Functional Resilience and Surgical Risk: Revisiting Multilevel Anterior Cervical Discectomy and Fusion in Younger versus Elderly Myelopathic Patients.

Degenerative cervical myelopathy (DCM) is an aging related progressive disease characterized by chronic spinal cord compression secondary to degenerative changes in the spinal column. These changes include degenerative processes such as intervertebral disc degeneration, osteophytes, facet arthropathy, spinal stenosis, ligamentum flavum hypertrophy and ossification of the posterior longitudinal ligament. The neurologic deficits associated with the above process are due to static and dynamic insults leading to ischemia, demyelination and ultimately neuronal loss. Since neurologic improvement following decompressive surgery is not always achieved, chronological age is no longer viewed as an important determinant for surgery. Anterior cervical discectomy and fusion are one of the surgical options which may be used in multilevel diseases. It may be associated with improvement in alignment and ventral decompression although complications are common. These include dysphagia, pseudarthrosis and adjacent segment disease. This study aims to review literature in MEDLINE/PubMed, Embase and Scopus databases to find out whether outcomes are better in elderly (≥65 year) compared to younger (<65 year) patients undergoing multilevel anterior cervical discectomy and fusion. Data regarding patients having spondylosis, ligament hypertrophy, OPLL, disc herniation and subluxation were gathered. Inclusion criteria of this meta-analysis consisted of excluding patients with infection, neoplasm, inflammatory spondyloarthropathies and lumbar stenosis. These data included mJOA score, Nurick grade, NDI, SF-36, sagittal alignment (C2-C7 Cobb, SVA), fusion rates and complications. All the studies have reported that there are clinically significant improvements among both age groups after surgery. High fusion rates with almost 94-96% rates reported by certain groups were noticed. Older patients have shown greater impairment in their baseline functionality, comorbid conditions, complications in early stages, longer stay in hospitals and being discharged to homes. Dysphagia was common among octogenarians. Frailty and pre-operative functional dependence were better predictors of complication, mortality, long stay and discharge as compared to age only. However, common frailty scores cannot completely represent resiliency of patients. Multilevel ACDF is an efficacious procedure in both younger and elderly patients; however, it is necessary to consider physiological reserves, frailty, dependence, disease severity and surgical complexity instead of age to help in determining risks and benefits.