appropriate use of surgery in the disclosures elderly ... · – 7.5% intraop – 12 control, 3...
TRANSCRIPT
Appropriate Use of Surgery in the Elderly Patient with Spinal Deformity
Preoperative Optimization in the Elderly
Disclosures
• Research/Institutional Support:– NIH, NSF, AO Spine, OREF
• Honoraria:– Medtronic, Stryker, Globus Medical
• Ownership/Stock/Options:– Providence Medical, Green Sun Medical
• Royalties:– Medtronic, Stryker
Overview• Broad Spectrum of Pathologies and Surgical Options in the Elderly
patient with deformity– Multiple Disciplines involved in care
– Variability in Care
• Optimization across the Continuum of Care– Non-operative
– Preoperative
– Operative
– Postoperative
• Risk Stratification and Modification
– Checklist/ Recognition
• Creating Standard Work Protocols
Introduction
• Spinal Deformity in the elderly– Degenerative changes within the deformity:
• Stenosis
• Spondylolisthesis
• Rotatory subluxation
• Lumbar hypolordosis
• Osteoporosis
• Neuromuscular Pathologies– Sarcopenia
Approaches to Spinal Pathology
• Characterized by significant variability– Non-operative care
– Operative Strategies
– Interdisciplinary Care
– Cost of Care
Variability in approach to care
• There is significant variability in operative and non-operative care for Spinal disorders
• An evidence-based approach to care guided by clinical outcomes research and predictive modelling may reduce variability in care
Informed Choice and Appropriate Care
Empowering informed choice in the management of Spinal Disorders
• Valid Information on Natural History
• Valid Information on Outcomes of operative and non-operative options– Risks of Care
– Expected Benefits of Care
Informed Choice under Conditions of Uncertainty
• AUC indicate reasonable care based on available evidence combined with a rigorous, transparent recommendation process and well-defined scenarios.
• Appropriate Use Criteria (AUC) specify when it is appropriate to perform a medical procedure or service. An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin.
Instructions for Rating Management Procedures and Strategies
Making Informed Choices under conditions of Uncertainty
9
1 2 3 4 5 6 7 8 9
AppropriateReasonableInappropriate
An inappropriate procedure or management strategy is defined as one in which the value (benefit per unit cost) is LOW: The expected negative consequences exceeds the expected health benefit such that the procedure should not be performed.
A reasonable procedure or management strategy is one in which:The balance of risk and benefit are not known, but there is a reasonable chance of positive net benefit, with limited risk.
An appropriate procedure or management strategy is defined as one in which the value (benefit per unit cost) is HIGH: The expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.
Most inappropriate
Most appropriate
Fitch et al. 2001
Rand/UCLA AUC Methodology
• Drivers of Appropriateness– Pre-operative Symptoms
– Progression of Deformity
– Sagittal Alignment
– Comorbidities
• Delphi panel with 53 surgeons from 23 countries
• Evaluation of appropriate evaluation and treatment strategies for adults with deformity in each stage of care– Preoperative- goals and preparation
– Intraoperative strategies
– Post-operative management
Appropriate Care
• Expected outcomes:– Risks
– Benefits
• Alternative options– Non-operative
– Limited surgery
– Extensive surgery
Risk and Behaviour
• Influence of risk/benefit calculations on appropriate decision making
• Moral Hazard– Dissociation of the risk and benefit
• Party that makes decision is recipient of benefit and shielded from risk
• Insurance, Banking, Medicine
Medical Decision Making
• Disassociation between the Decision maker and the Beneficiary– Judge and Executioner
– Home Inspector and Contractor
– Physician and Surgeon?
Defining the Goals of Surgical Care
• Safety• Neural decompression• Alignment of the spine
– Correction of deformity
• Prevention of Progression• Improvement of health-related
quality of life– General health status– Disease-specific health status
Adjusting Goals of Spine Surgery
• Management of Comorbidities– Cardiopulmonary
– Osteoporosis
– Frailty
• Adjustment of Surgical Strategies– MIS approaches
– Vertebral Augmentation/Fixation Strategies
– Adjustment of Surgical Goals
– When to do Less
– When to say “No” to surgical options
Goals of Deformity Correction
• SVA more anterior with increasing age
• Loss of Lumbar Lordosis with Age
• Analysis of Sagittal Alignment in 131 Volunteers– Forceplate Analysis
– Radiographic Parameters
Surgical Planning
• By failing to prepare, you are preparing to fail.
• - Benjamin Franklin
• Forewarned, forearmed; to be prepared is half the victory.
• - Miguel de Cervantes Saavedra
• Those who plan do better than those who do not plan even thou they rarely stick to their plan.
• - Winston Churchill
Adjusted Goals of Spine Surgery in the Elderly
SVA
C7 T1
T1 Tilt
<8cm <00
PT
<250Proportional:
LL=PI – (10 or 150)
Comorbidities in the Elderly
• Medical Considerations/ASA Score– Cardiovascular Fitness
– Pulmonary Health
– Renal disease
• Bone Quality
• Neuromuscular Comorbidity
• Mental Health– Depression/Anxiety
• Social Support
INTERSECTION OF DISEASES
•more common in the elderly
osteoporosis spinal disorders
Neuromuscular Comorbidity
Mitochondrial Myopathy
• Rapid Progression of
Decompensated and Atypical Deformity
Pre-operative Considerations
Risk Assessment
• Assess risk/benefit• Appropriateness
of surgery• Align
expectations• Shared decision
making
Medical Optimization
• Smoking• Nutrition• Obesity• Diabetes• Cardiopulmonary• Bone Health• Narcotics
Surgical Planning
• Multidisciplinary Planning• Preoperative
Planning Conference
• Manage adjacent levels
• Osteoporosis• Guidance system
Physical Optimization
• General physical conditioning
• BMI• Physical Therapy• Independence• Home Support
EMR based Risk Stratification
Standardized Ordersets
Preoperative OrdersetsModifiable Medical Co-morbidities
• Preop evaluation– Bone Density
– Pulmonary
– Cardiac
– Nutritional
– Psychological
– Social
Osteoporosis
• Pre-op identification with DEXA/Opportunistic CT
• Antiresorbtive Medications– Bisphosphonates
• Pre-operative Anabolic Medications– Teraperatide
• Fixation Strategies for the Osteoporotic Spine
Smoking• Relative risk of post operative
pulmonary complications: 1.4-4.3 (coronary bypass)
• Declines if d/c’d >8 wks preop• d/c’d > 6 mon, normal risk of pulm
complications• If d/c’d < 8 wks –> higher risk
• Complications increased by pulm function– ↑pack years– ↑surgical time– Use enflurane
» Warner, et al, 1989
COPD
• Up to 4.7 relative risk of pulmonary complications
• Bronchodilators, PT, antibiotics, smoking cessation, corticosteroids to minimize symptoms (airway obstuction), optimize exercise tolerance
Overall health
• Exercise capacity– Exercise Stress test
– Inability to perform 2 min supine exercise HR 99 bpm
– METS <4– strong predictor of cardiac
complications
– 79% of complications in patients with poor exercise tolerance patients
Cardiac
• Perioperative β-blockade– Eligible patients
• Minor criteria(2 of: >64yo, HT, smoker, chol >240, NIDDM)
• Cardiac risk (ischemic heart disease, cerebrovascular disease, IDDM, chronic renal insufficiency [Cr 2.0])
– 90% reduction in cardiac events (30 d)
– Decr mortality at 1 and 2 yr (intrathoracic/peritoneal vasc surg)
Obesity and BMI
• Identify patients with BMI >35– Dietary changes
– Gastric Bypass Surgery
Frailty/Sarcopenia
• Mortality Nomogram
Risk reduction
• Deep breathing exercises
• Cont positive airway pressure (for pts unable to coop)
• Incentive spirometry – Decr risk of pulm
complications up to 50%
Celli, 1984Thomas, 1994
Perioperative β blockade
• Pre-induction– PO up to 30 days prior or
– IV just before induction
– Decr HR <80/m (hold for <55 or BP sys <100)
• Up to 1 mon post op (or longer)
Pre op β blockade
• Side effects (unusual)– Bradycardia
– Heart block
– Hypotension
– Bronchospasm
– CHF
Post op β blockade
• TKR patients (107) risk of CAD randomized – esmolol 1 h post op, HR <80 bpm– metoprolol po, till hosp d/c
• EKG ischemia – 2.8% preop– 7.5% intraop– 12 control, 3 study pts post op
Urban et al, 2000
Relationship between cardiac and non-cardiac complications
• Reviewed 3970 pts (1191 ortho, incl spine)
• Cardiac complications more likely to suffer noncardiac comp (48%)
