The relationship of older age and perioperative outcomes following thoracolumbar three-column osteotomy for adult spinal deformity: an analysis of 300 consecutive cases

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Three-column osteotomies are increasingly being used in the elderly population to correct rigid spinal deformities. There is hesitation, however, in performing the technique in older patients because of the high risk for blood loss, longer operative times, and complications. This study assesses whether age alone is an independent risk factor for complications and length of stay.


All patients with thoracolumbar adult spinal deformity (ASD) who underwent 3-column osteotomy (vertebral column resection or pedicle subtraction osteotomy) performed by the senior author from 2006 to 2016 were identified. Demographics, clinical baseline, and surgical details were collected. Outcomes of interest included perioperative complication, ICU stay, and hospital stay. Bivariate and multivariate analyses were used to assess the association of age with outcomes of interest.


A total of 300 patients were included, and 38.3% were male. The mean age was 63.7 years: 10.3% of patients were younger than 50 years, 36.0% were 50–64 years, 45.7% were 65–79 years, and 8.0% were 80 years or older. The overall mean EBL was 1999 ml. The overall perioperative complication rate was 24.7%: 18.0% had a medical complication and 7.0% had a surgical complication. There were no perioperative or 30-day deaths. Age was associated with overall complications (p = 0.002) and medical-specific complications (p < 0.001); there were higher rates of overall and medical complications with increased age: 9.7% and 6.5%, respectively, for patients younger than 50 years; 16.7% and 10.2%, respectively, for patients 50–64 years; 31.4% and 22.6%, respectively, for patients 65–79 years; and 41.7% and 41.7%, respectively, for patients 80 years or older. However, after adjusting for relevant covariates on multivariate analysis, age was not an independent factor for perioperative complications. Surgical complication rates were similar among the 4 age groups. Longer ICU and total hospital stays were observed in older age groups, and age was an independent factor associated with longer ICU stay (p = 0.028) and total hospital stay (p = 0.003). ICU stays among the 4 age groups were 1.6, 2.3, 2.0, and 3.2 days for patients younger than 50 years, 50–64 years, 65–79 years, and 80 years or older, respectively. The total hospital stays stratified by age were 7.3, 7.7, 8.2, and 11.0 days for patients younger than 50 years, 50–64 years, 65–79 years, and 80 years or older, respectively.


Older age was associated with higher perioperative complication rates, but age alone was not an independent risk factor for complications following the 3-column osteotomy for ASD. Comorbidities and other unknown variables that come with age are likely what put these patients at higher risk for complications. Older age, however, is independently associated with longer ICU and hospital stays.

ABBREVIATIONS ASD = adult spinal deformity; EBL = estimated blood loss; HRQLS = health-related quality of life score; LL = lumbar lordosis; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SVA = sagittal vertical axis; VCR = vertebral column resection.

Article Information

Correspondence Christopher P. Ames: University of California, San Francisco, CA.

INCLUDE WHEN CITING Published online April 6, 2018; DOI: 10.3171/2017.10.SPINE17374.

Disclosures Dr. Deviren: consultant for NuVasive, Guidepoint, and Medicrea; and spine fellowship grant support to the institution from Globus, NuVasive, and AOSpine. Dr. Ames: employee of UCSF; consultant for Stryker, Medtronic, and DePuy; patent holder with Fish & Richardson, PC; and royalties from Biomet Spine and Stryker.

© AANS, except where prohibited by US copyright law.



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    Images obtained in a 85-year-old patient who presented with a several-year history of severe, debilitating low-back pain on walking and standing with a forward-stooping posture. He had been very active, but his back pain and posture made his quality of life intolerable. The patient underwent L-3 PSO and long segment fusion for correction of his thoracolumbar kyphoscoliosis. A and B: Preoperative lateral (A) and anteroposterior (B) standing radiographs. The preoperative sagittal spinopelvic parameters were as follows: SVA, 17.1 cm; thoracic kyphosis, 14°; LL, −6°; and PI, 58°. The PI-LL mismatch was 64°. The preoperative central sacral vertical line (CSVL) was 7.8 cm to the right, and 27° of scoliosis was present. C and D: Postoperative lateral (C) and anteroposterior (D) standing radiographs. The postoperative sagittal spinopelvic parameters were as follows: SVA, 1.1 cm; thoracic kyphosis, 44°; LL, 42°; and PI, 50°. After correction, LL and PI were within 8°. The postoperative CSVL was 0.8 cm to the right, and 11° of scoliosis was present.


