Cement Augmentation of Vertebral Compression Fractures May Be Safely Considered in the Very Elderly

Neurospine Neurospine 2021;18(1):226-233. https://doi.org/10.14245/ns.2040620.310 Original Article Corresponding Author Arya G. Varthi https://orcid.org/0000-0003-3362-1930 Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA Email: Received: October 8, 2020 Revised: November 4, 2020 Accepted: January 11, 2021 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2021 by the Korean Spinal Neurosurgery Society pISSN 2586-6583 eISSN 2586-6591 Cement Augmentation of Vertebral Compression Fractures May Be Safely Considered in the Very Elderly Anoop R. Galivanche1, Courtney Toombs1, Murillo Adrados1, Wyatt B. David1, Rohil Malpani1, Comron Saifi2, Peter G. Whang1, Jonathan N. Grauer1, Arya G. Varthi1 Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA 2 Penn Orthopaedics, University of Pennsylvania, Philadelphia, PA, USA 1 Objective: The objective of the current study was to perform a retrospective review of a national database to assess the safety of cement augmentation for vertebral compression fractures in geriatric populations in varying age categories. Methods: The 2005–2016 National Surgical Quality Improvement Program databases were queried to identify patients undergoing kyphoplasty or vertebroplasty in the following age categories: 60–69, 70–79, 80–89, and 90+ years old. Demographic variables, comorbidity status, procedure type, provider specialty, inpatient/outpatient status, number of procedure levels, and periprocedure complications were compared between age categories using chi-square analysis. Multivariate logistic regressions controlling for patient and procedural variables were then performed to assess the relative periprocedure risks of adverse outcomes of patients in the different age categories relative to those who were 60–69 years old. Results: For the 60–69, 70–79, 80–89, and 90+ years old cohorts, 486, 822, 937, and 215 patients were identified, respectively. After controlling for patient and procedural variables, 30day any adverse events, serious adverse events, reoperation, readmission, and mortality were not different for the respective age categories. Cases in the 80- to 89-year-old cohort were at increased risk of minor adverse events compared to cases in the 60- to 69-year-old cohort. Conclusion: As the population ages, cement augmentation is being considered as a treatment for vertebral compression fractures in increasingly older patients. These results suggest that even the very elderly may be appropriately considered for these procedures (level of evidence: 3). Keywords: Vertebroplasty, Kyphoplasty, Elderly, Nonagenarian, Geriatrics INTRODUCTION Vertebral compression fractures are the most common complication of osteoporosis.1 Population studies have estimated that 8% of adults over 50 years old have osteoporosis of the lumbar spine1 and the age-adjusted incidence of compression fractures is 117 per 100,000 person-years.2 The US Census Bureau projects that the population aged 65 years and older will double between 2012 and 2050.3 The very elderly are particularly vulnerable to compression fractures, as the risk of this con226 www.e-neurospine.org dition increases with advancing age.4 As the population ages, the safety of cement augmentation procedures, such as kyphoplasty and vertebroplasty, in geriatric patients with compression fractures is an important but unanswered question. Vertebral compression fractures are not all clinically significant, but the nearly 30% of patients who are symptomatic may suffer from debilitating pain and progressive kyphosis, causing a decrease in quality of life that has been shown to be more severe than geriatric hip, forearm, or humerus fractures.5,6 Alth ough compression fractures are typically managed conserva- Galivanche AR, et al. Geriatric Compression Fracture Treatment tively, cement augmentation of vertebral compression fractures is a viable treatment modality for patients with severe and intractable pain.7 Both kyphoplasty and vertebroplasty have been shown to have beneficial effects in selected patient populations.8 Perioperative complications following these procedures include medical/anesthetic complications, cement leakage, new vertebral fracture, and infection.9,10 Studies evaluating cement augmentation of compression fractures have shown that older geriatric patients do benefit from cement augmentation procedures.11,12 DePalma et al.11 followed 123 vertebroplasty patients and found similar rates of recurrent fracture between nonagenarian and younger patients. Kamei et al.12 retrospectively reviewed the postoperative courses of 130 vertebroplasty patients and found that nonagenarian patients had similar 1-year survival rates to younger patients. Both of these studies were limited by relatively small patient numbers, single-center design, and failure to assess short-term postprocedure adverse outcomes. As the population ages, cement augmentation is being considered for increasingly older patients. The very elderly are at increased risk for compression fractures and are perhaps the population with the most to gain from an expedited recovery after a fracture. The aim of the current study was to utilize the large, multicenter National Surgery Quality Improvement Program (NSQIP) database to assess the risk of postprocedural complications and adverse events in vertebroplasty and kyphoplasty cases performed in very elderly patients. operative levels was determined for each case by counting instances of additional level CPT codes 22512, 22515, 22522, and 22525. Cases involving concomitant decompression and/or fusion procedures were excluded. Additionally, cases of concomitant vertebroplasty and kyphoplasty were excluded from the study population for simplicity of analysis. Subcohorts were defined based on age categories of 60–69, 70–79, 80–89, and 90 years old and above were included. For each category, demographics were defined including: age, sex, height, and weight, which were directly abstracted from the NSQIP database. Height and weight data were used to calculate body mass index (BMI) (kg/m2). Preoperative functional status and American Society of Anesthesiologists (ASA) physical status classification are tracked in the NSQIP database, both of which were used to approximate each case’s comorbidity burden prior to operation. In order to determine provider specialty, cases were also identified as being performed by a neurosurgeon versus an orthopaedic surgeon and compared based on demographic statistics and outcomes. Cases performed by interventional radiologists were excluded from the study cohort due to low case (...truncated)