgers – new jersey medical school. DISCLOSURES. CONSULTING/TEACHING GLOBUS, INC. Why are we talking about this today?. Adult spinal deformity Heterogeneous Complex

ilya
Download Presentation

Complex Spine surgery in the Elderly Patient: When to Say No!

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Complex Spine surgery in the Elderly Patient: When to Say No! Colin b. harris, md Assistant professor Spine division Rutgers – new jersey medical school

  2. DISCLOSURES • CONSULTING/TEACHING • GLOBUS, INC

  3. Why are we talking about this today? • Adult spinal deformity • Heterogeneous • Complex • Often requires surgery • Surgery improves outcomes* • HRQoL years • However.. Smith, Lafage, Shaffrey et al. Neurosurgery 2016.

  4. The facts • Adult spinal deformity surgery OFTEN requires: • Long dissections • Long-segment spinal fusion • Osteotomies • 6-8 hr + surgery • Multiple transfusion PRBC • Extended hospitalization Cho, Bridwell, Lenke. Spine 2010 Yagi, Rahm, Gaines. Spine 2014 DeWald, Stanley. Spine 2006

  5. What are the risks? • Neurologic deficit • Implant related complications • SSI • Pneumonia/UTI • Delirium • Renal failure • Ileus • Failure to thrive

  6. What are the risks? • Neurologic deficit • Implant related complications • SSI • Pneumonia/UTI • Delirium • Renal failure • Ileus • Failure to thrive 30-60%

  7. What are the risks? New neurologic deficit 8.7% Mean EBL 2120 mL Mean OR time 7 hours 50.8% medical complications • Neurologic deficit • Implant related complications • SSI • Pneumonia/UTI • Delirium • Renal failure • Ileus • Failure to thrive 30-60% Kelly M, Lenke L, Shaffrey C, et al. Neurosurg Focus 2014

  8. Minimizing the risks • PATIENT SELECTION • Medical optimization • Meticulous preoperative planning

  9. Minimizing the risks • Medical optimization • Cardiology • Pulmonology • Every patient needs BMD evaluation • Nutrition status* • Albumin >3.5 g/dL • Total lymphocyte count >1500 cells/mm3 • Transferrin >200mg/dL • Zinc >95 mg/dL Gherini et al CORR 1993;293:188-95 Greene et al J Arthroplasty 1991;4:321-5

  10. Obesity • Defined as BMI>30 (morbid obesity = BMI>40) • Shown to result in increased risk of: • Medical complications • Wound complications • Higher cost per stay • Nutrition consult, involve PCP • Consider bariatric referral BMI>30 Puvanesarajah V, Werner B, Cancienne J, et al. Spine 42(2): 122-7, 2016

  11. Database review of control, obese (BMI >30), morbidly obese (BMI>40) • Obese/morbidly obese with higher rates of wound infection (3.5X), major medical complication (OR 1.79), respiratory failure, renal failure • Obese / MO with higher 30-day re-admission (OR 1.62) and LOS • In-hospital costs increased by $8,000 • Conclusion: Careful selection and counseling needed prior to surgery

  12. Database review of 156,517 patients undergoing elective lumbar fusion • Normal body weight (BMI <25) vs morbidly obese (BMI>40) vs bariatric surgery (BS) + obese • Rates of UTI, respiratory failure, ARF, infection, medical complications lower in BS vs morbidly obese group (p<0.05) • BS group = normal body weight group in medical complications • BS higher infection, reoperation and readmission rates • Conclusions: Consider referral for BS prior to elective spine fusion

  13. Osteoporosis • Consider teriparatide (Forteo) x9-12 months prior to surgery • Must coordinate with Endocrinology • Bony union rate 82%* • Decreased incidence pedicle screw loosening • =/- Follow-up preop DEXA (controversial) • Ohtori S, Inoue G, Orita S, et al. Spine 2012;37:E1464-8.* • Ohtori S, Inoue G, Orita S, et al. Spine 2013;38:E487-92.

  14. How about ASA class? • ASA class III/IV = significant risk factor for: • Mortality • Reoperation within 30 days • LOS • Need for transfusion • Postoperative sepsis • Must counsel regarding increased complications & potential poor outcome Somani S, Capua J, Kim J, et al. Global Spine J 7(8):719-26, 2017.

