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Ramos O, Razzouk J, Beauchamp E, Mueller B, Shafa E, Mehbod AA, Cheng W, Danisa O, Carlson BC. Adding Vertebral Bone Quality to the Fusion Risk Score: Does It Improve Predictions of Postoperative Complications? Spine (Phila Pa 1976) 2024; 49:916-922. [PMID: 38419578 DOI: 10.1097/brs.0000000000004974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE The current study evaluates whether the addition of the Vertebral Bone Quality (VBQ) score to the Fusion Risk Score (FRS) improves its ability to predict perioperative outcomes. SUMMARY OF BACKGROUND DATA The FRS was developed to assess preoperative risk in patients undergoing thoracic and lumbar fusions. It includes patient-derived and surgical variables, but it does not include one that directly accounts for bone health. The VBQ score allows assessment of bone quality and has been shown to correlate to DEXA-measured bone mineral density (BMD) scores. METHODS The VBQ score was weighted based on a regression model and then added to the FRS (FRS/VBQ). The ability of the two scores to predict the outcomes was then assessed using the area under the curve (AUC). PATIENT SAMPLE Patients undergoing elective thoracic and lumbar spinal fusion from January 2019 to June 2020 were included. OUTCOME MEASURES The study evaluated various perioperative adverse outcomes, including major and minor adverse events, discharge other than home, extended length of stay, 90-day emergency department visits, 90-day readmission, and 90-day and 2-year reoperation rates. RESULTS A total of 353 met the inclusion and exclusion criteria. The FRS/VBQ demonstrated improved predictive ability compared with the FRS alone when evaluating 90-day reoperation. Both scores showed fair predictive ability for any adverse event, major adverse events, minor adverse events, and 2-year reoperation rates, with AUCs ranging from 0.700 to 0.737. Both had poor predictive ability for the other outcomes. CONCLUSIONS Adding VBQ to the FRS significantly enhances its predictive accuracy for reoperation rate. This updated risk score provides a more comprehensive understanding of a patient's preoperative risk profile, aiding both patients and physicians in assessing surgical risks and optimizing outcomes through preoperative risk stratification. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Omar Ramos
- Twin Cities Spine Center, Minneapolis, MN
| | - Jacob Razzouk
- Loma Linda University Medical Center, Loma Linda, CA
| | | | | | | | | | - Wayne Cheng
- Loma Linda University Medical Center, Loma Linda, CA
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Tarawneh OH, Narayanan R, McCurdy M, Issa TZ, Lee Y, Opara O, Pohl NB, Tomlak A, Sherman M, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma. BRAIN & SPINE 2024; 4:102780. [PMID: 38510641 PMCID: PMC10951764 DOI: 10.1016/j.bas.2024.102780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/12/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
Introduction As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.
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Affiliation(s)
- Omar H. Tarawneh
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rajkishen Narayanan
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael McCurdy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tariq Z. Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Olivia Opara
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas B. Pohl
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexa Tomlak
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A. Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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Luck T, Zaki PG, Slotkin EM, Michels R, Ong A, Butts CA. Age-Adjusted Modified Frailty Index: Association With Hip Fracture Discharge Functional Dependence. J Surg Res 2024; 295:214-221. [PMID: 38039726 DOI: 10.1016/j.jss.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/20/2023] [Accepted: 10/28/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Hip fractures are a common traumatic injury that carry significant morbidity and mortality, and prognostication of functional outcome is becoming increasingly salient. Across multiple surgical specialties, the five-item and 11-item Modified Frailty Index (mFI-5 and mFI-11) have been found to be convenient, quick, and sensitive tools for identifying patients at risk for perioperative complications. A prior study described the superiority of an Age-Adjusted Modified Frailty Index (aamFI) for predicting perioperative complications compared to the mFI-5 in an elective hip surgery. We sought to externally validate the aamFI in a multicenter hip fracture cohort and hypothesize that these risk scores would not only predict functional dependence (FD) at discharge, but that the aamFI would outperform the mFI-5 and mFI-11. METHODS The Pennsylvania Trauma Systems Foundation registry was queried from 2010 to 2020 for CPT codes, ICD-9 and ICD-10 codes pertaining to hip fracture patients. Patients with missing locomotion and transfer mobility data were excluded. FD status was determined by discharge locomotion and transfer mobility scores per existing methodology. Univariable and Multivariable analysis as well as receiver operator characteristic curves were used to evaluate and compare the three indices for prediction of functional status at discharge. P value < 0.05 was considered significant. RESULTS Twelve thousand seven hundred and forty patients met inclusion criteria (FD: 8183; functional independent 4557). On univariable logistic regression analysis, the mFI-11 (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.47-1.58, P < 0.05), mFI-5 (OR 1.57, 95% CI 1.51-1.63), and aamFI (OR 1.57, 95% CI 1.52-1.62, P < 0.05) were associated with FD. On multivariable logistic regression analysis for predictors of FD, when controlling for age (for the mFI-11 and mFI-5), sex, injury severity score, and admission vitals (systolic blood pressure and respiratory rate), higher mFI-11 and mFI-5 scores independently predicted FD at discharge (OR 1.23, 95% CI 1.18-1.28, P < 0.05 and OR 1.23, 95% CI 1.18-1.29P < 0.05 respectively). Higher aaMFI scores had superior association with functional dependence (OR 1.59, 95% CI 1.54-1.64, P < 0.05). Receiver operator characteristic curves for the mFI-11, mFI-5, and aaMFI showed comparable diagnostic strength (area under curve [AUC] = 0.63 95% CI 0.62-0.64, P < 0.05; AUC = 0.63 95% CI 0.62-0.64, P < 0.05; and AUC = 0.67 95% CI 0.65-0.67, P < 0.05 respectively). CONCLUSIONS The mFI-11, mFI-5, and aamFI are predictive of functional outcome following hip fracture. By including age, the aamFI retains the ease of use of the mFI-5 while improving its prognostic utility for functional outcome.
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Affiliation(s)
- Trevor Luck
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Peter G Zaki
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Eric M Slotkin
- Division of Orthopedic Surgery, Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Ryan Michels
- Division of Orthopedic Surgery, Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Adrian Ong
- Division of Trauma, Department of Surgery, Acute Care Surgery, and Surgical Critical Care, Reading Hospital-Tower Health, West Reading, Pennsylvania
| | - Christopher A Butts
- Division of Trauma, Department of Surgery, Acute Care Surgery, and Surgical Critical Care, Reading Hospital-Tower Health, West Reading, Pennsylvania.
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Vadhera AS, Sachdev R, Andrade NS, Ren M, Zhang B, Kebaish KM, Cohen DB, Skolasky RL, Neuman BJ. Predicting major complications and discharge disposition after adult spinal deformity surgery. Spine J 2024; 24:325-329. [PMID: 37844627 DOI: 10.1016/j.spinee.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/29/2023] [Accepted: 09/30/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND CONTEXT Several spine-specific comorbidity indices are available to help risk-stratify patients before they undergo invasive spine procedures. Studies of patients with adult spinal deformity (ASD) typically use the Charlson Comorbidity Index (CCI), which is not specific to spine patients. PURPOSE To compare the CCI with the Seattle Spine Score (SSS), the Adult Spinal Deformity-Comorbidity Score (ASD-CS), and the Modified 5-Item Frailty Index (mFI-5) and identify which tool more accurately predicted major perioperative complications and discharge disposition after ASD surgery. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE Patients with ASD who underwent spinal arthrodesis of at least four levels at a single institution. OUTCOME MEASURES Self-reported measures include SSS, ASD-CS, and mFI-5. Functional measures include the CCI. METHODS We retrospectively reviewed records of 164 patients with ASD who underwent spinal arthrodesis of ≥ four levels from January 2008 to February 2018 at our U.S. academic tertiary care center and who had available Oswestry Disability Index values. To assess the predictive ability of the comorbidity indices, we created five multivariable logistic regression models, with the presence of major complications and discharge disposition (home or inpatient rehabilitation) as the primary outcome variables. The base model used validated demographic and surgical factors that were predictors of complications and outcomes in those with ASD and within the broader spinal literature. The other four models used the base model along with one of the four indices. The predictive ability of each model was compared using goodness-of-fit testing, with higher pseudo-R2 values and lower Akaike information criteria (AIC) values indicating better model fit. RESULTS Thirty-one patients (19%) experienced major perioperative complications, and 68 (42%) were discharged to inpatient rehabilitation facilities (vs home). The model using the SSS had the highest pseudo-R2 value and lowest AIC value for both major complications and discharge disposition. The mFI-5 had a similar predictive ability. The models using the CCI and ASD-CS were weaker predictors. CONCLUSIONS Compared with the CCI and the ASD-CS, the SSS and the mFI-5 were strong predictors of major complications and discharge disposition after ASD surgery. These results suggest that the SSS and the mFI-5 are preferable to the CCI for clinical risk stratification and outcomes research in patients undergoing ASD surgery.
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Affiliation(s)
- Amar S Vadhera
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Rahul Sachdev
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Nicholas S Andrade
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Mark Ren
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - David B Cohen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287.
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Wathen CA, Gallagher RS, Borja AJ, Malhotra EG, Collier T, Na J, McClintock SD, Yoon JW, Ozturk AK, Schuster JM, Welch WC, Marcotte PJ, Malhotra NR. Relationship Between Comorbidity Burden and Short-Term Outcomes Across 4680 Consecutive Spinal Fusions. World Neurosurg 2023; 180:e84-e90. [PMID: 37597658 DOI: 10.1016/j.wneu.2023.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Preoperative management requires the identification and optimization of modifiable medical comorbidities, though few studies isolate comorbid status from related patient-level variables. This study evaluates Charlson Comorbidity Index (CCI)-an easily derived measure of aggregate medical comorbidity-to predict outcomes from spinal fusion surgery. Coarsened exact matching is employed to control for key patient characteristics and isolate CCI. METHODS We retrospectively assessed 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion at a single academic center. Logistic regression evaluated the univariate relationship between CCI and patient outcomes. Coarsened exact matching generated exact demographic matches between patients with high comorbid status (CCI >6) or no medical comorbidities (matched n = 524). Patients were matched 1:1 on factors associated with surgical outcomes, and outcomes were compared between matched cohorts. Primary outcomes included surgical complications, discharge status, 30- and 90-day risk of readmission, emergency department (ED) visits, reoperation, and mortality. RESULTS Univariate regression of increasing CCI was significantly associated with non-home discharge, as well as 30- and 90-day readmission, ED visits, and mortality (all P < 0.05). Subsequent isolation of comorbidity between otherwise exact-matched cohorts found comorbid status did not affect readmissions, reoperations, or mortality; high CCI score was significantly associated with non-home discharge (OR = 2.50, P < 0.001) and 30-day (OR = 2.44, P = 0.02) and 90-day (OR = 2.29, P = 0.008) ED evaluation. CONCLUSIONS Comorbidity, measured by CCI, did not increase the risk of readmission, reoperation, or mortality. Single-level, posterior lumbar fusions may be safe in appropriately selected patients regardless of comorbid status. Future studies should determine whether CCI can guide discharge planning and postoperative optimization.
