The Aging Spine
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Although bone density changes do not appear to affect fusion rates, screw fixation and initial spinal stability the key to deformity correction are altered. In addition to strategies for improving fixation in the osteoporotic spine, less curve correction—while maintaining sagittal and coronal balance—should be the primary focus, and fusion and rigid implants should not end at a kyphotic segment. Initial decision making should seek the minimum level of intervention to accomplish the most functional improvement possible with the least risk of complication.
In a review of Medicare data for patients with lumbar stenosis, Deyo et al 64 showed that interspinous spacer procedures pose a trade-off: fewer complications at the index procedure but higher rates of revision.
They also showed that decompression alone was the least costly intervention versus interspinous spacers or fusion procedures for these patients. However, loss of lumbar lordosis, higher L3 obliquity, or significant listhesis portends a worse prognosis, and the addition of fusion should be considered. The extent of fusion and magnitude of the overall surgery must be weighed against comorbidities and associated risks.
Anterior- or lateral-only surgery is fairly new, and although some authors have reported success in case report series and prospective series, these approaches are somewhat controversial. Fusion to the sacrum now is often accompanied by fixation to the ilium. A discussion of deformity treatment in the adult should include an understanding of the elements of sagittal balance and how to measure and manage imbalance. Restoration of sagittal imbalance is critical to good outcomes. This effort is made more complex by adding pelvic tilt and pelvic incidence into the decision.
Preoperative understanding of the amount of lordosis required based on pelvic incidence is key. With significant sagittal imbalance, high pelvic tilt, and high pelvic incidence, the surgical plan may require the inclusion of an osteotomy. Smith-Petersen or Ponte osteotomies, with removal of posterior elements and compression of the posterior column potentially leading to distraction of the anterior column , are somewhat easier to accomplish when performed over several levels. These procedures can be combined at different levels for additive correction.
Risks are significant, including high levels of blood loss and neurologic injury. Whether to end an adult deformity construct at L5 or S1 is a topic frequently discussed. If the L5-S1 segment appears normal, with no degenerative changes, no listhesis, and no stenosis, and if it is not involved in the deformity, then it may be reasonable to exclude the segment from the fusion. The advantages are retained lumbosacral motion, which may allow for more normal gait and less risk of sacroiliac joint degeneration, and lower surgical times and complications, including pseudarthrosis, which is a particularly vexing problem at L5-S1.
However, there is a substantial risk of progressive disk degeneration at this level, and in patients with sagittal imbalance, also a risk for recurrence of the imbalance. This added fixation increases the fusion rate by three times, relieves strain on the S1 screws, and protects against screw pullout.
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Where to stop at the upper end of the construct is also a matter of controversy. Although initial studies suggested that crossing the thoracolumbar junction and stopping the construct at T9 or T10 would lead to fewer proximal problems, more recent reports have suggested that this is not so. Proximal junctional failure—no matter which specific level is chosen as the upper instrumented vertebra—remains a significant concern. To date, no clear strategy has emerged as optimal to prevent this complication. Spinal deformity surgery in the elderly is increasingly common, with concern for management of sagittal and coronal imbalance as well as the frequently accompanying spinal stenosis.
High complication rates remain a challenge and should be given careful consideration before embarking on surgery. Nonsurgical measures are often successful at controlling symptoms. When proceeding with surgery, osteoporosis and the parameters that affect sagittal imbalance should be identified.
The Comprehensive Treatment of the Aging Spine
Treatment may require an osteotomy, and the levels to include in the fusion should be given careful consideration. References printed in bold type are those published within the past 5 years. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Visit our other educational websites: AAOS.
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Separate multiple e-mails with a ;. Send a copy to your email. Some error has occurred while processing your request. Please try after some time. Received May 11, Accepted August 10, Back to Top Article Outline. Table 1. Figure 1. Figure 2. Figure 3.
Natural history of the aging spine
Figure 4. Figure 5. Cited Here February 06, Accessed October 16, Orthopedics ;37 12 :e—e J Clin Endocrinol Metab ;96 7 — Carlberg C: The physiology of vitamin D-far more than calcium and bone. Front Physiol ;5 5 Nutrients ;7 6 — Age Ageing ;43 5 — JAMA Surg ; 2 — BMC Geriatr ; PubMed CrossRef. Ross AC: The report on dietary reference intakes for calcium and vitamin D. Public Health Nutr ;14 5 — Vieth R: Vitamin D supplementation, hydroxyvitamin D concentrations, and safety. Am J Clin Nutr ;69 5 — Ann Epidemiol ;19 7 — Preventive Services Task Force.
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J Neurosurg Spine ;14 5 — A multicentre, randomised controlled trial. This is because the nerves serving those areas no longer transmit information well. It can be tough to diagnose cervical spondylotic myelopathy —that is, interruption of nerve service myelopathy as a result of any kind of degeneration spondylosis in the neck cervical spine. And, ok…it can be tough to say cervical spondylotic myelopathy , too. Other possible causes include fractures, tumors, or diseases like multiple sclerosis.
And finally, degeneration happens all the time, only sometimes causing myelopathy. But diagnosing and treating this condition is important. Cervical spondylotic myelopathy is the most common spinal cord disorder in Americans over Kaiser has been researching and treating this condition for many years, and he considers it important to educate his peers about it. For the last ten years, Dr. Kaiser has organized a course on this condition for the annual meeting of the American Association of Neurological Surgeons.
Experts like Dr. Kaiser on his bio page here. Search for:. Paul C. McCormick Dr. Peter D. Angevine Dr. Christopher E. Mandigo Dr.