[Neurosurgery in old age. I: Significance of the problem--herniated disk, spinal canal stenosis--craniocerebral injuries--chronic subdural hematoma--resorptive hydrocephalus]

Abstract

The relative percentage of patients over 60 years who underwent operations in our clinic has greatly increased from 18% in 1874 to 27% in 1989. Postoperatively, difficulties may also result from additional medical problems, which may be cardiovascular, pulmonary, metabolic (especially diabetes mellitus), increased thromboembolism in origin as well as from the reduced tendency to neurological recovery in elderly patients. On the other hand, advances in diagnostics and surgical treatment often make it possible to help even these patients effectively today. The clinical pictures which are especially frequent in our hospital are specified below. Disc herniations: Soft nucleus-pulposus herniations occur in every age group. In elderly patients, the osseous constriction of the lumbar canal (especially by spondylarthrosis) often leads to spinal claudication. Functional myelography with myelograms taken in the sitting and the standing position is important for preoperative appraisal. On the basis of the clinical/neuroradiological findings, it may be decided whether a selective or an extended decompression is necessary. Larger-scale decompressions are mostly possible in this age group without postoperative instability, with good results in more than 80% of the cases. In our clinic, anterior microsurgical decompression without graft is the most frequently used procedure in cervical disc herniations/spondylosis, a method which is well tolerated by spinal cord and nerve roots: 75% simple anterior discectomies/spondylectomies compared to only 25% classical Cloward operations with bone grafts. We use intervertebral bone grafts only in severe spondylosis and/or instabilities, if necessary in combination with metal plates (e.g. in the context of cervical myelopathy). Craniocerebral injuries: Epidural hematomas and CSF fistulae, but also circumscribed space-occupying contusions have a relatively favorable prognosis in every age group. The older the patient, the more serious is the acute subdural hematoma, which is often associated with extensive contusions, although surprisingly good recoveries are occasionally possible postoperatively even here. Detailed scrutiny of all prognostically relevant factors is important. In borderline situations we give the patient a chance in order to take later action, depending on the course. Chronic subdural hematomas are especially frequent and readily dealt with surgically in patients over 60 years. The simple borehole drainage to the outside is often sufficient. In extensive excreting membranes, which are especially frequent in elderly patients, we prefer today a subdural-peritoneal drainage for six to eight weeks to the very much more burdensome craniotomy: The relatively simple operation allows an early mobilization and almost always a prompt healing. Hydrocephalus male resorptivus is also very much more frequent in this age group.(ABSTRACT TRUNCATED AT 400 WORDS)