  • 1

    Adogwa OElsamadicy AAHan JKarikari IOCheng JBagley CA: Drivers of 30-day readmission in elderly patients (>65 years old) after spine surgery: an analysis of 500 consecutive spine surgery patients. World Neurosurg 97:5185222017

  • 2

    Afilalo JSteele RManning WJKhabbaz KRRudski LGLanglois Y: Derivation and validation of prognosis-based age cutoffs to define elderly in cardiac surgery. Circ Cardiovasc Qual Outcomes 9:4244312016

  • 3

    Ali RSchwalb JMNerenz DRAntoine HJRubinfeld I: Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg Spine 25:5375412016

  • 4

    Amelot ABalabaud LChoi DFox ZCrockard HAAlbert T: Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery! Spine J 17:7597672017

  • 5

    Auerbach JDLenke LGBridwell KHSehn JKMilby AHBumpass D: Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 37:119812102012

  • 6

    Baldus CRBridwell KHLenke LGOkubadejo GO: Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls. Spine (Phila Pa 1976) 35:2352392010

  • 7

    Bianco KNorton RSchwab FSmith JSKlineberg EObeid I: Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36(5):E182014

  • 8

    Daubs MDLenke LGCheh GStobbs GBridwell KH: Adult spinal deformity surgery: complications and outcomes in patients over age 60. Spine (Phila Pa 1976) 32:223822442007

  • 9

    Di Capua JSomani SKim JSLeven DMLee NJKothari P: Hospital-acquired conditions in adult spinal deformity surgery: predictors for hospital-acquired conditions and other 30-day postoperative outcomes. Spine (Phila Pa 1976) 42:5956022016

  • 10

    Flexman AMCharest-Morin RStobart LStreet JRyerson CJ: Frailty and postoperative outcomes in patients undergoing surgery for degenerative spine disease. Spine J 16:131513232016

  • 11

    Ghaferi AABirkmeyer JDDimick JB: Variation in hospital mortality associated with inpatient surgery. N Engl J Med 361:136813752009

  • 12

    Glassman SDBerven SBridwell KHorton WDimar JR: Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 30:6826882005

  • 13

    Good CRAuerbach JDO’Leary PTSchuler TC: Adult spine deformity. Curr Rev Musculoskelet Med 4:1591672011

  • 14

    Harroud ALabelle HJoncas JMac-Thiong JM: Global sagittal alignment and health-related quality of life in lumbosacral spondylolisthesis. Eur Spine J 22:8498562013

  • 15

    Hassanzadeh HJain AEl Dafrawy MHAin MCMesfin ASkolasky RL: Three-column osteotomies in the treatment of spinal deformity in adult patients 60 years old and older: outcome and complications. Spine (Phila Pa 1976) 38:7267312013

  • 16

    Kawaguchi YKanamori MIshihara HAbe YNobukiyo MSigeta T: Postoperative delirium in spine surgery. Spine J 6:1641692006

  • 17

    Kelly MPLenke LGShaffrey CIAmes CPCarreon LYLafage V: Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study. Neurosurg Focus 36(5):E172014

  • 18

    Kim KTLee SHSuk KSLee JHJeong BO: Outcome of pedicle subtraction osteotomies for fixed sagittal imbalance of multiple etiologies: a retrospective review of 140 patients. Spine (Phila Pa 1976) 37:166716752012

  • 19

    Lafage RSchwab FChallier VHenry JKGum JSmith J: Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age? Spine (Phila Pa 1976) 41:62682016

  • 20

    Lafage RSchwab FGlassman SBess SHarris BSheer J: Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976) 42:127512822017

  • 21

    Lafage VSchwab FPatel AHawkinson NFarcy JP: Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976) 34:E599E6062009

