Appropriate Use of Surgery in the Elderly Patient with Spinal - - PDF document

Appropriate Use of Surgery in the Elderly Patient with Spinal Deformity

Preoperative Optimization in the Elderly Disclosures

• Research/Institutional Support:

– NIH, NSF, AO Spine, OREF

• Honoraria:

– Medtronic, Stryker, Globus Medical

• Ownership/Stock/Options:

– Providence Medical, Green Sun Medical

• Royalties:

– Medtronic, Stryker

Overview

• Broad Spectrum of Pathologies and Surgical Options in the Elderly

patient with deformity

– Multiple Disciplines involved in care – Variability in Care

• Optimization across the Continuum of Care

– Non-operative – Preoperative – Operative – Postoperative

• Risk Stratification and Modification

– Checklist/ Recognition

• Creating Standard Work Protocols

Introduction

• Spinal Deformity in the elderly

– Degenerative changes within the deformity:

• Stenosis
• Spondylolisthesis
• Rotatory subluxation
• Lumbar hypolordosis
• Osteoporosis
• Neuromuscular Pathologies

– Sarcopenia

Approaches to Spinal Pathology

• Characterized by significant variability

– Non-operative care – Operative Strategies – Interdisciplinary Care – Cost of Care

Variability in approach to care

• There is significant variability in operative and non-
• perative care for Spinal disorders
• An evidence-based approach to care guided by clinical
• utcomes research and predictive modelling may reduce

variability in care

Informed Choice and Appropriate Care

Empowering informed choice in the management of Spinal Disorders

• Valid Information on Natural History
• Valid Information on Outcomes of
• perative and non-operative options

– Risks of Care – Expected Benefits of Care

Informed Choice under Conditions of Uncertainty

• AUC indicate reasonable care based on available evidence

combined with a rigorous, transparent recommendation process and well-defined scenarios.

• Appropriate Use Criteria (AUC) specify when it is

appropriate to perform a medical procedure or service. An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin.

Instructions for Rating Management Procedures and Strategies

Making Informed Choices under conditions of Uncertainty 9

1 2 3 4 5 6 7 8 9 Appropriate Reasonable Inappropriate

An inappropriate procedure or management strategy is defined as one in which the value (benefit per unit cost) is LOW: The expected negative consequences exceeds the expected health benefit such that the procedure should not be performed. A reasonable procedure or management strategy is

• ne in which:

The balance of risk and benefit are not known, but there is a reasonable chance of positive net benefit, with limited risk. An appropriate procedure or management strategy is defined as one in which the value (benefit per unit cost) is HIGH: The expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.

Most inappropriate Most appropriate Fitch et al. 2001

Rand/UCLA AUC Methodology

• Drivers of Appropriateness

– Pre-operative Symptoms – Progression of Deformity – Sagittal Alignment – Comorbidities

• Delphi panel with 53 surgeons from 23 countries
• Evaluation of appropriate evaluation and treatment

strategies for adults with deformity in each stage of care

– Preoperative- goals and preparation – Intraoperative strategies – Post-operative management

Appropriate Care

• Expected outcomes:

– Risks – Benefits

• Alternative options

– Non-operative – Limited surgery – Extensive surgery

Risk and Behaviour

• Influence of risk/benefit calculations on

appropriate decision making

• Moral Hazard

– Dissociation of the risk and benefit

• Party that makes decision is recipient of benefit and

shielded from risk

• Insurance, Banking, Medicine

Medical Decision Making

• Disassociation between the Decision maker

and the Beneficiary

– Judge and Executioner – Home Inspector and Contractor – Physician and Surgeon?

Defining the Goals of Surgical Care

• Safety
• Neural decompression
• Alignment of the spine

– Correction of deformity

• Prevention of Progression
• Improvement of health-related

quality of life

– General health status – Disease-specific health status

Adjusting Goals of Spine Surgery

• Management of Comorbidities

– Cardiopulmonary – Osteoporosis – Frailty

• Adjustment of Surgical Strategies

– MIS approaches – Vertebral Augmentation/Fixation Strategies – Adjustment of Surgical Goals – When to do Less – When to say “No” to surgical options

Goals of Deformity Correction

• SVA more anterior with increasing age
• Loss of Lumbar Lordosis with Age
• Analysis of Sagittal Alignment in 131 Volunteers

– Forceplate Analysis – Radiographic Parameters

Surgical Planning

• By failing to prepare, you are preparing to fail.
• - Benjamin Franklin
• Forewarned, forearmed; to be prepared is half the

victory.

