British Journal of Neurosurgery, October 2014; 28(5): 611–615 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.889809
ORIGINAL ARTICLE
Neurosurgery in octogenarians Matthew G. Stovell & Michael D. Jenkinson The Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool, UK
neurosurgical services and raises the question as to whether active neurosurgical intervention is beneficial in the very elderly. Advances in anaesthesia and microsurgery have led to an increase in the number of very elderly patients undergoing neurosurgical procedures but the evidence of benefit in this population is variable. Additionally, the incidence of many neurosurgical pathologies increases with age. Both benign and malignant intracranial neoplasms are more prevalent in the elderly.2,3 Falls causing head injuries are second in frequency only to young males.4 Spinal fractures are common in elderly patients due to reduced bone density and osteoarthritis causing degenerative spine disease. In 2010 the UK National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) carried out a review of the care received by elderly patients undergoing all types of surgery in UK hospitals.5 They concluded that extreme age (over 80 years old) was a separate risk factor requiring enhanced management and often aspects of this care was lacking. In response to this we performed a retrospective analysis of all neurosurgical admissions to a regional Neuroscience unit to determine the outcome and complications in patients ⱖ 80 years old.
Abstract Introduction. The developed world has an aging population with an increasing neurosurgical demand. The benefit of neurosurgical intervention in the octogenarian population and the outcome is unclear. The 2010 NCEPOD report on all surgical care for the elderly (⬎ 80 years) concluded that extreme age was an additional risk for which care was often lacking. Methods. Retrospective case review of 134 octogenarian admissions to a regional neurosurgical unit from January to December 2010. Admission pathology, co-morbidities, delay to surgery, length of stay, discharge destination, functional outcome and mortality were assessed. Results. There were 49 elective and 81 emergency admissions. Of which, 51% of elective admissions were for degenerative spine and 20% for functional/pain disorders. Also 55% of emergency admissions were for cranial trauma. Co-morbidities and ASA grade were higher in the emergency group. Peri-operative mortality was 0% for elective admission and 10.4% for emergency patients. Outcome following cranial trauma was good in 62% of patients. Degenerative spine outcome was good in 69% of patients. All patients with pain/functional pathology had immediate initial improvement but 56% had recurrence of pain at 6 months. 88% of elective admissions and 22% of emergency admissions were discharged directly to home with a mean length of stay of 7 days for elective and 13 days for emergency patients. Conclusions. Patient selection is crucial when considering neurosurgery in the octogenarian population. Our octogenarian patients had higher complication rate and 30-day mortality than those ⬍ 80 year old, demonstrating the additional risk and need for enhanced peri-operative care.
Methods A retrospective case review of all patients ⱖ 80 years old admitted to a regional neurosurgical unit over one calendar year (2010) was undertaken. Patients were admitted both electively for planned surgery following a clinic attendance and as emergency referrals through the on-call system. Patient demographics, admission type (elective or emergency), length of stay, admission category (cranial trauma, cranial tumour, spine trauma, degenerative spine, functional, other) and primary diagnosis were recorded. Co-morbidities such as chronic pulmonary disease, chronic kidney disease, ischaemic heart disease, previous myocardial infarction or valve disease were considered significant. Essential hypertension or osteoarthritis were not considered as significant co-morbidities as they were present in almost all patients.
Keywords: age and outcome; complications; elderly; neurosurgery; outcome; octogenarians
Introduction The developed world has an aging population. In 2008 the UK population consisted of 1.25 million people ⱖ 85 years old and this is expected to double in the next 25 years.1 This expanding elderly population places an increased burden on
Correspondence: Matthew George Stovell, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool L97AL, UK. E-mail: [email protected] Received for publication 4 September 2013; accepted 27 January 2014
611
612
M. G. Stovell & M. D. Jenkinson
Anticoagulant and antiplatelet agents were considered relevant medications and recorded if elective patients had taken the medication on the day before surgery or emergency patients had taken them on their acute admission to hospital. Time from admission to surgery, ASA grade, procedure and complications, 30-day mortality from admission and discharge location were recorded. Peri-operative mortality was defined as death ⱕ 30 days after surgery. Patient outcome at 2–6 month follow up was recorded (available for 90% cases). If patients did not attend follow up, their outcome was taken as their condition on discharge. In cranial trauma, a good outcome was considered as a Glasgow Outcome Score (GOS)6 of 4–5. A poor outcome or no-improvement was decided for patients with a GOS of ⱕ 3. For patients with cranial tumours, the ECOG score7 was used. An ECOG of 0–2 was considered good and a score of 3–5 was considered poor, or no-improvement. For spine patients an outcome was considered good if there was improvement in leg or back pain or functional/mobility improvement. If there was no improvement or return of symptoms on follow up the outcome was considered poor. For functional patients (mainly balloon compression for trigeminal neuralgia) outcome was considered good if there was pain improvement on early follow up. If pain had returned in this time then outcome was considered poor. Owing to the small number of patients with CSF-related disorders and primary neurovascular conditions, they were excluded from the outcome assessment.
Results A total of 134 patients ⱖ 80 years old were admitted between 1st January 2010 and the 31st December 2010. Age range varied from 80 to 100, median age was 83 years old. There were 49 elective admissions and 81 non-elective/emergency admissions (admission type). Patient demographics are shown in Table I. During the same period in the 16–80 category there were 4510 admissions (2506 elective, 2004 emergency). Octogenarian admissions accounted for 2.97% of the annual inpatient workload.
