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  • Age Effect on Surgical Outcomes

    Spine (Phila Pa 1976). 2010 Jul 30. [Epub ahead of print]
    Risk-Benefit Assessment of Surgery for Adult Scoliosis: An Analysis Based on Patient Age.

    Smith JS, Shaffrey CI, Glassman SD, Berven SH, Schwab FJ, Hamill CL, Horton WC, Ondra SL, Sansur CA, Bridwell KH; the Spinal Deformity Study Group.

    From the Departments of *Neurosurgery and daggerOrthopedic Surgery, University of Virginia, Charlottesville, VA; double daggerNorton Leatherman Spine Center, Louisville, KY; section signSpinal Disorders Service, University of California, San Francisco, CA; paragraph signNYU Hospital for Joint Diseases, New York City; parallelState University of New York, Buffalo, NY; **Emory Orthopedics and Spine Center, Atlanta, GA; daggerdaggerDepartment of Neurosurgery, Northwestern University, Chicago, IL; double daggerdouble daggerDepartment of Neurosurgery, University of Maryland Medical Center, Baltimore, MD; and section sign section signSpinal Deformity Service, WA University, St Louis, MO.
    Abstract

    STUDY DESIGN.: Retrospective review of a prospective, multicenter database. OBJECTIVE.: The purpose of this study was to assess whether elderly patients undergoing scoliosis surgery had an incidence of complications and improvement in outcome measures comparable with younger patients. SUMMARY OF BACKGROUND DATA.: Complications increase with age for adults undergoing scoliosis surgery, but whether this impacts the outcomes of older patients is largely unknown. METHODS.: This is a retrospective review of a prospective, multicenter spinal deformity database. Patients complete the Oswestry Disability Index (ODI), SF-12, Scoliosis Research Society-22 (SRS-22), and numerical rating scale (NRS; 0-10) for back and leg pain. Inclusion criteria included age 25 to 85 years, scoliosis (Cobb >/=30 degrees ), plan for scoliosis surgery, and 2-year follow-up. RESULTS.: Two hundred six of 453 patients (45%) completed 2-year follow-up, which is distributed among age groups as follows: 25 to 44 (n = 47), 45 to 64 (n = 121), and 65 to 85 (n = 38) years. The percentages of patients with 2-year follow-up by age group were as follows: 25 to 44 (45%), 45 to 64 (48%), and 65 to 85 (40%) years. These groups had perioperative complication rates of 17%, 42%, and 71%, respectively (P < 0.001). At baseline, elderly patients (65-85 years) had greater disability (ODI, P = 0.001), worse health status (SF-12 physical component score (PCS), P < 0.001), and more severe back and leg pain (NRS, P = 0.04 and P = 0.01, respectively) than younger patients. Mean SRS-22 did not differ significantly at baseline. Within each age group, at 2-year follow-up there were significant improvements in ODI (P </= 0.004), SRS-22 (P </= 0.001), back pain (P < 0.001), and leg pain (P </= 0.04). SF-12 PCS did not improve significantly for patients aged 25 to 44 years but did among those aged 45 to 64 (P < 0.001) and 65 to 85 years (P = 0.001). Improvement in ODI and leg pain NRS were significantly greater among elderly patients (P = 0.003, P = 0.02, respectively), and there were trends for greater improvements in SF-12 PCS (P = 0.07), SRS-22 (P = 0.048), and back pain NRS (P = 0.06) among elderly patients, when compared with younger patients. CONCLUSION.: Collectively, these data demonstrate the potential benefits of surgical treatment for adult scoliosis and suggest that the elderly, despite facing the greatest risk of complications, may stand to gain a disproportionately greater improvement in disability and pain with surgery.

    PMID: 20683385 [PubMed - as supplied by publisher]
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  • #2
    Quote: " CONCLUSION.: Collectively, these data demonstrate the potential benefits of surgical treatment for adult scoliosis and suggest that the elderly, despite facing the greatest risk of complications, may stand to gain a disproportionately greater improvement in disability and pain with surgery."

    Good news there for older patients who are worrying about their age = poor outcome.
    Surgery March 3, 2009 at almost 58, now 63.
    Dr. Askin, Brisbane, Australia
    T4-Pelvis, Posterior only
    Osteotomies and Laminectomies
    Was 68 degrees, now 22 and pain free

    Comment


    • #3
      That's very interesting.

      Is there any sense of the severity of the complications? Or do they not break it down like that?

      Actually, the oddest thing in the report is that, despite the fact that the older patients appeared to have more serious problems going in, there weren't any major difference in the baseline SRS-22. Is it just not a sensitive tool? Or is there some other reason why these dissimilar groups are self-reporting very similarly.

      Given the lower rates of problems in the younger patients going in, I'm not surprised that they didn't show as much improvement, but that complication rate is really jaw-dropping.

      Comment


      • #4
        Originally posted by JenniferG View Post
        Quote: " CONCLUSION.: Collectively, these data demonstrate the potential benefits of surgical treatment for adult scoliosis and suggest that the elderly, despite facing the greatest risk of complications, may stand to gain a disproportionately greater improvement in disability and pain with surgery."

        Good news there for older patients who are worrying about their age = poor outcome.
        Hi Jennifer...

        I agree.

        At UCSF, our average patient age is way higher than the norm, so I regularly see people in their 70's and 80's, and even some in their 90's, having big multi-level fusion surgeries, and having really miraculous outcomes. I think the reason their outcomes are so great is that this population aren't making their decision based on things like risk of progression, cosmesis, etc. They're almost certainly having surgery strictly because they've got severe pain or reduced function.

        --Linda
        Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
        ---------------------------------------------------------------------------------------------------------------------------------------------------
        Surgery 2/10/93 A/P fusion T4-L3
        Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

        Comment


        • #5
          Originally posted by hdugger View Post

          Given the lower rates of problems in the younger patients going in, I'm not surprised that they didn't show as much improvement, but that complication rate is really jaw-dropping.
          Which complication rate? The 25-44 year group?
          Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
          ---------------------------------------------------------------------------------------------------------------------------------------------------
          Surgery 2/10/93 A/P fusion T4-L3
          Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

          Comment


          • #6
            Originally posted by LindaRacine View Post
            Which complication rate? The 25-44 year group?
            No, it looked pretty good for the younger people (and better yet, I'd guess, for the under-25 crowd). It's the 71% complication rate in the older group that caught my attention.

            My main take-away from this would be that it's better to get the surgery sooner rather then later.

            Comment


            • #7
              Thanks Linda. Good to hear as I am in that middle age group and headed in for surgery Aug 31. Also, in the complications category, don't they report even very minor complications that are easily treated as "complications'" in studies like this? So it may not seem as bad as it looks?
              Age 56
              Wore a Milwaukee Brace for 3 years in hs
              Fused L4-S1 for high grade spondylolisthesis Jan '09 in Indy
              Thoracic 68
              Surgery Aug 31, 2010 T3 to L1
              Dr Bridwell St Louis
              http://www.scoliosis.org/forum/attac...1&d=1289881696

              Comment


              • #8
                Originally posted by hdugger View Post
                No, it looked pretty good for the younger people (and better yet, I'd guess, for the under-25 crowd). It's the 71% complication rate in the older group that caught my attention.

                My main take-away from this would be that it's better to get the surgery sooner rather then later.
                This general issue came up before. The complications they are probably including are mostly if not completely short-term and have no bearing on the long-term outcome.

                So while 71% sounds high (and is high!), it is probably the case that most of them are short-term. With the real-time nerve monitoring largely reducing the rate of permanent paralysis to very low levels, I wonder if there are any complications that are long-term. Maybe there are.
                Sharon, mother of identical twin girls with scoliosis

                No island of sanity.

                Question: What do you call alternative medicine that works?
                Answer: Medicine


                "We are all African."

