Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

doi:10.1016/j.spinee.2017.03.019

The Spine Journal

Volume 17, Issue 8, August 2017, Pages 1106-1112

https://doi.org/10.1016/j.spinee.2017.03.019 Get rights and content

Abstract

Background Context

There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort.

Purpose

The purpose of the study was to determine how safe lumbar surgery is in elderly patients. Does patient selection, type of surgery, length of surgery, and other comorbidities in the elderly patient affect complication and readmission rates after surgery?

Study Design/Setting

This is a retrospective cohort study.

Patient Sample

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Database was used in the study.

Outcome Measures

The outcome data that were analyzed were minor and major complications, mortality, and readmissions in geriatric patients who underwent lumbar spinal surgery from 2005 to 2015.

Materials and Methods

A retrospective cohort study was performed using data from the ACS NSQIP database. Patients over the age of 80 years who underwent lumbar spinal surgery from 2005 to 2013 were identified using International Statistical Classification of Diseases and Related Health Problems diagnosis codes and Current Procedural Terminology codes. Outcome data were classified as either a major complication, minor complication, readmission, or mortality. Multivariate logistic regression models were used to determine risks for developing adverse outcomes in the initial 30 postoperative days.

Results

A total of 2,320 patients over the age of 80 years who underwent lumbar spine surgery were identified. Overall, 379 (16.34%) patients experienced at least one complication or death. Seventy-five patients (3.23%) experienced a major complication. Three hundred thirty-eight patients (14.57%) experienced a minor complication. Eighty-six patients (6.39%) were readmitted to the hospital within 30 days. Ten deaths (0.43%) were recorded in the initial 30 postoperative days. Increased operative times were strongly associated with perioperative complications (operative time >180 minutes, odds ratio [OR]: 3.07 [95% confidence interval {CI} 2.23–4.22]; operative time 120–180 minutes, OR: 1.77 [95% CI 1.27–2.47]). Instrumentation and fusion procedures were also associated with an increased risk of developing a complication (OR: 2.56 [95% CI 1.66–3.94]). Readmission was strongly associated with patients who were considered underweight (body mass index [BMI] <18.5) and who were functionally debilitated at the time of admission (OR: 4.10 [1.08–15.48] and OR: 2.79 [1.40–5.56], respectively).

Conclusions

Elderly patients undergoing lumbar spinal surgery have high complications and readmission rates. Risk factors for complications include longer operative time and more extensive procedures involving instrumentation and fusion. Higher readmission rates are associated with low baseline patient functional status and low patient BMI.

Introduction

There is a paucity of literature describing adverse outcomes after lumbar spine surgery in the elderly patient. As the life expectancy and the elderly population increase, the prevalence of degenerative diseases of the lumbar spine also increases [1]. Degenerative disease of the lumbar spine includes spinal stenosis, degenerative spondylolisthesis, facet joint arthropathy, de novo lumbar scoliosis, and osteoporotic compression fractures [2], [3].

With the increase in life expectancy, elderly patients have remained more active later in life. Degenerative disorders of the lumbar spine may cause significant neural compression, increased pain, and a decrease in the mobility and quality of life of elderly patients. To help maintain their independence, more elderly patients who have failed medical interventional management of their lumbar spinal disorder, are looking toward a surgical solution. Surgical intervention in the elderly population is not without increased risk secondary to medical comorbidities, polypharmacy, osteoporosis, bone remodeling, and degenerative spinal anatomy [2], [4].

Over the past several years, the rate of lumbar spinal surgery in elderly patients has increased. Surgery for spinal stenosis has recently been shown to be one of the fastest-growing types of lumbar spine surgery in the United States [5]. The most rapid increase in the spinal fusion rates has been shown to occur in patients aged 60 years or above [6], [7]. To date, there are no large studies looking at complication and readmission rates in elderly patients undergoing spinal surgery.

The purpose of the present study was to evaluate two questions with respect to geriatric patients who underwent surgery of the lumbar spine:

1.
How safe is the surgical intervention?
2.
Does patient selection, type of surgery, length of surgery, and other patient comorbidities affect complication and readmission rates after surgery?

Section snippets

Materials and methods

A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was performed. The National Surgical Quality Improvement Program (NSQIP) database is compiled using data from multiple hospitals around the United Sates. Data are collected by a trained surgical clinical reviewer from each hospital. Data collected include patient demographic data, comorbidities, mortality, diagnoses, procedures performed, as well as complications

Results

Evidence & Methods

Context

In this retrospective database study, the authors aimed to assess complication rates of spinal surgery in patients over the age of 80.