Admission type and operation The majority of elective admissions were for degenerative spine and functional/pain disorders (Fig. 1). Degenerative spine procedures were mainly posterior lumbar decompressions with a smaller number of cervical laminectomies. Spinal trauma patients were admitted electively for CTguided percutaneous vertebroplasty. The majority of elective tumours were craniotomies for meningiomas. Functional admissions were mainly percutaneous balloon compression for trigeminal neuralgia. The majority of emergency admissions were for trauma (Fig. 1), in particular for chronic subdural haematomas (36 of 45 trauma admissions). The rest of the emergency admissions were almost equally made up of intracranial tumours undergoing resection or biopsy, degenerative spine pathology undergoing lumbar and cervical laminectomies and patients with spinal trauma having HALO fixation (Table I). There were few patients admitted with cerebrovascular disease, which reflects the poor neurological status in this age
Table I. Patient demographics. Age (years) Range Median Admission category no. (%) Cranial trauma Cranial tumour Spine trauma Degenerative spine Functional Other Significant co-morbidities no. (%) 0 1 2 3 4 5 ASA grade no. (%) I II III IV Anticoagulant/Antiplatelet no. (%) Nil Aspirin Clopidogrel Aspirin ⫹ Clopidogrel Dipyridamole Warfarin LMWH Mortality Mortality ⱖ 80-year olds 30 Day admission 30 Day operative Mortality ⱕ 80-year olds 30 Day admission 30 Day operative ⱖ 80 years outcomes Admission – Surgery interval (days) Range Mean Median Post-operative complications Nil Medical - Respiratory - Cardiac - Other Surgical Outcome -Cranial Trauma Good Poor -Cranial Tumour Good Poor -Spine trauma Good Poor -Degen. spine Good Poor -Functional Good Poor Discharge Length of stay Home Referring hospital Nursing home Died
Elective
Emergency
80–100 83
80–97 84
0 (0) 6 (12%) 4 (8%) 25 (51%) 10 (20%) 4 (8%)
45 (55%) 8 (10%) 10 (12%) 11 (13%) 0 (0) 8 (10%)
18 (37%) 19 (39%) 8 (16%) 3 (6%) 0 (0) 1 (2%)
22 (27%) 24 (29%) 17 (21%) 8 (10%) 7 (9%) 4 (5%)
13 (27%) 27 (55%) 8 (16%) 1 (2%)
5 (6%) 36 (44%) 31 (38%) 10 (12%)
41 (84%) 3 (6%) 1 (2%) 0 (0) 1 (2%) 0 (0) 0 (0)
45 (55%) 19 (23%) 2 (2%) 2 (2%) 0 (0) 13 (16%) 1 (1%)
1 (2%) 0 (0%)
10 (12%) 7 (10%)
5 (0.2%) 4 (0.15%)
74 (3.7%) 58 (2.9%)
0–6 1.4 1
0–29 2.4 1
32 5 2 1 2 9
58 16 9 2 5 3
0 (0) 0 (0)
28 (62%) 17 (38%)
6 (100%) 0 (0)
6 (75%) 2 (25%)
4 (100%) 0 (0)
7 (63%) 4 (37%)
25 (83%) 5 (17%) 4 (40%) 6 (60%) 7 days (mean) 43 (88%) 5 (10%) 0 (0) 1 (2%)
6 (60%) 4 (40%) 0 (0) 0 (0) 13 days (mean) 18 (22%) 54 (66%) 6 (7%) 4 (5%)
Neurosurgery in octogenarians EMERGENCY 50 45 40 35 30 25 20 15 10 5 0 Cran. Cran. Trauma Tumour
CSF
Degen. Spine Spine Infecon Vascular Spine Trauma Tumour
ELECTIVE 30 25 20 15 10 5 0 CSF
Cran. Funct. Degen. Spine Spine Tumour Spine Trauma Tum.
Fig. 1. Octogenarian patient admission: Type and category.
group. In our unit these patients are usually managed by stroke physicians in peripheral hospitals. Of elective admissions, 44 of 49 went on to have surgery: the reasons for cancellation were, hip fracture on the ward, a patient listed for balloon compression for trigeminal neuralgia who was unable to consent, theatre overrunning (surgery performed 3 weeks later), surgery no longer indicated and failure of procedure (lumbar drain insertion). Of emergency admissions, 67 of 82 went on to have surgery/procedures. Patients did not undergo an operation because surgery was not considered appropriate due to unlikely improvement or beneficial recovery, patients not being fit for an anaesthetic, and patients declining surgery. The median time from admission to surgery for elective cases was 1 day (range: 0–6 days). The median time from admission to surgery for emergency cases was 1 day (range: 0–29 days). One outlying patient who waited 29 days for surgery had a cranial wound infection and a period of medical management with antibiotics was tried prior to wound debridement. A total of 73% of emergency operations and 77% of elective operations took place within 24 h of admission.
613
Outcome Peri-operative mortality was 0% in the elective group and 10.4% in the emergency group. Peri-operative mortality during the same period in patients ⱕ 80 years old was 0.15% for elective admissions and 2.9% for emergency admissions. Including those patients who did not undergo surgery, the 30-day octogenarian mortality post admission was 1.9% for the elective group and 12% for the emergency group. In the same period, the 30-day mortality post admission was 0.2% for elective ⱕ 80 years admissions and 3.7% for emergency ⱕ 80 years admissions. Medical complications were more common in the emergency group (20%); in some cases precluding surgery. The medical complication rate in the elective group was lower (10%) (Table I). Surgical complications were more common in the elective group (20% operated) and were mostly related to spinal surgery; varying from post-op transient urinary retention to post-op lumbar haematomas requiring evacuation. The surgical complication rate in the (operated) emergency cases was lower than that in the elective cases (4%). These were all re-accumulation of evacuated chronic subdural haematomas. Patients’ outcome is demonstrated in Fig. 2. Of patients with cranial trauma, just under two thirds did well (62%). Patients referred with emergency spinal pathology had good outcome in a similar number of cases (60%). Outcome for patients with elective spinal pathology was much better: a good outcome in 77%. There were a small number of patients admitted with intracranial tumours: the outcome in emergency cases was good (good in 75%) but better in the elective group (good outcome in 100%). Antiplatelet/anticoagulant 30 EMERGENCY
25 20 15
Good
10 Poor 5 0 Degen Spine
Spine Trauma
Cranial Tumour
Cranial Trauma
30 ELECTIVE
25 20
Additional risk factors Co-morbidities are shown in Table I. The number of co-morbidities was higher in the emergency admission group. The majority of co-morbidities were cardiac in both groups. The ASA grades for the emergency admissions were higher than those for the elective admissions. A third of patients were either taking antiplatelet or anticoagulant medications on the day before surgery in elective patients or on their acute admission to hospital in the emergency patients.
15
Good
10
Poor
5 0 Degen Spine
Spine Trauma
Cranial Tumour
Funconal
Fig. 2. Bar graphs showing ‘good’ and ‘poor’ outcome per category.
614
M. G. Stovell & M. D. Jenkinson
therapy had trend towards a negative impact on overall patient outcome: only 59% of patients taking anticoagulants or antiplatelets had a good outcome, compared with 70% of patients not taking antiplatelets/anticoagulants (Fisher’s Exact test p ⫽ 0.227).
Length of stay and discharge Patients are discharged from our regional unit either to their home or back to their local hospitals as soon as their primary neurosurgical problem has been addressed and they require further rehabilitation or general medical input. The majority of elective admissions were discharged home (88%). One patient died as an inpatient and five required transfer to their local hospitals. Median length of stay was 5 days for the elective group. Of emergency admissions, 22% were discharged directly to home. The majority were transferred to their local hospitals (66%), 7% were discharged to nursing homes and 5% died in our hospital. The median length of stay for emergency admissions was 12 days.
Discussion This study has investigated the outcome of neurosurgery in the octogenarian population. The group accounts for 2.9% of total operations and 2.8% of all adult admissions. Degenerative spine and cranial trauma were the most common types of pathology. Surgical complication rate was 9% and medical complication rate was 16%. Thirty-day mortality was 8.4%. Good outcome was reported for 69% of patients at 6-month follow-up.
Cranial trauma Several studies have reported that patient outcome following traumatic brain injury is worse in the elderly when compared with younger patients.8–10 Patients over 60 years old with a mild head injury had a good outcome in 68%9 of cases. This can be compared with our group as the majority of our patients with cranial trauma suffered from chronic subdural haematomas associated with minor head injury. In our study, 62% of patients with cranial trauma had a good outcome (GOS 4–5); the slightly worse outcome may reflect age and additional co-morbidities in outpatient population.
inclusion of emergency procedures may also have skewed the outcome negatively. When the elective group are analysed separately significant functional improvement was achieved in 77% of patients at 6 months, which is comparable to previous studies.11,12 Surgical complications were seen more frequently in this cohort of patients. Since most of these patients underwent lumbar decompression for neurogenic claudication, the types of complications reflect the degree of stenosis and ligamentous hypertrophy.
Spinal trauma The majority of patients with emergency spinal trauma had odontoid fractures treated with HALO fixation. No significant difference between patients over 65 and those under 65 who underwent HALO fixation for C2 fractures has been reported by one study.13 Significant medical complications associated with HALO fixation in patients over 70 have been reported14; but this may be due to the associated significant underlying disease processes. In our group, outcome was good for 63% of patients and poor in 37%. There were two mortalities (18%) in this group associated with respiratory failure which is similar to that described by Horn (15%). Patients who were admitted electively due to spinal trauma all underwent percutaneous vertebroplasty. Outcome was good in all patients, which is similar to that reported previously in the literature.15
Intracranial tumours A study of the outcome of 44 patients over 80 years old undergoing neurosurgical procedures for a variety of intracranial tumours found that perioperative mortality in the octogenarian patients was higher than in the rest of the population (11% compared with 2%).16 They found improvement in 43%, no change in 34% and deterioration or death in 23%. Another study analysed outcome after craniotomy for meningioma in 74 octogenarian patients.17 They found perioperative mortality to be 0% and complications to be 9.4% but did not look at functional outcome post operatively. The outcome in our group of patients undergoing neurosurgical procedures for intracranial tumours was good in 86% of patients. It was better (100%) in the elective group, which consisted mostly of supratentorial meningiomas. The nonelective group more closely resembles Peitila’s group in aetiology and outcome.
Degenerative spine The outcome of surgery for lumbar degenerative spine disease has been shown to be ‘good’ in 92% of patients ⱖ 70 years.11 Those patients mostly underwent lumbar laminectomies and foramenotomies which is similar to our group. A prospective study12 found that 87% of patients over 70 years old claimed benefit from lumbar laminectomy at one year follow up. They also noted a significant improvement in EQ-5 D scores. At 6-month follow-up, we found a ‘good’ outcome of patient functional improvement in 69% of our patients with degenerative spinal disease. The outcome for our patients was derived from the notes and is a limitation of our study with no objective outcome measures. Our patient group is older which may account for less post-operative improvement (ⱖ 80 rather than ⱖ 70). Our
Functional The majority of functional patients were admitted for trigeminal neuralgia. The two patients who had microvascular decompression remained pain free at 6 months, as expected from the literature.18 All four patients who had balloon compression of the gasserian ganglion had initial post-operative pain relief. However, at 6-month follow-up three had return of pain and one had died of an unrelated medical condition. This recurrence is higher than previously reported19 and higher than our experience of younger patients in our hospital. The reason for this discrepancy is unclear but it should be noted that the number of patients is small. One patient was unable to consent for surgery and one was not medically fit for surgery.