                Comment


                • #9
                  Originally posted by LisaB View Post
                  Thanks Linda. Good to hear as I am in that middle age group and headed in for surgery Aug 31. Also, in the complications category, don't they report even very minor complications that are easily treated as "complications'" in studies like this? So it may not seem as bad as it looks?
                  Yes we posted almost at the same time. I think this is the case.
                  Sharon, mother of identical twin girls with scoliosis

                  No island of sanity.

                  Question: What do you call alternative medicine that works?
                  Answer: Medicine


                  "We are all African."

                  Comment


                  • #10
                    Originally posted by hdugger View Post
                    No, it looked pretty good for the younger people (and better yet, I'd guess, for the under-25 crowd). It's the 71% complication rate in the older group that caught my attention.

                    My main take-away from this would be that it's better to get the surgery sooner rather then later.
                    The high complication rate is really no surprise. This is major surgery on someone between 65 and 85 years old. I suspect they'd have a very high complication rate for something as simple (relatively speaking) as a simple cosmetic procedure. In the end, these people are happier than the other age ranges, so the complications were apparently not bad enough that it tainted their outcomes.
                    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                    ---------------------------------------------------------------------------------------------------------------------------------------------------
                    Surgery 2/10/93 A/P fusion T4-L3
                    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                    Comment


                    • #11
                      Originally posted by Pooka1 View Post
                      This general issue came up before. The complications they are probably including are mostly if not completely short-term and have no bearing on the long-term outcome.

                      So while 71% sounds high (and is high!), it is probably the case that most of them are short-term. With the real-time nerve monitoring largely reducing the rate of permanent paralysis to very low levels, I wonder if there are any complications that are long-term. Maybe there are.
                      I'll hopefully be able to read the full paper next week.
                      Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                      ---------------------------------------------------------------------------------------------------------------------------------------------------
                      Surgery 2/10/93 A/P fusion T4-L3
                      Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                      Comment


                      • #12
                        so does that mean that older patients are ....trusting that they will come out with less pain after they have healed...?

                        i can see those two reasons...less pain and wishing to restore lost functioning...as reasons for older people to turn to surgery...especially if they have tried most other treatments without much success...

                        but....there is no guarantee that the pain will be reduced...

                        jess

                        Comment


                        • #13
                          I DO wish they had been more precise about what is meant by "complications". Hopefully, though it's not defined in the abstract it IS explained in the full paper (and can be learned).

                          I think one reason older pts. fare relatively well, is that we've "grown into" our pain and disability over a period of many years and kind of lost track of what we've lost. Our changed status has become the "new normal". I know that's what's happened with me.
                          Not all diagnosed (still having tests and consults) but so far:
                          Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
                          main curve L Cobb 60, compensating T curve ~ 30
                          Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

                          Comment


                          • #14
                            So, the problem I have with this is the somewhat odd SRS-22 measure. Either old people are weinies and they complain about all kinds of pain even though they're no more incapacitated then younger people (explanation 1) or, what I suspect is the more likely explanation, older people have fewer things that they *have* to do, so as the pain gets worse, they just limit their lives more and more without really noticing the effect that this has had on them (explanation 2).

                            That would make the SRS-22 maybe not the best tool to compare people with different demands. So, people with lots of demands on them might rate very differently from people with fewer demands, even with the exact same amount of incapacity.

                            Comment


                            • #15
                              Originally posted by jrnyc View Post
                              there is no guarantee that the pain will be reduced...

                              jess
                              Guarantee? Certainly, not. Bur per this study as a population group


                              Collectively, these data demonstrate the potential benefits of surgical treatment for adult scoliosis and suggest that the elderly, despite facing the greatest risk of complications, may stand to gain a disproportionately greater improvement in disability and pain with surgery.
                              Not all diagnosed (still having tests and consults) but so far:
                              Ehler-Danlos (hyper-mobility) syndrome, 69 - somehow,
                              main curve L Cobb 60, compensating T curve ~ 30
                              Flat back, marked lumbar kyphosis (grade?) Spondilolisthesis - everyone gives this a different grade too. Cervical stenosis op'd 3-07, minimally invasive

                              Comment

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