Octogenarians Can Benefit from Surgery for Lumbar Stenosis and Degenerative Spondylolisthesis
This analysis of data from the SPORT study shows surgery has the potential to significantly improve quality of life for older patients without increased surgical risk.
Shaleen Vira, MD, and Peter G. Passias, MD
Rihn JA, Hilibrand AS, Zhao W, et al. Effectiveness of surgery for lumbar stenosis and degenerative spondylolisthesis in the octogenarian population: analysis of the spine patient outcomes research trial (SPORT) data. J Bone Joint Surg Am. 2015;97(3):177-185. doi:10.2106/JBJS.N.00313.
Operative treatment of lumbar stenosis and degenerative spondylolisthesis in patients more than 80 years old offered significant benefits with no increased risk of complications or mortality compared with younger patients.
The authors of this study performed a sub-group analysis of the Spine Patient Outcomes Research Trial (SPORT) data, the largest randomized control trial that has examined the benefits and complications with operative treatment of spinal stenosis, degenerative spondylolisthesis, and lumbar disk herniation.
Demographic information, comorbidities, operative details, complications, and mortality rates were calculated for 105 patients who were at least age 80 years and 1,130 who were younger than age 80 years. Outcome measures studied included SF-36, Oswestry Disability Index (ODI), stenosis bothersome index, low back pain bothersome scale, and overall satisfaction.
Notably, the octogenarian group had a higher prevalence of hypertension, heart disease, and osteoporosis at presentation. Additionally, patients at least 80 years old had a higher prevalence of multilevel stenosis, severe stenosis, and asymmetric motor weakness.
Despite some baseline disparities, the octogenarian cohort experienced significant improvements in patient-reported pain and outcome scores, and surgery offered significant benefit over non-operative treatment. Furthermore, the 2 age groups did not differ with respect to the rates of intraoperative and postoperative complications, reoperations, and postoperative mortality.
While treatment effects in older patients were similar to those in younger patients for most primary and secondary measures, the SF-36 (Short Form-36) bodily pain domain and the percentage who self-rated their progress as a major improvement were significantly smaller in the older age group.
Clinical management of octogenarians is challenging. They are known to be at increased risk for perioperative complications due to general frailty and presence of significant comorbidities. Furthermore, it is not clear whether surgically addressing spinal pathology in these patients will yield similar benefits compared with younger patients.
Earlier publications based on the SPORT data offered encouraging evidence that spine surgery provides significant benefits when compared with non-operative treatment of lumbar stenosis and degenerative spondylolisthesis. However, outcomes in the older population, particularly in patients over age 80 years, were not specifically studied. This study shows that the positive results published for the general population are maintained in the octogenarian population.
While this publication has clear clinical implications for the treatment of octogenarians with lumbar stenosis and degenerative spondylolisthesis, in that it represents the highest available evidence to date, it is important to note that this study does not eliminate the need for further research.
One important limitation of this series is the clinical applicability of the findings. This study represents the as-treated analysis of a study initially designed as a randomized controlled trial, the result of unacceptably high cross-over rates between the groups. The study population also represents an idealized study group chosen as optimal surgical candidates, with physician screening bias being inherent to the study design. Furthermore, the multivariate regression analysis in this series controlled for potential confounders in the form of medical comorbidities at baseline, while in the clinical setting optimizing medical comorbidities in octogenarians may not always be possible.
This study is of significant interest to general orthopaedic surgeons who may hesitate in referring patients with spinal complaints to a specialist for surgical consideration. In properly selected patients, surgical intervention for spinal stenosis and degenerative spondylolisthesis in patients at least 80 years old has the potential to significantly improve the quality of life similar to the improvements seen in younger patients without increased surgical risk.
Shaleen Vira, MD, is an orthopaedic surgery resident, NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York. Peter Passias, MD, is a Clinical Assistant Professor of Orthopaedic Surgery, Division of Spine Surgery, Department of Orthopaedic Surgery, at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.