Geriatric neurosurgery

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

With an increasing elderly population, the number of neurosurgical patients aged 65 and over is rising. Ageing is closely related to multimorbidity and frailty, which are both recognised risk factors for postoperative complications and mortality. Comanagement by geriatricians and surgeons has been shown to reduce the length of admission and improve postoperative outcomes in orthopaedics, but evidence for this in neurosurgical patients is limited.

• Evaluation of Neurosurgery Consultations in Hospitalized Geriatric Patients During and After the COVID-19 Pandemic
• Neurosurgery in the elderly: Findings from a cohort in the Philippines
• The role of medical speciality input in the management of older neurosurgical inpatients
• Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report
• Anti-Epileptic Drugs in Geriatric Neurosurgery: A Review of 669 Neurosurgical Cases
• Clinical Outcomes After Ventriculo-Peritoneal Shunting in Patients With Classic vs. Complex NPH
• Case Series of Skull Base Meningioma Resection in the Octogenarian Population
• Palliative care of older glioblastoma patients in neurosurgery

Geriatric neurosurgery is an evolving subspecialty in neurosurgery. There is an increasingly growing population of the elderly population all over the world ¹⁾)

All surviving baby boomers in Western countries will reach that age by 2030. In addition, the population of those aged 85 years and older is the world’s fastest-growing demographic and will represent 2%–3% of the world population by 2030. Also in 2030, China’s population will consist of more than 200 million people older than 65 years and 66 million people older than 80 years ²⁾

Elderly patients can tolerate neurosurgical procedures with satisfactory outcomes. Age, presence of comorbidity, and pre-operative performance status should not be used to deny this vulnerable population of neurosurgical procedures. ³⁾.

A critical part of assessing the appropriateness for surgical intervention in older patients may be to change from a mindset of age to one of frailty and growing interest in scales assessing this may aid treatment decisions in the future ⁴⁾.

To evaluate the demographics of the elderly neurosurgical population, and determine if input by medical teams or completion of frailty scores impacts patient outcomes.

A retrospective notes review and review of coding and HES data, including length of stay, number of comorbidity, and mortality rate, was collected for geriatric neurosurgery and spinal surgery patients 65 years and older who were discharged following inpatient admission from April 2019 - March 2020. Full medical notes were retrieved for patients with a length of stay exceeding 14 days, with data on frailty scores and involvement of medical teams collected. Statistical tests were applied to evaluate the difference in outcomes between those reviewed and those not reviewed by medical teams.

Eighty-one patients had a length of stay over 14 days. 43% of these 81 patients were reviewed by medical teams during their admission. The mean length of stay was significantly shorter in those receiving medical input (22.8 ± 10.6 days vs 32.4 ± 16.0 days, p = 0.003). There was also a significant association between the completion of a clinical frailty scale and subsequent input by medical teams.

The reduction in length of stay observed when patients were reviewed by medical teams supports the role of elderly care physician comanagement in the elderly inpatient neurosurgical population ⁵⁾.

This is a retrospective study of geriatric cases admitted to the Neurosurgery Department in Khoula Hospital from January 1, 2016 to December 31, 2019. A medical records of 669 patients were identified. Patients' demographics, risk factors, usage of anti-epileptic drug (AED), type of tumor, tumor location, neuro-vital signs diagnosis, Glasgow coma scale on arrival, treatment types, and length of stay (LOS) were recorded.

Results: The prevalence of AEDs use was 19%. Patients with traumatic brain injury (TBI) were found to have a higher rate of using AEDs (32.1%) followed by patients with oncological and vascular pathologies, respectively (30.1% and 21.6%). There was a significant relationship between the utilization of AEDs among different neurological diseases investigated (p<0.05). Patients who received surgical interventions were using AEDs much more than patients with conservative management (p=0.001). There was a significant difference in the LOS and the usage of AEDs. Added to that, the results signify a relationship between the intensive care unit (ICU) admission and the utilization of AEDs in which the majority of the patients who were not on AEDs were not admitted to the ICU (p<0.05). Phenytoin was the most commonly used AED among different neurosurgical pathologies in the present study (n=110).

Conclusions: AEDs are used as prophylaxis to prevent seizures before most neurosurgical procedures and were commonly prescribed in TBI patients. Phenytoin was found to be the commonest AEDs utilized among the different neurosurgical categories followed by levetiracetam ⁶⁾.

