Our next speaker is Dr. Odagwa, Interdisciplinary Neurosurgery Geriatric Care Model Reduces Time to Initiation of Postoperative Oral Narcotic Pain Regiment in Elderly Patients Undergoing Deformity Correction Surgery. Good afternoon. I was just thinking that was a very difficult talk to follow. I want to thank the scientific committee and certainly my collaborators for this work. My mentors, both at Rush and at the University of Cincinnati, nothing to disclose. The population of patients over the age of 65 remains the fastest-growing population in the country. If you look at those over the age of 85, that's even a faster-growing population. These patients are requiring surgical intervention not only to improve the quantity of life but also the quality of life. Most of the studies that have been published look at the rates of fusion procedures in elderly patients, and those numbers continue to trend up. Numerous studies, including some that we've been part of, have demonstrated that these patients, when selected properly, go on to do just fine with primary or revision operations. This is a study from Justin Smith and the International Spinal Deformity Study Group looking at outcomes across the board in all patients who undergo corrective surgery for degenerative scoliosis. And the take-home point from this is, and the graph on the left is the Osler Disability Index, and the one on the right is pain. Across the board, everyone does well with surgery for the most part. But you look at the patients between the age of 65 and 85, and these patients demonstrate the greatest improvement in functional ability and greatest reduction in pain after surgery. So there is a lot of benefit to these operations in elderly patients. It's a game of high-risk, high-return. This is another chart from that paper. The complication rates, both minor and major complications in these patient cohorts, and not surprisingly, three out of four patients experience a major or minor complication after these operations. Some of the biggest operations in all of medicine. These can range from cardiopulmonary complications to MIs to delirium and pneumonia and so on and so forth. One of the major drivers of post-operative complication in this patient cohort, at least we presumed, were patients with prolonged IV analgesics. These patients were more likely to have immobility-related complications, DVTs, PEs, pressure ulcers. There was a delayed ambulation in this cohort, increased incidence of delirium, ultramenal status, and certainly ileus. And we thought that this could potentially contribute to a prolonged length of hospital stay. In contrast, we thought that if you transition these patients earlier, within 24 hours, to an oral regimen, that you can mitigate or reduce the incidence of some of these complications. So how do you operate in elderly patients who clearly benefit from this operation in a safe manner and improve the outcomes in these patients while decreasing the complication rates? This is a model that we came up with about a year and a half ago looking at the geriatric neurosurgical care model. The aim of this model was threefold. One, identify patients, high-risk patients who were scheduled for surgery. We found that 50% of all our patients undergoing these big operations were malnourished at the time of surgery, retrospectively when we look at our numbers. Through a single multidisciplinary visit, identify risk factors for complications and mitigate those complications. And then have a multidisciplinary team, the nutritionist, the physical therapist, the geriatricians, and so on, or whatever teams you can put together for all these patients postoperatively, longitudinally in the hospital. This is the model that most of you are accustomed to. You schedule a patient for surgery. They see the pre-op anesthesia clinic. They optimize these patients. They get some blood work. And then you perform the operation, and they're managed by the neurosurgery service with help from nursing care. This is the model that we propose, which is through a single visit, integrate technical expertise across multiple disciplines to optimize these patients for surgery and hopefully improve the patient outcomes. In this case, we have geriatrics. You can bring in the social workers. In our case, we have them see them before surgery. One of the things we found was, you know, we had the folks in our hospital who had a prolonged length of hospitals. They weren't staying because of complications or illness. It was because of transfer to a subacute setting. So having the social workers involved early to understand the unique challenges of these patients and transition them seamlessly is very important. Nursing care understands the unique challenges of these patients. We now bring in pain service for patients who are habituated on narcotics, and obviously you can bring the physical therapist into this model. You proceed with surgery, and in a multidisciplinary fashion, all of these different subspecialists see these patients after surgery every single day prior to discharge. So the question is, does it work? Is there benefit? Do we have a decrease in complication rates, decrease in length of hospital stay? So this is a prospective study. We followed these patients, just a sample of these patients longitudinally to assess whether this works. We collected variables that one would collect for a study of this type, clinical presentation, demographics, co-morbid conditions, indications for surgery, and so on and so forth. We dichotomized patients into two groups. If you oralized or if you transitioned to an oral regimen within 24 hours, you were placed in the early cohort. And after 24 hours, you were placed in the late cohort. At baseline, we had 70 patients in the early cohort, 52 in the late cohort. And I won't belabor the point here, but the bottom line is, at baseline, there were no statistically significant differences between the patients we looked at in the early versus the late cohorts. When you look at the operative variables, there were no statistically significant differences as well in the operative time, blood loss, and any of the intraoperative complications one might expect. Post-operative complications, this was interesting. I expected to see a difference in delirium, a difference in the incidence of alias DVTs, PEs, but it didn't really pan out here. And my suspicion is, as we collect more of this data, that we might see some differences. But so far, we haven't seen any differences in the incidence of some of the post-operative complications profiles that we thought we'd see. But this is where I thought there was a lot of significant benefit. Look, the number of days from surgery to ambulation, 1.6 days in the early cohort, 2.1 in the late cohort. The number of feet ambulated, you could see there. The length of hospital stay, almost down by 28%, 5.9 days to 7.6 days. Where did those patients went after surgery? The vast majority of patients in the early cohort went straight home. Only 37% of the late cohort would discharge home. This structural skill nursing facility, you could see the numbers there. But the key thing is, if you look at the 30-day readmission rates, we are not sending these patients home prematurely. So there's actually real benefit to having these patients managed in a multidisciplinary fashion. If you look at the pain response at baseline, there were no differences. Clearly, between both groups, they both endorsed significant improvement in their pain. And you could see at three months and six weeks, there were absolutely no differences there. We created a regression model. And the question was, does this really help when we put all these variables in a regression model? And what you could see here is, if you're not part of the multidisciplinary cohort or team, those patients are three-fold more likely to remain on prolonged IV analgesics after surgery. So we think it works. We think there's benefit to managing these patients in a multidisciplinary fashion, not only transitioning these patients early, but certainly getting the patients home in a safe fashion and they don't bounce back to the hospital. Thank you very much. Thank you.

geriatric neurosurgical care model

elderly patients

deformity correction surgery

multidisciplinary approach

postoperative care