Neurosurgery in octogenarians
Delay to surgery There was little delay to surgery in both the emergency and the elective group. The NCEPOD report of surgery in octogenarians reported a delay to surgery for 21% of operations. Assessing if delay is clinically appropriate is difficult retrospectively; but a similar number of patients in our group waited more than 24 h for surgery (elective 23%, emergency 27%).
Discharge destination There was great difference in discharge destination in the elective and emergency groups. The majority of elective admissions had some form of formal or informal discharge planning pre-operatively and so could be discharged directly to home. Patients undergoing emergency neurosurgical procedures did not expect admission and the majority required further rehabilitation before they could go home. Some of these cases were also transferred to their local hospitals for further treatment of post-operative general medical complications.
Study limitations This analysis looks at a modest number of patients (134) in the extreme elderly group at a single neurosurgical centre over a calendar year. Unfortunately when the data is subdivided in to admission categories the groups are too small for robust statistical analysis. In addition, our group of patients is affected by selection bias. All emergency and elective admissions are assessed by a neurosurgical consultant to determine whether they are likely to benefit from admission to a specialist neurosurgical unit before they are accepted. Therefore this study cohort does not represent the octogenarian population as a whole with neurosurgical pathology; instead, it represents the outcome of octogenarian patients in whom neurosurgical intervention, whether operative or non-operative, has been deemed appropriate.
Conclusions In this selected cohort of octogenarian patients there was a higher complication rate and 30-day mortality rate compared with those less than 80 years old. Whilst age is an important factor in decision making about likely benefit from neurosurgical intervention, pre-morbid state and performance status should also be considered. Careful patient selection is key to achieving good outcomes for octogenarian patients. The higher complication rate in this group of patients supports the need for enhanced pre-op and post-op care and awareness of medical complications after emergency surgery.
615
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Statistics, O. of N. Population; Ageing. (2008). Available at: ⬍ http://www.statistics.gov.uk/cci/nugget.asp?id ⫽ 949 ⬎ [Accessed on 1/06/13]. 2. Claus EB, Bondy ML, Schildkraut JM, et al. Epidemiology of intracranial meningioma. Neurosurgery 2005;57:1088–95; discussion 1088–95. 3. Christensen HC, Kosteljanetz M, Johansen C. Incidences of gliomas and meningiomas in Denmark, 1943 to 1997. Neurosurgery 2003;52:1327–33; discussion 1333–4. 4. Faul M, Xu L, Wald M, Coronado V. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. … and Prevention, National Center for Injury … (2010). Available at: ⬍http://www.web.uvic.ca/psyc/skelton/ Teaching/General Readings/Ghajar TBI 2000.pdf⬎ [Accessed on 1/06/13]. 5. Wilkinson K, Martin IC, Gough MJ, et al. An Age-Old Problem: A review of the care received by elderly patients undergoing Surgery 2010;3:e37. 6. Teasdale GM, Pettigrew LE, Wilson JT, Murray G, Jennett B. Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow Outcome Scale. J Neurotrauma 1998;15:587–97. 7. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982;5:649–55. 8. LeBlanc J, De Guise E, Gosselin N, Feyz M. Comparison of functional outcome following acute care in young, middleaged and elderly patients with traumatic brain injury. Brain Inj 2006;20:779–90. 9. Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. J Trauma 2004;56:1042–8. 10. Kirkman MA , Jenks T, Bouamra O, et al. Increased mortality associated with cerebral contusions following trauma in the elderly: bad patients or bad management? J Neurotrauma 2013;30:1385–90. doi:10.1089/neu.2013.2881 11. Ragab AA , Fye MA , Bohlman HH. Surgery of the lumbar spine for spinal stenosis in 118 patients 70 years of age or older. Spine 2003;28:348–53. 12. Jakola AS, Sørlie A , Gulati S, et al. Clinical outcomes and safety assessment in elderly patients undergoing decompressive laminectomy for lumbar spinal stenosis: a prospective study. BMC Surg 2010;10:34. 13. Daentzer D, Flörkemeier T. Conservative treatment of upper cervical spine injuries with the halo vest: an appropriate option for all patients independent of their age? J Neurosurg Spine 2009;10:543–50. 14. Horn EM, Theodore N, Feiz-Erfan I, et al. Complications of halo fixation in the elderly. J Neurosurg Spine 2006;5:46–9. 15. Schofer MD, Illian CH, Illian JB, Kortmann HR. [Balloon kyphoplasty for recent vertebral fractures in the elderly]. Der Orthopäde 2008;37:462–9. 16. Pietilä TA , Stendel R, Hassler WE, et al. Brain tumor surgery in geriatric patients: a critical analysis in 44 patients over 80 years. Surg Neurol 1999;52:259–63; discussion 263–4. 17. Sacko O, Sesay M, Roux FE, et al. Intracranial meningioma surgery in the ninth decade of life. Neurosurgery 2007;61:950–4; discussion 955. 18. Javadpour M, Eldridge PR, Varma TRK, Miles JB, Nurmikko TJ. Microvascular decompression for trigeminal neuralgia in patients over 70 years of age. Neurology 2003;60:520. 19. Skirving DJ, Dan NG. A 20-year review of percutaneous balloon compression of the trigeminal ganglion. J Neurosurg 2001;94:913–7.
