Neurosurgery in the elderly patient
Authors: Iacob Gabriel 
Published: September 2019

Objective. For government officials and health providers, elderly population - aged 65 and over, especially neurosurgical patient, represent a larger concern, an increasing problem not only for socio-economic reasons related to the medical act, but also for additional care requirements which should be done by the family and society, including rehabilitation facilities, occupational & physical therapy, speech therapists, visiting nurses, to insure an effective recuperation after hospital discharge. A retrospective study with 325 "elderly" patients cohort, aged 65 and over, admitted in the Neurosurgery Department undergoing common neurosurgical procedures, in the last five years offer an evaluation for neurosurgical procedures, outcomes, comorbidities, anaesthetic and analgesic requirements, outcome.

Material and method. This study was performed on patients aged 65 years or older, with neurosurgical diseases, admitted to the Neurosurgery or the Intensive Care Unit of our hospital, between 2014-2019. An analysis was made on variables such as age, pathology, comorbidities, length of hospital stay especially in the ICU unit, type of cranio-cerebral or spinal procedures performed, anaesthesia protocols, complications, performance status, re-admissions and mortality.

Results. Patients age were divided into three categories: between 65-70 years old there were 152 patients (46,76%), between 70-85 years old 93 patients (28.61%) and over 85 years old 80 patients (24,61%). 173 patients were females (53,23%), 152 were males (46.76 %). The admission Glasgow Coma Scale (GCS) score to those over 85 years old was between 3-12 in 29 cases (8.02%) with early death in 13 patients. Several comorbidities were noticed in 294 patients (90.15%): cardiac, pulmonary, hematologic especially coumarinic overdose, hepatic and renal failures, psychiatric illnesses, concomitant systemic disease or immunosuppressed patients by decompensated diabetes, primitive cancers affecting various organs, infectious diseases, also severe osteoporosis, chronic ethylic intoxication, limiting surgical attitude, also obtaining the informed consent for surgery. There were 154 (47,38%) patients with cerebral pathology and 171 (52,61%) patients with spinal pathology. Most common surgical procedures performed were: craniotomies for tumours and hematoma removal, minimal invasive procedures for spine, endovascular and vertebroplasty. The median length of stay for emergency patients was significantly longer than that of elective patients (13 vs. 8 days). For 215 (66.15%) patients general anaesthesia was performed, local anaesthesia in 97 (29.84%) patients, 13 patients (4%) were not operated. Good quality of life results appreciated by patients and relatives were recorded in 236 cases (72.61%) in the first and second category; less better results to those over 85 years old; same symptoms especially pain 63 patients (19.38%), complications to 47 patients (14,46%) especially cardiac, renal and respiratory failures, also motor deficits, seizures, CSF fistula, mortality in 26 cases (8%), re-admissions in 45 cases (13.84%) less than 1 month after discharge.

Conclusions. Old prejudices that old age is a contraindication for surgery have to be removed. Clinical and surgical decisions for neurosurgical procedures in the elderly are decisive for limiting reported morbidity and mortality rates. For life quality, realistic family and society expectations, several aspects should be considered for safe and effective results: careful patient selection on patient status, comorbidities and physiological reserve; neurosurgical pathology, urgency of the surgical procedure, the strategy of neurosurgical management based on advances in imaging and interventional radiology, minimal invasive neurosurgical procedures with significant preoperative and postoperative care. Good results could be obtained even in elderly people for chronic subdural hematoma, simple brain or spinal tumour, good grade aneurysm, trigeminal pain, vertebroplasty in spinal vertebral fractures, etc.