  15. Preoperative planning • Consider digital planning program (Surgimap, Nemaris, Inc) • Must assess alignment on full length scoliosis radiographs C7 plumb line SVA CSVL

  16. Goals of Surgery • Decompress neural elements • Obtain solid fusion • Restore spinal balance • Avoid complications Glassman S, Bridwell K, Dimar J et al. Spine 2005 Schwab F, Ungar B, Blondel B, et al. Spine 2012

  17. Goals of Surgery • PI – LL <11º • PT < 22º • SVA <5cm Sagittal plane drives disability Coronal plane not so much Schwab F, Ungar B, Blondel B, et al. Spine 2012

  18. SVA +7cm Planned correction SVA 0

  19. Preop Planning SVA +12cm PI – LL = 44

  20. Preop Planning C7 plumb SVA +12cm PI – LL = 44 12 cm

  21. Executing the plan • Consider staging if >6hrs, EBL>1L • Stage 1: Exposure, remove prior implants, instrument • Stage 2: Perform decompression, osteotomies, place graft / rods Lin J, Lenke L, Shillingford J, et al. Spine Deform 2018;6(2):189-94

  22. Executing the plan • Consider staging if >6hrs, EBL>1L • Stage 1: Exposure, remove prior implants, instrument • Stage 2: Perform decompression, osteotomies, place graft / rods • 2-surgeon approach can save time and EBL Lin J, Lenke L, Shillingford J, et al. Spine Deform 2018;6(2):189-94

  23. Executing the plan • Consider staging if >6hrs, EBL>1L • Stage 1: Exposure, remove prior implants, instrument • Stage 2: Perform decompression, osteotomies, place graft / rods • 2-surgeon approach can save time and EBL • Consider O-arm, Stealth, robotics for complex deformities • Cell Saver, 4-6 units T&C, neuromonitoring Lin J, Lenke L, Shillingford J, et al. Spine Deform 2018;6(2):189-94

  24. Executing the plan • Consider staging if >6hrs, EBL>1L • Stage 1: Exposure, remove prior implants, instrument • Stage 2: Perform decompression, osteotomies, place graft / rods • 2-surgeon approach can save time and EBL • Consider O-arm, Stealth, robotics for complex deformities • Cell Saver, 4-6 units T&C, neuromonitoring • Consider tranexamic acid 50mg/k loading dose -> 5mg/kg/hr until closure Lin J, Lenke L, Shillingford J, et al. Spine Deform 2018;6(2):189-94

  25. Executing the plan • Consider BMP, ICBG for long fusions • Meticulous layered closure over drains, incisional wound VAC • Plastic Surgery paraspinal flaps helpful if wound under tension • Observe closely for new neuro deficits in first 24 hrs postop

  26. Complications • EARLY • Paralysis, nerve root injury (most common) • Infection, wound healing problems • Blood loss requiring transfusion • CSF leak • LATE • Non-union (leading to rod or screw fracture) • Adjacent segment “PJK” (Proximal, Distal) >50%!

  27. WHEN TO SAY NO! • Smokers • Chronic opioid use • Poorly controlled DM (HgbA1C >7) • Osteoporosis – use caution • T-score <2.5 SD below mean • Obesity (BMI > 40), Beware BMI > 35 • Chronic steroid use • Moderate or Severe COPD De la Garza Ramos R, Nakhla J, Echt M, et al. Global Spine J 2018

  28. Surgeon Experience Matters

  29. Single surgeon early and late outcomes with posterior VCR • N=34 consecutive patients • Overall 58% experienced complications (13 vs 3) • Results: • Group 1 (inexperienced): 492 min, EBL 1294, 22.8 day LOS • Group 2 (Experienced): 350 min, EBL 974, 13.4 day LOS • CUSUM: complications may reduce after 17 cases and stabilize by 29 cases • Conclusion: PVCR is safer when performed by experienced surgeon

  30. Bottom Line • Adult deformity correction can improve QOL but fraught with dangers • Success depends on many factors that must align: • Meticulous planning & understanding of sagittal parameters • Medical/nutrition/osteoporosis optimization • Must know when to say no…

  31. If in doubt… • Refer to a high volume tertiary center • Get a second opinion!

  32. Thank you!

More Related