Treatment of Spine Disease in the Elderly: Cutting Edge Techniques and Technologies

Description:

As the population continues to age worldwide, spinal disease will become more prevalent in the elderly population.  The treatment of spinal disease requires an individual approach encorporating  best practices.  Optimal management in the elderly may differ from younger patients due to increased comorbidities, decreased bone health, and a higher risk of perioperative morbidity and mortality.
While more and more elderly patients will require evaluation and management of their spinal disease, most modern books discuss operative and nonoperative management based upon disease process.  Techniques and approaches are described for a specific pathology, and are usually tailored for a young or middle aged patient.
Treatment of Spine Disease in the Elderly: Cutting Edge Techniques and Technologies is designed to address this gap in today’s literature by expressly addressing spinal conditions in the elderly and current advanced techniques and technologies for treating their spinal disease.  It will be intended as a resource for the beginning to the advanced surgeon and practitioner whom undertakes treatment of patients in this age group.

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Foreword

Advances in spine care in both technology and technique have created significant improvements in the lives of many. As the population throughout the world ages, spinal pathology affecting the elderly will become an increasingly important public health concern. Previous literature has focused on different populations, such as spinal trauma in young patients and degenerative disease in the middle aged. Older patients suffer from high rates of spinal trauma, spinal deformity, oncology, and of course progressive degenerative disease. These patients often present differently than those in younger groups. Different fracture patterns, oncological etiologies, and deformity issues are some common examples. Comorbidities increase in number and severity with age, with elderly patients requiring treatment that considers frailty and osteoporosis among other severe pathology. Elderly patients require a tailored approach to their spine care. Previous textbooks have presented the advances and current concepts of modern surgical spinal care. However, this textbook is unique in its sole focus on advances in spinal care for the elderly. The editors sought to present a comprehensive text on all aspects of spinal care in the elderly. From evaluation of the medical comorbidities and bone health to advanced techniques in pain management, physiatry, and less invasive surgical means, this text provides a reference for all of those that treat elderly patients.

Christopher I. Shaffrey MD Professor of Neurosurgery Professor of Orthopedic Surgery Chief: Duke Spine Center
Duke University Durham NC, USA

Table of contents :

Foreword
Elderly Specific Considerations in Spine Disease
Trauma
Tumor
Adult Deformity
Osteoporosis
References
Contents
Part I: Special Perioperative Considerations in the Elderly
Chapter 1: Bone Health, Advances in Assessment and Treatment
Introduction
Identification of Patients at Risk for Postoperative Complications
Dual-Energy X-ray Absorptiometry (DXA)
Computed Tomography (CT)-Based Techniques
Trabecular Bone Score (TBS)
High-Resolution Peripheral QCT (HR-pQCT)
Optimization of Bone Strength Perioperatively
Bisphosphonates
Anabolic Agents: Teriparatide
Anabolic Agents: Abaloparatide
Combination Therapy
Conclusion
References
Chapter 2: Antithrombotic Management in Spine Surgery in the Elderly
Introduction
Preoperative Antithrombotic Therapy
Antithrombotic Agent Classes
Antiplatelets
Aspirin (Acetylsalicylic Acid, ASA)
Clopidogrel and Other P2Y12 Receptor Antagonists
Oral Anticoagulants
Warfarin
Direct Oral Anticoagulants (DOACs)
Heparin Compounds
Unfractionated Heparin (UFH)
Low Molecular Weight Heparin (LMWH)
Fondaparinux
Bridging Anticoagulation
Intraoperative Anticoagulation
Postoperative Antithrombotic Therapy
Antiplatelets
Aspirin (Acetylsalicylic Acid, ASA)
Clopidogrel and Other P2Y12 Receptor Antagonists
Oral Anticoagulants
Warfarin
Direct Oral Anticoagulants (DOACs)
Heparin Compounds
Unfractionated Heparin and LMWH
Antithrombotic Management in the Emergent Setting
Antiplatelets
Aspirin
Clopidogrel
Oral Anticoagulants
Warfarin
DOACs
Heparin Compounds
Unfractionated Heparin
LMWH
Fondaparinux
Special Considerations
Changes in Body Composition
Pharmacokinetics
Absorption
Volume of Distribution
Protein Binding
Clearance
Hepatic Impairment
Renal Impairment
Fall Risk
Diet
Polypharmacy
Future Directions
References
Chapter 3: Managing Multiple Medical Comorbidities
Pre-operative Risk Stratification and Communication of Risk
Geriatric-Specific Risk Factors
Age as a Risk Factor
Obesity
Management of Diabetes
Cardiac and Pulmonary Disease
Venous Thromboembolism
Anemia
Delirium
Pain Management Before and After Surgery
Smoking, Alcohol, and Substance Use
Post-operative Disposition
Conclusions
Bibliography
Chapter 4: Anesthetic Concerns for Spinal Surgery in the Elderly
Introduction
Age-Related Physiologic Changes
Central Nervous System
Cardiovascular
Respiratory
Renal
Gastrointestinal
Musculoskeletal and Cutaneous
Preanesthetic Consultation
Frailty
Prehabilitation
Cognition and Dementia
Medication Management
Intraoperative Management
Anesthetic Techniques: General and Regional Anesthesia and Monitored Anesthesia Care
Depth of Sedation
Hemodynamic Perfusion Monitoring
Intraoperative Neurophysiological Monitoring
Postoperative Management
Screening for Delirium
Postoperative Cognitive Dysfunction
Management Strategies
Conclusions
References
Chapter 5: Spinal Prehab/Rehab in the Elderly
Early Postoperative Rehabilitation
Conclusion
References
Chapter 6: ERAS and Spine Surgery
Introduction
Rationale for the Use of ERAS in Spinal Surgery
ERAS Components
Preoperative Period
Intraoperative Period
Postoperative Period
Outcomes by Type of Spine Surgery
Surgery by Anatomical Level
Minimally Invasive Surgery
Deformity Surgery
Tumor Surgery
Outcomes in Elderly Patients
ERAS Implementation
Conclusion
References
Part II: Spine Disease in the Elderly
Chapter 7: Surgical Treatment of Cervical Spondylotic Myelopathy
Introduction
Pathophysiology
Elderly Perioperative Considerations
Surgical Management
Ventral Approaches
ACDF
Corpectomy
Dorsal Approaches
Laminectomy
Laminectomy and Fusion
Laminoplasty
Combined Approach
Complications
Age
Approach
Common Complications
Future Research
Conclusions
References
Chapter 8: Atlantoaxial Fracture Management
Introduction
Anatomy and Mechanical Properties of the Atlantoaxial Complex
Epidemiology
Odontoid Fractures
Diagnosis
Imaging
Morbidity and Mortality
Management
External Immobilization
Operative Management
Fractures of the Atlas
Diagnosis and Treatment
C1–2 Dislocation and Subluxation
Imaging and Diagnosis
Treatment
Hangman’s Fractures
The Modified Effendi Classification System
Diagnosis
Management and Operative Technique
Conclusions
References
Chapter 9: MIS Cervical Approaches in the Elderly
Introduction
MIS Posterior Fusion via Facet Joint Arthrodesis
MIS Posterior Cervical Foraminotomy (PCF)
Tubular Cervical Unilateral Laminotomy for Bilateral Decompression
Conclusion
References
Chapter 10: Subaxial Spinal Trauma
Introduction
Epidemiology
Etiology
Diagnosis
Classification
Treatment
Outcomes, Mortality and Complications
References
Chapter 11: Anterior vs. Posterior Cervical Approaches for the Elderly
Introduction
Patient Selection
Cervical Spine Alignment
Number of Levels Requiring Decompression
Approach-Related Complications to Consider
C5, C8, and T1 Nerve Root Injuries
Dysphagia
Dysphonia
Wound Complications
Other Considerations
OPLL
Pseudarthrosis
Revision Surgery
Anterior Cervical Approaches
Anterior Cervical Discectomy and Fusion (ACDF)
Other Surgical Considerations
Anterior Cervical Corpectomy and Fusion (ACCF)
Other Surgical Considerations
Anterior Cervical Hemi-Corpectomy and Fusion (ACHCF)
Cervical Disc Arthroplasty (CDA)
Posterior Cervical Approaches
Laminectomy and Fusion
Laminoplasty
Laminoplasty Versus ACDF
Laminoplasty Versus Laminectomy and Fusion
Conclusion
References
Chapter 12: Cervical Spine Disease in Elderly Patients with Ankylosing Spondylitis
Background and Etiology
Epidemiology and Risk Factors
Medical Treatments for AS
Cervical Spine Fracture in the Elderly
Cervical Deformity in the Elderly
Navigation Technology for the Surgical Treatment of Ankylosing Spondylitis
Nanomedicine: A Novel Treatment
AI and Technological Modeling
References
Chapter 13: Cervical Spine Deformity in the Elderly
Background
Cervical Spinal Deformity Development in the Elderly
Evaluation for Surgery in Cervical Spine Deformity in the Elderly
Initial Evaluation
Radiographic Evaluation
Surgical Planning
Algorithmic Approach to Cervical Spine Deformity Correction
Fixed Deformity Without Ankylosis
Fixed Deformity with Anterior Ankylosis
Fixed Deformity with Posterior Ankylosis
Fixed Deformity with Circumferentially Fused Cervicothoracic Junction
Flexible Deformity with Mild Kyphosis
Flexible Deformity with Moderate Kyphosis
Flexible Deformity with Severe Kyphosis
Radiographic Success After Cervical Spine Deformity Correction in the Elderly
Complications After Cervical Spine Deformity Correction in the Elderly
Conclusion
References
Chapter 14: Spinal Cord Injury in the Elderly Population
Introduction
Central Cord Syndrome
Spinal Trauma Associated with SCI: Odontoid Fracture, Penetrating Injury, and Fracture Dislocation
Odontoid Fractures
Penetrating Injury
Thoracolumbar Fracture/Dislocation Associated with SCI
Medical Management
Surgical Management
Outcomes
Experimental Treatments
Conclusion
References
Chapter 15: Cervical Spinal Oncology
Introduction
Frailty in the Elderly Spine Oncology Patient
Primary Spine Tumors
Tumors of the Vertebral Column
Tumors of the Spinal Cord and Meninges
Intradural Extramedullary Lesions
Intradural Intramedullary (Intrinsic) Lesions
Metastatic Lesions
Goals of Surgery
Who Is a Surgical Candidate?
Minimally Invasive Surgical Techniques and Alternatives for Frail Patients
Nonsurgical Alternatives
Conclusion
References
Part III: Thoracolumbar Disease in the Elderly
Chapter 16: Management of Spondylolisthesis in the Elderly Population
Introduction
Diagnosis
Nonsurgical Treatment
Physical Therapy
Medications and Injections
Conservative vs. Surgical Treatment
Surgical Treatment
Indications for Surgical Treatment
Overview of Surgical Alternatives for Lumbar Spondylolisthesis
Outcomes of Surgical Treatment
Complications
Conclusion
References
Chapter 17: Sagittal Plane Deformity Considerations in the Elderly
Pathophysiology
Radiographic Parameters
Pelvic Parameters
Pelvic Incidence
Pelvic Tilt
Sacral Slope
Regional Spine Alignment
Relationship of Lumbar Lordosis to Pelvic Incidence
Roussouly Spine Types
Global Spinal Alignment
Radiographic Parameters and Patient-Reported Outcomes
Age-Adjusted Radiographic Parameters
Surgical Correction of Adult Spinal Deformity in the Elderly
Conclusion
References
Chapter 18: Revision Surgery in the Elderly
Introduction
Preoperative Evaluation
Surgical Revision Considerations
Infection
Proximal Junctional Kyphosis
Pedicle Screws
Anterior Versus Posterior Approach
Sacral Insufficiency
Conclusion
References
Chapter 19: Thoracolumbar Trauma in the Elderly
Introduction
Unique Factors in Thoracolumbar Trauma of the Elderly
Osteoporosis
Ankylosing Spondylitis (AS)
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Classification of Thoracolumbar Injuries
Conservative Management
Operative Management
Complications
Conclusion
References
Chapter 20: Osteomyelitis
Case Presentation
Epidemiology
Demographics
Incidence
Etiology
Location
Pathophysiology and Pathogenesis
Clinical Presentation
Diagnosis/Workup
Treatment
Outcomes and Complications
Conclusion
References
Chapter 21: Thoracolumbar Spinal Oncology in the Geriatric Population
Introduction
Historical Data
Evaluation of an Elderly Patient with Spinal Metastases
Minimally Invasive Spine Surgery
Frailty
Geriatric Co-management
Illustrative Case
Conclusion
References
Part IV: Surgical Technical Advances
Chapter 22: Surgical Technical Advances: Interbody Arthrodesis
Introduction
Spinal Fusion Surgery in Elderly Patients: Key Considerations
Interbody Fusion in Geriatric Patients: A Review of the Literature
ALIF
LLIF (Trans-psoas)
LLIF (Pre-psoas)
PLIF
TLIF
Future Directions
References
Chapter 23: Pedicle Screw Fixation
History
Biomechanics
Screw Characteristics
Pedicle Screw Insertion
Pedicle Anatomy
Pedicle Screw Insertion Technique
Technical Advances
Special Considerations in the Elderly
Challenges
Alternatives
References
Chapter 24: Treatment of Spine Disease in the Elderly: Cutting-Edge Techniques and Technologies
Introduction
Plain Radiographs
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Nuclear Medicine
Dual-Energy X-Ray Absorptiometry (DEXA)
Full-Body Imaging and EOS
Conclusion
References
Chapter 25: Robotics and Navigation
Introduction
Minimally Invasive Spine Surgery
Navigation and Image Guidance
Robotic Spine Surgery
Operative Technique
Pedicle Screw Placement Accuracy
Operative Time
Radiation Exposure
Conclusions
References
Chapter 26: Awake Spine Surgery in the Elderly
Introduction
History and Impetus
Enhanced Recovery After Surgery
Anesthetic Technique
Surgical Technique (See Video 26.1)
Postoperative Care
Outcomes
Conclusions
References
Chapter 27: Endoscopic Spine Surgery in the Geriatric Population
Introduction
Advantages and Disadvantages of Endoscopic Discectomy and Decompression
Preoperative Considerations
Imaging
Anesthesia
Endoscopic Approach
Operative Considerations
Interlaminar Endoscopic Discectomy: Illustrative Case
Brief Clinical History
Indication for Surgery
Surgical Approach
Operative Procedure
Postoperative Care
References
Part V: Advances in Pain Management Treatments for Elderly Patients
Chapter 28: CT-Guided Radiofrequency Ablation
Introduction to Ablation
Principles of RF Ablation
Spinal Metastases
Malignant Primary Osseous Lesions
Chordoma
Plasmacytoma and Myeloma
Aggressive Intraosseous Venous Malformations (Vertebral Hemangioma)
Benign Primary Osseous Lesions
Osteoid Osteoma and Osteoblastoma
Aneurysmal Bone Cyst and Giant Cell Tumor
Intraosseous Spinal Glomus Tumors
Chronic Back Pain and Degenerative Spine Disease
Coccydynia and Pudendal Neuralgia
Cervicogenic Headache
Trigeminal Neuropathic Pain
Conclusion
References
Chapter 29: Dorsal Root Ganglion and Peripheral Nerve Stimulation in the Treatment of Low Back and Leg Pain
Introduction
Neurophysiology of Low Back Pain
Dorsal Root Ganglion Stimulation
Peripheral Nerve Stimulation
Conclusion
References
Chapter 30: SI Joint in the Elderly
References
Index