Intraoperative considerations in elderly patients undergoing spine surgery

Abstract

Advanced age and other comorbid factors correlate with age-increased morbidity associated with spine surgery. It is crucial that spine surgeons critically assess perioperative risks versus postoperative benefits of spine surgery in the growing elderly population. Close coordination between the surgeon, anesthesia team and the patient can minimize complications, improve function and contribute to decreased costs of these complex procedures.

Introduction

The elderly population, consisting of patients greater than 60 years old, is the fastest growing demographic in the U.S. The number of patients requiring treatment for degenerative spinal disorders will concomitantly increase¹ as more elderly patients are expected to have painful or dysfunctional spinal conditions that are amenable to spinal surgery. Nearly 50% of individuals over 60 will experience lumbar spinal stenosis,² 68% meet the definition of scoliosis as defined by a Cobb angle >10 degrees,³ and 26% of patients greater than 64 years old have spinal cord stenosis secondary to degenerative disc disease and spondylolysis.⁴ Elderly patients presenting with spinal pathology present a dilemma for spine surgeons as they seek to minimize morbidity and mortality in this population that has a higher baseline incidence of chronic diseases, illness, and age-related disability.^1,5

Preoperative identification of risk factors and predictors of perioperative complications has become increasingly important for the spine surgeon treating these patients, as age has been shown to be an independent risk factor for complications after spine surgery.6., 7., 8., 9. A successful outcome after spine surgery in the older population is associated with several factors. Notably, limiting blood loss is of critical importance when attempting to reduce potential morbidity and mortality.¹⁰ Blood loss can result in changes in physiologic fluid shifts, coagulopathy, antibiotic dilution, and increase the need for perioperative blood product transfusions.¹¹ Elderly patients may be more likely to experience acute decompensation, especially patients with coexisting renal and cardiac conditions.¹² Transfusion of a single unit of packed red blood cells has been associated with increased lengths of stay after elective spine surgery, independent of the preoperative hematocrit level and patient comorbidities.¹³

Blood loss management requires a coordinated effort on the part of the surgeon, anesthesia team and the patient. With increased awareness of the potential hazards of allogeneic blood transfusion, reducing blood loss during major spine procedures has become increasingly important. This review discusses the considerations that spine surgeons and associated healthcare professionals should be aware of specifically when treating the elderly spine patient. The surgeon's attention to intraoperative hemostasis and the use of local hemostatic agents to lessen intraoperative bleeding as well as antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss.