title: Surgical outcomes of elderly patients with cervical spondylotic myelopathy: a meta-analysis of studies reporting on 2868 patients.
abstract: OBJECTIVE Cervical spondylotic myelopathy usually presents in the 5th decade of life or later but can also present earlier in patients with congenital spinal stenosis. As life expectancy continues to increase in the United States, the preconceived reluctance toward operating on the elderly population based on older publications must be rethought. It is a known fact that outcomes in the elderly cannot be as robust as those in the younger population. There are no publications with detailed meta-analyses to determine an acceptable level of outcome in this population. In this review, the authors compare elderly patients older than 75 years to a nonelderly population, and they discuss some of the relevant strategies to minimize complications. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors performed a PubMed database search to identify English-language literature published between 1995 and 2015. Combinations of the following phrases that describe the age group ("elderly," "non-elderly," "old," "age") and the disease of interest as well as management ("surgical outcome," "surgery," "cervical spondylotic myelopathy," "cervical degenerative myelopathy") were constructed when searching for relevant articles. Two reviewers independently assessed the outcomes, and any disagreement was discussed with the first author until it was resolved. A random-effects model was applied to assess pooled data due to high heterogeneity between studies. The mean difference (MD) and odds ratio were calculated for continuous and dichromatic parameters, respectively. RESULTS Eighteen studies comprising elderly (n = 1169) and nonelderly (n = 1699) patients who received surgical treatment for cervical spondylotic myelopathy were included in this meta-analysis. Of these studies, 5 were prospective and 13 were retrospective. Intraoperatively, both groups required a similar amount of operation time (p = 0.35). The elderly group had lower Japanese Orthopaedic Association (JOA) scores (MD -1.36, 95% CI -1.62 to -1.09; p < 0.00001) to begin with compared with the nonelderly group. The nonelderly group also had a higher postoperative JOA score (MD -1.11, 95% CI -1.44 to -0.79; p < 0.00001), therefore demonstrating a higher recovery rate from surgeries (MD -11.98, 95% CI -16.16 to -7.79; p < 0.00001). The length of stay (MD 4.14, 95% CI 3.54-4.73; p < 0.00001) was slightly longer in the elderly group. In terms of radiological outcomes, the elderly group had a smaller postoperative Cobb angle but a greater increase in spinal canal diameter compared with the nonelderly group. The complication rates were not significant. CONCLUSIONS Cervical myelopathy is a disease of the elderly, and age is an independent factor for recovery from surgery. Postoperative and long-term outcomes have been remarkable in terms of improvement in mobility and independence requiring reduced nursing care. There is definitely a higher potential risk while operating on the elderly population, but no significant difference in the incidence of postoperative complications was noted. Withholding surgery from the elderly population can lead to increased morbidity due to rapid progression of symptoms in addition to deconditioning from lack of mobility and independence. Reduction in operative time under anesthesia, lower blood loss, and perioperative fluid management have been shown to minimize the complication rate. The authors request that neurosurgeons weigh the potential benefit against the risks for every patient before withholding surgery from elderly patients.
authors.affiliation: Department of Neurological Surgery, University of Miami, Florida.
authors.forename: Karthik
authors.initials: K
authors.lastname: Madhavan
authors.affiliation: Department of Neurological Surgery, University of Miami, Florida.
authors.forename: Lee Onn
authors.initials: LO
authors.lastname: Chieng
authors.affiliation: Department of Neurological Surgery, University of Miami, Florida.
authors.forename: Hanyao
authors.initials: H
authors.lastname: Foong
authors.affiliation: Department of Neurological Surgery, University of Miami, Florida.
authors.forename: Michael Y
authors.initials: MY
authors.lastname: Wang
mesh_terms: D000367:Age Factors; D000375:Aging; D002574:Cervical Vertebrae / Q000601:surgery; D016208:Databases, Factual / Q000706:statistics & numerical data; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013123:Spinal Fusion / Q000379:methods*; D055009:Spondylosis / Q000601:surgery*; D016896:Treatment Outcome
keywords: ERAS; JOA = Japanese Orthopaedic Association; MD = mean difference; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; cervical decompression; complication; elderly population; enhanced recovery after surgery; meta-analysis