• - Miguel de Cervantes Saavedra
• Those who plan do better than those who do not

plan even thou they rarely stick to their plan.

• - Winston Churchill

Adjusted Goals of Spine Surgery in the Elderly

SVA

C7 T1

T1 Tilt

<8cm <00

PT

<250

Proportional:

LL=PI – (10 or 150)

Comorbidities in the Elderly

• Medical Considerations/ASA Score

– Cardiovascular Fitness – Pulmonary Health – Renal disease

• Bone Quality
• Neuromuscular Comorbidity
• Mental Health

– Depression/Anxiety

• Social Support

INTERSECTION OF DISEASES

• more common in the elderly
• steoporosis

spinal disorders

Neuromuscular Comorbidity

Mitochondrial Myopathy

• Rapid Progression of

Decompensated and Atypical Deformity

Pre-operative Considerations

Risk Assessment

• Assess

risk/benefit

• Appropriateness
• f surgery
• Align

expectations

• Shared decision

making Medical Optimization

• Smoking
• Nutrition
• Obesity
• Diabetes
• Cardiopulmonary
• Bone Health
• Narcotics

Surgical Planning

• Multidisciplinary

Planning

• Preoperative

Planning Conference

• Manage adjacent

levels

• Osteoporosis
• Guidance system

Physical Optimization

• General physical

conditioning

• BMI
• Physical Therapy
• Independence
• Home Support

EMR based Risk Stratification

Standardized Ordersets Preoperative Ordersets Modifiable Medical Co-morbidities

• Preop evaluation

– Bone Density – Pulmonary – Cardiac – Nutritional – Psychological – Social

Osteoporosis

• Pre-op identification with DEXA/Opportunistic CT
• Antiresorbtive Medications

– Bisphosphonates

• Pre-operative Anabolic Medications

– Teraperatide

• Fixation Strategies for the Osteoporotic Spine

Smoking

• Relative risk of post operative

pulmonary complications: 1.4-4.3 (coronary bypass)

• Declines if d/c’d >8 wks preop
• d/c’d > 6 mon, normal risk of pulm

complications

• If d/c’d < 8 wks –> higher risk
• Complications increased by  pulm

function – ↑pack years – ↑surgical time – Use enflurane » Warner, et al, 1989

COPD

• Up to 4.7 relative risk of

pulmonary complications

• Bronchodilators, PT,

antibiotics, smoking cessation, corticosteroids to minimize symptoms (airway

• bstuction), optimize

exercise tolerance

Overall health

• Exercise capacity

– Exercise Stress test – Inability to perform 2 min supine exercise  HR 99 bpm – METS <4

–  strong predictor of cardiac complications – 79% of complications in patients with poor exercise tolerance patients

Cardiac

• Perioperative β-blockade

– Eligible patients

• Minor criteria(2 of: >64yo, HT, smoker, chol >240,

NIDDM)

• Cardiac risk (ischemic heart disease, cerebrovascular

disease, IDDM, chronic renal insufficiency [Cr 2.0])

– 90% reduction in cardiac events (30 d) – Decr mortality at 1 and 2 yr (intrathoracic/peritoneal vasc surg)

Obesity and BMI

• Identify patients with BMI >35

– Dietary changes – Gastric Bypass Surgery

Frailty/Sarcopenia

• Mortality Nomogram

Risk reduction

• Deep breathing exercises
• Cont positive airway

pressure (for pts unable to coop)

• Incentive spirometry

– Decr risk of pulm complications up to 50% Celli, 1984 Thomas, 1994

Perioperative β blockade

• Pre-induction

– PO up to 30 days prior or – IV just before induction – Decr HR <80/m (hold for <55 or BP sys <100)

• Up to 1 mon post op (or

longer)

Pre op β blockade

• Side effects (unusual)

