title: Perioperative morbidity and mortality after lumbar trauma in the elderly.
abstract: OBJECT Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal trauma. Lumbar spine trauma in the elderly is a growing public health problem with relatively little evidence to guide clinical management. The authors sought to characterize the complications, morbidity, and mortality associated with surgical and nonsurgical management in elderly patients with traumatic fractures of the lumbar spine. METHODS Using the National Sample Program of the National Trauma Data Bank, the authors performed a retrospective analysis of patients ≥ 55 years of age who had traumatic fracture to the lumbar spine. This group was divided into middle-aged (55-69 years) and elderly (≥ 70 years) cohorts. Cohorts were subdivided into nonoperative, vertebroplasty or kyphoplasty, noninstrumented surgery, and instrumented surgery. Univariate and multivariable analyses were used to characterize and identify predictors of medical and surgical complications, mortality, hospital length of stay, ICU length of stay, number of days on ventilator, and hospital discharge in each subgroup. Adjusted odds ratios, mean differences, and associated 95% CIs were reported. Statistical significance was assessed at p < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis. RESULTS Between 2003 and 2012, 22,835 people met the inclusion criteria, which represents 94,103 incidents nationally. Analyses revealed a similar medical and surgical complication profile between age groups. The most prevalent medical complications were pneumonia (7.0%), acute respiratory distress syndrome (3.6%), and deep venous thrombosis (3%). Surgical site infections occurred in 6.3% of cases. Instrumented surgery was associated with the highest odds of each complication (p < 0.001). The inpatient mortality rate was 6.8% for all subjects. Multivariable analyses demonstrated that age ≥ 70 years was an independent predictor of mortality (OR 3.16, 95% CI 2.77-3.60), whereas instrumented surgery (multivariable OR 0.38, 95% CI 0.28-0.52) and vertebroplasty or kyphoplasty (OR 0.27, 95% CI 0.17-0.45) were associated with decreased odds of death. In surviving patients, both older age (OR 0.32, 95% CI 0.30-0.34) and instrumented fusion (OR 0.37, 95% CI 0.33-0.41) were associated with decreased odds of discharge to home. CONCLUSIONS The present study confirms that lumbar surgery in the elderly is associated with increased morbidity. In particular, instrumented fusion is associated with periprocedural complications, prolonged hospitalization, and a decreased likelihood of being discharged home. However, fusion surgery is also associated with reduced mortality. Age alone should not be an exclusionary factor in identifying surgical candidates for instrumented lumbar spinal fusion. Future studies are needed to confirm these findings.
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: Ethan A
authors.initials: EA
authors.lastname: Winkler
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: John K
authors.initials: JK
authors.lastname: Yue
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: Harjus
authors.initials: H
authors.lastname: Birk
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: Caitlin K
authors.initials: CK
authors.lastname: Robinson
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Manley
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: Sanjay S
authors.initials: SS
authors.lastname: Dhall
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco; and Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California.
authors.forename: Phiroz E
authors.initials: PE
authors.lastname: Tarapore
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007297:Inpatients; D007902:Length of Stay; D008161:Lumbosacral Region / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D010024:Osteoporosis / Q000453:epidemiology / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality*; D013123:Spinal Fusion / Q000379:methods*; D013124:Spinal Injuries / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery*; D054854:Vertebroplasty / Q000379:methods
keywords: ARDS = acute respiratory distress syndrome; CCI = Charlson Comorbidity Index; ED = emergency department; GCS = Glasgow Coma Scale; HR = hazard ratio; ISS = Injury Severity Score; LOS = length of stay; NSP = National Sample Program; NTDB = National Trauma Data Bank; SBP = systolic blood pressure; elderly; lumbar spine fracture; morbidity; mortality; trauma