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Affiliation(s)
- Connor A Wathen
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ryan S Gallagher
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Emelia G Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Tara Collier
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, USA
| | - Jianbo Na
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, USA
| | - Scott D McClintock
- West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania, USA
| | - Jang W Yoon
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - James M Schuster
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
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Akbik OS, Al-Adli N, Pernik MN, Hicks WH, Hall K, Aoun SG, Bagley CA. A Comparative Analysis of Frailty, Disability, and Sarcopenia With Patient Characteristics and Outcomes in Adult Spinal Deformity Surgery. Global Spine J 2023; 13:2345-2356. [PMID: 35384776 PMCID: PMC10538316 DOI: 10.1177/21925682221082053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective case series study. OBJECTIVES This study aims to compare preoperative indices, including the modified frailty index-11 (mFI-11), modified frailty index-5 (mFI-5), Oswestry Disability Index (ODI), and psoas muscle index (PMI), as they relate to outcomes in adult spinal deformity (ASD) surgery. METHODS We identified 235 patients who underwent thoracolumbar ASD surgery (≥4 levels). The mFI-11, mFI-5, ODI, and PMI were determined from preoperative visits and correlated to outcome measures, including perioperative transfusion, duration of anesthesia, hospital and ICU length of stay (LOS), discharge disposition, readmission, change in ODI at last follow-up, revision surgery, and mortality. RESULTS Our cohort had a mean age of 69.6 years and a male:female ratio of 1:2 with 177 undergoing an index surgery and 58 patients presenting after a failed multilevel fusion. The average number of levels fused was 9.3. The mFI-11 and mFI-5 were similar in predicting the need for intraoperative and postoperative transfusion. However, the mFI-11 was able to predict longer ICU and hospital LOS and mortality. The average preoperative ODI was 44.9% with an average decrease of 10.1% at the last follow-up. Preoperative ODI was the most significant predictor of postoperative change of ODI. Sarcopenia, defined as the lowest quartile of PMI values measured at L3 and L4, was not associated with any meaningful outcomes. CONCLUSION The mFI-11 better correlated with outcomes, indicating its increased prognostic value compared to other preoperative indices in ASD surgery. Preoperative ODI remains a significant predictor of postoperative change in ODI when evaluating ASD patients.
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Affiliation(s)
- Omar S. Akbik
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nadeem Al-Adli
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William H. Hicks
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristen Hall
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Orthopedic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Castel X, Pelletier JB, Sulpis B, Charier D, Buhot B, Mihail G, Carlioz V, Barral-Clavel F, Sylvain G, Tetard MC, Vassal F. MFI-11 Predicts Post-Operative Serious Complications in Patients Undergoing Surgery for Odontoid Fractures. Global Spine J 2023:21925682231205103. [PMID: 37776203 DOI: 10.1177/21925682231205103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVES The objective of this study was to analyze postoperative complications in different mFI-11 groups after surgery for odontoid fractures in a geriatric population. METHODS A single center retrospective review of odontoid fractures surgery (between 2013 and 2022) in patients aged 65 years and older was conducted. The primary outcome was the occurrence of a major complication (Calvien-Dindo ≥4) within 30 days post-surgery. The secondary outcome was the occurrence of a major complication within 3 months after surgery, and death within 1-month post-surgery. Survival curve, multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated. RESULTS There were 92 patients included in this study, with a mean age of 80.5 years. Serious complication occurred for 16 patients (17%) during hospitalization. Multivariate analysis demonstrated an mFI 11 >.27 was strongly and independently associated with serious complications within 1-month post-surgery (OR = 16.7, 95% CI = 4.50-83), as well as serious complications within 3 months post-surgery (OR = 11.8, 95% CI = 3.48-49.1) and death within 1 month post-surgery (OR = 11.7; 95% CI = 3.02-60.4). The Receiver Operator Characteristics (ROC) curves for the three models all have an Area Under the Curve (AUC) value greater than 0.7. CONCLUSIONS The mFI-11 is a straightforward and validated tool that can be used during the preoperative period to identify the patient's level of frailty and assess their risk of postoperative complications. Patients with mFI-11 ≥.27 are at greater risk of serious complications within 1 and 3 months' post-surgery and death within 1 month post-surgery.
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Affiliation(s)
- Xavier Castel
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Jean-Baptiste Pelletier
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Benoit Sulpis
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - David Charier
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Benjamin Buhot
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Gurschi Mihail
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Violette Carlioz
- Dermatology Department, Centre Hospitalier de Firminy, Firminy, France
| | - Fanelie Barral-Clavel
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Granges Sylvain
- Radiology Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Marie-Charlotte Tetard
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Francois Vassal
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
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Miękisiak G. Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1255. [PMID: 37512066 PMCID: PMC10384667 DOI: 10.3390/medicina59071255] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.
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Affiliation(s)
- Grzegorz Miękisiak
- Institute of Medicine, University of Opole, 45-040 Opole, Poland
- Vratislavia Medica Hospital, 51-134 Wrocław, Poland
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Arora A, Cummins DD, Wague A, Mendelis J, Samtani R, McNeill I, Theologis AA, Mummaneni PV, Berven S. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform 2023; 11:773-785. [PMID: 36811703 PMCID: PMC10261200 DOI: 10.1007/s43390-023-00654-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery. METHODS Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009). RESULTS Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization. CONCLUSIONS Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Aboubacar Wague
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Joseph Mendelis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Rahul Samtani
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Ian McNeill
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University California, San Francisco, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA.
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10
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Quigley M, Apos E, Truong TA, Ahern S, Johnson MA. Comorbidity data collection across different spine registries: an evidence map. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:753-777. [PMID: 36658363 DOI: 10.1007/s00586-023-07529-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/28/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Comorbidities are significant patient factors that contribute to outcomes after surgery. There is highly variable collection of this information across the literature. To help guide the systematic collection of best practice data, the Australian Spine Registry conducted an evidence map to investigate (i) what comorbidities are collected by spine registries, (ii) how they are collected and (iii) the compliance and completeness in collecting comorbidity data. METHOD A literature search was performed to identify published studies of adult spine registry data reporting comorbidities. In addition, targeted questionnaires were sent to existing global spine registries to identify the maximum number of relevant results to build the evidence map. RESULTS Thirty-six full-text studies met the inclusion criteria. There was substantial variation in the reporting of comorbidity data; 55% of studies reported comorbidity collection, but only 25% reported the data collection method and 20% reported use of a comorbidity index. The variation in the literature was confirmed with responses from 50% of the invited registries (7/14). Of seven, three use a recognised comorbidity index and the extent and methods of comorbidity collection varied by registry. CONCLUSION This evidence map identified variations in the methodology, data points and reporting of comorbidity collection in studies using spine registry data, with no consistent approach. A standardised set of comorbidities and data collection methods would encourage collaboration and data comparisons between patient cohorts and could facilitate improved patient outcomes following spine surgery by allowing data comparisons and predictive modelling of risk factors.
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Affiliation(s)
- Matthew Quigley
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Esther Apos
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia. .,Spine Society of Australia, 3-5 West Street, North Sydney, NSW, 2060, Australia.
| | - Trieu-Anh Truong
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Susannah Ahern
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Michael A Johnson
- Spine Society of Australia, 3-5 West Street, North Sydney, NSW, 2060, Australia
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11
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Woldu S, Solumsmoen S, Bech-Azeddine R. Age and BMI equal Modified Frailty Index, Modified Charlson Comorbidity Index and ASA in predicting adverse events in spinal surgery for cervical degenerative diseases. Clin Neurol Neurosurg 2023; 228:107698. [PMID: 37028252 DOI: 10.1016/j.clineuro.2023.107698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE To compare Modified Frailty Index (mFI), Modified Charlson Comorbidity (mCCI) and ASA with demographic data such as age, BMI and gender in the prediction of AEs obtained using a validated systematic reporting system in a prospective cohort undergoing cervical spine surgery. METHODS All adult patients undergoing spine surgery for cervical degenerative disease at our academic tertiary referral center from February 1, 2016, to January 31, 2017, were included. Morbidity and mortality were determined according to the predefined adverse event (AE) variables using the Spinal Adverse Events Severity (SAVES) System. Area under the curve (AUC) analyses from receiver operating characteristics (ROC) curves were used to assess the discriminative ability in predicting AEs for the comorbidity indices mFI, mCCI, ASA and for BMI, age and gender. RESULTS A total of 288 consecutive cervical cases were included. BMI was the most predictive demographic factor for an AE (AUC = 0.58), the most predictive comorbidity index was mCCI (AUC = 0.52). No combination of comorbidity indices or demographic factors reached a threshold of AUC ≥ 0.7 for AEs. As predictor of extended length of stay: age (AUC = 0.77), mFI (AUC = 0.70) and ASA (AUC = 0.70) were similar and fair. CONCLUSION Age and BMI equal mFI, mCCI and ASA in predicting postoperative AEs, amongst patients operated for cervical degenerative disease. No significant difference was found between mFI, mCCI and ASA in the discriminative abilities in predicting morbidity, based on prospectively collected AEs according to the SAVES grading system.
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12
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Geng EA, Gal JS, Kim JS, Martini ML, Markowitz J, Neifert SN, Tang JE, Shah KC, White CA, Dominy CL, Valliani AA, Duey AH, Li G, Zaidat B, Bueno B, Caridi JM, Cho SK. Robust prediction of nonhome discharge following elective anterior cervical discectomy and fusion using explainable machine learning. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07621-8. [PMID: 36854862 DOI: 10.1007/s00586-023-07621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/25/2023] [Accepted: 02/19/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE Predict nonhome discharge (NHD) following elective anterior cervical discectomy and fusion (ACDF) using an explainable machine learning model. METHODS 2227 patients undergoing elective ACDF from 2008 to 2019 were identified from a single institutional database. A machine learning model was trained on preoperative variables, including demographics, comorbidity indices, and levels fused. The validation technique was repeated stratified K-Fold cross validation with the area under the receiver operating curve (AUROC) statistic as the performance metric. Shapley Additive Explanation (SHAP) values were calculated to provide further explainability regarding the model's decision making. RESULTS The preoperative model performed with an AUROC of 0.83 ± 0.05. SHAP scores revealed the most pertinent risk factors to be age, medicare insurance, and American Society of Anesthesiology (ASA) score. Interaction analysis demonstrated that female patients over 65 with greater fusion levels were more likely to undergo NHD. Likewise, ASA demonstrated positive interaction effects with female sex, levels fused and BMI. CONCLUSION We validated an explainable machine learning model for the prediction of NHD using common preoperative variables. Adding transparency is a key step towards clinical application because it demonstrates that our model's "thinking" aligns with clinical reasoning. Interactive analysis demonstrated that those of age over 65, female sex, higher ASA score, and greater fusion levels were more predisposed to NHD. Age and ASA score were similar in their predictive ability. Machine learning may be used to predict NHD, and can assist surgeons with patient counseling or early discharge planning.
