Surgery delays for elderly patients with traumatic spinal cord injury

By Lucy Piper, Senior medwireNews Reporter

Older patients with traumatic spinal cord injury experience significant delays in being transferred to a specialist treatment centre and receiving surgery, compared with younger patients, study findings show.

Falls were the primary reason for injury among the older group of 167 patients aged at least 70 years, and these patients had less severe incomplete neurologic injuries, most often at the cervical level, compared with a group of 1273 younger patients.

The time from injury to arrival at an acute care centre was about twice as long for patients aged 70 years or older, at 14.5 hours versus 8.0 hours for younger patients. And there was a similar lag in the time from admission to undergoing surgery, at 37 versus 19 hours. This difference was also seen at age thresholds of 60 and 65 years.

The researchers, led by Henry Ahn (University of Toronto, Ontario, Canada), suggest that delays may have occurred in the older patients due to the lesser severity of their injuries and a perceived lower urgency for imaging and establishing a diagnosis and treatment plan. It could also reflect a potential age-related therapeutic bias, they add.

The team found that while patients aged 70 years or older were less likely than younger patients to receive surgical treatment (80.2 vs 87.7%), this was due to them having less severe injuries resulting from low-energy trauma.

However, they note in CMAJ that in a post-hoc sensitivity analysis using age thresholds of 60, 65, and 75 years in addition to 70 years, age was a significant factor determining the likelihood of surgery at the 65-year-old threshold, at an adjusted odds ratio of 0.39.

Among the 1250 patients who underwent surgery, the 134 aged 70 years or older had significantly longer hospital stays than the 1116 younger patients (35 vs 28 days) and were significantly more likely to have major postoperative complications, such as urinary tract infection, pneumonia and deep vein thrombosis (32.5 vs 22.2%), and to die while in hospital (4.2 vs 0.6%).

Although there is not yet clear evidence of a causal link between the delays in triage and surgery among older patients and the increased morbidity and mortality, the researchers believe that the differences they found “necessitate rethinking the management of traumatic spinal cord injury among older patients.”

They point out: “Reducing surgical delays for traumatic spinal cord injury, regardless of age, may help maximize neurologic improvement and avoid prolonged preoperative cervical spine precautions, which often result in adverse events such as pneumonia.”

The researchers recommend policies with mandated time frames, similar to those adopted for fragility fractures of the hip, that help optimise the appropriate imaging, clearance and urgent booking for surgery of patients with spinal cord injuries.

“Such an approach would circumvent any potential for surgical delay, including potential surgeon bias”, they conclude.

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