What is assessed before surgery
The risk is determined by the state of the systems that bear the strain of the operation and the anaesthetic:
- The heart - a past heart attack, arrhythmia, heart failure, the state of the valves.
- The blood vessels - how well blood pressure is controlled.
- The lungs - chronic disease, smoking, asthma.
- Blood clotting - and the drugs that affect it.
- Diabetes - how well controlled it is. Uncontrolled diabetes sharply raises the risk of infection and impairs healing.
- The kidneys and liver - they clear the anaesthetic drugs.
- Weight - excess weight complicates both the operation and the recovery.
- Bone density - when implant fixation is planned: screws hold less well in osteoporotic bone.
- Infections - any active focus, including teeth and the urinary tract.
That is exactly why a full work-up is required before surgery rather than a note from a physician. If a value is out of range, the operation is postponed and that value is put right first.
Age: 70, 80 and beyond
That is not a polite formula. An eighty-year-old with controlled blood pressure, normal tests and an active life tolerates an operation better than a fifty-year-old with untreated hypertension and uncontrolled diabetes.
Elderly patients were the subject of my PhD thesis: I studied the course and the treatment strategy of traumatic peripheral nerve injuries in exactly this age group. The conclusion, borne out by thirty years of practice: what decides is the state of the body, not the date of birth.
What does change with age is the choice of method. For older patients, these are more often the right choice:
- Percutaneous techniques - vertebroplasty, nerve blocks, denervation. Often under local anaesthesia, without a general anaesthetic.
- Minimally invasive operations - less blood loss, a shorter anaesthetic, earlier mobilisation.
- A smaller procedure wherever that solves the problem.
And one more consideration that is rarely voiced: in an older patient the risk of doing nothing is often greater than the risk of operating. A month in bed because of a vertebral fracture means pneumonia, thrombosis and a loss of muscle after which the person never gets up again. Against that, a forty-minute procedure under local anaesthesia is far safer than it may seem.
What complications occur
An honest conversation before the operation beats searching a forum for answers afterwards.
Common to any operation:
- A reaction to the anaesthetic.
- Bleeding and blood loss.
- Wound infection.
- Deep vein thrombosis, especially with prolonged immobility.
- A flare-up of chronic conditions.
- Injury to the dura with leakage of cerebrospinal fluid - usually repaired during the same operation.
- Injury to a nerve root - rare, but possible.
- Recurrence of the herniation at the same level.
- Scar tissue around the root.
- Instability of the segment after removing a significant amount of bone.
- With implants, their displacement or loosening, more often in bone of low density.
- Persisting numbness if the root was compressed for a long time.
- Injury to the dura with leakage of cerebrospinal fluid - usually repaired during the same operation.
- Injury to a nerve root - rare, but possible.
- Recurrence of the herniation at the same level.
- Scar tissue around the root.
- Instability of the segment after removing a significant amount of bone.
- With implants, their displacement or loosening, more often in bone of low density.
- Persisting numbness if the root was compressed for a long time.
Pain after a successful operation goes away almost always. Numbness does not always: a nerve recovers slowly and incompletely if it suffered for years. That is worth knowing in advance, so that the normal course of events is not mistaken for failure.
If surgery is not an option right now
- Weakness in a limb is increasing
- Loss of bladder or bowel control
- The pain has not been controlled for months
- The walking distance is shrinking
- Quality of life is falling and the cause is visible on the scan
- A nerve block - relieves the pain and pinpoints its source
- Denervation - for facet pain, without an incision
- Vertebroplasty - for a fracture, under local anaesthesia
- Physical therapy and rehabilitation
- Getting coexisting conditions under control and reassessing later
What next
If you were refused because of your age, come with your scans on a disc or a flash drive and we will look at them together. If you doubt the scope of the operation you have been offered, a second opinion is normal practice, not an insult to the surgeon.