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Affiliation(s)
- Eric A Geng
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jonathan S Gal
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America.,Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America.
| | - Michael L Martini
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jonathan Markowitz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Sean N Neifert
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, United States of America
| | - Justin E Tang
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Kush C Shah
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Christopher A White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Calista L Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Aly A Valliani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Akiro H Duey
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Gavin Li
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Bashar Zaidat
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Brian Bueno
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - John M Caridi
- Department of Neurosurgery, McGovern Medical School at University of Texas Health, Houston, United States of America
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
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13
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Tran KS, Lambrechts MJ, Issa TZ, Tecce E, Corr A, Toci GR, Wong A, DiMaria S, Kirkpatrick Q, Chu J, Gilmore G, Kurd MF, Rihn JA, Woods BI, Kaye ID, Canseco JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Modified Frailty Index Does Not Provide Additional Value in Predicting Outcomes in Patients Undergoing Elective Transforaminal Lumbar Interbody Fusion. World Neurosurg 2023; 170:e283-e291. [PMID: 36356842 DOI: 10.1016/j.wneu.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the predictive value of the modified Frailty Index (mFI) in evaluating sarcopenia and clinical outcomes in patients undergoing 1-level or 2-level transforaminal lumbar interbody fusion (TLIF). METHODS Patients who underwent a 1-level or 2-level TLIF between 2012 and 2020 were retrospectively identified. Frailty was compared among groups using mFI, and sarcopenia was classified by the psoas muscle cross-sectional area. Bivariate statistics compared demographics, comorbidities, and clinical outcomes. A linear regression model was developed using the Charlson Comorbidity Index (CCI) or mFI as independent variables to determine potential predictors for improvement in 1-year patient-reported outcomes. RESULTS Of 488 included patients, 60 were severely frail and 60 patients had sarcopenia, but sarcopenia was not associated with patient frailty (P = 0.469). Severely frail patients had worse baseline Oswestry Disability Index (ODI) (P < 0.001), Mental Component Score-12 (P = 0.001), and Physical Component Score-12 (P < 0.001), and worse improvement in ODI (P = 0.037), Physical Component Score-12 (P < 0.001), and visual analog scale (VAS) back (P = 0.007). mFI was an independent predictor of poorer improvement in VAS back and ODI, whereas age + CCI in addition predicted poorer improvement in VAS leg. Patients with higher mFI experienced longer length of stay, less frequent home discharge, and higher rates of complications, but similar readmission and reoperation rates. CONCLUSIONS Frailer patients experience poorer improvement in back pain, physical functioning, and disability after TLIF. mFI and the combination of age and CCI comparably predict patient-reported outcomes but do not correlate to baseline sarcopenia. Frailty increased the risk of complications, length of hospital stay, and risk of nonhome discharge.
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Affiliation(s)
- Khoa S Tran
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eric Tecce
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andrew Corr
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory R Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashley Wong
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen DiMaria
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Quinn Kirkpatrick
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justin Chu
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Griffin Gilmore
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffery A Rihn
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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14
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Pean CA, Thomas HM, Singh UM, DeBaun MR, Weaver MJ, von Keudell AG. Use of a Six-Item Modified Frailty Index to Predict 30-day Adverse Events, Readmission, and Mortality in Older Patients Undergoing Surgical Fixation of Lower Extremity, Pelvic, and Acetabular Fractures. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202301000-00010. [PMID: 36701242 PMCID: PMC9857364 DOI: 10.5435/jaaosglobal-d-22-00286] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/10/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION This is a retrospective study evaluating the use of a new six-item modified frailty index (MF-6) to predict short-term outcomes of patients receiving surgery for lower extremity fractures. METHODS Patients older than 65 years undergoing open reduction and internal fixation for lower extremity, pelvic, and acetabulum fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program. The MF-6 was calculated by assigning one point for each of six common conditions. Multivariable analysis was used to compare patients with an MF-6 of <3 and ≥3. Outcome measures included complications, mortality, readmission, revision surgery, and length of stay. An area under the curve receiver operator analysis was conducted to compare the MF-6 with MF-5, an existing five-item frailty index. RESULTS Nine thousand four hundred sixty-three patients were included. Patients with an MF-6 of ≥3 were at markedly higher risk of discharge destination other than home (Exp[B] = 2.09), mortality (Exp[B] = 2.48), major adverse events (Exp[B] = 2.16), and readmission (Exp[B] = 1.82). Receiver-operating curve analysis demonstrated an area under the curve of 0.65 for mortality, 0.62 for major adverse events, and 0.62 for discharge destination other than home, all of which outperformed the MF-5. DISCUSSION The MF-6 was correlated with a 30-day postoperative incidence of infectious complications, readmission, and discharge destination. MF-6 scores can be used to risk-stratify patient populations as shifts to value-based care continue to develop.
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Affiliation(s)
- Christian A. Pean
- From the Duke Department of Orthopedic Trauma Surgery, University Health System, Durham, NC (Dr. Pean and Dr. DeBaun); the Harvard Orthopedic Trauma Initiative, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA (Thomas, Dr. Weaver, and Dr. von Keudell); the Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (Dr. Singh and Dr. von Keudell), and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark (Dr. von Keudell)
| | - Hannah M. Thomas
- From the Duke Department of Orthopedic Trauma Surgery, University Health System, Durham, NC (Dr. Pean and Dr. DeBaun); the Harvard Orthopedic Trauma Initiative, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA (Thomas, Dr. Weaver, and Dr. von Keudell); the Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (Dr. Singh and Dr. von Keudell), and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark (Dr. von Keudell)
| | - Upender M. Singh
- From the Duke Department of Orthopedic Trauma Surgery, University Health System, Durham, NC (Dr. Pean and Dr. DeBaun); the Harvard Orthopedic Trauma Initiative, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA (Thomas, Dr. Weaver, and Dr. von Keudell); the Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (Dr. Singh and Dr. von Keudell), and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark (Dr. von Keudell)
| | - Malcolm R. DeBaun
- From the Duke Department of Orthopedic Trauma Surgery, University Health System, Durham, NC (Dr. Pean and Dr. DeBaun); the Harvard Orthopedic Trauma Initiative, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA (Thomas, Dr. Weaver, and Dr. von Keudell); the Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (Dr. Singh and Dr. von Keudell), and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark (Dr. von Keudell)
| | - Michael J. Weaver
- From the Duke Department of Orthopedic Trauma Surgery, University Health System, Durham, NC (Dr. Pean and Dr. DeBaun); the Harvard Orthopedic Trauma Initiative, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA (Thomas, Dr. Weaver, and Dr. von Keudell); the Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (Dr. Singh and Dr. von Keudell), and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark (Dr. von Keudell)
| | - Arvind G. von Keudell
- From the Duke Department of Orthopedic Trauma Surgery, University Health System, Durham, NC (Dr. Pean and Dr. DeBaun); the Harvard Orthopedic Trauma Initiative, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA (Thomas, Dr. Weaver, and Dr. von Keudell); the Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (Dr. Singh and Dr. von Keudell), and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark (Dr. von Keudell)
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15
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Mohamed B, Ramachandran R, Rabai F, Price CC, Polifka A, Hoh D, Seubert CN. Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review. J Neurosurg Anesthesiol 2023; 35:19-30. [PMID: 34354024 PMCID: PMC8816967 DOI: 10.1097/ana.0000000000000787] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023]
Abstract
Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.
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Affiliation(s)
- Basma Mohamed
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Ramani Ramachandran
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Ferenc Rabai
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
- Perioperative Cognitive Anesthesia Network, University of Florida College of Medicine, Gainesville, Florida
| | - Catherine C. Price
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions, Gainesville, Florida
- Perioperative Cognitive Anesthesia Network, University of Florida College of Medicine, Gainesville, Florida
| | - Adam Polifka
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Daniel Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
| | - Christoph N. Seubert
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
- UF Health Comprehensive Spine Center, University of Florida, Gainesville, Florida
- Perioperative Cognitive Anesthesia Network, University of Florida College of Medicine, Gainesville, Florida
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Cai XY, Lin JH, Huang WC, Wu JC, Chen PY, Chiu HY. Sensory Symptoms and effects on Health-related Quality of Life of Patients Undergoing Lumbar Spine Surgery. Pain Manag Nurs 2022; 24:216-221. [PMID: 36396530 DOI: 10.1016/j.pmn.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/23/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with lumbar degenerative spine diseases (LDSDs) commonly report sensory symptoms before and after lumbar spine surgery. AIM To explore the changing patterns of sensory symptoms-namely pain, numbness, stinging, itching, and burning-and investigate the influences of sensory symptom changes on the health-related quality of life (HRQoL) of patients who experienced lumbar spine surgery. METHODS All sensory symptoms (i.e., pain, numbness, paresthesia) were measured using a visual analog scale. The Chinese versions of the Oswestry Disability Index, Pittsburgh Sleep Quality Index, Clinically Useful Depression Outcome Scale, and EuroQol-five dimensions (EQ-5D) Scale were used to assess patients 1 week prior to surgery and 6 weeks and 6 months after surgery. A generalized estimating equation was used for data analysis. RESULTS A total of 101 patients with mean age of 58.38 years were included. All sensory symptoms declined significantly over time (all p < .05) with the exception of itching (feeling on toes and thighs). Patients experiencing moderate-to-severe pain had poorer QoL over time, even after controlling for other sensory symptoms and potential confounders. CONCLUSIONS Sensory symptoms gradually declined after surgery, but itching symptom did not. Moderate-to-severe pain was the only sensory symptom that influenced HRQoL over time in patients with LDSDs.
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Affiliation(s)
- Xin-Yi Cai
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Jiann-Her Lin
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan; Division of Neurosurgery, Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Center for Neural Regeneration, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial, Hospital, Keelung, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan.
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Steinle AM, Nian H, Pennings JS, Bydon M, Asher A, Archer KR, Gardocki RJ, Zuckerman SL, Stephens BF, Abtahi AM. Complications, readmissions, reoperations and patient-reported outcomes in patients with multiple sclerosis undergoing elective spine surgery - a propensity matched analysis. Spine J 2022; 22:1820-1829. [PMID: 35779839 DOI: 10.1016/j.spinee.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease that can lead to significant functional disability. Improving treatment regimens have extended life expectancy and led to an increase in the number of elective spine surgeries for degenerative conditions in the MS population. Recent literature has reported mixed results regarding the efficacy of elective spine surgery for patients with MS. There is also a paucity of literature comparing postoperative patient reported outcomes (PROs) and reoperation rates between patients with and without MS. PURPOSE To determine if patients with MS have worse PROs and higher complication, readmission and reoperation rates after elective spine surgery compared with patients without neurodegenerative conditions when adjusting for baseline covariates through propensity matching. STUDY DESIGN/SETTING Retrospective review of prospectively collected data from the Quality Outcomes Database (QOD), a national, longitudinal, multicenter spine outcomes registry. PATIENT SAMPLE For the lumbar cohort, 312 patients with MS and 46,738 patients without MS were included. The cervical myelopathy cohort included 91 patients with MS and 6,426 patients without MS. The cervical radiculopathy cohort consisted of 103 patients with MS and 13,751 patients without MS. OUTCOME MEASURES 1) complication rates, 2) readmission rates, 3) reoperation rates, and 4) PROs at 3- and 12-months including ODI/NDI, NRS back/neck/arm/leg pain, mJOA scores and patient satisfaction ratings. METHODS Data from the QOD was queried for patients with surgeries occurring between 04/2013-01/2019. Three surgical groups were included: 1) Elective lumbar surgery, 2) Elective cervical surgery for myelopathy, 3) Elective cervical surgery for radiculopathy. Patients with any neurodegenerative condition other than MS were excluded. Patients without MS were propensity matched against patients with MS in a 5 to 1 ratio without replacement based on ASA grade, arthrodesis, surgical approach, number of operated levels, age, and baseline ODI/NDI, NRS leg/arm pain, NRS back/neck pain, and EQ-5D. Multivariable regressions with cluster-robust standard errors were used to estimate average effect of how the outcome would change if the MS patient didn't have the disease. The mean difference was used for continuous outcomes and the risk difference was used for binary outcomes. RESULTS For the lumbar cohort, no differences were found between the 2 groups at 3 or 12 months in any of the outcome measures. For the myelopathy cohort, patients with MS patients had a lower rate of reoperation at 12 months (risk difference=-0.036, p=.007) and worse 3-month mJOA scores (mean difference=-1.044, p=.004) compared with patients without MS. For the radiculopathy cohort, patients with MS had a lower rate of reoperation at 3 months (risk difference=-0.019, p=.018) and 12 months (risk difference=-0.029, p=.007) compared with those without MS. CONCLUSIONS Patients with MS had similar PROs compared with patients without MS when adjusting for baseline covariates through propensity matching, except for 3-month mJOA scores in the myelopathy cohort. Reoperation rates were found to be lower in patients with MS undergoing elective cervical surgery for both myelopathy and radiculopathy. These results suggest that when analyzed independently, a diagnosis of MS does not significantly impact complication, readmission and reoperation rates or PROs, and therefore should not represent a major contraindication to elective spine surgery. Surgical decisions in this patient population should be made based on careful consideration of patient factors including other comorbidities as well as baseline patient functional status.
