Dear Dr. Roach: I am a 90-year-old woman, and I consider myself reasonably healthy, except for one problem. I have severe lumbar spinal stenosis. For a number of years, I’ve been receiving an epidural injection, roughly every four months. So far, the injections totally eliminate the pain for approximately two months; then the pain gradually returns, and it becomes quite painful for me to walk. My internist is urging me to have what she refers to as “a minimally invasive procedure that has a high rate of success” — a foraminotomy.
I’d like to put off the surgery, and only consider it if I reach a point where the epdiruals no longer help me. The physician told me chances of success diminish as time goes on. Because I’m 90, back surgery frightens me, as does being put under general anesthesia. What would you advise?
Anon.
Most of my patients have done well with a foraminotomy. However, even in the very best hands, there are times when back surgery fails to improve symptoms, and rarely, symptoms can worsen. Seeing only a few cases of failed back surgery makes a conservative physician like me loath to recommend surgery lightly.
Weakness, especially progressive weakness, is a strong indication for back surgery. I also recommend a neurosurgical referral for patients whose function is limited due to pain or patients who cannot get adequate pain relief with other treatments. At age 90, surgical complications are more likely, even though patients at any age would still be considered for surgery if it were the best option.
Since you are not anxious to get surgery, and because you are still getting relief from the epidurals (even if they needed to be repeated frequently), I wouldn’t push surgery for you. However, this is a situation where reasonable physicians may disagree.
Dear Dr. Roach: For years, my BMI index has been right at or below 25. It’s OK, not great, but at least I made it to age 82. On a recent visit to my primary care physician, my BMI was slightly higher, which made me wonder if this does not need adjusting for older folks.
Over the years, I have lost 2.5 inches in height due to compression of discs, which is typical and common. But if you do not adjust the height when checking BMI, by adding back those 2.5 inches, you will get a higher reading.
I also wonder if height should be used at younger ages instead of older ages to get an accurate BMI reading. The fact that a person loses height due to disc compression should have nothing to do with the BMI calculation, but it does if it isn’t adjusted. What are your thoughts?
R.S.
I don’t think much of the BMI for use in clinical medicine. It is helpful at population levels, but by itself, it isn’t particularly helpful in making decisions for an individual patient.
You are quite right that we tend to lose height as we get older. The intervertebral discs tend to dry out and shrink a little, but the loss of 2.5 inches (6.4 cm) makes me concerned about your vertebral bodies, which can be crushed and flattened in people with osteoporosis. (An 82-year-old person is at risk.)
But, as far as the BMI, it was developed in younger people, so I agree that the loss of height through normal aging adds error to the BMI. If there is one measurement that adds help, it is the waist size, which better predicts the risk of heart disease.
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