  • 22

    Lau DEl-Sayed AMZiewacz JEJayachandran PHuq FSZamora-Berridi GJ: Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years. J Neurosurg 116:2342452012

  • 23

    Lee MJKonodi MACizik AMBransford RJBellabarba CChapman JR: Risk factors for medical complication after spine surgery: a multivariate analysis of 1,591 patients. Spine J 12:1972062012

  • 24

    Leven DMLee NJKothari PSteinberger JGuzman JSkovrlj B: Frailty index is a significant predictor of complications and mortality after surgery for adult spinal deformity. Spine (Phila Pa 1976) 41:E1394E14012016

  • 25

    Li FSagi HCLiu BYuan HA: Comparative evaluation of single-level closing-wedge vertebral osteotomies for the correction of fixed kyphotic deformity of the lumbar spine: a cadaveric study. Spine (Phila Pa 1976) 26:238523912001

  • 26

    Li GSun TWLuo GZhang C: Efficacy of antifibrinolytic agents on surgical bleeding and transfusion requirements in spine surgery: a meta-analysis. Eur Spine J 26:1401542017

  • 27

    Marshall LGriffin RMundy J: Frailty assessment to predict short term outcomes after cardiac surgery. Asian Cardiovasc Thorac Ann 24:5465542016

  • 28

    McMillan DCHole DJMcArdle CS: The impact of old age on cancer-specific and non-cancer-related survival following elective potentially curative surgery for Dukes A/B colorectal cancer. Br J Cancer 99:104610492008

  • 29

    Mehta VAAmin AOmeis IGokaslan ZLGottfried ON: Implications of spinopelvic alignment for the spine surgeon. Neurosurgery 70:7077212012

  • 30

    O’Lynnger TMZuckerman SLMorone PJDewan MCVasquez-Castellanos RACheng JS: Trends for spine surgery for the elderly: implications for access to healthcare in North America. Neurosurgery 77 (Suppl 4):S136S1412015

  • 31

    Orouji Jokar TIbraheem KRhee PKulavatunyou NHaider APhelan HA: Emergency general surgery specific frailty index: a validation study. J Trauma Acute Care Surg 81:2542602016

  • 32

    Phan KKim JSSomani SDi Capua JKim RShin J: Impact of age on 30-day complications after adult deformity surgery. Spine (Phila Pa 1976) 43:1201262018

  • 33

    Ramanathan KBWeiman DSSacks JMorrison DASedlis SSethi G: Percutaneous intervention versus coronary bypass surgery for patients older than 70 years of age with high-risk unstable angina. Ann Thorac Surg 80:134013462005

  • 34

    Sacramento-Domínguez CYagi MAyamga JNemani VMAkoto HMahmud R: Apex of deformity for three-column osteotomy. Does it matter in the occurrence of complications? Spine J 15:235123592015

  • 35

    Scheer JKMundis GMKlineberg EHart RADeviren VNguyen S: Postoperative recovery after adult spinal deformity surgery: comparative analysis of age in 149 patients during 2-year follow-up. Spine (Phila Pa 1976) 40:150515152015

  • 36

    Scheer JKSmith JSClark AJLafage VKim HJRolston JD: Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction. J Neurosurg Spine 22:5405532015

  • 37

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 74:1121202014

  • 38

    Schwab FPatel AUngar BFarcy JPLafage V: Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976) 35:222422312010

  • 39

    Schwab FJBlondel BBess SHostin RShaffrey CISmith JS: Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976) 38:E803E8122013

  • 40

    Sciubba DMScheer JKYurter ASmith JSLafage VKlineberg E: Patients with spinal deformity over the age of 75: a retrospective analysis of operative versus non-operative management. Eur Spine J 25:243324412016

  • 41

    Smith JSKlineberg ELafage VShaffrey CISchwab FLafage R: Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 25:1142016

  • 42

    Smith JSSansur CADonaldson WF IIIPerra JHMudiyam RChoma TJ: Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976) 36:9589642011

  • 43

    Smith-Petersen MNLarson CBAufranc OE: Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res 66:691969

  • 44

    Soroceanu ABurton DCOren JHSmith JSHostin RShaffrey CI: Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine (Phila Pa 1976) 41:171817232016




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