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Affiliation(s)
- Anthony M Steinle
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA
| | - Hui Nian
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Ave Ste 1100, Nashville, TN 37203, USA
| | - Jacquelyn S Pennings
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, 200 First St SW Floor 8. Rochester, MN 55905, USA
| | - Anthony Asher
- Neuroscience Institute, Atrium Health and Department of Neurosurgery, Carolinas Medical Center, Charlotte, North Carolina; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Physical Medicine & Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, 3401 West End Ave Suite 380, Nashville, TN 37203, USA
| | - Raymond J Gardocki
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA
| | - Scott L Zuckerman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA.
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Turk RD, Li LT, Saini S, MacAskill M, Ross G, Shah SS. A Novel Comorbidity Risk Score for Predicting Post-Operative 30-day Complications in Total Shoulder Arthroplasty & Elucidation of Potential Racial Disparities. JSES Int 2022; 6:867-873. [PMID: 36353420 PMCID: PMC9637582 DOI: 10.1016/j.jseint.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Efficient and effective preoperative identification of those patients with elevated risk may allow for more cost-effective interventions, accurate bundled payment adjustments, and overall improved patient care. Few comorbidity indices have provided clinical utility and adequate discriminative ability in the setting of complications after shoulder arthroplasty (SA). Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for anatomic and/or reverse SA procedures between 2010 and 2019. A subset of comorbidities were utilized including end-stage renal disease, history of hypertension, chronic obstructive pulmonary disease, functional status, history of bleeding disorder, and disseminated cancer. Results A total of 25,927 patients with an average age of 69.2 (standard deviation ±9.5) years were included in the study. Patients with a comorbidity risk score (CRS) at or above 2 were indicated to have at least a 29.6% 30-day postoperative complication rate after undergoing total shoulder arthroplasty, significantly higher than the described average of approximately 15%. The area under receiver operator curve for the novel CRS scoring system was 0.595, indicating fair discriminative ability to predict 30-day postoperative complications after SA. This illustrates a discriminative ability similar to that of the American Society of Anesthesiologists classification (0.584, confidence interval [CI] 0.578-0.589), modified Charlson Comorbidity Index (0.567, CI 0.561-0.573), and modified Frailty Index (0.534, CI 0.529-0.539), each of which are common comorbidity indices used for the National Surgical Quality Improvement Program database. The average CRS for the population was 0.8537 (CI 0.8011-0.8150; P < .05) while that for the Black demographic was 1.08 (CI 1.03-1.13; P < .001). Our results suggest that if the disparity in CRS among races was corrected, the average complication rate would be decreased by 2.0%. Discussion and Conclusion A higher CRS score resulted in higher rates of 30-day postoperative complications following SA. Black patients had a higher average CRS than all other races illustrating a racial disparity in comorbidity risk. Although the average complication rate of each race would still be unequal, this could mitigate some of the racial disparities observed and decrease the overall 30-day complication rate in SA. With the rise of bundled payments further increasing the need to preoperatively identify patients at high risk for costly complications, the CRS is based on easily identified, relevant comorbidities that may be an advantageous tool to identify patients at increased risk of complications following SA.
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Affiliation(s)
- Robby D. Turk
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Lambert T. Li
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Sundeep Saini
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | | | - Glen Ross
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
- New England Shoulder and Elbow Center, Brighton, MA, USA
| | - Sarav S. Shah
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
- New England Shoulder and Elbow Center, Brighton, MA, USA
- Corresponding author: Sarav Shah, MD, New England Baptist Hospital Sports Medicine Division 125 Parker Hill Ave Boston, MA 02120.
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Moskven E, Charest-Morin R, Flexman AM, Street JT. The measurements of frailty and their possible application to spinal conditions: a systematic review. Spine J 2022; 22:1451-1471. [PMID: 35385787 DOI: 10.1016/j.spinee.2022.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/19/2022] [Accepted: 03/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Frailty is associated with an increased risk of postoperative adverse events (AEs) within the surgical spine population. Multiple frailty tools have been reported in the surgical spine literature. However, the applicability of these tools remains unclear. PURPOSE Primary objective is to appraise the construct, feasibility, objectivity, and clinimetric properties of frailty tools reported in the surgical spine literature. Secondary objectives included determining the applicability and the most sensitive surgical spine population for each tool. STUDY DESIGN Systematic Review. PATIENT SAMPLE Studies reporting the use of a clinical frailty tool with a defined methodology in the adult surgical population (age ≥18 years). OUTCOME MEASURES Postoperative adverse events (AEs) including mortality, major and minor morbidity, length of stay (LOS), unplanned readmission and reoperation, admission to the Intensive Care Unit (ICU), and adverse discharge disposition; postoperative patient-reported outcomes (health-related quality of life (HRQoL), functional, cognitive, and symptomatic); radiographic outcomes; and postoperative frailty trajectory. METHODS This systematic review was registered with PROSPERO: CRD42019109045. Publications from January 1950 to December 2020 were identified by a comprehensive search of PubMed, Ovid, and Embase, supplemented by manual screening. Studies reporting and validating a frailty tool in the surgical spine population with a measurable outcome were included. Each tool and its clinimetric properties were evaluated using validated criteria and definitions. The applicability of each tool and its most sensitive surgical spine population was determined by panel consensus. Bias was assessed using the Newcastle-Ottawa Scale. RESULTS 47 studies were included in the final qualitative analysis. A total of 14 separate frailty tools were identified, in which 9 tools assessed frailty according to the cumulative deficit definition, while 4 instruments utilized phenotypic or weighted frailty models. One instrument assessed frailty according to the comprehensive geriatric assessment (CGA) model. Twelve measures were validated as risk stratification tools for predicting postoperative AEs, while 1 tool investigated the effect of spine surgery on postoperative frailty trajectory. The modified frailty index (mFI), 5-item mFI, adult spinal deformity frailty index (ASD-FI), FRAIL Scale, and CGA had the most positive ratings for clinimetric properties assessed. CONCLUSIONS The assessment of frailty is important in the surgical decision-making process. Cumulative deficit and weighted frailty instruments are appropriate risk stratification tools. Phenotypic tools are sensitive for capturing the relationship between spinal pathology, spine surgery, and prehabilitation on frailty trajectory. CGA instruments are appropriate screening tools for identifying health deficits susceptible to improvement and guiding optimization strategies. Studies are needed to determine whether spine surgery and prehabilitation are effective interventions to reverse frailty.
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Affiliation(s)
- Eryck Moskven
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Raphaële Charest-Morin
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alana M Flexman
- Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada; Department of Anaesthesiology and Perioperative Care, St. Paul's Hospital/Providence Health Care, Vancouver, British Columbia, Canada
| | - John T Street
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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20
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Zhou Y, Wang L, Cao A, Luo W, Xu Z, Sheng Z, Wang J, Zhu B. Modified Frailty Index Combined with a Prognostic Nutritional Index for Predicting Postoperative Complications of Hip Fracture Surgery in Elderly. J INVEST SURG 2022; 35:1739-1746. [PMID: 35906737 DOI: 10.1080/08941939.2022.2101166] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Aim: There is currently no consensus on the best risk assessment technique for predicting complications after hip surgery in the elderly, which is hindering the accuracy of surgical risk assessment. The goal of this study was to build a risk assessment model and evaluate its predictive value using the modified frailty index (5-mFI) and the prognostic nutritional index (PNI).Methods: A retrospective investigation was undertaken on 150 patients (aged ≥60 years) who had hip fracture surgery. Using univariate and multivariate logistic regression models, the relationship between combined 5-mFI and PNI and the evaluation of postoperative unfavorable outcomes such as infection and unscheduled intensive care unit (ICU) admission was investigated. Finally, utilizing receiver operating characteristic (ROC) curve analysis, the model's predictive value for adverse outcomes following hip fracture surgery in elderly patients was assessed.Results: Univariate and multivariate logistic analyses revealed that preoperative PNI, 5-mFI, ASA, and gender acted as independent predictors of adverse outcomes after hip fracture surgery in the elderly. According to the ROC curve analysis, the predictive model demonstrated a high predictive value for total postoperative complications (AUC: 0.788; 95%CI: 0.715-0.860; p<0.01), infectious complications (AUC: 0.798; 95% CI: 0.727-0.868; P<0.001), and unplanned ICU admission (AUC: 0.783; 95% CI: 0.705-0.861; P<0.001).Conclusions: The multivariable evaluation model, which included 5-mFI and PNI, showed a high predictive value and can hence be applied to predict the adverse outcomes in elderly patients undergoing hip fracture surgery.
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Affiliation(s)
- Yanling Zhou
- Department of anesthesiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Long Wang
- Department of Nephrology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Angyang Cao
- Department of anesthesiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Wenjun Luo
- Department of anesthesiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Zhipeng Xu
- Department of anesthesiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Zhiren Sheng
- Nursing department, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Jianhua Wang
- Department of Radiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Binbin Zhu
- Department of anesthesiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
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21
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Which frailty scales for patients with adult spinal deformity are feasible and adequate? A systematic review. Spine J 2022; 22:1191-1204. [PMID: 35123046 DOI: 10.1016/j.spinee.2022.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Frailty as a concept is not yet fully understood, and is not the same as comorbidity. It is associated with an increased risk of adverse events and mortality after surgery, which makes its preoperative assessment significant. Despite its relevance, it still remains unclear which scales are appropriate for use in patients with spinal pathology. PURPOSE To evaluate the feasibility and measurement properties of frailty scales for spine patients, specifically with adult spinal deformity (ASD), and to propose adequate scales for primary triage to prevent surgery in too frail patients and for preoperative assessment to modify patients' condition and surgical plans. STUDY DESIGN/SETTING Systematic review. METHODS Systematic search was performed between 2010 and 2021 including terms relating to spinal disorders, frailty scales, and methodological quality. Characteristics of the studies and frailty scales and data describing relation to treatment outcomes were extracted. The risk of bias was determined with the QAREL score. RESULTS Of the 1993 references found, 88 original studies were included and 23 scales were identified. No prospective interventional study was found where the preoperative frailty assessment was implemented. Predictive value of scales for surgical outcomes varied, dependent on spinal disorders, type of surgeries, patients' age and frailty at baseline, and outcomes. Seventeen studies reported measurement properties of eight scales but these studies were not free of bias. In 30 ASD studies, ASD-Frailty Index (ASD-FI, n=14) and 11-item modified Frailty Index (mFI-11, n=11) were most frequently used. These scales were mainly studied in registry studies including young adult population, and carry a risk of sample bias and make their validity in elderly population unclear. ASD-FI covers multidisciplinary concepts of frailty with 40 items but its feasibility in clinical practice is questionable due to its length. The Risk Analysis Index, another multidisciplinary scale with 14 items, has been implemented for preoperative assessment in other surgical domains and was proven to be feasible and effective in interventional prospective studies. The FRAIL is a simple questionnaire with five items and its predictive value was confirmed in prospective cohort studies in which only elderly patients were included. CONCLUSIONS No adequate scale was identified in terms of methodological quality and feasibility for daily practice. Careful attention should be paid when choosing an adequate scale, which depends on the setting of interest (eg triage or preoperative work-up). We recommend to further study a simple and predictive scale such as FRAIL for primary triage and a comprehensive and feasible scale such as Risk Analysis Index for preoperative assessment for patients undergoing spine surgery, as their adequacy has been shown in other medical domains.
