European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
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Canal stenosis is now the most common indication for lumbar spine surgery in elderly subjects. Degenerative disc disease is by far the most common cause of lumbar spinal stenosis. It is generally accepted that surgery is indicated if a well-conducted conservative management fails. ⋯ Another principle of surgical treatment is interspinous process distraction This device is implanted between the spinous processes, thus reducing extension at the symptomatic level(s), yet allowing flexion and unrestricted axial rotation and lateral flexion. It limits the further narrowing of the canal in upright and extended position. In accordance with the current general tendency towards minimally invasive surgery, such techniques, which preserve much of the anatomy, and the biomechanical function of the lumbar spine may prove highly indicated in the surgical treatment of lumbar stenosis, especially in the elderly.
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Lumbar spinal stenosis is a common condition in elderly patients and also one of the most common reasons to perform spinal surgery at an advanced age. Disc degeneration, facet degeneration and hypertrophy, and ligamentum flavum hypertrophy and calcification usually participate in the genesis of a stenotic condition in the elderly. These changes can lead to symptoms by themselves or decompensate a preexisting narrow canal. ⋯ Various conditions can lead to a narrowing of the neural pathways and differential diagnosis with vascular troubles, also common in the elderly, can be challenging. The investigation of stenotic symptoms should be extremely careful and thorough and include a choice of technical examinations including vascular investigations. This is of utmost importance, especially if a surgical sanction is considered to avoid disappointing results.
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Bony metastases are a frequent problem in elderly patients affected by cancer, and those with bony metastases involve the spine in approx. 50%. The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer. The chance that an elderly patient (60-79 years old) is affected by bony metastases is four times higher in men and three times higher in women than a middle-aged patient (40-59 years old). ⋯ Surgical management shows the greatest improvement in pain reduction, but also in other domains of quality of life. Since prospective randomized studies comparing different treatment modalities for spinal metastases including surgery are not available and are ethically difficult to achieve, each case remains an interdisciplinary, shared decision making process for what is considered best for a patient or elderly patient. However, whenever surgery is an option, it should be planned before irradiation since surgery after irradiation has a significant higher complication rate.
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The costs of vertebral fractures are less well defined than the costs of hip fractures. Large studies are urgently needed. ⋯ These new data on the cost of vertebral fractures will have an impact on health economy calculations. In the future it may be be cost-effective only to prevent vertebral fractures.
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There is a relatively high prevalence of osteoporotic vertebral compression fractures (VCFs) in the elderly population, especially in women aged 50 or older. The result of these VCFs is increased morbidity and mortality in the short and long term. Medical treatment of these fractures includes bed rest, orthotics, analgesic medication and time. ⋯ Research continues into the development of injectable biomaterials that are resorbable and allow for new bone formation. Vertebroplasty and kyphoplasty are safe and effective in the treatment of osteoporotic VCFs. They may allow for a faster return to function, and thus avoid the morbidity associated with medical treatment.