– Bradycardia – Heart block – Hypotension – Bronchospasm – CHF

Post op β blockade

• TKR patients (107) risk of CAD randomized

– esmolol 1 h post op, HR <80 bpm – metoprolol po, till hosp d/c

• EKG ischemia

– 2.8% preop – 7.5% intraop – 12 control, 3 study pts post op

Urban et al, 2000

Relationship between cardiac and non-cardiac complications

• Reviewed 3970 pts (1191
• rtho, incl spine)
• Cardiac complications 

more likely to suffer noncardiac comp (48%)

• Non-cardiac compl

more likely to suffer cardiac comp

Fleischmann, et al, 2003

Diabetes

• Perioperative glucose control
• HgbA1c<7.5, BS<200 mg/dl

– Decr rate of wound infections – Respiratory failure – Shortened ICU stay Wiener-Kronish 2005

Nutritional status

• Studies demonstrating

increased infection and complication rates if nutritional depleted

– Identify by Serum Pre- albumin levels – Preop nutritional depletion most likely:

• Chronic disease
• Age >60
• Osteomyelitis
• Spinal cord injury
• Klein et al, 1996

Evaluate at risk patients

• Prealbumin
• Albumin
• Transferrin
• Treat with supplementation

pre op, perioperatively

– TPN:well tolerated, expensive, complications – Tube feeds: more physiologic, low acceptance

Psychological preparation

• Stress of surgery,

hospitalization can increase psychologic symptoms

• Increased depression post op
• Therapeutic medication

levels can be hard to maintain post op (NPO patients, Li)

Social preparation

• Family engagement
• Support system

– Anticipate post op challenges – Stability

• Perioperative stressors: recent
• r upcoming events (divorce,

death, marriage)

• Expectations for surgery: need

for care, time off work, financial burden, pain relief

Intra-operative Considerations

Blood Conservation/Fluid Management

• Amicar/TXA
• Cellsaver
• Transfusion

Protocol

• Colloid to

Crystalloid ratio Neuromonitoring

• Neuromonitoring

protocols

• Algorithm for

positive change Surgical Technique

• Two attendings
• Protocol for

staging

• Equipment
• Radiography
• Achieve goals of

surgery

• Intra-op
• Post-op

Reduce complications

• Pain management
• Antibiotic

prophylaxis

• Blood sugar

control

• Normothermia

Six Sigma Methodology

DMAIC – Process Improvement

• Define the problem
• Measure the causes
• Analyze the root causes
• Improve with trial interventions
• Control the implementation and follow-up processes

Post-operative Considerations

Pain Management

• Standardized

protocol

• Chronic Pain

Considerations Mobilization

• Early

Mobilization

• Post-op chairs
• PT protocols

Nutrition

• Early enteric

feeding

• 2400kcal/d

Medical Complications

• DVT

prophylaxis

• Delirium

prevention

• Foley

Discharge Considerations

Home

• Preoperative

Preparation

• Home Health

Services

• PT/OT

Rehabilitation

• Mobilization

protocols

• Communication
• f Care Plan
• Precautions

SNF

• Mobilization
• PT Protocols

Communication Pathways

• Health Loop
• Nurse Navigator
• Clinic Visits over

ER visits

• Measuring
• utcomes and

PROs

Post-operative Accountability

• Measurement of HRQoL/Registries

– NASS – ISSG – AOKF – N2QOD

Conclusions

• Spinal Deformity is an important and common cause of

morbidity in elderly patients

• Recognition of factors associated with perioperative

complications and mortality is important for patient safety

• Perioperative risk is important for informed choice in

spine surgery, and for participating in the choice to “say no” or to work toward preoperative optimization

• Preoperative optimization of modifiable risk factors

reduces risk of perioperative complications and death in deformity surgery

Conclusions

• Spinal Disorders encompass a broad spectrum of pathologies, and

require care from multiple disciplines including non-operative and

• perative providers
• Optimal Management of Spinal Disorders requires interdisciplinary

collaboration, and care plans that span the continuum of care

• Accountability across the continuum of care is an important goal for
• ur spine service, especially in the era of healthcare reform
• Our Spine Surgical Home is directed to integration of the multiple disciplines

that care for patients with spinal disorders, and the development of an evidence- based approach to care characterized by consensus rather than variability.

UCSF Center for Outcomes Research