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22
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Chung JH, Mierke A, Ramos O, Kagabo W, Boling W, Cheng W, Danisa O. Preoperative opiate use leads to increased postoperative opiate use and readmissions after anterior cervical discectomy and fusion. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:214-223. [PMID: 35875623 PMCID: PMC9263740 DOI: 10.21037/jss-21-126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Determine effects of pre-operative opiate use on anterior cervical discectomy and fusion (ACDF) surgery outcomes. METHODS The study design was a single center retrospective cohort study. Patient records were reviewed from 2013 and 2018 for elective 1 to 2 level ACDF surgeries. Patients were classified as: opiate naive (ON: no history of opiate) use, acute opiate (AO: <6 months preoperatively) use, and chronic opiate (CO: 6-12 months preoperatively) use based on prescription history before surgery. Opiate use was quantified by milligram morphine equivalents (MME) at 6-12 months preop, 0-6 months preop, 0-6 months postop, and 6-12 months postop. Charts were reviewed for American Society of Anesthesiologists (ASA) physical status classification and smoking history. RESULTS Readmission rates were 9.8% for ON, 9.1% for AO, and 30% for CO (P value <0.05). Average opiate use measured in MME 6-12 months post-surgery was 5.76 for ON, 18.44 for AO, and 39.92 for CO (P value <0.05). Readmission rate between nonsmokers, former smokers, and active smokers was 4.4%, 0%, and 10.8% (P value <0.05) at 30-90 days post-surgery, and 1.1%, 14.5%, and 2.5% (P value <0.05) in the 91 days to 1-year post-surgery. CONCLUSIONS There is statistically significant relationship between CO and higher readmission rates after ACDF. Preoperative opiate use is also associated with increased opiate use 6-12 months after surgery. Smoking history is also associated with increased readmission rates.
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Affiliation(s)
- Jun Ho Chung
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Alex Mierke
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Omar Ramos
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Whitney Kagabo
- Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Warren Boling
- Department of Neurosurgery, Loma Linda University Health, Loma Linda, California, USA
| | - Wayne Cheng
- Veterans Affairs Loma Linda Health Care, Loma Linda, California, USA
| | - Olumide Danisa
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, California, USA
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Costa F, Sharif S, Bajamal AH, Shaikh Y, Anania CD, Zileli M. Clinical and Radiological Factors Affecting Thoracolumbar Fractures Outcome: WFNS Spine Committee Recommendations. Neurospine 2022; 18:693-703. [PMID: 35000322 PMCID: PMC8752690 DOI: 10.14245/ns.2142518.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/16/2021] [Indexed: 11/19/2022] Open
Abstract
To obtain a list of recommendations about clinical and radiological factors affecting outcome in thoraco-lumbar fractures with the aim of helping spine surgeons in daily practice. A systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020 on the topic "thoracolumbar fracture AND radiology AND surgical outcomes" and "thoracolumbar fracture AND radiology AND surgical outcomes." A total of 58 papers were analyzed and WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meetings to formulate the specific recommendations the first in Peshawar in December 2019 and in a subsequent virtual meeting in June 2020 to reach an agreement. Both meetings utilized the Delphi method to analyze preliminary literature review statements based on the current evidence levels to generate recommendations through a comprehensive voting session. Eight statements were presented and reached the consensus about this topic. A variety of clinical factors is known to influence outcome of patients with thoracolumbar fractures. Some of these are well-known established factors such as blood pressure augmentation and patient age, while some are not well studied. Overall, the quality of evidence is low and we need more randomized controlled studies to validate our results. Similarly, radiological factors that can predict outcome are well stated and there is a high accordance worldwide. In reverse, still under debate is the application to choose which surgical treatment is advisable based on them.
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Affiliation(s)
- Francesco Costa
- IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Abdul Hafid Bajamal
- Division of Neuro-Spine, Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Airlangga, Indonesia.,Airlangga University Hospital, Surabaya, Indonesia
| | - Yousuf Shaikh
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | | | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Izmir, Turkey
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Ray N, Buchheit T. Improving Pain and Outcomes in the Perioperative Setting. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Wyatt MC, Kieser DC, Frampton CMA, Woodfield T, Hooper GJ. How do 3D-printed primary uncemented acetabular components compare with established uncemented acetabular cups? The experience of the New Zealand National Joint Registry. Hip Int 2022; 32:73-79. [PMID: 32340486 DOI: 10.1177/1120700020918233] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND 3D-printed or additive manufactured acetabular implants are an exciting new technology being used in hip surgery with increasing frequency especially in complex acetabular reconstructions. However, the performance of acetabular components produced by this method for primary THR is unknown. METHODS 41,272 uncemented cups in primary THR for OA were identified in the NZJR for the purposed of this study. There were 39,080 uncemented cups in the control group (15,798 Pinnacle cups, 12,724 Trident cups and 10,558 RM Pressfit cups) compared to 2192 3D-printed uncemented implants (1397 Delta TT cups, 640 Ti Por and 155 Polymax cups). All-cause revision rates and reasons for revision were examined. Kaplan-Meier survival analysis was performed. RESULTS 3D-printed cups were inserted into younger, fitter patients with a higher mean BMI compared to those in the control group (p < 0.001). The overall all-cause revision rate for 3D-printed cups was not significantly different to the controls: 0.77/100 cys (95% CI 0.59-1) compared to 0.55/100 cys (95% CI 0.52-0.58) in the control group (p = 0.058, Hazards ratio 1.29, 95% CI 0.992-1.678). There was no difference in aseptic cup loosening or deep infection rates between either group or indeed individual implant designs. CONCLUSIONS 3D-printed uncemented cups provide reliable survivorship and clinical results in primary THR comparable to established designs manufactured by traditional means. The theoretical concerns of increased rates of fatigue failure or deep infection are unsubstantiated.
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Affiliation(s)
- Michael C Wyatt
- Department of Trauma and Orthopaedic Surgery, Midcentral District Health Board, Palmerston North Hospital, Palmerston North, New Zealand.,Massey University, Palmerston North, New Zealand
| | - David C Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
| | - Chris M A Frampton
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
| | - Tim Woodfield
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
| | - Gary J Hooper
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
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Lemos JL, Welch JM, Xiao M, Shapiro LM, Adeli E, Kamal RN. Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions. JBJS Rev 2021; 9:01874474-202112000-00006. [PMID: 34936580 DOI: 10.2106/jbjs.rvw.21.00065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery. METHODS A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported. RESULTS The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome. CONCLUSIONS There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores. CLINICAL RELEVANCE Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.
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Affiliation(s)
- Jacie L Lemos
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Jessica M Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Michelle Xiao
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, California
| | - Ehsan Adeli
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Chapman EK, Scherschinski L, Gal JS, Shuman WH, Doctor T, Neifert SN, Martini ML, McNeill IT, Yuk FJ, Schupper AJ, Caridi JM. The Impact of ASA Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion. World Neurosurg 2021; 161:e54-e60. [PMID: 34856400 DOI: 10.1016/j.wneu.2021.11.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Increasing numbers of posterior cervical decompression and fusion (PCDF) over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of healthcare costs, length of stay, and other postoperative outcomes in PCDF patients. OBJECTIVE To evaluate correlations between ASA and postoperative outcomes, length of stay (LOS), and healthcare costs in patients undergoing PCDF. METHODS 971 patients that underwent PCDF between 2008 and 2016 at a single institution were evaluated by low (I and II) versus high (III and IV) ASA. Demographics were compared using univariate analysis. Cost of care, LOS and postoperative complications were compared using multivariable logistic and linear regression, controlling for gender, age, length of surgery and number of segments fused. RESULTS The high ASA cohort had greater mean age (62 vs. 55, p<0.0001) and higher Elixhauser comorbidity index (ECI) scores (p<0.0001). ASA was independently associated with longer LOS (+2.1 days, CI: 1.3-2.9; p<0.0001) and higher cost (+$2,936, CI: $1,457-$4,415; p<0.0001). High ASA patients were more likely to have a non-home discharge (3.9, 95% CI 2.8-5.6, p<0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, p=0.006), ICU stay (2.4, 95% CI 1.5-3.7, p=0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, p=0.03) and 30-day (3.2, 95% CI 1.5-6.8, p=0.003) and 90-day (3.2, 95% CI 1.8-5.7, p=0.0001) readmission. CONCLUSIONS High ASA is strongly associated with increased costs, LOS and adverse outcomes following PCDF. Therefore, ASA could be useful for preoperative prediction of these outcomes.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Lea Scherschinski
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John M Caridi
- Department of Neurosurgery, UT Health, Houston, TX, USA
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Saltzman EB, Evans DR, Anastasio A, Guisse N, Belay ES, Anakwenze OA, Gage MJ, Pidgeon TS, Richard MJ, Ruch DS, Klifto CS. Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of distal humerus fractures. JSES Int 2021; 5:1111-1118. [PMID: 34766092 PMCID: PMC8569009 DOI: 10.1016/j.jseint.2021.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction We hypothesized that the modified Fragility Index (mFI), which predicts surgical complications, would be applicable to surgical complications in patients older than 50 years with distal humerus fractures (DHF). Methods We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a DHF. A 5-item mFI score was calculated. Postoperative complications, readmission and reoperation rates, and length of stay were recorded. Univariate as well as a multivariable statistical analysis was performed, controlling for age, sex, body mass index, length of stay, and operative time. Results We identified 864 patients (mean age, 68.6 years ± 10.4), and 74.1% were female. As the mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 3% to 10% (P value = .01), rate of discharge to rehabilitation facility increased from 12% to 32% (P value = .0), and any complication rate increased from 4% to 19% (P value = .0). Rates of pulmonary complications increased significantly in patients with the mFI of 2 or greater (P value = .047). Patients with the mFI of 2 or greater were nearly 4 times more likely to be readmitted within 30 days (odds ratio [OR] = 3.5, P value = .007) and had an increased OR of 30-day reoperation and any complication (OR = 3.7, P value = .02; OR = 4.5, P value = .00, respectively) on multivariate analysis. Conclusion A fragility state is predictive of postoperative complications, readmission, and reoperation after surgical management of DHF. Our data suggest that a fragility evaluation can help inform surgical decision-making in patients older than 50 years with DHF.
