Around the Chinese New Year, there are more patients with degenerative lumbar spine diseases, especially the elderly, often over 65 years old, with many patients over 80 years old coming to our hospital for surgical treatment. We choose a minimally invasive surgical approach, and patients are discharged from the hospital in an average of 3 days after surgery. The cost of hospitalization was around 30,000. One of the elderly patients, 78 years old, for his preoperative cardiac evaluation, the heart ejection fraction was 49%. At that time, considering the high risk of the operation, as the operator, I was tempted to abandon this operation, but the patient himself insisted on the operation, and with the strong support of the anesthesiology department, the operation achieved a successful result. In reviewing the medical history, the process of seeking medical treatment, the psychological changes of these elderly patients to the final decision to come to our hospital for surgery, I deeply appreciate that as an elderly person, suffering from pain, facing a variety of treatment options, facing various talks and signatures from doctors, considering the concerns of his partner and children at home, the decision of the elderly to make surgery is not difficult and not brave. Wu Hao of the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University Elderly patients who are considering the option of surgery basically come to the hospital only when their symptoms are getting worse and worse and they are really hard to tolerate, and many of them finally make up their mind to operate because their neighbors and relatives have good results after surgery in our department, and some of them also give up surgery because they have heard of someone’s poor results after surgery and delay their illness. Therefore, I would like to talk to elderly patients about our lumbar degenerative diseases, so that elderly patients can understand and realize the necessity and safety of surgery, put down their psychological baggage and make the right decision. I The characteristics and treatment of lumbar degenerative disease The lumbar degenerative disease of the elderly is actually the most common one. Due to the degeneration of the endocrine and immune functions of the body, the structure of the spine also changes accordingly and loses its normal physiological characteristics, which leads to lumbar spinal stenosis, lumbar disc protrusion, and even lumbar instability, mainly manifested as lumbar pain and intermittent claudication. Low back pain, especially with lower extremity radiated pain, commonly known as “scurrying” from the waist to the leg pain, is often caused by degenerative diseases of the lumbar spine. Some patients also have numbness in the lower extremities, commonly in the lower legs and dorsal part of the foot. It is worth noting that joints can also cause lower limb pain, but predominantly in the joint region, often without accompanying lumbar pain. Intermittent claudication refers to the discomfort of pain, numbness, and weakness in both lower limbs after walking a certain distance and having to stop and rest in order to continue walking, and as the condition develops, the walking distance becomes shorter and shorter, and even 10 meters need to be stopped. Intermittent claudication is divided into neurogenic and vascular origin, the lumbar spinal stenosis and other implementation lesions caused by the neurogenic, lower limb arteriosclerosis caused by the vascular origin, the biggest difference between the two is that the neurogenic is only manifested in walking, the patient can ride a bike and will not cause discomfort, the vascular origin of the patient as long as any movement to increase the activity of the lower limbs will produce lower limb symptoms. Surveys show that more than 80% of people have experienced low back and leg pain in their lifetime, mostly after the age of 30, and the incidence increases gradually with age, and the incidence is extremely high above the age of 60. In Europe and the United States, the medical cost of low back pain is the second highest among all diseases, and about 700,000 people are hospitalized for low back pain every year, of which about 200,000 receive surgical treatment. However, in China, lumbar spine implementation disease has not received much attention. Because lumbar pain is extremely common, many elderly people do not pay much attention to it, and even when typical symptoms such as low back pain occur, most of them take to tolerate it, which leads to a serious decline in quality of life. For the treatment of lumbar spine implementation diseases in elderly patients, most patients can reduce their symptoms through conservative treatment, and some of them even improve significantly. Conservative treatment is generally drugs, physical therapy, Chinese massage, acupuncture, etc. Under the guidance of a doctor, the corresponding conservative treatment measures should be taken according to different causes and conditions. It should be noted that there are many conservative treatment modalities, the use of massage needs to be carried out in formal institutions, for patients with lumbar instability (lumbar spine slippage), massage has the possibility of aggravating the disease. In developed countries in Europe and the United States, people pay attention to the quality of life, and at the same time, economic and medical conditions are developed, so in the treatment of low back pain, especially the emergence of intermittent claudication and other symptoms now more inclined to surgical treatment, and obtained very good results. In China, due to the level of medical technology, doctors’ philosophy, social concept and patients’ own comorbidities, many elderly patients cannot receive surgical treatment and are accompanied with pain for life. Currently, with the development of the economy, the increasing per capita life expectancy, the increase of economic income level, and the change of concept, people’s demand for quality of life has become higher and higher, and with the continuous development of minimally invasive surgical methods and surgical techniques, the advancement of modern anesthesiology, and the further maturation of perioperative management, more and more patients have opted for surgical treatment. When is surgery needed Most of the low back pain caused by degenerative diseases of the lumbar spine often manifests itself in good and bad times, with recurrent attacks, especially in winter and spring when the patient’s symptoms are aggravated by the influence of the external environment. So, what kind of patients with low back pain need surgery? First, patients who do not respond to conservative treatment usually need surgery. Usually, most patients are effective with conservative treatment, and surgery