Editorial "Management of Spine Pathologies in Geriatric Patients"

Ismail Zaed^1*Gabriele Capo²Aria Nouri³Luca Ricciardi⁴

• ¹Neurocenter of Southern Switzerland, Bellinzona, Switzerland
• ²IRCCS Humanitas Research Hospital, Rozzano, Italy
• ³Hopitaux Universitaires Geneve, Geneva, Switzerland
• ⁴Universita degli Studi di Roma La Sapienza Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Rome, Italy

Population aging is reshaping spine care. Older adults present with a dense tangle of multimorbidity, frailty, osteoporosis, sarcopenia, polypharmacy, and goals-of-care that often prioritize function and independence as much as pain relief [1,2]. This Research Topic set out to synthesize pragmatic, patient-centered advances across the continuum—from diagnosis to anesthesia, intervention, complication surveillance, and rehabilitation—in order to help clinicians individualize decisions for geriatric patients with spine disease. The eight contributions collected here move the field forward in four overarching ways: (1) sharpening risk prediction, (2) elevating peri-procedural safety, and (3) testing realistic rehabilitative and non-pharmacologic strategies, while also spotlighting emerging (4) diagnostic tools. 1) Sharpening risk prediction in osteoporotic vertebral compression fractures (OVCF). Two original studies offer complementary lenses on why some older patients sustain new vertebral compression fractures (NVCF) after vertebral augmentation—and how to anticipate that risk in clinic. A large single-center study (n=420) developed and internally validated a streamlined nomogram in which cement leakage, poor cement dispersion, and pre-existing endplate fracture were independent predictors of NVCF with very strong discrimination (training AUC 0.974; validation AUC 0.965). The model is simple enough to operationalize at the point of care and focuses attention on modifiable intraoperative quality targets (cement handling and dispersion). (Construction of a nomogram…). Frontiers. A second, two-cohort analysis (internal n=235; external n=105) integrates paraspinal muscle health into risk stratification. It shows that the multifidus skeletal muscle index (SMI)—a surrogate of sarcopenia—along with surgical approach and spinal CT values, predicts NVCF; the resulting nomogram demonstrated reasonable performance across validations and, notably, greater negative predictive value, useful in reassuring low-risk patients. The message is clear: bone and muscle form a functional unit in the aging spine, and sarcopenia matters when counseling about augmentation. (Paraspinal muscle parameters' predictive value…). Frontiers Together, these papers support pre-and intra-operative checklists that couple imaging of paraspinal muscle quality with cement technique standards—and they justify post-procedure secondary prevention that addresses both osteoporosis and sarcopenia. 2) Improving the safety around interventions. Minimally invasive augmentation is effective for selected OVCF, but geriatric anesthesia and rare complications remain front of mind. In a randomized comparison of sedative regimens during percutaneous kyphoplasty, ciprofol (a propofol analogue) provided more stable hemodynamics and less respiratory depression than traditional propofol while achieving comparable sedation—an attractive profile for older adults with limited cardiopulmonary reserve. (Ciprofol vs. propofol for percutaneous kyphoplasty…). Frontiers At the other end of the safety spectrum, a vivid case report describes simultaneous spinal subdural and epidural hematomas after percutaneous kyphoplasty (PKP), reminding us that even "routine" procedures can produce rare, catastrophic bleeds. The clinical pearl is vigilance: prompt recognition of disproportionate pain or new neurological deficit post-PKP should trigger urgent imaging and decompression when indicated, with careful attention to coagulation status in the pre-op work-up. (Case report: simultaneous SDH and EDH after PKP). Frontiers Finally, this Topic includes the protocol for a randomized controlled trial directly comparing percutaneous vertebroplasty vs. optimized conservative care in OVCF, an area where practice varies. By specifying outcomes a priori and enrolling a geriatric cohort, the trial is poised to clarify effect sizes that matter to older patients—pain relief trajectories, mobility, and downstream fracture risk. (Comparing the efficacy of vertebroplasty and conservative therapy…). Frontiers 3) Real-world rehabilitation and non-pharmacologic options. Functional recovery and preservation of quality of life are generally the main aim in the management of geriatric patients. In a pragmatic inpatient study of older adults with degenerative spinal disease, robot-assisted gait training did outperform conventional therapy on walking distance over a short, two-week horizon in terms of satisfaction; however, it appeared most helpful for those with severe baseline mobility limitations, suggesting a role as a targeted adjunct rather than a universal solution. For resource-constrained systems, this nuance matters. (Robot-assisted gait training vs. conventional therapy…). Frontiers Complementing this, a multicenter randomized placebo-controlled trial protocol will test acupuncture for degenerative lumbar spinal stenosis, an archetypal geriatric condition where pharmacologic options are limited and surgery is not always preferable. If positive, such data about the effectiveness and safety of optimal acupuncture therapy could expand low-risk, scalable treatments that align with older patients' preferences. (Effectiveness and safety of optimal acupuncture therapy…). Frontiers 4) Emerging diagnostics for smarter decisions. Beyond structure, metabolism matters. A systematic review and meta-analysis highlights proton MR spectroscopy in cervical spondylotic myelopathy (CSM), linking metabolite ratios to clinical severity and functional outcomes. Although currently limited by small samples and technical variability, MR spectroscopy shows promise as a non-invasive biomarker to refine timing of surgery and to personalize follow-up. Larger, standardized studies are warranted. (Magnetic resonance spectroscopy in CSM: a systematic review). Frontiers Where do these studies leave us? In our opinion, there are three different practical takeaways from these studies: 1. Think "bone–muscle" when planning augmentation. Incorporate paraspinal muscle assessment alongside bone health and prioritize cement technique. Use simple nomograms to flag risk early—and to guide conversations about expectations and prevention. Frontiers+1 2. Match intervention intensity to physiologic reserve. Favor hemodynamically gentle sedation strategies for PKP in frail patients, and maintain a low threshold to investigate atypical pain or neurologic changes for rare hematomas. Protocolized trials comparing augmentation to high-quality conservative care will help right-size indications. Frontiers+2Frontiers+2 Frontiers 3 3. Prioritize function with scalable supports. Robot-assisted training may be most valuable for the most impaired; meanwhile, rigorous trials of acupuncture may broaden low-risk options for lumbar stenosis. Frontiers+1 Future directions. The common thread across this Topic is personalization—using better predictors, gentler anesthetic choices, vigilant complication pathways, and realistic rehabilitation to meet older adults where they are. Future work should emphasize multicenter external validation of risk tools (including muscle metrics), standardized safety bundles around augmentation, and patient-reported outcomes that capture mobility and independence [3,4]. The promise of metabolic imaging in CSM is real, and investment in technical standardization could transform it from research tool to bedside biomarker.