Impact of instrumentation in lumbar spinal fusion in elderly patients

Abstract

Background and purpose An increasing number of lumbar fusions are performed using allograft to avoid donor-site pain. In elderly patients, fusion potential is reduced and the patient may need supplementary stability to achieve a solid fusion if allograft is used. We investigated the effect of instrumentation in lumbar spinal fusion performed with fresh frozen allograft in elderly patients.Methods 94 patients, mean age 70 (60–88) years, who underwent posterolateral spinal fusion either non-instrumented (51 patients) or instrumented (43 patients) were followed for 2–7 years. Functional outcome was assessed with the Dallas pain questionnaire (DPQ), the low back pain rating scale pain index (LBPRS), and SF-36. Fusion was assessed using plain radiographs.Results Instrumented patients had statistically significantly better outcome scores in 6 of 7 parameters. Fusion rate was higher in the instrumented group (81% vs. 68%, p = 0.1). Solid fusion was associated with a better functional outcome at follow-up (significant in 2 of 7 parameters). 15 patients (6 in the non-instrumented group and 9 in the instrumented group) had repeated lumbar surgery after their initial fusion procedure. Functional outcome was poorer in the group with additional spine surgeries (significant in 4 of 7 parameters).Interpretation Superior outcomes after lumbar spinal fusion in elderly patients can be achieved by use of instrumentation in selected patients. Outcome was better in patients in which a solid fusion was obtained. Instrumentation was associated with a larger number of additional surgeries, which resulted in a lesser degree of improvement. Instrumentation should not be discarded just because of the age of the patient.

Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar spine pathologies

“…Studies show that clinical outcomes such as pain and disability following spinal fusion improve for 12 months, with little further improvement or even worsening after this point. 38,39 Our results suggest MIS is just as effective as open spinal fusion, similar to other studies. 3,40 However, a study by Kasis 18 comparing PLIF procedures (standard compared to less-invasive) found significantly greater improvements for the less invasive PLIF group.…”

Clinical and radiographic outcomes of concentrated bone marrow aspirate with allograft and demineralized bone matrix for posterolateral and interbody lumbar fusion in elderly patients

“…Carreon et al reported an increased risk of perioperative complications in elderly patients who underwent spine fusion [30]. Instrumented spinal fusion in elderly patients is also associated with complications due to the risk of screw loosening from poor bone quality even though spinal instrumentation has been shown to increase fusion rates compared to non-instrumented fusion [31][32][33]. Okuyama et al published a study examining the influence of bone mineral density (BMD) on pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients.…”

Long-term health care utilisation and costs after spinal fusion in elderly patients

“…The next step then is to prove evidence of a consistent long-term effect of fusion surgery in the population of older patients. Several studies have done this and shown stable results, both at short term up to 2 years and at longterm follow-up [4,6,29]. So cost-effectiveness of fusion surgery in the older patients in a long-term perspective might be expected, but still needs to be documented.…”

“…All patients underwent uninstrumented lumbar spinal fusion using fresh frozen allograft with or without direct-current stimulation. The second cohort was an observational cohort of 94 patients who underwent either uninstrumented spinal fusion (51 patients) or fusion using pedicle screw instrumentation (43 patients) [4]. Reasons for surgery in this cohort were the same as in the other group and all fusions were performed using fresh-frozen allograft.…”