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Affiliation(s)
- Eliana B Saltzman
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Albert Anastasio
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ndeye Guisse
- Emory University School of Medicine, Atlanta, GA, USA
| | - Elshaday S Belay
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke A Anakwenze
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark J Gage
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Tyler S Pidgeon
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marc J Richard
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - David S Ruch
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
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Hospital outcomes of scoliosis surgery in children with Prader-Willi Syndrome: comparison with adolescent idiopathic scoliosis. Spine Deform 2021; 9:1641-1647. [PMID: 33950464 DOI: 10.1007/s43390-021-00359-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the peri-operative outcomes of patients with Prader-Willi Syndrome (PWS) undergoing spinal deformity correction and compare the outcomes to patients with adolescent idiopathic scoliosis (AIS). METHODS A retrospective review of the Kid's Inpatient Database was performed from 2000 to 2012 to identify all pediatric patients with scoliosis undergoing spinal fusion. Cohorts were created on the basis of PWS diagnosis and adolescent idiopathic scoliosis. Statistical analysis was performed for differences in post-operative outcomes between these two patient cohorts. RESULTS Between 2000 and 2012, the number of spinal fusions performed increased by 24.6 and 32.2% in the PWS and adolescent idiopathic scoliosis populations, respectively. There was no difference between the incidence of major complications in PWS patients when compared to AIS (1.7% vs. 1.0% in idiopathic scoliosis; p = 0.362). Although there was no significant difference in the rate of overall minor complications, PWS patients were demonstrated to be more likely to experience post-operative pneumonia (p < 0.0001) and implant complications (p < 0.001). CONCLUSION Patients with scoliosis associated with PWS do not have any increased risk of major complications following spinal deformity correction when compared to patients with adolescent idiopathic scoliosis. Two important minor complications to keep in mind when surgically treating scoliosis in PWS patients include pulmonary and implant-related complications. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Eckers F, Laux CJ, Schaller S, Berli M, Achermann Y, Fucentese SF. Risk factor analysis for above-knee amputation in patients with periprosthetic joint infection of the knee: a case-control study. BMC Musculoskelet Disord 2021; 22:884. [PMID: 34663297 PMCID: PMC8525022 DOI: 10.1186/s12891-021-04757-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a severe complication following knee arthroplasty. Therapeutic strategies comprise a combination of surgical and antibiotic treatment modalities and aim to eradicate the infection. Sometimes control of the disease can only be attained by above-knee amputation (AKA). While a vast amount of literature exists illuminating predisposing factors for PJI, risk factors favoring the endpoint AKA in this context are sparsely known. Methods The purpose of this investigation was to delineate whether patients with PJI of the knee present specific risk factors for AKA. In a retrospective case-control study 11 cases of PJI treated with AKA were compared to 57 cases treated with limb salvage (LS). The minimum follow-up was 2 years. Comorbidities, signs and symptoms of the current infection, factors related to previous surgeries and the implant, microbiology, as well as therapy related factors were recorded. Comparative analysis was performed using student’s t-test, chi-square test or Fisher’s exact test. Binary differences were calculated using odds ratio (OR). Reoperation frequency was compared using Mann-Whitney U test. In-depth descriptive analysis of 11 amputees was carried out. Results A total of 68 cases aged 71 ± 11.2 years were examined, 11 of which underwent AKA and 57 had LS. Severe comorbidities (p = 0.009), alcohol abuse (p = 0.015), and preoperative anemia (p = 0.022) were more frequently associated with AKA. Preoperative anemia was found in all 11 amputees (100%) and in 33 of 57 LS patients (58%) with an average preoperative hemoglobin of 99.9 ± 15.1 g/dl compared to 118.2 ± 19.9 g/dl (p = 0.011). No other parameters differed significantly. AKA patients underwent a median of eight (range 2–24) reoperations, LS patients a median of five (range 2–15). Conclusion Factors potentially influencing the outcome of knee PJI are diverse. The indication of AKA in this context remains a rarity and a case-by-case decision. Patient-intrinsic systemic factors such as alcohol abuse, severe comorbidities and preoperative anemia may elevate the individual risk for AKA in the setting of PJI. We recommend that anemia, being a condition well amenable to therapeutic measures, should be given special consideration in management of PJI patients. Trial registration This study was registered with Kantonale Ethikkommission Zürich, (BASEC-No. 2016–01048).
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Affiliation(s)
- Franziska Eckers
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Christoph J Laux
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sebastian Schaller
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin Berli
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Yvonne Achermann
- Department of Infectious Diseases and Hospital Epidemiologie, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Carlstrom LP, Helal A, Perry A, Lakomkin N, Graffeo CS, Clarke MJ. Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy. J Clin Neurosci 2021; 93:48-53. [PMID: 34656260 DOI: 10.1016/j.jocn.2021.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Type-II odontoid fractures are common and highly morbid injuries, particularly among elderly patients. However, few risk stratification resources exist to predict outcomes and guide management decision making. Frailty indices have been increasingly utilized for these purposes in elective surgery, but have not been assessed for trauma. A single-center prospective trauma registry identified patients aged ≥ 80 years with type-II odontoid fractures. Frailty was the independent variable, using three independent indices: modified-5-item frailty (mFI-5), modified Charlson comorbidity (mCCI), and Davies. 97 patients had complete frailty data and sufficient follow up information, with median mIF-5 of 2 (range 0-4; 34 frail, mFI-5 > 2), median mCCI score of 6 (range 4-14), and median Davies score of 2 (range 0-7). For all indices, increasing score was associated with mortality, mIF-5 (HR = 1.76, 95%CI = 1.06-2.88), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Median post-injury survival among patients with mIF-5 of ≤ 2 was 10-fold longer than patients with mIF-5 of > 2 (70 vs. 710 days, p = 0.0026). After adjusting for initial treatment strategy, frailty status remained an independent predictor of patient mortality; mIF-5 (HR = 1.72, 95%CI = 1.02-2.80), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Among octogenarian patients with type-II odontoid fractures, frailty was associated with increased mortality, independent of treatment strategy.
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Affiliation(s)
| | - Ahmed Helal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Sinclair ST, Emara AK, Orr MN, McConaghy KM, Klika AK, Piuzzi NS. Comorbidity indices in orthopaedic surgery: a narrative review focused on hip and knee arthroplasty. EFORT Open Rev 2021; 6:629-640. [PMID: 34584773 PMCID: PMC8441846 DOI: 10.1302/2058-5241.6.200124] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Comorbidity indices currently used to estimate negative postoperative outcomes in orthopaedic surgery were originally developed among non-orthopaedic patient populations. While current indices were initially intended to predict short-term mortality, they have since been used for other purposes as well. As the rate of hip and knee arthroplasty steadily rises, understanding the magnitude of the effect of comorbid disease on postoperative outcomes has become increasingly more important. Currently, the ASA classification is the most commonly used comorbidity measure and is systematically recorded by the majority of national arthroplasty registries. Consideration should be given to developing an updated, standardized approach for comorbidity assessment and reporting in orthopaedic surgery, especially within the setting of elective hip and knee arthroplasty.
Cite this article: EFORT Open Rev 2021;6:629-640. DOI: 10.1302/2058-5241.6.200124
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Affiliation(s)
- SaTia T Sinclair
- Cleveland Clinic Foundation, Department of Orthopedic Surgery, Cleveland, Ohio, United States
| | - Ahmed K Emara
- Cleveland Clinic Foundation, Department of Orthopedic Surgery, Cleveland, Ohio, United States
| | - Melissa N Orr
- Cleveland Clinic Foundation, Department of Orthopedic Surgery, Cleveland, Ohio, United States
| | - Kara M McConaghy
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Alison K Klika
- Cleveland Clinic Foundation, Department of Orthopedic Surgery, Cleveland, Ohio, United States
| | - Nicolas S Piuzzi
- Cleveland Clinic Foundation, Department of Orthopedic Surgery, Cleveland, Ohio, United States
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Varady NH, Gillinov SM, Yeung CM, Rudisill SS, Chen AF. The Charlson and Elixhauser Scores Outperform the American Society of Anesthesiologists Score in Assessing 1-year Mortality Risk After Hip Fracture Surgery. Clin Orthop Relat Res 2021; 479:1970-1979. [PMID: 33930000 PMCID: PMC8373577 DOI: 10.1097/corr.0000000000001772] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/11/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated. QUESTION/PURPOSE Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era? METHODS A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%. RESULTS The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days. CONCLUSION Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Nathan H. Varady
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen M. Gillinov
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Caleb M. Yeung
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel S. Rudisill
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonia F. Chen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3755-3762. [PMID: 34398335 DOI: 10.1007/s00586-021-06960-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/29/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. METHODS The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals. CONCLUSIONS Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.
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Nolte MT, Parrish JM, Jenkins NW, Cha EDK, Lynch CP, Mohan S, Geoghegan CE, Jadczak CN, Hrynewycz NM, Singh K. The Influence of Comorbidity on Postoperative Outcomes Following Lumbar Decompression. Clin Spine Surg 2021; 34:E390-E396. [PMID: 33560010 DOI: 10.1097/bsd.0000000000001133] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 12/22/2020] [Indexed: 01/05/2023]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE Evaluate the association between comorbidity burden and reaching minimum clinically important difference (MCID) following lumbar decompression (LD). SUMMARY OF BACKGROUND DATA There is limited research on the influence of preoperative comorbidity burden on patient-reported outcome improvement following LD. METHODS A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries between 2015 and 2019. Inclusion criteria were primary, single, or multilevel LD. Patients were excluded for missing preoperative patient-reported outcome surveys. Stratification was based on Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1-2 points (low CCI), ≥3 points (high CCI). Demographics and perioperative characteristics were evaluated for differences. Linear regression assessed postoperative improvement for visual analogue scale (VAS) back, VAS leg, Oswestry disability index (ODI), Short Form-12 Physical Composite Score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) scores through 1 year. Achievement rate of MCID was compared between groups and evaluated for significant predictors. RESULTS Three hundred fourteen patients were included (123 no comorbidities, 100 low CCI, 91 high CCI). Higher CCI patients were older, more likely to smoke, and have comorbid diseases (all P<0.001). Perioperative differences included increased operative time, levels decompressed, length of stay, and discharge day in the CCI≥3 group. No differences in the rate of achieving MCID for VAS back, VAS leg, and ODI. CCI≥3 subgroup had a lower rate of reaching MCID at 6 months for SF-12 PCS, at 6 weeks for PROMIS-PF, and the overall rate for both SF-12 PCS and PROMIS-PF (all P<0.05). Multilevel procedures was a predictor for MCID achievement for ODI. CONCLUSIONS Patients with increased comorbidities undergoing LD had an equivalent MCID achievement rate for pain and disability metrics through 1 year. High CCI patients did, however, have a lower rate of achieving MCID for their physical function surveys which suggests that comorbidity burden influences improvement in physical function following LD.
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Affiliation(s)
- Michael T Nolte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Pierce KE, Naessig S, Kummer N, Larsen K, Ahmad W, Passfall L, Krol O, Bortz C, Alas H, Brown A, Diebo B, Schoenfeld A, Raad M, Gerling M, Vira S, Passias PG. The Five-item Modified Frailty Index is Predictive of 30-day Postoperative Complications in Patients Undergoing Spine Surgery. Spine (Phila Pa 1976) 2021; 46:939-943. [PMID: 34160372 DOI: 10.1097/brs.0000000000003936] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery. SUMMARY OF BACKGROUND DATA The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions. METHODS Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes. RESULTS After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P < 0.001). Each index established significant (all P < 0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P < 0.001), whereas MF increased (9.2% to 16.2%, P < 0.001), and SF remained constant (2% to 1.6%, P > 0.05). With increase in severity, postoperative rates of morbidities and complications increased. CONCLUSION The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3.
