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

Disclosures Appropriate Use of Surgery in the Elderly Patient with Spinal Deformity • Research/Institutional Support: – NIH, NSF, AO Spine, OREF • Honoraria: Preoperative Optimization in the Elderly – Medtronic, Stryker, Globus Medical • Ownership/Stock/Options: – Providence Medical, Green Sun Medical • Royalties: – Medtronic, Stryker Overview Introduction • Broad Spectrum of Pathologies and Surgical Options in the Elderly patient with deformity • Spinal Deformity in the elderly – Multiple Disciplines involved in care – Variability in Care – Degenerative changes within the deformity: • Optimization across the Continuum of Care • Stenosis – Non-operative • Spondylolisthesis • Rotatory subluxation – Preoperative – Operative • Lumbar hypolordosis – Postoperative • Osteoporosis • Neuromuscular Pathologies • Risk Stratification and Modification – Sarcopenia – Checklist/ Recognition • Creating Standard Work Protocols

Approaches to Spinal Pathology Variability in approach to care • Characterized by significant variability • There is significant variability in operative and non- – Non-operative care operative care for Spinal disorders – Operative Strategies • An evidence-based approach to care guided by clinical – Interdisciplinary Care outcomes research and predictive modelling may reduce – Cost of Care variability in care Informed Choice and Appropriate Informed Choice under Care Conditions of Uncertainty Empowering informed choice in the • AUC indicate reasonable care based on available evidence management of Spinal Disorders combined with a rigorous, transparent recommendation process and well-defined scenarios. • Valid Information on Natural History • Valid Information on Outcomes of • Appropriate Use Criteria (AUC) specify when it is operative and non-operative options appropriate to perform a medical procedure or service. An “appropriate” procedure is one for which the expected – Risks of Care health benefits exceed the expected health risks by a wide – Expected Benefits of Care margin.

Rand/UCLA AUC Methodology Making Informed Choices under conditions of Uncertainty Instructions for Rating Management Procedures and Strategies Inappropriate Reasonable Appropriate • Drivers of Appropriateness Most Most 1 2 3 4 5 6 7 8 9 inappropriate appropriate – Pre-operative Symptoms – Progression of Deformity An inappropriate procedure or A reasonable procedure or An appropriate procedure or management management strategy is defined as one management strategy is strategy is defined as one in which the – Sagittal Alignment in which the value (benefit per unit one in which: value (benefit per unit cost) is HIGH : cost) is LOW : The balance of risk and The expected health benefit exceeds the – Comorbidities The expected negative consequences benefit are not known, but expected negative consequences by a exceeds the expected health benefit there is a reasonable sufficiently wide margin that the such that the procedure should not be chance of positive net procedure is worth doing. performed. benefit, with limited risk. Fitch et al. 2001 9 Appropriate Care • Expected outcomes: – Risks • Delphi panel with 53 surgeons from 23 countries – Benefits • Evaluation of appropriate evaluation and treatment • Alternative options strategies for adults with deformity in each stage of care – Non-operative – Preoperative- goals and preparation – Limited surgery – Intraoperative strategies – Extensive surgery – Post-operative management

Risk and Behaviour Medical Decision Making • Disassociation between the Decision maker • Influence of risk/benefit calculations on and the Beneficiary appropriate decision making – Judge and Executioner • Moral Hazard – Home Inspector and Contractor – Dissociation of the risk and benefit – Physician and Surgeon? • Party that makes decision is recipient of benefit and shielded from risk • Insurance, Banking, Medicine Defining the Goals of Surgical Care Adjusting Goals of Spine Surgery • Management of Comorbidities – Cardiopulmonary • Safety – Osteoporosis • Neural decompression – Frailty • Alignment of the spine – Correction of deformity • Adjustment of Surgical Strategies • Prevention of Progression – MIS approaches • Improvement of health-related – Vertebral Augmentation/Fixation Strategies quality of life – Adjustment of Surgical Goals – General health status – When to do Less – Disease-specific health status – When to say “No” to surgical options

