Abstract
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Study Design
Retrospective comparative study.
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Purpose
To evaluate and compare the clinical outcomes and complication profiles of decompression alone versus decompression with instrumented fusion in elderly patients aged 75 and older with lumbar spinal stenosis.
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Overview of Literature
Lumbar spinal stenosis is a common cause of disability in elderly patients. The decision between decompression alone and fusion surgery in the geriatric population remains controversial due to surgical risks and comorbidities.
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Methods
A retrospective analysis of 121 patients aged ≥75 years treated either with laminectomy alone (n=60) or with posterior lumbar interbody fusion (PLIF, n=61) from April 2016 to December 2022. Baseline characteristics, perioperative parameters, and postoperative outcomes were compared.
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Results
There were no significant differences in baseline characteristics. The PLIF group showed longer operative times, greater blood loss, and longer hospital stay, but similar complication rates. Both groups showed significant postoperative improvement in VAS, ODI, and EQ-5D scores.
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Conclusions
Decompression alone and fusion surgery both provide substantial clinical benefit in elderly patients with spinal stenosis. With careful selection, fusion may be safely considered even in the elderly.
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Keywords: Lumbar spinal stenosis, Decompression surgery, Spinal fusion, Elderly, Outcomes
Abstract
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연구 설계
후향적 비교 연구
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연구 목적
75세 이상의 고령 환자에서 요추관 협착증 치료 시 감압술 단독과 기기 고정술을 동반한 감압술 간의 임상적 및 수술적 결과를 비교하고자 한다.
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문헌 개요
고령 인구에서 요추관 협착증은 흔한 퇴행성 질환으로, 치료에 있어 수술적 접근은 여전히 논란이 많다. 고정술은 감압술보다 더 침습적이지만, 불안정성이 있는 경우 필요할 수 있다.
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대상 및 방법
2016년 4월부터 2022년 12월까지 한 단일 기관에서 수술받은 75세 이상의 요추관 협착증 환자를 대상으로 후향적 분석을 시행하였다. 감압술 단독군(n=74)과 후방 요추간 유합술(PLIF)군(n=47)으로 나누어 수술 전후의 통증 점수(VAS), 장애 지수(ODI), 삶의 질(EQ-5D) 및 수술 관련 지표(수술 시간, 출혈량, 수혈, 합병증)를 비교 분석하였다.
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결과
감압술 단독군은 수술 시간, 출혈량, 수혈률 면에서 유의하게 낮았다. 그러나 두 군 모두에서 통증 감소 및 기능 향상은 유사하게 나타났으며, 임상 지표(VAS, ODI, EQ-5D)에서도 유의미한 차이는 없었다. 전체 합병증 발생률은 PLIF군에서 다소 높았지만 통계적으로 유의하지 않았다(p<0.06).
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결론
75세 이상의 고령 요추관 협착증 환자에서 감압술 단독은 유사한 임상적 효과를 보이면서도 수술 부담이 적은 대안이 될 수 있다. 고정술은 적절한 적응증 하에 선택적으로 고려되어야 하며, 고령 환자에서 반드시 필요한 경우가 아니라면 침습도를 고려해 감압술 단독도 충분히 효과적인 치료 옵션으로 고려될 수 있다.
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색인 단어: 요추관 협착증, 감압술, 척추 유합술, 고령, 임상 결과
Introduction
Lumbar spinal stenosis (LSS) is a major cause of pain and disability in the elderly population. The degenerative narrowing of the spinal canal typically leads to symptoms such as neurogenic claudication and reduced mobility. With increasing life expectancy and an aging society, the prevalence of LSS is on the rise.
1)
Traditionally, decompression surgery has been the standard intervention for LSS. It effectively relieves nerve root compression, especially in patients without evidence of instability. However, for patients with concomitant spondylolisthesis or segmental instability, instrumented fusion may offer superior stability and potentially better long-term outcomes.
2,3)
Despite its potential benefits, spinal fusion in the elderly remains controversial due to increased operative time, blood loss, and perioperative risks. Recent advancements in minimally invasive surgical techniques and perioperative care have made such procedures more feasible, but consensus is lacking. Thus, comparing decompression alone to fusion surgery in this population remains a crucial clinical question.
4)
Materials and Methods
We retrospectively reviewed medical records of patients aged 75 years or older who underwent surgical treatment for lumbar spinal stenosis at a single tertiary institution between April 2016 and December 2022. Patients were divided into two groups: decompression alone (n=60) and posterior lumbar interbody fusion (PLIF, n=61).