Copyright of British Journal of Neurosurgery is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Neurosurgery in octogenarians Matthew G. Stovell & Michael D. Jenkinson The Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool, UK
neurosurgical services and raises the question as to whether active neurosurgical intervention is beneficial in the very elderly. Advances in anaesthesia and microsurgery have led to an increase in the number of very elderly patients undergoing neurosurgical procedures but the evidence of benefit in this population is variable. Additionally, the incidence of many neurosurgical pathologies increases with age. Both benign and malignant intracranial neoplasms are more prevalent in the elderly.2,3 Falls causing head injuries are second in frequency only to young males.4 Spinal fractures are common in elderly patients due to reduced bone density and osteoarthritis causing degenerative spine disease. In 2010 the UK National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) carried out a review of the care received by elderly patients undergoing all types of surgery in UK hospitals.5 They concluded that extreme age (over 80 years old) was a separate risk factor requiring enhanced management and often aspects of this care was lacking. In response to this we performed a retrospective analysis of all neurosurgical admissions to a regional Neuroscience unit to determine the outcome and complications in patients ⱖ 80 years old.
Abstract Introduction. The developed world has an aging population with an increasing neurosurgical demand. The benefit of neurosurgical intervention in the octogenarian population and the outcome is unclear. The 2010 NCEPOD report on all surgical care for the elderly (⬎ 80 years) concluded that extreme age was an additional risk for which care was often lacking. Methods. Retrospective case review of 134 octogenarian admissions to a regional neurosurgical unit from January to December 2010. Admission pathology, co-morbidities, delay to surgery, length of stay, discharge destination, functional outcome and mortality were assessed. Results. There were 49 elective and 81 emergency admissions. Of which, 51% of elective admissions were for degenerative spine and 20% for functional/pain disorders. Also 55% of emergency admissions were for cranial trauma. Co-morbidities and ASA grade were higher in the emergency group. Peri-operative mortality was 0% for elective admission and 10.4% for emergency patients. Outcome following cranial trauma was good in 62% of patients. Degenerative spine outcome was good in 69% of patients. All patients with pain/functional pathology had immediate initial improvement but 56% had recurrence of pain at 6 months. 88% of elective admissions and 22% of emergency admissions were discharged directly to home with a mean length of stay of 7 days for elective and 13 days for emergency patients. Conclusions. Patient selection is crucial when considering neurosurgery in the octogenarian population. Our octogenarian patients had higher complication rate and 30-day mortality than those ⬍ 80 year old, demonstrating the additional risk and need for enhanced peri-operative care.
Methods A retrospective case review of all patients ⱖ 80 years old admitted to a regional neurosurgical unit over one calendar year (2010) was undertaken. Patients were admitted both electively for planned surgery following a clinic attendance and as emergency referrals through the on-call system. Patient demographics, admission type (elective or emergency), length of stay, admission category (cranial trauma, cranial tumour, spine trauma, degenerative spine, functional, other) and primary diagnosis were recorded. Co-morbidities such as chronic pulmonary disease, chronic kidney disease, ischaemic heart disease, previous myocardial infarction or valve disease were considered significant. Essential hypertension or osteoarthritis were not considered as significant co-morbidities as they were present in almost all patients.
Keywords: age and outcome; complications; elderly; neurosurgery; outcome; octogenarians
Introduction The developed world has an aging population. In 2008 the UK population consisted of 1.25 million people ⱖ 85 years old and this is expected to double in the next 25 years.1 This expanding elderly population places an increased burden on
Correspondence: Matthew George Stovell, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool L97AL, UK. E-mail: [email protected] Received for publication 4 September 2013; accepted 27 January 2014
611
612
M. G. Stovell & M. D. Jenkinson
Anticoagulant and antiplatelet agents were considered relevant medications and recorded if elective patients had taken the medication on the day before surgery or emergency patients had taken them on their acute admission to hospital. Time from admission to surgery, ASA grade, procedure and complications, 30-day mortality from admission and discharge location were recorded. Peri-operative mortality was defined as death ⱕ 30 days after surgery. Patient outcome at 2–6 month follow up was recorded (available for 90% cases). If patients did not attend follow up, their outcome was taken as their condition on discharge. In cranial trauma, a good outcome was considered as a Glasgow Outcome Score (GOS)6 of 4–5. A poor outcome or no-improvement was decided for patients with a GOS of ⱕ 3. For patients with cranial tumours, the ECOG score7 was used. An ECOG of 0–2 was considered good and a score of 3–5 was considered poor, or no-improvement. For spine patients an outcome was considered good if there was improvement in leg or back pain or functional/mobility improvement. If there was no improvement or return of symptoms on follow up the outcome was considered poor. For functional patients (mainly balloon compression for trigeminal neuralgia) outcome was considered good if there was pain improvement on early follow up. If pain had returned in this time then outcome was considered poor. Owing to the small number of patients with CSF-related disorders and primary neurovascular conditions, they were excluded from the outcome assessment.
Results A total of 134 patients ⱖ 80 years old were admitted between 1st January 2010 and the 31st December 2010. Age range varied from 80 to 100, median age was 83 years old. There were 49 elective admissions and 81 non-elective/emergency admissions (admission type). Patient demographics are shown in Table I. During the same period in the 16–80 category there were 4510 admissions (2506 elective, 2004 emergency). Octogenarian admissions accounted for 2.97% of the annual inpatient workload.
