The Geriatric Spine Syndrome: No Surgery For Her

By | June 15, 2011

Denying a person appropriate medical care is a form of Elder Abuse, even if it is unintentional.

You will remember that one of the classic features of the Geriatric Spine Syndrome is that the patient and the family refuse surgery before it has been proposed. This statement results from one of two misconceptions: either all spinal surgery is bad or mother is too old or sick to undergo back surgery.

Let’s deal with the second problem first. This is nothing other than simple age discrimination. All patients deserve the same quality of care regardless of age. This does not mean that we will make the same decisions regardless of age, but simply that the intellectual rigor and the level of concern cannot be lower for the elderly than the young.

 

I usually council the patient and the family that practically speaking, the workup of a new adult patient with back pain should vary little if at all, based on age. By this I mean that the history, physical exam, laboratory tests and imaging studies should be nearly the same for a 30 year old as a 90 year old. Now the prevalence of different spinal conditions will vary markedly with age and the decisions that one would make even given the same findings will also vary, but the steps necessary to arrive at an accurate diagnosis don’t. Even when one takes age into account, I remind the patients and families that it is physiologic age and not chronologic age that matters. A healthy 90 year old may be a capable of undergoing a procedure that a chronically ill 50 year old would not. There are no simple rules and the only way to make such decisions is after extensive discussions with the physician, patient and concerned others.

 

Furthermore, when I speak to the patients about obtaining a surgical consultation, this is usually not a recommendation that the patient have surgery, but rather that they see a surgeon to assess questions of spinal stability and to enumerate the surgical options. This is critically important because as we will discuss in the next blog, surgical procedures vary widely as do their success rates, morbidity, convalescent periods and complications. Obviously a short, simple procedure with a high success rate, low morbidity, rapid convalescent phase and minimal complications would be worthy of consideration even in a 90 year old, whereas a more extensive procedure with a relatively low success rate, high morbidity, long arduous convalescence and multiple severe complications wouldn’t.

 

One size fits all is not a good model for baseball bats, barbeques, belts, bridge bids or bowling balls and it is certainly not a good model for health care. I hope that you can now see that age is not a simple discriminator, but merely another factor to be considered in the delivery of personalized health care.

 


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