• Non-cardiac complmore likely to suffer cardiac comp
Fleischmann, et al, 2003
Diabetes
• Perioperative glucose control
• HgbA1c<7.5, BS<200 mg/dl– Decr rate of wound infections
– Respiratory failure
– Shortened ICU stay
Wiener-Kronish 2005
Nutritional status
• Studies demonstrating increased infection and complication rates if nutritional depleted– Identify by Serum Pre-
albumin levels
– Preop nutritional depletion most likely:
• Chronic disease
• Age >60
• Osteomyelitis
• Spinal cord injury -Klein et al, 1996
Evaluate at risk patients
• Prealbumin
• Albumin
• Transferrin
• Treat with supplementation pre op, perioperatively– TPN:well tolerated, expensive,
complications
– Tube feeds: more physiologic, low acceptance
Psychological preparation
• Stress of surgery, hospitalization can increase psychologic symptoms
• Increased depression post op• Therapeutic medication
levels can be hard to maintain post op (NPO patients, Li)
Social preparation
• Family engagement• Support system
– Anticipate post op challenges– Stability
• Perioperative stressors: recent or upcoming events (divorce, death, marriage)
• Expectations for surgery: need for care, time off work, financial burden, pain relief
Intra-operative Considerations
Blood Conservation/Fluid
Management
• Amicar/TXA• Cellsaver• Transfusion
Protocol• Colloid to
Crystalloid ratio
Neuromonitoring
• Neuromonitoringprotocols
• Algorithm for positive change
Surgical Technique
• Two attendings• Protocol for
staging• Equipment• Radiography• Achieve goals of
surgery• Intra-op• Post-op
Reduce complications
• Pain management• Antibiotic
prophylaxis• Blood sugar
control• Normothermia
Six Sigma Methodology
DMAIC – Process Improvement
• Define the problem
• Measure the causes
• Analyze the root causes
• Improve with trial interventions
• Control the implementation and follow-up processes
Post-operative Considerations
Pain Management
• Standardized protocol
• Chronic Pain Considerations
Mobilization
• Early Mobilization
• Post-op chairs• PT protocols
Nutrition
• Early enteric feeding
• 2400kcal/d
Medical Complications
• DVT prophylaxis
• Delirium prevention
• Foley
Discharge Considerations
Home
• Preoperative Preparation
• Home Health Services
• PT/OT
Rehabilitation
• Mobilization protocols
• Communication of Care Plan
• Precautions
SNF
• Mobilization• PT Protocols
Communication Pathways
• Health Loop• Nurse Navigator• Clinic Visits over
ER visits• Measuring
outcomes and PROs
Post-operative Accountability
• Measurement of HRQoL/Registries– NASS
– ISSG
– AOKF
– N2QOD
Conclusions
• Spinal Deformity is an important and common cause of morbidity in elderly patients
• Recognition of factors associated with perioperative complications and mortality is important for patient safety
• Perioperative risk is important for informed choice in spine surgery, and for participating in the choice to “say no” or to work toward preoperative optimization
• Preoperative optimization of modifiable risk factors reduces risk of perioperative complications and death in deformity surgery
Conclusions
• Spinal Disorders encompass a broad spectrum of pathologies, and require care from multiple disciplines including non-operative and operative providers
• Optimal Management of Spinal Disorders requires interdisciplinary collaboration, and care plans that span the continuum of care
• Accountability across the continuum of care is an important goal for our spine service, especially in the era of healthcare reform
• Our Spine Surgical Home is directed to integration of the multiple disciplines that care for patients with spinal disorders, and the development of an evidence-based approach to care characterized by consensus rather than variability.
UCSF Center for Outcomes Research