Inclusion criteria included clinical symptoms consistent with LSS, radiological confirmation via MRI or CT, and failure of conservative management for at least six weeks. Patients with trauma, tumor, infection, or previous lumbar surgery were excluded.
Data collected included demographic characteristics, ASA class, operative time, estimated blood loss, and length of hospital stay. Clinical outcomes were measured using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol-5D (EQ-5D) at baseline and one-year followup. Complication rates were also recorded. Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA) with p<0.05 considered significant.
Results
A total of 121 patients were included in the study, with 74 patients undergoing laminectomy and 47 undergoing posterior lumbar interbody fusion (PLIF). The mean age in both groups was 78.3 years. The average follow-up duration was 523.1±594.8 days in the laminectomy group and 482.0±481.5 days in the PLIF group. Sex distribution was nearly equal in both groups. Bone mineral density (BMD) values were slightly better in the PLIF group, although not statistically significant. ASA physical status scores were similarly distributed across the two groups, with most patients classified as ASA class 2 or 3 (
Table 1).
Underlying diseases were common in both groups, with hypertension, diabetes, and coronary artery disease being the most prevalent comorbidities. The overall prevalence of underlying disease was 85% in both groups. Notably, the PLIF group had slightly fewer cases of chronic kidney disease and dual antiplatelet use (
Table 2).
Surgical outcomes showed that the PLIF group had significantly longer operative time (260.4±75.4 minutes vs. 134.3±66.7 minutes, p=0.000) and greater estimated blood loss (249.0±159.5 mL vs. 116.7±173.0 mL, p=0.000). Hemoglobin drop was also greater in the PLIF group (1.93±0.97 g/dL vs. 1.03±0.85 g/dL, p=0.000). The rate of transfusion was higher in the PLIF group (8 vs. 4 cases, p=0.037). Length of hospital stay was not significantly different between the two groups (
Table 3).
Both groups demonstrated clinical improvement in VAS for back and leg pain, EQ-5D, and ODI scores. Although baseline scores were slightly worse in the PLIF group, the magnitude of improvement was comparable across both groups (all p<0.001) (
Table 3).
Complication rates were higher in the PLIF group (34.0%) compared to the laminectomy group (18.9%), although the difference did not reach statistical significance (p=0.06) (
Table 4). Medical complications such as urinary tract infections, pneumonia, and sepsis were more frequent in the PLIF group. Surgical complications were comparable between the groups, with wound problems and surgical site infections being the most common. There was one reported death in the PLIF group, whereas no mortality occurred in the laminectomy group.
Discussion
This study highlights that both decompression and fusion surgery provide clinically significant improvements in elderly patients with LSS. While fusion was associated with greater surgical burden, outcomes were comparable to decompression alone, suggesting that fusion can be safely performed in well-selected older patients.
5)
Similar findings were reported by Lee et al., who demonstrated comparable clinical outcomes and complication rates between elderly patients undergoing decompression versus fusion.
6) Epstein also observed no significant advantage in long-term outcomes of fusion over decompression in geriatric patients with moderate stenosis.
7)
In contrast, Kim et al. noted a higher revision rate in patients treated with decompression alone due to delayed instability, advocating for prophylactic fusion in select elderly patients with grade I spondylolisthesis.
8)
Our results suggest that with careful patient selection, fusion can be offered to elderly patients without significant increase in complications. Fusion may prevent future instability or recurrent stenosis, particularly in those with borderline instability.
9)
This study contributes meaningful data to the growing body of evidence supporting tailored surgical strategies in elderly populations. Unlike previous studies, we focused exclusively on patients aged ≥75 years and compared outcomes within a matched institutional cohort. We believe this provides a realistic representation of current surgical practice.
Limitations of our study include its retrospective design, single-center data, and lack of long-term radiological follow-up. Future prospective studies with a larger sample size and longer follow-up are warranted to validate these findings.
Conclusions
In patients aged ≥75 years, both decompression and fusion surgeries result in significant clinical improvement with acceptable complication rates. Fusion may be safely considered in select elderly patients with radiological signs of instability.