Admission type and operation The majority of elective admissions were for degenerative spine and functional/pain disorders (Fig. 1). Degenerative spine procedures were mainly posterior lumbar decompressions with a smaller number of cervical laminectomies. Spinal trauma patients were admitted electively for CTguided percutaneous vertebroplasty. The majority of elective tumours were craniotomies for meningiomas. Functional admissions were mainly percutaneous balloon compression for trigeminal neuralgia. The majority of emergency admissions were for trauma (Fig. 1), in particular for chronic subdural haematomas (36 of 45 trauma admissions). The rest of the emergency admissions were almost equally made up of intracranial tumours undergoing resection or biopsy, degenerative spine pathology undergoing lumbar and cervical laminectomies and patients with spinal trauma having HALO fixation (Table I). There were few patients admitted with cerebrovascular disease, which reflects the poor neurological status in this age
Table I. Patient demographics. Age (years) Range Median Admission category no. (%) Cranial trauma Cranial tumour Spine trauma Degenerative spine Functional Other Significant co-morbidities no. (%) 0 1 2 3 4 5 ASA grade no. (%) I II III IV Anticoagulant/Antiplatelet no. (%) Nil Aspirin Clopidogrel Aspirin ⫹ Clopidogrel Dipyridamole Warfarin LMWH Mortality Mortality ⱖ 80-year olds 30 Day admission 30 Day operative Mortality ⱕ 80-year olds 30 Day admission 30 Day operative ⱖ 80 years outcomes Admission – Surgery interval (days) Range Mean Median Post-operative complications Nil Medical - Respiratory - Cardiac - Other Surgical Outcome -Cranial Trauma Good Poor -Cranial Tumour Good Poor -Spine trauma Good Poor -Degen. spine Good Poor -Functional Good Poor Discharge Length of stay Home Referring hospital Nursing home Died
Elective
Emergency
80–100 83
80–97 84
0 (0) 6 (12%) 4 (8%) 25 (51%) 10 (20%) 4 (8%)
45 (55%) 8 (10%) 10 (12%) 11 (13%) 0 (0) 8 (10%)
18 (37%) 19 (39%) 8 (16%) 3 (6%) 0 (0) 1 (2%)
22 (27%) 24 (29%) 17 (21%) 8 (10%) 7 (9%) 4 (5%)
13 (27%) 27 (55%) 8 (16%) 1 (2%)
5 (6%) 36 (44%) 31 (38%) 10 (12%)
41 (84%) 3 (6%) 1 (2%) 0 (0) 1 (2%) 0 (0) 0 (0)
45 (55%) 19 (23%) 2 (2%) 2 (2%) 0 (0) 13 (16%) 1 (1%)
1 (2%) 0 (0%)
10 (12%) 7 (10%)
5 (0.2%) 4 (0.15%)
74 (3.7%) 58 (2.9%)
0–6 1.4 1
0–29 2.4 1
32 5 2 1 2 9
58 16 9 2 5 3
0 (0) 0 (0)
28 (62%) 17 (38%)
6 (100%) 0 (0)
6 (75%) 2 (25%)
4 (100%) 0 (0)
7 (63%) 4 (37%)
25 (83%) 5 (17%) 4 (40%) 6 (60%) 7 days (mean) 43 (88%) 5 (10%) 0 (0) 1 (2%)
6 (60%) 4 (40%) 0 (0) 0 (0) 13 days (mean) 18 (22%) 54 (66%) 6 (7%) 4 (5%)
Neurosurgery in octogenarians EMERGENCY 50 45 40 35 30 25 20 15 10 5 0 Cran. Cran. Trauma Tumour
CSF
Degen. Spine Spine Infecon Vascular Spine Trauma Tumour
ELECTIVE 30 25 20 15 10 5 0 CSF
Cran. Funct. Degen. Spine Spine Tumour Spine Trauma Tum.
Fig. 1. Octogenarian patient admission: Type and category.
group. In our unit these patients are usually managed by stroke physicians in peripheral hospitals. Of elective admissions, 44 of 49 went on to have surgery: the reasons for cancellation were, hip fracture on the ward, a patient listed for balloon compression for trigeminal neuralgia who was unable to consent, theatre overrunning (surgery performed 3 weeks later), surgery no longer indicated and failure of procedure (lumbar drain insertion). Of emergency admissions, 67 of 82 went on to have surgery/procedures. Patients did not undergo an operation because surgery was not considered appropriate due to unlikely improvement or beneficial recovery, patients not being fit for an anaesthetic, and patients declining surgery. The median time from admission to surgery for elective cases was 1 day (range: 0–6 days). The median time from admission to surgery for emergency cases was 1 day (range: 0–29 days). One outlying patient who waited 29 days for surgery had a cranial wound infection and a period of medical management with antibiotics was tried prior to wound debridement. A total of 73% of emergency operations and 77% of elective operations took place within 24 h of admission.
