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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Recent advances in both the pharmacological and surgical treatment of osteoporosis and vertebral compression fractures offer exciting new options for elderly patients. However, these treatments should be considered only with an indepth knowledge of osteoporosis as a metabolic disorder with complex effects on bone, its homeostatic regulation, and vertebral strength. ⋯ The strength of a vertebra is directly influenced by the amount and relative proportions of its components, with bone mineral density a useful measure of fracture risk. The purpose of this article is to discuss these issues, among others, in order to offer the reader a better understanding of the pathophysiology of osteoporosis and the determinants of bone strength as they relate to the aging skeleton.
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Cervical spondylotic myelopathy is a clinical entity that manifests itself due to compression and ischemia of the spinal cord. The goal of treatment is to decompress the spinal cord and stabilize the spine in neutral, anatomical position. Since the obstruction and compression of the cord are localized in front of the cord, it is obvious that an anterior surgical approach is the preferred one. The different surgical procedures, complications, and outcome are discussed here.
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Bisphosphonates are compounds characterized by a P-C-P structure. They act essentially on bone, inhibiting bone resorption. Through this mechanism they decrease bone loss, increase bone mineral density, and decrease bone turnover. ⋯ In the latter they diminish both vertebral and nonvertebral fractures. The adverse events are few, mostly gastrointestinal, and can be avoided to a large extent by correct administration. Since there are no other compounds available which have a similar profile, they represent today the drugs of choice in the treatment and the secondary prevention of osteoporosis.
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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.