Lumbar decompression and fusion in elderly osteoporotic patients: a prospective study using less rigid titanium rod fixation.

TYPE OF STUDY: A 2 to 4-year clinical and radiologic prospective study was conducted for 39 patients over the age of 65 treated by lumbar arthrodesis. OBJECTIVES: Evaluate the quality of lumbar arthrodesis results in elderly patients, in which the bone osteoporosis (poor quality of the spine's anatomic components) and general factors (frequent comorbidity) are likely to make this surgery difficult if not dangerous and evaluate a dedicated instrumentation for osteoporotic bone. MATERIALS AND METHODS: Thirty-nine patients over 65 years of age (average 73 y) underwent arthrodesis surgery in 2001 and 2002 and were followed for at least 2 years. The instrumentation used (Equation, Medtronic, Memphis, USA) was selected for its mechanical properties adapted for bone of poor mechanical quality. The clinical analysis was based on Oswestry, Visual Analog Scale, and Japanese Orthopaedic Association scores. Radiologic results were evaluated on standard anteroposterior, lateral, and 3/4 radiographs, and computed tomography scans if necessary. RESULTS: All the patients were followed for 2 to 4 years. Clinical analysis confirmed a very satisfactory progression of the clinical parameters such as lumbar and radicular pain, and the results were maintained between the first and second years and at last follow-up. No serious general complication or need for reoperation was seen in this series. On x-rays, 35 grafts appear to have fused. The anchors did not come out nor did the instrumentation come apart. On the other hand, 2-year radiographs revealed that 2 screws and 2 rods had failed, but this did not affect correction in the 4 completely asymptomatic patients. These 4 cases are considered stable at last follow-up. CONCLUSIONS: Arthrodesis for elderly patients will undoubtedly increase in the coming years. The conditions for this surgery are different than those for younger patients and it is desirable to try to provide reliable surgical techniques and solutions regarding options for instrumentation and overall perioperative care for these fragile patients. Dedicated instrumentation for osteoporotic bone seems to allow good clinical outcomes.

Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007.

OBJECT: Opinions vary widely as to the role of surgery (from none to wide margin excision) in the management of spinal metastases. In this study the authors set out to ascertain if surgery improves the quality of remaining life in patients with spinal metastatic and tumor-related systemic disease. METHODS: The authors included 223 patients in this study who were referred by oncologists and physicians over a 2-year period. All underwent surgery. Surgery was classified according to extent of excision ranging from en bloc excision or debulking to palliative surgery. All patients had a histologically confirmed diagnosis of epithelial spinal metastasis, and an oncology specialist undertook appropriately indicated adjuvant therapy in almost half of the patients. RESULTS: The mean patient age was 61 years. Excisional en bloc or debulking surgery was performed in 74%; the rest had (minimal) palliative decompression. All patients considered for surgery were included in the study. Patients presented with pain in 92% of cases, paraparesis in 24%, and abnormal urinary sphincter function in 22% (5% were incontinent). Breast, renal, lung, and prostate accounted for 65% of the cancers, and in 60% of patients there were widespread spinal metastases (Tomita Type 6 or 7). The incidence of perioperative death (within 30 days of surgery) was 5.8%. Postoperatively 71% of the entire group had improved pain control, 53% regained or maintained their independent mobility, and 39% regained urinary sphincter function. The median survival for the cohort was 352 days (11.7 months); those who underwent excision survived significantly longer than those in the palliative group (p = 0.003). As with survival results, functional improvement outcome was better in those who underwent excision. CONCLUSIONS: Surgical treatment was effective in improving quality of life by providing better pain control, enabling patients to regain or maintain mobility, and offering improved sphincter control. Although not a treatment of the systemic cancer, surgery is feasible, has acceptably low mortality and morbidity rates, and for many will improve the quality of their remaining life.