613
Outcome Peri-operative mortality was 0% in the elective group and 10.4% in the emergency group. Peri-operative mortality during the same period in patients ⱕ 80 years old was 0.15% for elective admissions and 2.9% for emergency admissions. Including those patients who did not undergo surgery, the 30-day octogenarian mortality post admission was 1.9% for the elective group and 12% for the emergency group. In the same period, the 30-day mortality post admission was 0.2% for elective ⱕ 80 years admissions and 3.7% for emergency ⱕ 80 years admissions. Medical complications were more common in the emergency group (20%); in some cases precluding surgery. The medical complication rate in the elective group was lower (10%) (Table I). Surgical complications were more common in the elective group (20% operated) and were mostly related to spinal surgery; varying from post-op transient urinary retention to post-op lumbar haematomas requiring evacuation. The surgical complication rate in the (operated) emergency cases was lower than that in the elective cases (4%). These were all re-accumulation of evacuated chronic subdural haematomas. Patients’ outcome is demonstrated in Fig. 2. Of patients with cranial trauma, just under two thirds did well (62%). Patients referred with emergency spinal pathology had good outcome in a similar number of cases (60%). Outcome for patients with elective spinal pathology was much better: a good outcome in 77%. There were a small number of patients admitted with intracranial tumours: the outcome in emergency cases was good (good in 75%) but better in the elective group (good outcome in 100%). Antiplatelet/anticoagulant 30 EMERGENCY
25 20 15
Good
10 Poor 5 0 Degen Spine
Spine Trauma
Cranial Tumour
Cranial Trauma
30 ELECTIVE
25 20
Additional risk factors Co-morbidities are shown in Table I. The number of co-morbidities was higher in the emergency admission group. The majority of co-morbidities were cardiac in both groups. The ASA grades for the emergency admissions were higher than those for the elective admissions. A third of patients were either taking antiplatelet or anticoagulant medications on the day before surgery in elective patients or on their acute admission to hospital in the emergency patients.
15
Good
10
Poor
5 0 Degen Spine
Spine Trauma
Cranial Tumour
Funconal
Fig. 2. Bar graphs showing ‘good’ and ‘poor’ outcome per category.
614
M. G. Stovell & M. D. Jenkinson
therapy had trend towards a negative impact on overall patient outcome: only 59% of patients taking anticoagulants or antiplatelets had a good outcome, compared with 70% of patients not taking antiplatelets/anticoagulants (Fisher’s Exact test p ⫽ 0.227).
Length of stay and discharge Patients are discharged from our regional unit either to their home or back to their local hospitals as soon as their primary neurosurgical problem has been addressed and they require further rehabilitation or general medical input. The majority of elective admissions were discharged home (88%). One patient died as an inpatient and five required transfer to their local hospitals. Median length of stay was 5 days for the elective group. Of emergency admissions, 22% were discharged directly to home. The majority were transferred to their local hospitals (66%), 7% were discharged to nursing homes and 5% died in our hospital. The median length of stay for emergency admissions was 12 days.
Discussion This study has investigated the outcome of neurosurgery in the octogenarian population. The group accounts for 2.9% of total operations and 2.8% of all adult admissions. Degenerative spine and cranial trauma were the most common types of pathology. Surgical complication rate was 9% and medical complication rate was 16%. Thirty-day mortality was 8.4%. Good outcome was reported for 69% of patients at 6-month follow-up.
Cranial trauma Several studies have reported that patient outcome following traumatic brain injury is worse in the elderly when compared with younger patients.8–10 Patients over 60 years old with a mild head injury had a good outcome in 68%9 of cases. This can be compared with our group as the majority of our patients with cranial trauma suffered from chronic subdural haematomas associated with minor head injury. In our study, 62% of patients with cranial trauma had a good outcome (GOS 4–5); the slightly worse outcome may reflect age and additional co-morbidities in outpatient population.
inclusion of emergency procedures may also have skewed the outcome negatively. When the elective group are analysed separately significant functional improvement was achieved in 77% of patients at 6 months, which is comparable to previous studies.11,12 Surgical complications were seen more frequently in this cohort of patients. Since most of these patients underwent lumbar decompression for neurogenic claudication, the types of complications reflect the degree of stenosis and ligamentous hypertrophy.
Spinal trauma The majority of patients with emergency spinal trauma had odontoid fractures treated with HALO fixation. No significant difference between patients over 65 and those under 65 who underwent HALO fixation for C2 fractures has been reported by one study.13 Significant medical complications associated with HALO fixation in patients over 70 have been reported14; but this may be due to the associated significant underlying disease processes. In our group, outcome was good for 63% of patients and poor in 37%. There were two mortalities (18%) in this group associated with respiratory failure which is similar to that described by Horn (15%). Patients who were admitted electively due to spinal trauma all underwent percutaneous vertebroplasty. Outcome was good in all patients, which is similar to that reported previously in the literature.15
Intracranial tumours A study of the outcome of 44 patients over 80 years old undergoing neurosurgical procedures for a variety of intracranial tumours found that perioperative mortality in the octogenarian patients was higher than in the rest of the population (11% compared with 2%).16 They found improvement in 43%, no change in 34% and deterioration or death in 23%. Another study analysed outcome after craniotomy for meningioma in 74 octogenarian patients.17 They found perioperative mortality to be 0% and complications to be 9.4% but did not look at functional outcome post operatively. The outcome in our group of patients undergoing neurosurgical procedures for intracranial tumours was good in 86% of patients. It was better (100%) in the elective group, which consisted mostly of supratentorial meningiomas. The nonelective group more closely resembles Peitila’s group in aetiology and outcome.
Degenerative spine The outcome of surgery for lumbar degenerative spine disease has been shown to be ‘good’ in 92% of patients ⱖ 70 years.11 Those patients mostly underwent lumbar laminectomies and foramenotomies which is similar to our group. A prospective study12 found that 87% of patients over 70 years old claimed benefit from lumbar laminectomy at one year follow up. They also noted a significant improvement in EQ-5 D scores. At 6-month follow-up, we found a ‘good’ outcome of patient functional improvement in 69% of our patients with degenerative spinal disease. The outcome for our patients was derived from the notes and is a limitation of our study with no objective outcome measures. Our patient group is older which may account for less post-operative improvement (ⱖ 80 rather than ⱖ 70). Our
Functional The majority of functional patients were admitted for trigeminal neuralgia. The two patients who had microvascular decompression remained pain free at 6 months, as expected from the literature.18 All four patients who had balloon compression of the gasserian ganglion had initial post-operative pain relief. However, at 6-month follow-up three had return of pain and one had died of an unrelated medical condition. This recurrence is higher than previously reported19 and higher than our experience of younger patients in our hospital. The reason for this discrepancy is unclear but it should be noted that the number of patients is small. One patient was unable to consent for surgery and one was not medically fit for surgery.
