Think you’re too old for spinal surgery?
The graying of America brings with it more people with degenerative spinal conditions, including spinal stenosis and herniated discs. Both cause pain and weakness through compression of nerves, which is known as radiculopathy.
These natural consequences of aging can be successfully treated in patients, no matter what their age, according to neurosurgeon David C. Leppla, MD, who joined the Neurosurgeons of Cape Cod practice in Hyannis in late 2017. He estimated 50 to 60 percent of his Cape patients are on Medicare, for which most people become eligible at 65, and 70 to 80 percent of his practice is spine-related.
“We should let people know they shouldn’t be afraid,” to have spine surgery, he said.
For instance, in the case of a simple herniated disc in a relatively healthy individual over 65, surgery would entail cutting a 1.5-inch incision and the patient might go home the same day, he said.
Dr. Leppla’s comfort in treating older patients is backed up by two recent studies that examined data from the Norwegian Registry for Spine Surgery. One looked at surgical outcomes for patients with a herniated or “slipped” disc. The other reviewed those with spinal stenosis.
A herniated disc occurs when one of the cushioning pads between the bones of the spine, or vertebrae, bulges or leaks and presses on a nerve. Researchers at the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital in Trondheim, Norway, examined post-surgical reports from 381 patients 65 and older and 5,195 younger patients. The results were published in JAMA Surgery in May 2017. Both groups showed significant improvement.
According to The JAMA Network, the two age groups did not differ in amount of disability, quality of life or leg pain after surgery. The older group did report greater improvement in back pain. The older group also reported longer hospital stays (2.7 days vs. 1.8 days), slightly more complications immediately after surgery (4.2 percent vs. 2.3 percent), and more complications within three months after discharge (12.4 percent vs. 5.4 percent).
Spinal stenosis is a narrowing of the vertical canal within the spine through which the spinal cord and nerves pass. Norwegian researchers at NTNU, St. Olav’s and two other hospitals compared surgical results of 178 patients with central lumbar spinal stenosis who were 80 and older with 1,325 patients who were 18 to 79 years old. The findings were published in the Journal of American Geriatrics Society in October 2016.
Researchers found both groups showed similar levels of significant improvement with no substantial differences in leg or back pain. As in the first study, the older group stayed longer in the hospital (4.5 days on average, compared with 3.2 days for the younger group), and the older group did report more complications three months following surgery, chiefly urinary tract infections.
Older patients tend to have higher rates of chronic diseases, such as diabetes, high blood pressure and cardiovascular disease, which can increase the risk of post-surgical complications and lengthen hospital stays, Dr. Leppla said.
“The length of stay is likely to be longer,” for older patients with one or more chronic conditions, he said.
An earlier study supported by the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases questioned the value of surgery for diabetic patients with spinal stenosis, herniated discs or degenerative spondylolisthesis, a condition that occurs when a vertebra moves forward out of alignment with the one below it. The study, published in Spine, was part of the federal Spine Patient Outcomes Research Trial (SPORT), and looked at outcomes for 2,405 patients, of which 199 had diabetes, who underwent surgery for one of these conditions. In 2011, the institute reported the diabetic patients did not improve as much as other patients, older diabetic patients had more complications and that for diabetic patients with herniated discs, non-surgical treatments seemed as effective as surgery.
How to Decide
The demand for spinal surgery – other than to treat emergencies – is patient-driven, Dr. Leppla said.
“Lower back pain is the second most common reason for visiting a primary physician,” he said.
If the pain is just in the lower back, it’s probably not caused by a herniated disc, Dr. Leppla said. A disc likely is to blame if the pain starts in the lower back and goes down the buttock and leg on one side, a symptom called sciatica, after the sciatic nerve located in that area. Usually a doctor will order a MRI to examine the lower back and will try other means, such as pain relievers, physical therapy, heat, exercise and steroid shots, before recommending surgery for a herniated disc, Dr. Leppla said. Then, it’s up to the patient to seek surgery if pain and weakness don’t improve.
The exceptions would be emergency surgery for a patient who has lost control of their bladder or bowel, and surgery is recommended for a patient who has experienced worsening foot drop over a period of weeks, Dr. Leppla said.
Surgery would be ruled out for patients who recently had a heart attack, are on blood thinners for a year following implantation of drug-eluting stents in their coronary arteries, or have severe pulmonary disease, he added.
There is no set period of how many weeks or months patients should try non-surgical therapies before opting for surgery for a herniated disc. Dr. Leppla said he once had a professional golfer as a patient who wanted it done immediately because pain and weakness interrupted his busy schedule.
“If you’re miserable and you’re dragging your leg,” then consider surgery, he said.