All right. Our next speaker is Dr. Bruce Splavsky from Croatia. Shifting Paradigms in the Surgical Treatment of Cervical Spine Degenerative Disease Related to Age. Good chairpersons, ladies and gentlemen, good morning. First of all, I would like to express my gratitude to the organizers of this meeting for giving me the opportunity to present our research which is concerned with the effects of surgery of cervical spine degenerative disease on the elderly population. This research is, in fact, a mutual effort from our institution in Zagreb, Croatia, and our colleagues and friends from Sam's Murphy Surgical Clinic and the University of Tennessee in Memphis, Tennessee. So the topic of our presentation is Shifting Paradigms in the Surgical Treatment of Cervical Spine Degenerative Disease in Elderly Population. In the introduction, I would like to mention that the dynamic anatomy of the cervical spine has a decisive influence to the development of cervical degenerative disease which is related to the age. Sorry. Anterior cervical dystectomy and fusion, known as ADCF, is a surgical method to treat cervical spine degenerative disease, allowing sufficient neurotic compression, cervical lordosis restoration, and solid bone fusion. Various ACDF implants are in use, including P-cages, titanium cages, osteocelegraphs, and having variable effects on treatment outcomes. Aging of the population results in increasing number of advanced age patients who are candidates for cervical spine surgery and require particular assessments. The objective of this research was to investigate clinical and radiological parameters of osteocelegraphs ACDF and outcomes in different age groups of patients. And the additional aim was to find out the surgical agility of elderly patients with cervical spinal degenerative disease is concerned. In this research, a cohort of patients who underwent bone allograft ACDF surgery for cervical degenerative disease at a single institution over a three-year period was analyzed. Radicular pain density was assessed before and after surgery using a vascale. And clinical symptoms and radiological signs of the disc herniation and or cervical spondylosis or myelopathy were reviewed. The NAC disability index was also used as an additional assessment of preoperative and postoperative limitation of daily activities. Odom's criteria were employed as standardized outcome measure, dividing the patients, the outcome of the patients into poor, fair, good, and excellent. All patients were followed up for at least two years after surgery and statistical analysis of the investigated variables were performed. As I have said, preoperative and postoperative radicular pain intensity was assessed by visual analog scale, which provides an estimate of patient's pain intensity starting with no pain and proceeding with annoying, uncomfortable, dreadful, and finishing with horrible and agonizing or excruciating pain, which was numbered as WAS10. Preoperative and postoperative limitations of daily activities was assessed by NAC disability index, which consists of 10 items considering pain intensity, personal care, lifting, weight lifting, sleeping, driving, recreation, headaches, concentration, reading, and work. The 10 items with six possible answers in each are scored zero when there were no activity limitation to five when there were major activity limitations, and then the answers are summed up to yield a total score. Clinical signs and symptoms were also assessed. Neurological status was considered normal if no objective neurological findings were present. Minor deficit were considered if sensory changes in the arms and minor loss of motor strength in the arms. Moderate deficit was proclaimed when significant sensory or motor deficits were present in the arms, and severe deficit was considered when signs of compressive myelopathy were present. The outcome was assessed by standardized outcome measure according to the Odom's criteria, which divides the patient between excellent outcome. It is the outcome when all preoperative symptoms were relieved and the patients were able to carry out duties, occupations, daily occupations without any impairment. It was considered good when minimum persistence of preoperative symptoms were present and the patients were able to carry out daily occupations without significant interference, and it was considered fair when relief of symptoms of preoperative symptoms but whose physical activities were significantly limited and poor when symptoms and signs were unchanged or worse. Cervical spine configuration was assessed on cervical spine functional radiographs before and after surgery according to Bansal's criteria, and a quantitative analysis of preoperative and postoperative cervical spine configuration was done using the posterior tangent angle according to Harrison. The relationship between preoperative and postoperative cervical spine configuration and pain intensity were analyzed, and the patients were divided into three subgroups according to their age, a younger age group between 20 and 39 years old, middle age group between 40 and 59 years old, and elderly population about 60 years old. The outcome for each subgroup was analyzed separately before being analyzed together and compared afterwards. Assessment of cervical spine configuration according to Bansal's criteria divides the position of the spine among large oses, straight spine, and kyphosis. Preoperative functional lateral radiographs inflection extensions performed at 6, 12, 18, and 24 months were the criteria used for the fusion, bone fusion assessment. Quantitative analysis of cervical spine configuration and cervical spine curvature measurement were done using the posterior tangent angle according to Harrison when were negative values denoting kyphosis. So this is the results, demographic data of 154 analyzed patients. There were female predominance, and the distribution according to the age was more or less similar. There were no major differences in the age distribution of the series. According to the number of levels operated on, the majority of patients were single level or two level, while three or four levels were less frequent. Considering the preoperative and postoperative pain intensity, a statistically significant difference was observed between pre and post pain intensity. Pre and post-op activity limitations assessed by NDI were also significantly significant, statistically significant. Considering the neurological status, postoperative intact neurological status was significantly increased after the operation was carried on. Considering spine configuration, postoperative preservation of low doses was recorded in great majority of patients undergoing ACDF regardless of age. Considering the treatment outcome, excellent or good outcomes were achieved in great majority of patients also regardless of age. But this is interesting. Distribution of patients according to the age groups, no statistically significant difference were observed among four categories of treatment outcomes according to Odom's criteria. And in conclusion, I would like to stress that postoperative pain intensity was significantly decreased in our series of patients, intact neurological status were overwhelmingly recorded, postoperative limitation of daily activities was markedly reduced, and marked improvements in postoperative spine configuration or preservation of low doses were recorded. Outcomes were favorable in the majority of our patients regardless of age. Therefore, treatment outcomes were independent of patient's age or type of compression, compressive pathology, indicating that also cellographed ACDF is not influenced by age-related parameters. So advanced age patients suffering cervical spine degenerative disease should not be denied surgery but should be selected for surgical treatment based on their symptoms and radiological signs alone. Paradigms of surgical treatment of cervical spine degenerative disease are shifting towards all categories of patients regardless of their age. Thank you for your attention and greetings from Croatia.

Dr. Bruce Splavsky

surgical treatment

cervical spine degenerative disease

age

osteocelegraphs ACDF