Goals of Deformity Correction • SVA more anterior with increasing age • Loss of Lumbar Lordosis with Age Surgical Planning • By failing to prepare, you are preparing to fail. • - Benjamin Franklin • Analysis of Sagittal Alignment in 131 Volunteers – Forceplate Analysis • Forewarned, forearmed; to be prepared is half the – Radiographic Parameters 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 Comorbidities in the Elderly the Elderly C7 • Medical Considerations/ASA Score T1 – Cardiovascular Fitness – Pulmonary Health – Renal disease • Bone Quality • Neuromuscular Comorbidity SVA T1 Tilt PT • Mental Health Proportional: – Depression/Anxiety <8cm <0 0 <25 0 LL=PI – (10 or 15 0 ) • Social Support Neuromuscular Comorbidity INTERSECTION OF DISEASES spinal osteoporosis disorders •more common in the elderly

Mitochondrial Myopathy Pre-operative Considerations Medical Physical Risk Assessment Surgical Planning Optimization Optimization • Assess • Smoking • Multidisciplinary • General physical risk/benefit Planning conditioning • Nutrition • Rapid Progression of • Appropriateness • Preoperative • BMI • Obesity of surgery Planning • Diabetes • Physical Therapy Conference • Align Decompensated and • Independence • Cardiopulmonary expectations • Manage adjacent • Home Support • Bone Health Atypical Deformity levels • Shared decision • Narcotics making • Osteoporosis • Guidance system EMR based Risk Stratification

Standardized Ordersets Preoperative Ordersets Modifiable Medical Co-morbidities • Preop evaluation – Bone Density – Pulmonary – Cardiac – Nutritional – Psychological – Social

Osteoporosis Smoking • Pre-op identification with DEXA/Opportunistic CT • Relative risk of post operative pulmonary complications: 1.4-4.3 • Antiresorbtive Medications (coronary bypass) – Bisphosphonates • Declines if d/c’d >8 wks preop • d/c’d > 6 mon, normal risk of pulm • Pre-operative Anabolic Medications complications • If d/c’d < 8 wks –> higher risk – Teraperatide • Complications increased by  pulm • Fixation Strategies for the Osteoporotic Spine function – ↑ pack years – ↑ surgical time – Use enflurane » Warner, et al, 1989 COPD Overall health • Up to 4.7 relative risk of • Exercise capacity pulmonary complications – Exercise Stress test • Bronchodilators, PT, – Inability to perform 2 min antibiotics, smoking supine exercise  HR 99 cessation, corticosteroids to bpm minimize symptoms (airway – METS <4 obstuction), optimize –  strong predictor of cardiac exercise tolerance complications – 79% of complications in patients with poor exercise tolerance patients

Cardiac Obesity and BMI • Perioperative β -blockade – Eligible patients • Identify patients with BMI >35 • Minor criteria(2 of: >64yo, HT, smoker, chol >240, – Dietary changes NIDDM) – Gastric Bypass Surgery • 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) Frailty/Sarcopenia Risk reduction • Deep breathing exercises • Cont positive airway pressure (for pts unable to coop) • Mortality Nomogram • Incentive spirometry – Decr risk of pulm complications up to 50% Celli, 1984 Thomas, 1994

Perioperative β blockade Pre op β blockade • Pre-induction • Side effects (unusual) – PO up to 30 days prior or – Bradycardia – IV just before induction – Heart block – Hypotension – Decr HR <80/m (hold for – Bronchospasm <55 or BP sys <100) – CHF • Up to 1 mon post op (or longer) Relationship between cardiac and Post op β blockade non-cardiac complications Urban et al, 2000 Fleischmann, et al, 2003 • TKR patients (107) risk of CAD randomized • Reviewed 3970 pts (1191 ortho, incl spine) – esmolol 1 h post op, HR <80 bpm • Cardiac complications  – metoprolol po, till hosp d/c more likely to suffer noncardiac comp (48%) • EKG ischemia • Non-cardiac compl  – 2.8% preop more likely to suffer – 7.5% intraop cardiac comp – 12 control, 3 study pts post op