Life Example
The 80-year-old Master Wang has been suffering from lumbar pain for more than 10 years. After sneezing 3 months ago, he felt pain from his waist to his right hip to his right foot, and the pain was getting heavier and heavier, and he had to rest in bed for the past 2 weeks. The children sent Master Wang to the hospital to investigate, it turned out to be a lumbar disc herniation, need to open surgery. But the old man is so old, and has high blood pressure, diabetes, renal insufficiency, and a previous cerebral infarction, how to do?
After a multidisciplinary joint consultation and a period of conditioning in orthopedics, cardiology, endocrinology, nephrology, respiratory medicine and neurology, Master Wang’s blood pressure, blood sugar and kidney function all improved significantly. Then, under neurological supervision, with the purpose of small trauma and low cost, the doctor performed herniated discectomy, interbody fusion and unilateral pedicle screw internal fixation for Master Wang.
After surgery, Master Wang experienced post-operative cognitive dysfunction: his temperament changed greatly, sometimes he lost his temper at every turn, sometimes he ignored doctors, nurses and children, sometimes he said he saw a mirage …… Later, after careful care and symptomatic medication by medical staff, Master Wang finally recovered. After the stitches were removed 12 days after surgery, the elderly man was discharged from the hospital walking joyfully.
Elderly patients with spinal disorders like Master Wang have some of the following common features that make it difficult to treat
1, a long course of disease: patients with neck, shoulder, back and leg pain and/or numbness and weakness in the hands and feet last an average of 3 to 5 years, and as many as 20 to 30 years.
2, serious symptoms: elderly patients have severe spinal degeneration, involving multiple segments, often with significant muscle strength loss, sensory loss and urinary and fecal abnormalities.
3, many comorbidities: often combined with other multi-system diseases, such as cardiovascular disease, liver and kidney insufficiency, diabetes, etc., the body’s ability to tolerate significantly reduced.
4.Many complications: Bedridden patients are prone to complications, including pneumonia, urinary tract infection, decubitus ulcers, deep vein thrombosis of lower limbs, etc., which can be life-threatening in serious cases. Combined with symptoms such as neuralgia that are difficult to relieve, the quality of life of elderly patients declines dramatically, and the burden of care on children is very heavy.
Therefore, for elderly patients with spinal disorders, if, after careful evaluation by an orthopedic surgeon in collaboration with the relevant internist, the patient is deemed to be physically able to tolerate surgery, it is still advisable to opt for more aggressive surgical treatment to maximize the elderly’s ability to care for themselves and improve their quality of life, as well as to reduce the burden of care on their children. If, after evaluation, the patient’s general condition is deemed to be intolerant to surgery, it is also important to actively prevent and treat bed-ridden complications along with pharmacological treatment.
Multidisciplinary combination to adjust the patient’s systemic condition
Before surgery, a multidisciplinary joint consultation of cardiology, nephrology and neurology should be organized to adjust the treatment plan and improve the patient’s systemic condition so that the patient can tolerate the surgery in view of the comorbidities of elderly patients. For example, in patients with combined hypertension, they may take antihypertensive drugs at their own discretion, but before surgery, they need cardiologists to adjust the medication plan according to blood pressure and electrocardiogram, and take medication and monitor blood pressure regularly; in patients with combined diabetes, they usually take oral hypoglycemic drugs with satisfactory blood sugar control, but during the perioperative period, they may need to use insulin to prevent the rapid increase of blood sugar induced by anesthesia and surgery.
Comprehensive examination and integrated analysis to identify major lesion sites
The spine is made up of 33 vertebrae connected by intervertebral discs and is divided into four regions: cervical, thoracic, lumbar and sacrococcygeal. Elderly patients with spinal disorders may have varying degrees of lesions in the cervical, thoracic, and lumbar spine, and often have symptoms of cervical spondylosis such as neck and shoulder pain and hand numbness, as well as symptoms of lumbar spondylosis such as lumbar leg pain, but these symptoms are often dominated by a certain region. In addition, even if only one area of the cervical, thoracic or lumbar spine is involved, multiple segments are often involved. This requires the physician to take a detailed patient history, conduct a careful and comprehensive physical examination, and then combine these imaging data with X-rays, CT, MRI, and, if necessary, spine imaging, electromyography, as well as requesting neurology to rule out related diseases, for a comprehensive analysis to finally identify the main lesion site.
Intraoperative neurological function monitoring to ensure safe decompression
Spinal degeneration and spinal stenosis are more severe in the elderly, which means that the nerve “living area” is smaller in elderly patients with spinal disorders, making spinal decompression surgery in elderly patients more difficult as it is like saving a person from a collapsing small house. We routinely use neurological monitoring when operating on elderly patients with spinal disorders to detect any subtle changes in nerve function in real time during surgery and to ensure safe release of nerve compression.
Finding ways to reduce trauma
The elderly have a reduced ability to tolerate large surgical procedures, so it is important to find ways to reduce surgical trauma. We generally strip the paravertebral muscles on one side to reveal the surgical field, perform subtle decompression on the opposite side, and perform only unilateral internal fixation if the patient does not have severe osteoporosis, all of which reduce surgical trauma and thus reduce surgical risk. These measures reduce the use of internal fixation and therefore the cost to the patient.
Post-operative care, doctors and families must “give”
Elderly patients often have more complications after surgery, including poor appetite, pneumonia, cognitive dysfunction, etc. Therefore, the postoperative period requires multidisciplinary cooperation, close observation and timely diagnosis and treatment of various complications. For example, Master Wang, who was raised earlier, developed cognitive dysfunction after surgery, and his family did not understand at first and complained about him, thinking that he had become eccentric. After the neurology consultation, it turned out that this is a common complication after surgery for the elderly, which requires symptomatic medication and more careful care by medical staff and family members to prevent accidental injuries.