Spine Surgery Profile in the Fourth Age

doi:10.4236/ojmn.2011.12002

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Open Journal of Mo dern Neurosurgery, 2011, 1, 5-9

doi:10.4236/ojmn.2011.12002 Published Online October 2011 (http://www.SciRP.org/journal/ojmn)

Spine Surgery Profile in the Fourth Age

Mohammad Sami Walid, Priyal Shah, Moataz Abbara, Nadezhda Zaytseva

Department of Medic al Education & Research, Medical Center of Central Georgia,

Macon, Georgia, USA

E-mail: [email protected]

Received August 1, 2011; revised August 25, 2011; accepted September 5, 2011

Abstract

As the population of the United States undergoes significant qualitative and quantitative changes the health-

care needs of the population changes accordingly. Since the “old-old” ≥85 years sector of the population is

growing fast we embarked on studying how spine surgery profile changes across age groups. Methods: A

database of 6147 spine surgery patients operated in a tertiary care center in Middle Georgia between 2003

and 2009 was divided to four age groups. The threshold for old-old age was set at 75. The percentage of

old-old patients was calculated and their spine surgery profile for the whole period was studied. Changes in

spine surgery profile were evaluated in relation to age group and gender. Type of surgery was determined by

ICD-9 code. Results: For the whole study period, the percentage of old-old spine surgery patients was 6.7%.

The percentage of old-old spine surgery patients increased from 4.7% in 2003 to 7.3% in 2009. Females

were preponderant in the later three age groups (53.8%, 53.2% and 55.0%) while males were more in the

<40 group (52.8%). Significant differences in the spine surgery profile between age groups were detected

(Χ2 = 1446.958, P = 0.000). The spine surgery profile for the whole study period was characterized by shifts

in the ≥75 age group toward less primary fusions of the cervical and lumbar spine and more refusions of the

lumbar spine, more intervertebral disk excisions and more canal exploratory operations in older-old patients.

In addition to the age factor, the gender factor had an impact on the spine surgery profile. Statistically sig-

nificant differences (P < 0.5) were noted between males and females in each age group. Conclusions: Spine

surgery profile shows a tendency toward less invasive procedures in the older-old population unless indi-

cated by previous surgery failures, upper neck injuries or osteoporosis-induced fractures.

Keywords: Spine Surgery, Fourth Age, Very Old, Old-Old, Older-Old

1. Introduction

As the population of the United States undergoes sig-

nificant qualitative and quantitative changes the health-

care needs of the population change accordingly. Latest

data (July 2009) show that 307.007 million people live in

the United States, 5.722 million of them (July 2008) are

85 years and older, 3.858 million of which are females

[1]. While the total population of the United States in-

creased by 0.4 fold over 19 years (from 226.542 million

in July 1980), the ≥85 age group more than doubled dur-

ing this period (from 2.271 million in July 1980, Figure

1).

The ≥85 age group (and in some references ≥75) has

recently been dubbed “the Fourth Age”, “the very old”,

or “the old(er)-old” [2-5]. Since the senior sector of the

Western population is growing rapidly, owing to better

healthcare services and improved longevity, we at-

tempted to study the spine surgery profile of this patient

population compared with other age groups.

2. Materials & Methods

A database of 6147 spine surgery patients operated in a

tertiary care center in Middle Georgia between 2003 and

2009 was divided per age. Four age groups were demar-

cated and the threshold for old-old group was set at 75

[6,7]. Some references use 80 or 85 years as a threshold,

pointing to lack of consensus on the definition of this

new terminology [5,8,9].

The percentage of old-old patients was calculated and

their spine surgery profile for the whole period was

M. S. WALID ET AL.

Figure 1. Growth of the U.S. senior population. Data source: U.S. Census Bureau. Graph source: Google public data ex-

plorer.

studied. Spine surgery profile for a cohort of patients was

defined as the distribution of spine surgical interventions

for the named cohort per type of procedure. Changes in

spine surgery profile were studied in relation to age

group and gender. Type of surgery was determined by

ICD-9 code. Percentages were statistically compared

using Pearson Chi-square analysis.

3. Results

3.1. Growing Old-Old Percentage

For the whole study period, the largest group (51.1%)

was the 40 - 59 age group. The percentage of old-old

spine surgery patients (≥75 years old) was 6.7% (Figure

2). Over the years, the percentage of old-old spine sur-

gery patients increased from 4.7% in 2003 to 7.3% in

2009. Females were preponderant in the later three age

groups (53.8%, 53.2% and 55.0%) while males were

more in the <40 group (52.8%).

3.2. Summated Spine Surgery Profile

In the whole cohort for the whole study period, the top

five surgical procedures were:

 Anterior cervical decompression and fusion (40.7%).

 Lumbar/Lumbosacral fusion, lateral approach (19.2%).

 Excision of intervertebral disk (15.0%).

 Spinal canal exploration (8.3%).

 Lumbar/Lumbosacral fusion, posterior approach

(5.7%).

