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Keyhole spine surgery saved 79-year-old’s back – and sanity

SINGAPORE – When a severe degenerative spinal condition kept Mdm Tan Beow Kheng in constant pain for more than two years, the 79-year-old housewife entertained thoughts of suicide.

X-rays, post-spinal fusion surgery, of titanium screws and a spacer to fuse bones in the spine.

X-rays, post-spinal fusion surgery, of titanium screws and a spacer to fuse bones in the spine.

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SINGAPORE – When a severe degenerative spinal condition kept Mdm Tan Beow Kheng in constant pain for more than two years, the 79-year-old housewife entertained thoughts of suicide.

Speaking in Hokkien, Mdm Tan said: “I ate so many painkillers until I was ‘gong gong’ (in a daze). The 24/7 pain made me feel like I wasn’t a human being.”

Due to the intense pain from nerve compression, Mdm Tan, who used to be active and independent, could not sit up properly or walk. She tried physiotherapy, injections and traditional Chinese medicine but nothing offered long-term relief.

Last year, Mdm Tan chose to undergo spine surgery at Tan Tock Seng Hospital (TTSH) despite her initial fears and apprehension about the operation due to her advanced age.

The keyhole surgery, which was performed via small incisions of not more than 3 cm in the lower back, saved her back and sanity.

Two days after the surgery, Mdm Tan was up on her feet and could walk with assistance.

“I was very scared to do surgery at first because of the risks involved. But if I don’t do it, I felt like I might die too (from the poor quality of life),” said Mdm Tan.

MORE SENIORS SEEKING SPINE SURGERY

While the idea of spine surgery may strike fear in many elderly patients, more seniors with severe, debilitating spinal conditions are going under the knife to improve their quality of life.

TTSH, which runs a combined spine service with the National Neuroscience Institute (NNI), has seen a steady increase in elderly patients seeking spine surgery. The centre performs about 500 spinal surgeries across all age groups each year.

In 2010, a third of its patients were above the age of 60. Last year, more than half were above 60. While most elderly patients are in their sixties and seventies, some of them are above 80, said Adjunct Assistant Professor Jacob Oh, chief of spine surgery at TTSH’s department of orthopaedic surgery.

At Island Orthopaedic Consultants, about two in five patients who undergo spine surgery are above 60.

The majority of spine diseases seen in this group are linked to age-related degenerative conditions due to nerve compression, said the experts.

This could be from growth of bone spurs or spinal disc diseases in the neck and lower back, said consultant orthopaedic surgeon Leslie Ng of Island Orthopaedic Consultants.

Dr Ng’s oldest patient was an 89-year-old woman who was physically and mentally fit for her age, and had no major organ disease.

Spinal conditions as well as other musculoskeletal problems, one of the leading causes of years lost to disability in Singapore, are expected to increase with the ageing population.

Surgery is considered in cases where the pain is severe and disabling, and all other conservative and non-invasive treatment options like medications, injections, physiotherapy and lifestyle changes have failed.

“While some patients are contented with being confined to their home because of the pain, we are seeing more patients who demand a better quality of life. They want to enjoy their golden years being independent and helpful, rather than being a burden on their family,” said Adj Assistant Prof Oh, who treated Mdm Tan.

“The initial reaction of most patients and their family and friends, is to avoid spine surgery as they are too old... but eventually many choose to undergo the operation because they are so disabled by the pain and their daily function is limited, after many years of failed conservative treatment.”.

Besides symptoms of back pain, patients with nerve compression issues may experience sciatica, which is often described as a shooting electric current travelling down the leg.

In mild cases, patients may only experience mild pain or slight difficulty walking. Most of them can be managed conservatively with medication and physiotherapy, said Adj Assistant Prof Oh.

“But in severe cases, they may be able to walk for only five to 10 minutes before they have to sit down to relieve symptoms. In even worse cases, the nerve compression is so severe the patients develop weakness in the leg,” said Adj Assistant Prof Oh, who has encountered patients who become depressed due to the severe pain.