Table 1.Demographic and clinical characteristics of patients
|
Laminectomy |
PLIF |
|
Total |
74 |
47 |
|
Age |
78.3 ± 3.3 |
78.3 ± 3.2 |
|
F/U duration (Days) |
523.1 ± 594.8 |
482.0 ± 481.5 |
|
Sex (M:F) |
39:35 |
23:24 |
|
Femur BMD |
-1.6 ± 1.2 |
-1.2 ± 1.4 |
|
Spine BMD |
-0.2 ± 2.1 |
-0.4 ± 2.0 |
|
ASA – Physical Status |
|
|
|
2 |
45 |
24 |
|
3 |
28 |
22 |
|
3E |
1 |
1 |
Table 2.Prevalence of underlying diseases in each group
|
Underlying disease |
Laminectomy 63 (85%) |
PLIF 40 (85%) |
|
Hypertension |
54 |
36 |
|
Diabetes |
25 |
18 |
|
CVA |
2 |
2 |
|
Dyslipidemia |
10 |
7 |
|
GI |
4 |
3 |
|
Coronary disease |
13 |
4 |
|
COPD |
2 |
4 |
|
CKD |
5 |
0 |
|
Antiplatelet single |
14 |
7 |
|
Antiplatelet dual |
4 |
1 |
|
Anticoagulation |
9 |
2 |
Table 3.Operative and clinical outcomes
|
Outcomes |
Laminectomy (n=74) |
PLIF (n=47) |
p-value |
|
Operation Outcomes |
|
|
|
|
OP time (min) |
134.3±66.7 |
260.4±75.4 |
≈0.000 |
|
Transfusion (cases) |
4 |
8 |
≈0.037 |
|
Estimated blood loss (ml) |
116.7±173.0 |
249.0±159.5 |
≈0.000 |
|
Hgb drop (g/dL) |
1.03±0.85 |
1.93±0.97 |
≈0.000 |
|
Clinical Outcomes (all p≈0.000) |
|
|
|
|
VAS-L |
7.6→4.6 |
8.2→5.6 |
|
|
EQ-5D |
47→60 |
52→53 |
|
|
EQ-5D SUM |
11.5→7.5 |
12.2→8.7 |
|
|
ODI |
28.6→19.4 |
31.2→22.6 |
|
Table 4.Complications in laminectomy and PLIF groups
|
Complications |
Laminectomy (n=74) |
PLIF (n=47) |
|
Total complications |
14 (18.9%) |
16 (34.0%) |
|
Medical complications |
9 (12.5%) |
11 (23.4%) |
|
UTI |
3 |
3 |
|
Urinary frequency |
2 |
|
|
FUO |
1 |
2 |
|
Sepsis |
|
1 |
|
Sore |
|
1 |
|
Meningitis |
|
1 |
|
GI ulcer |
|
1 |
|
Pneumonia |
2 |
2 |
|
Anaphylaxis |
1 |
|
|
Surgical complications |
9 (12.2%) |
6 (12.8%) |
|
Neurologic deficit |
|
1 |
|
Wound problem |
7 |
4 |
|
Surgical site infection |
4 (5.4%) |
2 (4.3%) |
|
Hematoma |
1 |
|
|
Instrumentation (screw loosening) |
|
1 |
|
Revision |
8 (10.8%) |
4 (8.5%) |
|
Death |
0 |
1 |
References
- 1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates. Spine (Phila Pa 1976). 2006;31(23):2724-7.
- 2. Ghogawala Z, Dziura J, Butler WE, et al. Laminectomy plus fusion vs laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;374(15):1424-34.
- 3. Park Y, Ha JW. Comparison of one-level PLIF performed with minimally invasive vs traditional open technique. Spine. 2007;32(5):537-43.
- 4. Lee CK, Lee WS, Hyun SJ. Efficacy of lumbar fusion in elderly with stenosis. J Korean Neurosurg Soc. 2015;58(5):468-74.
- 5. Martin BI, Mirza SK, Comstock BA, et al. Reoperation rates following lumbar spine surgery. Spine. 2007;32(3):382-7.
- 6. Epstein NE. Laminectomy alone vs with fusion for stenosis in elderly. Surg Neurol Int. 2015;6(Suppl 18):S413-21.
- 7. Lee JH, Ahn DK, Shin WS. Outcomes of decompression alone vs fusion in elderly. Asian Spine J. 2014;8(6):775-82.
- 8. Kim CH, Chung CK, Park SB, et al. Decompression vs fusion outcomes in aged patients. Spine J. 2013;13(10):1230-7.
- 9. Glassman SD, Carreon LY, Shaffrey CI, et al. Riskbenefit profile of lumbar fusion in elderly. Spine J. 2005;5(5):375-9.
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