3.3. Spine Surgery Profile across Age

Significant differences in the spine surgery profile be-

Figure 2. Patient database divided per age group and gen-

der.

tween age groups were detected (Χ2 = 1446.958, P =

0.000). The spine surgery profile of the ≥75 age group

was characterized by a relative increase in the following

procedures:

 Spinal canal exploration (from 3.1% in patients <40

to 26.7% in patients ≥75).

 Insertion or replacement of interspinous device (from

0.4% in patients <40 to 26.8% in patients ≥75).

 Excision of intervertebral disk (from 17.8% in pa-

tients <40 to 23.7% in patients ≥75).

 Implantation of interspinous process decompression

device (from 0.0% in patients <40 to 3.9% in patients

M. S. WALID ET AL.7

≥75).

 Vertebral fracture repair (from 1.7% in patients <40

to 2.7% in patients ≥75).

 Atlas-axis fusions (from 0.5% in patients <40 to 1.2%

in patients ≥75).

 Reopening laminectomy site (from 0.0% in patients

<40 to 0.5% in patients ≥75).

 Refusion of lumbar, lateral or posterior (from 0.0% in

patients <40 to 0.5% in patients ≥75).

On the other hand, the following procedures relatively

decreased in the ≥75 age group:

 Anterior cervical fusion (from 36.0% in patients <40

to 14.7% in patients ≥75).

 Lumbar and lumbosacral fusions, lateral (from 17.1%

in patients <40 to 7.8% in patients ≥75).

 Lumbar and lumbosacral fusions, posterior (from

6.4% in patients <40 to 5.1% in patients ≥75).

 Dorsal/dorsolumbar fusion, posterior (from 5.3% in

patients <40 to 1.2% in patients ≥75).

 Spinal structure repair (from 3.5% in patients <40 to

0.2% in patients ≥75).

 Dorsal/dorsolumbar and lumbar/lumbosacral fusions,

anterior (from 0.7% in patients <40 to 0.0% in pa-

tients ≥75).

Summarizing the above-mentioned trends, it is evident

that the spine surgery profile changes toward less pri-

mary fusions of the cervical and lumbar spine and more

refusions of the lumbar spine, more intervertebral disk

excisions and more canal exploratory operations in older-

old patients (Figure 3).

In addition to the age factor, the gender factor has an

impact on the spine surgery profile. Statistically signifi-

cant differences (P < 0.5) were noted between males and

females in each age group (Figure 4). Older-old female

Figure 3. Spine surgery profile for a database of spine surgery patients divided per age group. Procedures in the <40 group

sorted in descending order.

M. S. WALID ET AL.

Figure 4. Spine surgery profile for a database of spine surgery patients divided per age group and gender. Procedures in the

<40 female group sorted in desce nding or de r.

patients had more lumbar fusions (11.1% vs. 3.8 for lat-

eral; 7.1% vs. 2.7% for posterior), more interspinous

devices (8.0% vs. 5.4%) and more vertebral fracture re-

pairs (3.1% vs. 2.2%). Older-old female patients had

fewer excisions of intervertebral disks (19.6% vs. 28.8%)

and less canal exploratory operations (25.3% vs. 28.3%).

4. Commentary

Aging has always been synonymous in the traditional

people’s imagination with decreased functionality, in-

creasing pain, fear of disability and impending death [10].

Current developments in technology and surgery have to

some extent challenged this concept by extending length

of human life and improving quality of everyday living.

The share of the old-old is expected to grow twice as fast

as the conventional old group in the coming decades [10].

This qualitative change in the population’s composition

is accompanied by a parallel increase in demand for

healthcare services related to degenerative and chronic

diseases, including degenerative spine disease and chro-

nic back pain.

The old-old subgroup of the senior population presents

their own needs as their functional reserves rapidly de-

cline and the capacity to self-repair becomes extremely

impaired. The demand for spine surgery in the old-old is

therefore characterized by higher requirement for ex-

plorative decompressive interventions with the least pos-

sible trauma. Decompressive procedures are less invasive

than fusion procedures and are mostly done through

laminectomy and less frequently with the help of an in-

terspinous device. Other types of fusions that increase in

the older-old are refusion procedures performed to cor-

rect complications, namely pseudoarthrosis, resulting

M. S. WALID ET AL.9

from previous fusion attempts. Atlas-axis fusions also

increase in older-old patients due to a comparatively

elevated risk of upper cervical spine injuries in elderly

patients [11]. Female old-old patients unsurprisingly

present with higher frequency of vertebral fracture acci-

dents and therefore require more such repairs due to

higher prevalence of osteoporosis [7]. The relatively

higher occurrence of dorsal/dorsolumbar fusions and

spine structure repair operations in the <40 age group

could be related to more frequent traumatic and congeni-

tal etiology in younger age. The preponderance of fe-

males patients in the later three age groups and males in

the younger group reflects the fact that younger males

are subject to suffer more professional spine injuries

while females have better longevity and the longer they

live the higher the risk of osteoporosis.

In summary, the spine surgery profile of our patients

shows a tendency toward less invasive procedures in the

older-old population unless indicated by previous sur-

gery failures, upper neck injuries or osteoporosis-induced

fractures.

5. References

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[4] J. Cohen-Mansfield, D. Shmotkin, N. Eyal, Y. Reichental

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