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Affiliation(s)
- Katherine E Pierce
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Sara Naessig
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Nicholas Kummer
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Kylan Larsen
- Department of Orthopedics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Waleed Ahmad
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Lara Passfall
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Oscar Krol
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Cole Bortz
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Haddy Alas
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Avery Brown
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Andrew Schoenfeld
- Department of Orthopedic Surgery at Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Micheal Raad
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Michael Gerling
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Shaleen Vira
- Department of Orthopedics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
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Park SJ, Lee KH, Lee CS, Kim KT, Kim DH, Lee CH, Kim GL. Best versus worst surgical outcomes after single-level posterior lumbar interbody fusion for degenerative spondylolisthesis. J Orthop Surg (Hong Kong) 2021; 29:2309499020983038. [PMID: 33590777 DOI: 10.1177/2309499020983038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Previous studies have shown conflicting results regarding the factors affecting the clinical outcome after fusion for degenerative spondylolisthesis. However, no study has compared the best and worst clinical outcome groups using patient-reported outcome measures. We aimed to compare the characteristics of patients with best and worst outcomes following single-level lumbar fusion for degenerative spondylolisthesis. METHODS 200 patients underwent single-level interbody fusion with a minimum 2-years follow-up were included. We excluded patients with surgical complications already-known to be associated with poor postoperative outcomes, including pseudoarthrosis and postoperative infection. According to 2-year postoperative Oswestry disability index scores, patients were divided into two groups; Best and Worst. Demographic, clinical and radiographic variables were compared between the two groups. RESULTS Compared with patients in the Best group, those in the Worst group were older (59.5 and 67.0 years, respectively; p = 0.012; odds ratio [OR], 1.143; 95% confidence interval [CI], 1.030-1.269) and had a longer duration of pain from onset (2.6 and 7.2 years, respectively; p = 0.041; OR, 1.021; 95% CI, 1.001-1.041). The cutoff value of pain duration from onset was measured as ≥3.5 years on Receiver operating characteristic analysis. Patients in the Worst group had a lower preoperative angular motion compared to those in the Best group (12.7° and 8.3°, respectively; p = 0.016; OR, 0.816; 95% CI, 0.691-0.963). CONCLUSIONS Degenerative spondylolisthesis patients of good clinical outcome after single-level lumbar interbody fusion were relatively young, had a short symptom duration before surgery, and a high preoperative instability compared with the patient having poor postoperative clinical outcome. Therefore, these findings should be considered preoperatively when deciding the appropriate individual treatment plan.
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Affiliation(s)
- Se-Jun Park
- Department of Orthopedic Surgery, Spine Center, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keun-Ho Lee
- Department of Orthopedic Surgery, College of Medicine, Hallym University, 37993Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Spine Center, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki-Tack Kim
- Department of Orthopedic Surgery, 58937Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Dong Hyeon Kim
- Department of Orthopedic Surgery, College of Medicine, Hallym University, 37993Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Chae Ho Lee
- Department of Orthopedic Surgery, College of Medicine, Hallym University, 37993Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Gab-Lae Kim
- Department of Orthopedic Surgery, College of Medicine, Hallym University, 37993Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
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Moses ZB, Oh SY, Fontes RBV, Deutsch H, O'Toole JE, Fessler RG. The modified frailty index and patient outcomes following transforaminal lumbar interbody fusion surgery for single-level degenerative spine disease. J Neurosurg Spine 2021; 35:163-169. [PMID: 34087787 DOI: 10.3171/2020.11.spine201263] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The modified frailty index (mFI) is a simple tool that measures physiological reserve based on a thorough history and physical examination. Its use has been validated in several surgical specialties, including spinal deformity surgery. Prior research has suggested no significant differences in clinical outcomes between elderly and nonelderly patients undergoing posterior lumbar interbody fusion. The authors sought to investigate the use of the mFI in patients undergoing transforaminal lumbar interbody fusion (TLIF) and the relationship between frailty scores and clinical outcomes. METHODS A retrospective chart review was conducted on 198 patients who underwent a single-level TLIF over a 60-month period at a single institution. For all patients, an mFI score was computed incorporating a set of 11 clinical factors to assess preexisting comorbidities and functional status. Clinical follow-up and health-related quality-of-life (HRQOL) scores were obtained at baseline and regular intervals of 6 weeks, 6 months, and 1 year following surgery. RESULTS Patients were grouped according to their level of frailty: no frailty (mFI = 0), mild frailty (mFI = 0.09), moderate frailty (mFI = 0.18), and severe frailty (mFI ≥ 0.27). One-way ANOVA revealed increasing levels of frailty to be associated with an increased rate of complications, from 10.3% to 63.6%. In addition, increasing levels of frailty were associated with longer hospital length of stay (LOS), from 3.1 days to 6.5 days, and lower rates of disposition to home. At the 1-year follow-up, increased levels of frailty were associated with worse HRQOL measures. CONCLUSIONS Increasing mFI score was associated with higher morbidity, longer inpatient LOS, and a lower probability of discharge to home in patients undergoing single-level TLIF. Consideration of the mFI may help surgeons improve decision-making across the spectrum of patients who are at risk from frailty.
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Chan V, Wilson JRF, Ravinsky R, Badhiwala JH, Jiang F, Anderson M, Yee A, Wilson JR, Fehlings MG. Frailty adversely affects outcomes of patients undergoing spine surgery: a systematic review. Spine J 2021; 21:988-1000. [PMID: 33548521 DOI: 10.1016/j.spinee.2021.01.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/16/2020] [Accepted: 01/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND With an aging population, there are an increasing number of elderly patients undergoing spine surgery. Recent literature in other surgical specialties suggest frailty to be an important predictor of outcomes. PURPOSE The aim of this review was to examine the association between frailty and outcomes after spine surgery. STUDY DESIGN A systematic review was performed. PATIENT SAMPLE Electronic databases from 1946 to 2020 were searched to identify articles on frailty and spine surgery. OUTCOME MEASURES The primary outcome was adverse events. Secondary outcomes included other measures of morbidity, mortality, and patient outcomes. METHODS Sample size, mean age, age limitation, data source, study design, primary pathology, surgical procedure performed, follow-up period, assessment of frailty used, surgical outcomes, and impact of frailty on outcomes were extracted from eligible studies. Quality and bias were assessed using the PRISMA 27-point item checklist and the QUADAS-2 tool. RESULTS Thirty-two studies were selected for review, with a total of 127,813 patients. There were eight different frailty indices/measures. Regardless of how frailty was measured, frailty was associated with an increased risk of adverse events, mortality, extended length of stay, readmission, and nonhome discharge. CONCLUSION There is strong evidence that frailty is associated with an increased risk of morbidity and mortality in patients who received spine surgery. However, it remains inconclusive whether frailty impacts patient outcomes and quality of life after surgery.
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Affiliation(s)
- Vivien Chan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8
| | - Jamie R F Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8
| | - Robert Ravinsky
- Department of Orthopaedic Surgery, University of Arizona College of Medicine - Phoenix, 755 E. McDowell Rd, 2nd Floor, Phoenix, AZ,85006; Spine Division, The CORE Institute, 18444 N. 25th Ave, suite 210, Phoenix, AZ, 85023
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8
| | - Fan Jiang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8
| | - Melanie Anderson
- Library and Information Services, University Health Network, Toronto, Ontario, M5T 2S8
| | - Albert Yee
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Department of Orthopedic Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, M4N 3M5
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Department of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, M5B 1W8
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8.
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Wang KY, Ikwuezunma I, Puvanesarajah V, Babu J, Margalit A, Raad M, Jain A. Using Predictive Modeling and Supervised Machine Learning to Identify Patients at Risk for Venous Thromboembolism Following Posterior Lumbar Fusion. Global Spine J 2021; 13:1097-1103. [PMID: 34036817 DOI: 10.1177/21925682211019361] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To use predictive modeling and machine learning to identify patients at risk for venous thromboembolism (VTE) following posterior lumbar fusion (PLF) for degenerative spinal pathology. METHODS Patients undergoing single-level PLF in the inpatient setting were identified in the National Surgical Quality Improvement Program database. Our outcome measure of VTE included all patients who experienced a pulmonary embolism and/or deep venous thrombosis within 30-days of surgery. Two different methodologies were used to identify VTE risk: 1) a novel predictive model derived from multivariable logistic regression of significant risk factors, and 2) a tree-based extreme gradient boosting (XGBoost) algorithm using preoperative variables. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area-under-the-curve (AUC) statistic. RESULTS 13, 500 patients who underwent single-level PLF met the study criteria. Of these, 0.95% had a VTE within 30-days of surgery. The 5 clinical variables found to be significant in the multivariable predictive model were: age > 65, obesity grade II or above, coronary artery disease, functional status, and prolonged operative time. The predictive model exhibited an AUC of 0.716, which was significantly higher than the AUCs of ASA and CCI (all, P < 0.001), and comparable to that of the XGBoost algorithm (P > 0.05). CONCLUSION Predictive analytics and machine learning can be leveraged to aid in identification of patients at risk of VTE following PLF. Surgeons and perioperative teams may find these tools useful to augment clinical decision making risk stratification tool.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ijezie Ikwuezunma
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jacob Babu
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Adam Margalit
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, 1501The Johns Hopkins Hospital, Baltimore, MD, USA
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Veronesi F, Borsari V, Martini L, Visani A, Gasbarrini A, Brodano GB, Fini M. The Impact of Frailty on Spine Surgery: Systematic Review on 10 years Clinical Studies. Aging Dis 2021; 12:625-645. [PMID: 33815887 PMCID: PMC7990375 DOI: 10.14336/ad.2020.0904] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/04/2020] [Indexed: 12/19/2022] Open
Abstract
Frailty is a condition characterized by a high vulnerability to low-power stressor. Frailty increases with age and is associated with higher complications and mortality. Several indexes have been used to quantify frailty. Spine diseases, both degenerative and oncologic, frequently require surgery which is related to complications and mortality. Aim of the present systematic review was to collect the most frequently used frailty indexes in clinics to predict surgical outcomes in patients affected by spine diseases, taking into account gender differences. Three databases were employed, and 29 retrospective clinical studies were included in this systematic review. The identified spine pathologies were primary and metastatic spine tumors, adult spine deformity (ASD), degenerative spine disease (DSD), cervical deformity (CD) and other pathologies that affected lumbar spine or multiple spine levels. Eleven indexes were identified: modified Frailty Index (mFI), Adult spinal deformity frailty index (ASD-FI), mFI-5, Metastatic Spinal Tumor Frailty Index (MSTFI), Fried criteria, Cervical deformity frailty index (CD-FI), Spinal tumor frailty index (STFI), Frailty Phenotype criteria (FP), Frailty Index (FI), FRAIL scale and Modified CD-FI (mCD-FI). All these indexes correlated well with minor and major postoperative complications, mortality and length of stay in hospital. Results on gender differences and frailty are still conflicting, although few studies show that women are more likely to develop frailty and more complications in the post-operative period than men. This systematic review could help the surgeon in the adoption of frailty indexes, before the operation, and in preventing complications in frail patients.
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Affiliation(s)
- Francesca Veronesi
- 1Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Veronica Borsari
- 1Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Lucia Martini
- 1Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Visani
- 1Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gasbarrini
- 2Spine Surgery prevalently Oncologic and Degenerative, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giovanni Barbanti Brodano
- 2Spine Surgery prevalently Oncologic and Degenerative, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Milena Fini
- 1Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Yi BC, Gowd AK, Agarwalla A, Chen E, Amin NH, Nicholson GP, Romeo AA, Liu JN. Efficacy of the modified Frailty Index and the modified Charlson Comorbidity Index in predicting complications in patients undergoing operative management of proximal humerus fracture. J Shoulder Elbow Surg 2021; 30:658-667. [PMID: 32650081 DOI: 10.1016/j.jse.2020.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Comorbidity indices such as the 5-factor modified Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI) are widely used in outcomes research. METHODS A total of 3893 patients who underwent total shoulder arthroplasty (n=975), hemiarthroplasty (n=495), or open reduction and internal fixation (n=2423) for the treatment of proximal humerus fracture from 2005-2017 were identified from the National Surgical Quality Improvement Program database. Data regarding demographics, comorbidities, American Society of Anesthesiologists class, and postoperative complications were collected, and the mFI-5 and mCCI were calculated for each case. Multivariate logistic regression models and receiver operating characteristic curve analyses were performed. RESULTS The patient population had a mean age of 68.0 ± 13.2 years, body mass index of 29.1 ± 8.1 and mean operative time of 119.9 ± 55.5 minutes. The most common complications within this cohort were extended length of stay (4 days or more) (1085/3893; 27.87%), transfusion (377/3893; 9.68%), unplanned reoperation (97/3893; 2.49%), urinary tract infection (43/3893; 1.10%), death (42/3893; 1.08%), and deep vein thrombosis (40/3893; 1.03%). After accounting for patient demographics, the mFI-5 (odds ratio [OR] = 1.105, P < .001) and mCCI (OR = 1.063, P < .001) were significantly associated with incidence of any adverse event. Both comorbidity indices had low positive predictive value and high negative predictive value for all adverse events. CONCLUSION The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures.