can be considered if regular conservative treatment is not effective. Second, severe neurogenic symptoms, alternating sciatica, progressive aggravation of nerve damage, numbness, decreased or absent sensation in both lower limbs and perineum, weakness in urination and defecation, urinary retention, urinary and fecal incontinence, and impotence in men may also occur. This condition requires early surgery, and delayed surgery often results in irreversible nerve damage. Third, it is accompanied by symptoms of intermittent claudication and increasingly shorter walking distances. Early surgical intervention can improve the quality of survival of patients, but of course, this type of surgery requires careful evaluation. Surgery There are three types of surgery for degenerative lumbar spine disease: simple decompression, decompression + fusion, and minimally invasive surgery. The most widely used surgical procedure for lumbar degenerative disease is decompression + pedicle screw fusion. Laminectomy decompression and nerve root decompression are the standard procedures for treating lumbar spinal stenosis or lumbar disc herniation. In other words, the spinal canal volume is enlarged and nerve compression is released by removing the lamina, articular processes, ligaments and other structures. Because decompression destabilizes the spine, a transforaminal screw internal fixation fusion is performed at the same time as decompression. Fusion means that two or more vertebral segments are artificially joined and fixed together as one, increasing their stability but losing some of the mobility of the spine. Internal fixation is an expensive procedure with long postoperative recovery times and complications for the patient. In recent years, minimally invasive, non-fusion surgery has been a major trend in surgery, and new minimally invasive procedures for degenerative lumbar spine diseases have emerged, such as single- or multi-segmental side access, bilateral decompression surgery for lumbar spinal stenosis, and simple lumbar disc removal. Sometimes non-fused interspinous devices are used under certain conditions to increase stability while preserving spinal mobility and reducing the recurrence of lumbar disc herniation. Neurosurgery has always incorporated the minimally invasive concept of neurosurgery since the beginning of spine surgery, and the routine use of microscopes and mensuration drills is the basis and condition for minimally invasive surgery. The procedure is performed under a microscope, and a high-speed molar drill is used to grind away part of the patient’s hemivertebral plate without injuring the small joints and spinous processes, and to bite away the thickened ligamentum flavum in the spinal canal from different angles, and to enlarge the lateral saphenous fossa on the affected side with adequate decompression in the spinal canal. Minimally invasive surgery features: preserving the spinous process and small joints, the surgery is minimally invasive and can be tolerated by most elderly patients, with little effect on the stability of the spine. It is a function-preserving surgery. The operation uses a microscope, so the field of view is good, which better protects the nerve roots and reduces complications. Patients can be on the floor the day after surgery, which greatly reduces the length of hospital stay and significantly reduces the costs associated with surgery. The safety of surgery is extremely important for surgery in elderly patients, especially when the patient is over 70 years old and has hypertension, diabetes, or poor cardiopulmonary function, so the operation time is required to be as short as possible, with less bleeding, short postoperative bed time, early access to the floor, and short hospital stay. I think the surgery is successful if the postoperative recovery is 60-70%, and it is difficult to complete the 100% symptom solution itself by overly pursuing the perfection of imaging, and it increases the risk of surgery. Minimally invasive surgery is the solution. For example, if an elderly patient has a multi-stage disc herniation, we can choose a one-sided approach with decompression on both sides of the spinal canal, or we can choose to do simple decompression on a single segment that causes symptoms. In older patients with a certain stage of stenosis, ligamentum flavum hypertrophy plays a large role. Considering the stability of the spine, sometimes removal of the disc is not necessary and removal of the ligamentum flavum is sufficient to relieve most of the symptoms. The choice of surgical procedure for each patient is based mainly on symptoms, examination and imaging. Extensive decompression with internal fixation may often create new problems in elderly patients. Since modern medicine has led to rapid development of imaging, doctors are increasingly dependent on imaging, and even many patients are seen by doctors who just look at the films and decide whether to operate, ignoring symptoms and physical examination. For the elderly, symptoms and physical examination are extremely important. Many patients have multiple stenoses and herniated discs on imaging, but symptoms and physical examination may be localized to only one of these stages, and relieving the problem at this stage will allow the elderly patient to achieve a satisfactory outcome. Another extremely important aspect of surgery for elderly patients is anesthesia. Lumbar spine surgery often requires a prone position, and this prone position makes it difficult for elderly people to complete the surgery under local anesthesia, while general anesthesia can reduce patient pain and alleviate patient apprehension and fear, but general anesthesia is more demanding for anesthesiologists and requires careful preoperative assessment of the patient’s cardiopulmonary function. Our hospital has been focusing on geriatric diseases for many years, and the Department of Anesthesiology has extremely rich experience in general anesthesia for the elderly, which allows our operators to start a lot of work, and without the escort of anesthesia, we cannot relieve the pain of many elderly patients. In conclusion, lumbar spine implementation diseases are common and frequent, and can be caused by a variety of factors. While some patients can be treated conservatively, some patients require and may be relieved of their pain through surgery early. Therefore, patients who meet the indications for surgery should seize the last chance to restore a healthy life and avoid a long and painful life by seeking early and effective surgical treatment. Connecting hospitals Better hospitals for minimally invasive treatment of lumbar degenerative diseases in elderly patients 1 Xuanwu Hospital Neurosurgery Department 2 Tianjin General Hospital 3 Tongren Hospital Neurosurgery Department