Does the Outcome of Adult Deformity Surgery Justify the Complications in Elderly (Above 70 y of Age) Patients?

Deformity of the spine is an important disorder affecting the aging spine, and management of spinal deformity with operative care accounts for a significant and increasing portion of our health care economy. In the United States, the “Baby Boomers” born between 1946 and 1964 are a large and significant population of older Americans who are more racially diverse, better educated, and have higher expectations for activity than previous generations.2 Spinal deformity is among the most prevalent spinal disorders in the aging population, and has a significant impact on health-related quality of life (HRQOL).3 Population-based studies demonstrate increasing prevalence of degenerative spinal disorders with age. Schwab et al demonstrated spinal deformity in over 60% of adult volunteers over the age of 60. The role of surgery in the management of symptomatic spinal deformity in the elderly patient is variable, and requires careful consideration of risks of surgery and expected outcomes. Minimizing the risk of surgery while optimizing outcome and durability of surgery remains the goal of a value-based approach to care. An informed and shared decision between the patient and physician is important in pursuing an evidence-based approach to care. Many surgical interventions in our elderly population are cost-effective and return patients to an age-appropriate health status. Appropriate surgical interventions are those in which the expected health benefits of surgery (eg, increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceed the expected negative consequences (eg, mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin.5 Smith et al6 demonstrated that there are significantly higher complications in elderly patients with spinal deformity compared with a younger population. However, the improvement of HRQOL was also significantly greater in older patients, yielding a similar ratio of risk and benefit. In a comparison with younger patients (45 y of age and below), Scheer et al7 found that elderly patients (65 y of age and above) who underwent pedicle subtraction osteotomy had more preoperative deformity, and were more likely to reach a minimum clinically important difference after surgery than younger patients. These results demonstrate that the risk to benefit ratio may be similar between older and younger patients, and that surgical care may be as appropriate in older patients. Surgical treatment of patients with symptomatic spinal deformity leads to a greater increase in HRQOL scores compared with nonoperative techniques. Sciubba et al8 demonstrated that patients over 75 years of age who underwent Z4-level spinal fusion had significant improvement in pain and disability, and reported a significant increase in HRQOL 2 years after surgery compared with patients treated nonoperatively. There is a clear relationship between surgical realignment including improvement of C7 SVA and matching of lumbar lordosis with pelvic incidence and successful clinical outcomes. Comparatively, the authors found that the group that underwent nonoperative treatments including physical therapy, steroid injections, and/or pharmacological therapy showed no significant improvement in pain, disability, and HRQOL. In this series, surgery rather than a nonoperative approach yielded better outcomes in elderly patients. The spectrum of clinical presentations associated with spinal deformity in our elderly patients is broad, and includes pain, functional limitations, neural symptoms, and compromise in overall HRQOL. Surgical options for the management of deformity of the spine include decompression, simple fusion, and complex realignment procedures. More limited interventions may reduce the risk of surgical complications, and may be appropriate if the clinical outcome and durability of the surgery is similar to the expected outcome in a more complex approach or extensive procedure. Understanding the appropriate Received for publication July 9, 2015; accepted July 31, 2015. From the *Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA; wNeurological Institute, Cleveland Clinic, Cleveland, OH; and zUniversity of Wisconsin, Madison, WI. The authors declare no conflict of interest. Reprints: Sigurd H. Berven, MD, Department of Orthopaedic Surgery, University of California, San Francisco, 400 Parnassus Ave., Third Floor, San Francisco, CA 94143-0332 (e-mail: sigurd.berven@ ucsf.edu). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. CONTROVERSIES IN SPINE SURGERY