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Affiliation(s)
- Brendan C Yi
- School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Eric Chen
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - Anthony A Romeo
- Department of Orthopaedic Surgery, The Rothman Institute, New York, NY, USA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA.
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Ottesen TD, Bagi PS, Malpani R, Galivanche AR, Varthi AG, Grauer JN. Underweight patients are an often under looked “At risk” population after undergoing posterior cervical spine surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 5:100041. [PMID: 35141608 PMCID: PMC8820029 DOI: 10.1016/j.xnsj.2020.100041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/07/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022]
Abstract
Background Body Mass Index (BMI) is a weight-for-height metric that is used to quantify tissue mass and weight levels. Past studies have mainly focused on the association of high BMI on spine surgery outcomes and shown variable conclusions. Prior results may have varied due to insufficient power or inconsistent categorical separation of BMI groups (e.g. underweight, overweight, or obese). Additionally, few studies have considered outcomes of patients with low BMI. The aim of the current study was to analyze patients along the entirety of the BMI spectrum and to establish specific granular BMI categories for which patients become at risk for complication and mortality following posterior cervical spine surgery. Methods Patients undergoing elective posterior cervical spine surgery were abstracted from the 2005–2016 National Surgical Quality Improvement Program (NSQIP) databases. Patients were aggregated into pre-established WHO BMI categories and adverse outcomes were normalized to average risk of normal-weight subjects (BMI 18.5–24.9 kg/m2). Risk-adjusted multivariate regressions were performed controlling for patient demographics and overall health. Results A total of 16,806 patients met inclusion criteria. Odds for adverse events for underweight patients (BMI < 18.5 kg/m2) were the highest among any category of patients along the BMI spectrum. These patients experienced increased odds of any adverse event (Odds Ratio (OR) = 1.67, p = 0.008, major adverse events (OR=2.08, p = 0.001), post-operative infection (OR = 1.95, p = 0.002), and reoperation (OR = 1.84, p = 0.020). Interestingly, none of the overweight or obese categories were found to be correlated with increased risk of adverse event categories other than super-morbidly obese patients (BMI>50.0 kg/m2) for post-operative infection (OR = 1.54, p = 0.041). Conclusions The current study found underweight patients to have the highest risk of adverse events after posterior cervical spine surgery. Increased pre-surgical planning and resource allocation for this population should be considered by physicians and healthcare systems, as is often already done for patients on the other end of the BMI spectrum.
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Association of preoperative medication with postoperative length of stay in elderly patients undergoing hip fracture surgery. Aging Clin Exp Res 2021; 33:641-649. [PMID: 32440842 DOI: 10.1007/s40520-020-01567-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND For elderly patients who are about to undergo surgery, research on the effects of preoperative medication on postoperative outcomes is rare, especially preoperative discontinuation-requiring medication (PDRM) which needed to be discontinued because of its increased risk of postoperative complications. AIM To investigate whether preoperative medication (PDRM and polypharmacy) is associated with postoperative length of hospital stay (LOS) in elderly patients undergoing hip fracture surgery. METHODS Patients aged ≥ 65 who were scheduled for hip (limited to femoral tuberosity) fracture surgery were included. Baseline characteristics, preoperative medication and postoperative LOS were collected from the electronic medical record. The primary outcome was postoperative LOS. RESULTS A total of 369 hip fracture patients were included. There were 188 and 122 patients exposed to PDRM and polypharmacy, respectively. Multivariate analysis models were constructed using significant factors for prolonged postoperative hospital stay from univariate analysis: Model I (body mass index (BMI), Charlson comorbidity index (CCI) ≥ 7, creatinine clearance rate (Ccr) < 60 and PDRM) and Model II (BMI, Ccr ≥ 7, Ccr < 60 and polypharmacy). CCI was the most significant factor. Its adjusted odds ratio was as large as 2.7 and attributable risk was 63%. In preoperative medication use, both polypharmacy and PDRM showed significant association with postoperative LOS. CONCLUSION The present study supported the impact of PDRM on postoperative LOS in geriatric hip fracture patients. The results added a further aspect to preoperative medication optimization in elderly patients undergoing hip fracture surgery.
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Jang HJ, Chin DK, Park JY, Kuh SU, Kim KS, Cho YE, Kim KH. Influence of Frailty on Life Expectancy in Octogenarians After Lumbar Spine Surgery. Neurospine 2021; 18:303-310. [PMID: 33494553 PMCID: PMC8255765 DOI: 10.14245/ns.2040688.344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objective Many studies have reported positive surgical outcomes and decreased mortality after spine surgery in the elderly population, including patients between 85 and 90 years of age. Here, in addition to patient age, we investigated the influence of frailty on short and long-term mortality in octogenarians after lumbar surgery.
Methods We performed a retrospective analysis of 162 patients over 80 years of age who underwent posterior lumbar fusion or decompressive laminectomy between January 2011 and September 2016. We examined patient survival and modified frailty index (mFI) from medical records.
Results By October 2019, 29 of 162 patients had expired (follow-up period: 1–105 months). Three-month mortality was 1.9%, and 1-year mortality was 4.9%. Frailty did not affect long-term survival at 1 year but was associated with 3-month mortality (p = 0.024).
Conclusion There was no relationship in long-term survival according to frailty in patients 80 years of age or older, but a difference was identified in short-term mortality. When making a surgical decision for lumbar spine surgery in frail patients over 80 years of age, surgeons should pay attention to the short-term prognosis.
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Affiliation(s)
- Hyun-Jun Jang
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Kyu Chin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Uk Kuh
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun-Su Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Hyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Evans DR, Saltzman EB, Anastasio AT, Guisse NF, Belay ES, Pidgeon TS, Richard MJ, Ruch DS, Anakwenze OA, Gage MJ, Klifto CS. Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures. JSES Int 2020; 5:212-219. [PMID: 33681840 PMCID: PMC7910730 DOI: 10.1016/j.jseint.2020.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hypothesis We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture. Methods We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time. Results We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (P-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (P-value < .001), and rates of any complication increased from 6.5% to 13.9% (P-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (P-value = .042 and P-value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, P-value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, P-value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time. Conclusion An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.
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Affiliation(s)
| | - Eliana B Saltzman
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Albert T Anastasio
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Elshaday S Belay
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Tyler S Pidgeon
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marc J Richard
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - David S Ruch
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke A Anakwenze
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark J Gage
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA
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Zhang M, Hayden Gephart M, Zygourakis CC. Commentary: Predicting Postoperative Outcomes in Brain Tumor Patients With a 5-Factor Modified Frailty Index. Neurosurgery 2020; 88:E36-E38. [PMID: 32888308 DOI: 10.1093/neuros/nyaa407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford Medical Center, Palo Alto, California
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Hadjiathanasiou A, Kilinc F, Behmanesh B, Bernstock J, Güresir E, Heimann M, Konczalla J, Scharnböck E, Schneider M, Weinhold L, Seifert V, Vatter H, Gessler F, Schuss P. Impact of Comorbidities and Frailty on Early Shunt Failure in Geriatric Patients With Normal Pressure Hydrocephalus. Front Med (Lausanne) 2020; 7:596270. [PMID: 33330560 PMCID: PMC7734184 DOI: 10.3389/fmed.2020.596270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
Background/Aim: Older patients are considered to bear a higher perioperative risk. Since idiopathic normal pressure hydrocephalus (NPH) predominantly concerns older patients, identifying risk factors for early shunt failure for preoperative risk/benefit assessment is indispensable for indication and/or consultation of patients for ventriculoperitoneal shunting (VPS). Methods: We performed a retrospective study design, including data acquired from two university hospital neurosurgical institutions between 2012 and 2019. Overall, 211 consecutive patients with clinical/radiological signs for NPH who additionally showed alleviation of symptoms after lumbar cerebrospinal fluid (CSF) drainage, received VPS and were included for further analysis. Frailty was measured using the Clinical Frailty Scale (CFS). Main outcome was early shunt failure or post-operative complications within 30 days after initial VPS surgery. Results: The overall complication rate was 14%. Patient-related complications were observed in 13 patients (6%) and procedure-related complications in 16 patients (8%). Early post-operative complications resulted in a significantly prolonged length of hospital stay 6.9 ± 6.8 vs. 10.8 ± 11.8 days (p = 0.03). Diabetes mellitus with end-organ damage (OR 35.4, 95% CI 6.6 – 189.4, p < 0.0001) as well as preexisting Parkinson's disease were associated with early patient-related post-surgical complications after VPS for NPH. Conclusions: Patients comorbidities but not frailty were associated with early post-operative patient-related complications in patients suffering NPH. While frailty may deter patients from other (neurosurgical) procedures, VPS surgery might contribute to treating NPH in these patients at a tolerable risk.
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Affiliation(s)
| | - Fatma Kilinc
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Joshua Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, United States
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Muriel Heimann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Elisa Scharnböck
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Leonie Weinhold
- Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Bonn, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
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Zreik J, Alvi MA, Yolcu YU, Sebastian AS, Freedman BA, Bydon M. Utility of the 5-Item Modified Frailty Index for Predicting Adverse Outcomes Following Elective Anterior Cervical Discectomy and Fusion. World Neurosurg 2020; 146:e670-e677. [PMID: 33152490 DOI: 10.1016/j.wneu.2020.10.154] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty is an increasingly studied tool for preoperative risk stratification, but its prognostic value for anterior cervical discectomy and fusion (ACDF) patients is unclear. We sought to evaluate the association of the 5-item modified Frailty Index (5i-mFI) with 30-day adverse outcomes following ACDF and its predictive performance compared with other common metrics. METHODS The National Surgical Quality Improvement Program was queried from 2016-2018 for patients undergoing elective ACDF for degenerative diseases. Outcomes of interest included 30-day complications, extended length of stay (LOS), non-home discharge, and unplanned readmissions. Unadjusted/adjusted odds ratios were calculated. The discriminatory performance of the 5i-mFI compared with age, American Society of Anesthesiologists (ASA) classification, and body mass index was computed using the area under the receiver operating characteristic curve (AUC). RESULTS A total of 23,754 patients were identified. On adjusted analysis, an index of 1 was significantly associated with extended LOS, non-home discharge, and unplanned readmissions (P < 0.001, P = 0.023, P = 0.003, respectively), but not complications (all P > 0.05). An index ≥2 was significantly associated with each outcome (all P < 0.001). The 5i-mFI was found to have a significantly higher AUC than body mass index for each outcome, a similar AUC compared with ASA classification and age for complications and unplanned readmissions, and a significantly lower AUC than ASA classification and age for extended LOS and non-home discharge. CONCLUSIONS The 5i-mFI was found to be significantly associated with 30-day adverse outcomes following ACDF but had similar or lesser predictive performance compared with more universally available and easily implemented metrics, such as ASA classification and age.
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Affiliation(s)
- Jad Zreik
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA; Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Yagiz U Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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The 5 and 11 Factor Modified Frailty Indices are Equally Effective at Outcome Prediction Using TQIP. J Surg Res 2020; 255:456-462. [DOI: 10.1016/j.jss.2020.05.090] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/07/2020] [Accepted: 05/24/2020] [Indexed: 12/21/2022]
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