Neurosurgery in octogenarians
Delay to surgery There was little delay to surgery in both the emergency and the elective group. The NCEPOD report of surgery in octogenarians reported a delay to surgery for 21% of operations. Assessing if delay is clinically appropriate is difficult retrospectively; but a similar number of patients in our group waited more than 24 h for surgery (elective 23%, emergency 27%).
Discharge destination There was great difference in discharge destination in the elective and emergency groups. The majority of elective admissions had some form of formal or informal discharge planning pre-operatively and so could be discharged directly to home. Patients undergoing emergency neurosurgical procedures did not expect admission and the majority required further rehabilitation before they could go home. Some of these cases were also transferred to their local hospitals for further treatment of post-operative general medical complications.
Study limitations This analysis looks at a modest number of patients (134) in the extreme elderly group at a single neurosurgical centre over a calendar year. Unfortunately when the data is subdivided in to admission categories the groups are too small for robust statistical analysis. In addition, our group of patients is affected by selection bias. All emergency and elective admissions are assessed by a neurosurgical consultant to determine whether they are likely to benefit from admission to a specialist neurosurgical unit before they are accepted. Therefore this study cohort does not represent the octogenarian population as a whole with neurosurgical pathology; instead, it represents the outcome of octogenarian patients in whom neurosurgical intervention, whether operative or non-operative, has been deemed appropriate.
Conclusions In this selected cohort of octogenarian patients there was a higher complication rate and 30-day mortality rate compared with those less than 80 years old. Whilst age is an important factor in decision making about likely benefit from neurosurgical intervention, pre-morbid state and performance status should also be considered. Careful patient selection is key to achieving good outcomes for octogenarian patients. The higher complication rate in this group of patients supports the need for enhanced pre-op and post-op care and awareness of medical complications after emergency surgery.
615
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Statistics, O. of N. Population; Ageing. (2008). Available at: ⬍ http://www.statistics.gov.uk/cci/nugget.asp?id ⫽ 949 ⬎ [Accessed on 1/06/13]. 2. Claus EB, Bondy ML, Schildkraut JM, et al. Epidemiology of intracranial meningioma. Neurosurgery 2005;57:1088–95; discussion 1088–95. 3. Christensen HC, Kosteljanetz M, Johansen C. Incidences of gliomas and meningiomas in Denmark, 1943 to 1997. Neurosurgery 2003;52:1327–33; discussion 1333–4. 4. Faul M, Xu L, Wald M, Coronado V. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. … and Prevention, National Center for Injury … (2010). Available at: ⬍http://www.web.uvic.ca/psyc/skelton/ Teaching/General Readings/Ghajar TBI 2000.pdf⬎ [Accessed on 1/06/13]. 5. Wilkinson K, Martin IC, Gough MJ, et al. An Age-Old Problem: A review of the care received by elderly patients undergoing Surgery 2010;3:e37. 6. Teasdale GM, Pettigrew LE, Wilson JT, Murray G, Jennett B. Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow Outcome Scale. J Neurotrauma 1998;15:587–97. 7. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982;5:649–55. 8. LeBlanc J, De Guise E, Gosselin N, Feyz M. Comparison of functional outcome following acute care in young, middleaged and elderly patients with traumatic brain injury. Brain Inj 2006;20:779–90. 9. Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. J Trauma 2004;56:1042–8. 10. Kirkman MA , Jenks T, Bouamra O, et al. Increased mortality associated with cerebral contusions following trauma in the elderly: bad patients or bad management? J Neurotrauma 2013;30:1385–90. doi:10.1089/neu.2013.2881 11. Ragab AA , Fye MA , Bohlman HH. Surgery of the lumbar spine for spinal stenosis in 118 patients 70 years of age or older. Spine 2003;28:348–53. 12. Jakola AS, Sørlie A , Gulati S, et al. Clinical outcomes and safety assessment in elderly patients undergoing decompressive laminectomy for lumbar spinal stenosis: a prospective study. BMC Surg 2010;10:34. 13. Daentzer D, Flörkemeier T. Conservative treatment of upper cervical spine injuries with the halo vest: an appropriate option for all patients independent of their age? J Neurosurg Spine 2009;10:543–50. 14. Horn EM, Theodore N, Feiz-Erfan I, et al. Complications of halo fixation in the elderly. J Neurosurg Spine 2006;5:46–9. 15. Schofer MD, Illian CH, Illian JB, Kortmann HR. [Balloon kyphoplasty for recent vertebral fractures in the elderly]. Der Orthopäde 2008;37:462–9. 16. Pietilä TA , Stendel R, Hassler WE, et al. Brain tumor surgery in geriatric patients: a critical analysis in 44 patients over 80 years. Surg Neurol 1999;52:259–63; discussion 263–4. 17. Sacko O, Sesay M, Roux FE, et al. Intracranial meningioma surgery in the ninth decade of life. Neurosurgery 2007;61:950–4; discussion 955. 18. Javadpour M, Eldridge PR, Varma TRK, Miles JB, Nurmikko TJ. Microvascular decompression for trigeminal neuralgia in patients over 70 years of age. Neurology 2003;60:520. 19. Skirving DJ, Dan NG. A 20-year review of percutaneous balloon compression of the trigeminal ganglion. J Neurosurg 2001;94:913–7.
Copyright of British Journal of Neurosurgery is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