IMPROVED TECHNIQUES AND TECHNOLOGY A GAME-CHANGER

Some people have the perception that spine surgery is not safe and should be avoided at all cost. But this is not necessarily true and surgery candidates should be selected properly, said Dr Colum Nolan, consultant at NNI’s department of neurosurgery.

While conventional open spinal surgery was considered risky for seniors in the past, minimally invasive keyhole techniques and more advanced technologies have improved outcomes and reduced risks for older patients.

“Previously, in conventional open surgery, surgeons might make a big cut of around 10cm to 20cm. But now with advanced innovation and techniques, we are able to localise and treat the nerve compression more precisely.  This allows us to perform the entire procedure through a small incision, which limits collateral damage to the back muscles. We know from research that there is less risk of bleeding, wound infection and faster recovery time (with keyhole surgery),” said Adj Assistant Prof Oh.

Less tissue trauma sustained during surgery will result in less blood loss and minimise stress to the heart during surgery, said Dr Ng. Keyhole surgery can also reduce the need for pain medications, which may have adverse effects on elderly patients, he added.

Newer technologies include computer-guided navigation system, which works like a live GPS feed using an intraoperative CT scanner to guide placement of screws with up to 97 per cent accuracy, said Adj Assistant Prof Oh.

The development of a real-time nerve and spinal cord monitoring system has also helped prevent possible nerve injuries, said Dr Ng.

A recent advancement in spine surgery is an endoscopic “camera” system, which allows surgeons to peer into small areas of the spine and perform an operation using a small skin incision.

IS 80 TOO OLD?

Despite the advances, complications are possible for spine procedures, as with any operation, said Dr Ng.

For spine surgeons, elderly patients pose some unique challenges stemming from health issues like reduced bone quality, decreased mobility, degeneration of spinal soft tissue and poor balance, said Dr Ng.

However, age alone is not the sole determining factor in deciding if a patient is fit for surgery. The risk is also determined by the patient’s general health and any associated diseases of the major organs such as the heart, lung and kidney, he added.

In a study published in The Journal of Bone and Joint Surgery in 2015, researchers found that those 80 years and older can benefit significantly from surgical treatment for lumbar spinal stenosis (nerve compression).

Additionally, they did not have higher rates of complications during and after surgery, compared to younger patients.

Dr Nolan said the risk of the surgery damaging the spinal cord, causing paralysis, is “very low” (less than 1 per cent) for both older and younger patients. However, elderly patients may face slightly higher complication rates due to other health issues like osteoporosis and wound healing, he said.

Adj Assistant Prof Oh said the success rate of surgery for spinal stenosis is around 80 to 90 per cent.

“Some patients may get persistent symptoms, particularly when the nerve compression has been going on for too long, but most of them are usually better off after surgery,” he said.

Not all elderly patients with spinal conditions can undergo surgery.

Surgery may be considered if the patient leads a relatively active lifestyle before his or her spinal condition, and does not have significant medical conditions like a recent stroke or heart attack, said Adj Assistant Prof Oh.

Dr Ng said an elderly patient who has poor mental capacity to understand his condition and is unable to cope with post-surgery physiotherapy is a poor candidate for spine surgery.

“All patients, regardless of age, must be able to comply with post-surgery rehabilitation and work with a therapist to ensure a good outcome,” said Dr Ng.

Family involvement and support is important during the pre-surgery consultation and recovery process, he added.

For Mdm Tan, the surgery has drastically improved her quality of life. No longer limited to using a wheelchair and depending on painkillers, she now takes 30 to 45-minute walks every evening with her helper.

“Before I did the surgery, I would always scold people as I felt frustrated by the pain. Now I’m very happy. To other seniors who are in the same situation as I was, please see a doctor and if you are suitable for surgery, be courageous and go for it. You don’t have to live with the pain,” said Mdm Tan.

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