A retrospective series reviews skull base tumor surgeries performed at a single academic institution over the past 15 years in octogenarian patients. Primary endpoint was 30-day mortality; however, potential risk factors, perioperative morbidity, postdischarge disposition, and longer term follow-up were also captured. Multivariate logistic regression was performed to identify relevant perioperative and medical characteristics that increases the risk of adverse events. Results Fourteen patients underwent craniotomies for skull base procedures with an average age of 84.5, with a 14% 30-day mortality rate. One patient required a tracheostomy on discharge and approximately half were able to either go home or rehabilitation after their procedure. On statistical analysis, there were no noted characteristics that predisposed any of the patients to a poorer outcome. Conclusion Octogenarian patients were able to tolerate surgery for skull base meningiomas resection. This outcome data may be used to inform surgical decision and guide conversation with patients and their families ⁷⁾

The study has two components; (i) a pilot study was performed that specifically focused upon patients with Complex NPH and following the inclusion of the Complex NPH subtype into consideration for the clinical NPH programme, (ii) a retrospective snapshot study was performed to confirm and characterize differences between Classic and Complex NPH patients being seen consecutively over the course of 1 year within a working subspecialist NPH clinic. We studied the characteristics of patients with Complex NPH, utilizing clinical risk stratification and multimodal biomarkers.

Results: There was no significant difference between responders and non-responders to CSF diversion on comorbidity scales. After VPS insertion, significantly more Classic NPH patients had improved cognition compared to Complex NPH patients (p = 0.005). Improvement in gait and urinary symptoms did not differ between the groups. 26% of the Classic NPH group showed global improvement of the triad, and 42% improved in two domains. Although only 8% showed global improvement of the triad, all Complex NPH patients improved in gait.

The study has demonstrated that the presence of neurodegenerative disorders co-existing with NPH should not be the sole barrier to the consideration of high-volume tap test or lumbar drainage via a specialist NPH programme. Further characterization of distinct cohorts of NPH with differing degrees of CSF responsiveness due to overlay from neurodegenerative or comorbidity risk burden may aid toward more precise prognostication and treatment strategies. We propose a simplistic conceptual framework to describe NPH by its Classic vs. Complex subtypes to promote the clinical paradigm shift toward subspecialist geriatric neurosurgery by addressing needs for rapid screening tools at the clinical-research interface ⁸⁾.

A retrospective cohort study was performed on individuals aged 70 years or older admitted to the Neurosurgery or the Intensive Care Unit of the Hospital General Universitario de Castellón in Spain, with a neurosurgical disease, between two periods: 1999-2000 and 2010-2011. An analysis was made on variables such as age, pathology, length of stay, comorbidity, performance status, re-admissions, and mortality.

Results: Similar numbers of patients were admitted during the two periods: 409 and 413. However, there was an increase of 77.5% in patients older than 70 years: 80 versus 142. Statistically significant differences were observed in the Charlson Comorbidity Index, the admission Glasgow Coma Scale (GCS) score, length of stay, and re-admissions. Comorbidity and admission GCS scores were particularly worse in the second period. Nevertheless, the mean length of stay was lower in that period but showed more hospital readmissions. After multivariate analysis, it was observed that re-admissions were associated with comorbidity, but not with early hospital discharge. No differences were found in performance status or mortality.

A very considerable increase in the percentage of patients older than 70 years old was found. There were no differences in performance status or mortality, which was probably due to the multidisciplinary management of these patients. The results of this study support the development of an interdisciplinary work group dedicated to Geriatric Neurosurgery ⁹⁾

A study outlines the demographics and outcomes of the elderly admitted to the neurosurgery department of Queen Elizabeth Hospital in Hong Kong. The pattern variation across the 10 years showed that there was an increasing demand for geriatric neurosurgical care. Nowadays, there was about one octogenarian in every eight neurosurgery patients. Their causes of admission were mostly trauma-related and nearly one-fifth of them required neurosurgical interventions. However, functional and performance status should be considered together with calendar age in surgical decision-making and patient counseling ¹⁰⁾.

The trend of geriatric neurosurgery is increasing in developing countries. The most common reason for admission to the neurosurgical ward was TBI. The length of stay was longer in the surgical intervention group compared with the conservative group. Special care must be taken when dealing with geriatric neurosurgical cases and with a more holistic approach ¹¹⁾.

Journal of Korean Society of Geriatric Neurosurgery

A 92-year-old right-handed female with history of hypertension and basal cell skin cancer presented with a 1-month history of progressive aphasia and was found to have a ring-enhancing left frontoparietal mass abutting the rolandic cortex concerning for malignant neoplasm. Frailty scoring with the recalibrated risk analysis index (RAI-C) tool revealed a score of 30 (of 81) indicating low surgical risk. The patient and family were counseled appropriately that, despite advanced chronological age, a low frailty score predicts favorable surgical outcomes. The patient underwent left-sided AC for resection of tumor and experienced immediate improvement of speech intraoperatively. After surgery, the patient was neurologically intact and had an unremarkable postoperative course with significant improvements from preoperatively baseline at follow-up.

This case represents the oldest patient to undergo successful AC for brain tumor resection. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric neurosurgery population ¹²⁾.