Contribution

They found that longer operations, operations using instrumentation, poor baseline functional status, and low BMI were associated with greater risks.

Implications

A confluence of factors—an aging population, better general health of that population, better anesthesia techniques, etc.—has led to greater confidence amongst surgeons as they

Discussion

As the elderly population increases and the number of surgical procedures performed on geriatric patients also increases, the safety of these procedures must be evaluated. Several studies have shown positive outcomes in geriatric patients undergoing lumbar spinal surgery [8], [9], [10], [11], [12], [13], [14]. In a systematic review of complications in lumbar stenosis or spondylolisthesis in geriatric patients, Lee et al. demonstrated the lack of randomized clinical trials regarding

Conclusions

Elderly patients undergoing lumbar spinal surgery experience high complication and readmission rates. Risk factors for complications and readmission in geriatric lumbar spinal surgery include the triad of decreased baseline functional status, lengthy surgical procedures, and higher-complexity procedures. Surgeons should be aware of these risk factors and exercise caution when planning lumbar spine surgery in elderly patients.

References (22)

Z.H. Arinzon et al.
Surgical management of spinal stenosis: a comparison of immediate and long term outcome in two geriatric patient populations
Arch Gerontol Geriatr
(2003)
E.M. Hudak et al.
Outpatient minimally invasive spine surgery using endoscopy for the treatment of lumbar spinal stenosis among obese patients
J Orthop
(2015)
M.G. Fehlings et al.
The aging of the global population: the changing epidemiology of disease and spinal disorders
Neurosurgery
(2015)
J.H. Lee et al.
Perioperative risk factors related to lumbar spine fusion surgery in Korean geriatric patients
J Korean Neurosurg Soc
(2012)
G.K. Jeong et al.
Spinal disorders in the elderly
Clin Orthop Relat Res
(2004)
J.M. Cloyd et al.
Complications and outcomes of lumbar spine surgery in elderly people: a review of the literature
J Am Geriatr Soc
(2008)
R.A. Deyo et al.
Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults
JAMA
(2010)
R.A. Deyo et al.
United States trends in lumbar fusion surgery for degenerative conditions
Spine
(2005)
N.E. Epstein
Spine surgery in geriatric patients: sometimes unnecessary, too much, or too little
Surg Neurol Int
(2011)
Z. Arinzon et al.
Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients
Eur Spine J
(2004)

S.J. Atlas et al.

Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study

Spine

(2000)

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We enrolled 546 patients aged 65–79 and 184 octogenarians. Degenerative diseases were most common in both groups, with higher infection and tumor rates in the younger cohort. Octogenarians had a higher Charlson Comorbidity Index and longer ICU/hospital stays. Surgery-related AE rates were 8.1% for 65-79-year-olds and 15.8% for octogenarians, with mortality around 2% in both groups.
Our prospective analysis shows octogenarians are more susceptible to surgical AEs, linked to greater health complexities. Despite higher AEs in older patients, low mortality rates across both age groups highlight the safety of spinal surgery. Tracking AEs is crucial for patient communication and impacts healthcare accreditation and funding.
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: Author disclosures: AS: Nothing to disclose. CT: Nothing to disclose. AM: Nothing to disclose. RWM: Nothing to disclose.

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Clinical StudyComplications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

Abstract

Background Context

Purpose

Study Design/Setting

Patient Sample

Outcome Measures

Materials and Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Context

Contribution

Implications

Discussion

Conclusions

Arch Gerontol Geriatr

J Orthop

The aging of the global population: the changing epidemiology of disease and spinal disorders

Neurosurgery

Perioperative risk factors related to lumbar spine fusion surgery in Korean geriatric patients

J Korean Neurosurg Soc

Spinal disorders in the elderly

Clin Orthop Relat Res

Complications and outcomes of lumbar spine surgery in elderly people: a review of the literature

J Am Geriatr Soc

Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults

JAMA

United States trends in lumbar fusion surgery for degenerative conditions

Spine

Spine surgery in geriatric patients: sometimes unnecessary, too much, or too little

Surg Neurol Int

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients

Eur Spine J

Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study

Spine

Clinical Study
Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients