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Minimally Invasive Spine Surgery in the Elderly

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Minimally Invasive Spine Surgery

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Abstract

Spine surgery in the elderly population is associated with an increased complication rate compared to the younger population, due to the presence of comorbidities, poor bone quality, as well as a decreased physiologic reserve. As our population ages, an asymmetric increase in those over 65 years is occurring, placing higher demands on society and surgeons to treat increasingly severe spinal pathologies in older and sometimes frail patients. At present, there continues to be a lack of level 1 evidence comparing minimally invasive procedures to traditional open techniques in the geriatric population. However, level 2 and 3 evidence suggests that minimally invasive surgery (MIS) of the spine in the elderly (and younger) population lowers complication rates, allows faster surgical recovery rates, and produces equivalent outcomes, for many common spine procedures in this patient population. Specifically related to the elderly, available literature supports MIS decompressions for cervical and lumbar stenosis, MIS discectomy for herniated discs, and lumbar interbody fusions for various pathologies via either lateral lumbar approaches or posterior MIS transforaminal approaches in the elderly population and is therefore a reasonable option and in some cases a better option than traditional open procedures. Furthermore, cortical bone trajectory screws have shown increased pullout strength in osteoporotic bone, as well as minimize the need for extensive posterior exposure. MIS techniques continue to evolve, including advances in endoscopic decompression as well as mini-open decompression and fusion. It is important for spine surgeons to evolve with these advances in order to optimize the surgical treatment of spine pathology in the elderly population.

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Author information

Authors and Affiliations

  1. Department of Orthopaedics, Georgetown University Hospital, Washington, DC, USA

    Oliver Tannous

  2. Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA, USA

    R. Todd Allen

Authors
  1. Oliver Tannous
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  2. R. Todd Allen
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Corresponding author

Correspondence to R. Todd Allen .

Editor information

Editors and Affiliations

  1. Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Frank M. Phillips

  2. Texas Back Institute Texas Health Presbyterian Hospital Plano Scoliosis and Spine Tumor Center, Plano, TX, USA

    Isador H. Lieberman

  3. Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA

    David W. Polly Jr.

  4. Department of Neurological Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA

    Michael Y. Wang

Appendices

Quiz Questions

  1. 1.

    According to Phan et al. [71], has the literature shown any difference in outcomes or complications after surgical treatment for lumbar disc herniation with full-endoscopic, micro-endoscopic, or open discectomy?

  2. 2.

    In the elderly, osteoporotic patient, what is the biomechanical advantage of a LLIF cage compared to a PLIF, TLIF, or ALIF cage? Is a stand-alone LLIF feasible in the elderly osteoporotic patient?

  3. 3.

    When comparing a midline lumbar interbody fusion (MID LIF) with CBT screws, to a traditional posterolateral fusion with pedicle screws, what are the advantages of the MIDLIF with regard to (1) soft tissue invasiveness and (2) biomechanical characteristics of the CBT vs. pedicle screws?

Answers

  1. 1.

    No

  2. 2.

    The LLIF cage is larger/wider than the TLIF and PLIF cages and is placed from the lateral approach, allowing the LLIF cage to sit on the stronger outer apophyseal ring of the vertebral body rather than the weaker cancellous bone. This gives it a distinct advantage over the TLIF and PLIF cages in osteoporotic bone. The lateral approach facilitates this cage placement. Compared to the ALIF, though the ALIF cage is often large, it is typically placed in the center of the vertebral body where osteoporotic bone is weaker. If the ALIF cage is not appropriately sized or the approach or vertebra doesn’t allow it to be placed where it contacts/loads the apophyseal ring, the ALIF cage placed centrally may lose some of its large size advantages. In osteoporotic bone, priority should be placed on sitting both the ALIF and LLIF cages onto the stronger outer ring of the vertebral body It is not recommended to use a stand-alone LLIF cage in elderly, osteoporotic patients

  3. 3.

    There is significantly less soft tissue disruption and less dissection using a MID LIF with CBT screws approach, versus an open approach where standard pedicle screws and/or posterolateral fusion is performed In osteoporotic bone, CBT screws have shown superior results in biomechanical studies for pullout strength, insertional torque, stiffness with cephalocaudal and mediolateral loading, and resistance to flexion/extension versus pedicle screws. However, CBT screws have shown inferior results with axial rotation and lateral bending. In osteoporotic bone, it appears they have an overall biomechanical advantage to traditional pedicle screw fixation. Clinically, CBT screws (as a result of their medial starting point) lead to less blood loss and surgical time, and possibly less length of stay, while showing comparable clinic results

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Tannous, O., Allen, R.T. (2019). Minimally Invasive Spine Surgery in the Elderly. In: Phillips, F., Lieberman, I., Polly Jr., D., Wang, M. (eds) Minimally Invasive Spine Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-19007-1_45

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