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-operative care for Spinal disorders

• An evidence-based approach to care guided by clinical outcomes 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 operative 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

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1 2 3 4 5 6 7 8 9

AppropriateReasonableInappropriate

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 one 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

<250Proportional:

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

osteoporosis spinal disorders

Neuromuscular Comorbidity

Mitochondrial Myopathy

• Rapid Progression of

Decompensated and Atypical Deformity

Pre-operative Considerations

Risk Assessment

• Assess risk/benefit• Appropriateness

of 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 OrdersetsModifiable 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 obstuction), 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, 1984Thomas, 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 ortho, incl spine)

• Cardiac complications more likely to suffer noncardiac comp (48%)

• Non-cardiac complmore 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 or 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

• Neuromonitoringprotocols

• 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 of Care Plan

• Precautions

SNF

• Mobilization• PT Protocols

Communication Pathways

• Health Loop• Nurse Navigator• Clinic Visits over

ER visits• Measuring

outcomes 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 operative 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 our 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