Frailty adversely affects outcomes of patients undergoing spine surgery: a systematic review

Complementary effects of postoperative delirium and frailty on 30-day outcomes in spine surgery

BACKGROUND CONTEXT

With an increasingly older population, the number of frail patients requiring surgical management for degenerative spine diseases is rapidly increasing. Older patients are at increased risk of developing postoperative delirium (POD), which increases the odds of postoperative morbidity and mortality in spine surgery patients. Therefore, frail spine surgery patients may be at greater risk of developing POD and subsequent adverse outcomes.

PURPOSE

To understand the relationship between frailty and POD in spine surgery patients, and the effect of POD on nonfatal and fatal adverse outcomes in frail patients.

STUDY DESIGN/SETTING

Retrospective cohort study utilizing data from the 2021 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

PATIENT SAMPLE

Patients aged ≥75 years undergoing spine surgery screened for POD, with a total sample size of 4,195 patients.

OUTCOME MEASURES

Primary outcomes were postoperative delirium (POD), 30-day mortality, and nonfatal adverse outcomes.

METHODS

Frailty was measured using the Risk Analysis Index (RAI) with tiered cutoffs indicating increasing frailty. Statistical methods included multivariable logistic regression and mediation analysis to evaluate the relationships between RAI, postoperative delirium, and 30-day mortality.

RESULTS

Out of 4,195 spine surgery patients aged ≥75 years screened for POD, 353 (8.4%) exhibited POD. POD patients had significantly higher RAI scores relative to those without POD (p<.001). Multivariable analysis demonstrated that increasing frailty predicted POD (p<.001). In patients with POD, there were increased odds of mortality and all nonfatal adverse outcomes within 30 days (p<.001). A complementary mediation effect of POD on frailty's contribution to 30-day mortality was observed (p<.001).

CONCLUSION

POD and increasing preoperative frailty RAI scores were independent predictors of mortality and morbidity in older spine surgery patients. POD has a significant synergistic contribution to the adverse effects of frailty following spine surgery. The RAI may be used to identify frail patients at risk of developing POD to enable optimal surgical candidate selection and provide opportunities for risk mitigation, such as prehabilitation and/or specialized perioperative care teams for frail patients.

Factors and Experiences Associated With Unscheduled Hospital Readmission After Lateral Lumbar Interbody Fusion: A Case-Controlled Study

PURPOSE

Understanding the risk factors associated with unscheduled readmission following lateral lumbar interbody fusion (LLIF) is crucial for mitigating the occurrence of these costly events. This study aims to ascertain the incidence and factors of unscheduled hospital readmission subsequent to LLIF.

METHODS

A retrospective analysis was conducted on patients who underwent LLIF at our institution from March 2016 to February 2023. Instances of unscheduled hospital readmission after LLIF were meticulously recorded, including baseline demographics, characteristics of spine pathology, surgical interventions, duration between two hospitalizations, and hospitalization costs and duration. Reasons for readmission were categorized based on their etiology. A case-control methodology was employed to compare unscheduled hospital readmission patients against planned readmission patients due to staged surgery. Parametric data were analyzed with a two-tailed T-test, nonparametric data with the Wilcoxon rank-sum test, and categorical data with the χ2 test.

RESULTS

A total of 1521 patients who received LLIF at our institution were included in the study. A total of 59 patients (3.88%) were unscheduled readmitted due to adjacent segment disease (ASD), cage subsidence, the original surgical segments remaining narrow, spondylodiscitis, and pain. 51 patients (3.35%) experienced reoperation, predominantly attributable to ASD. Compared to planned readmission patients, unscheduled readmission patients tended to be younger, had a lower likelihood of having scoliosis, and were more likely to have short-segment surgery and higher initial hospitalization costs. Among unscheduled readmission patients, patients receiving short-segment surgery, as well as those who paid less during the initial hospitalization, demonstrated a higher likelihood of a 90-day readmission rate.

CONCLUSION

Our findings indicated the heightened risks of unscheduled hospital readmission after LLIF. Taking targeted measures against these risk factors is expected to reduce the healthcare burden caused by unplanned readmissions in the future.

Orthopedic frailty risk stratification (OFRS): a systematic review of the frailty indices predicting adverse outcomes in orthopedics

BACKGROUND

With a growing number of elderly patients requiring elective and non-elective procedures, frailty-based preoperative risk stratification is an emerging tool in orthopedic surgery to minimize adverse postoperative outcomes. This paper sought to understand the current literature regarding preoperative Orthopedic Frailty Risk Stratification (OFRS) and describe the disparate frailty indices and their capabilities for discrimination in predicting adverse postoperative outcomes.

METHODS

A literature search was conducted in Pubmed, Cochrane, and Scopus for articles published during or prior to February 2024 assessing frailty following surgery for orthopedic pathologies. Qualitative variables including study characteristics and application of frailty were collected and synthesized. Quantitative meta-analysis was performed for pooled odds ratio (OR) and area under the curve (AUC) of frailty for mortality and complications. All methods were performed in accordance with PRISMA guidelines.

RESULTS

Of the 81 included articles, over half (52%) addressed traumatic orthopedic pathologies with traumatic hip fractures being the most studied in the OFRS (25 studies). Less common categories included oncology, sports, and foot/ankle. Functional status and independence were the most common frailty domain (25, 96.2%) and component across scales (20, 76.9%), respectively. The 5-Item Modified Frailty Index (mFI-5) was the most common frailty index (28 publications). Meta-analysis demonstrated increasing frailty was an independent predictor of mortality (30-day OR: 2.89, 95% CI: 2.00-4.18; 1 year OR: 1.81, 95% CI: 1.48-2.22, p < 0.001), major complications (OR: 1.63, 95% CI: 1.10-2.41, p = 0.02), and Clavien-Dindo IV complications (OR: 3.26, 95% CI: 2.18-4.87, p < 0.001). Frailty had good discriminatory accuracy for predicting mortality at 30-days (AUC: 0.71, 95% CI: 0.68-0.74, p < 0.001), 3-months (OR: 0.75, 95% CI: 0.65-0.83, p < 0.001), and 1-year (OR:0.74, 95% CI: 0.73-0.75, p < 0.001).

CONCLUSIONS

The orthopedic surgery frailty literature is extremely heterogeneous, with disparate frailty scales implemented to measure varying outcomes across many orthopedic pathologies. Despite no consensus on exact scales or definitions, various frailty indices have predicted adverse outcomes.

Predicting morbidity and mortality after surgery for isolated traumatic spinal injury without spinal cord injury

BACKGROUND

Traumatic spinal injuries are associated with a high risk of morbidity and mortality. The aim of this study is to investigate which variables best predict adverse outcomes in patients who had surgery for isolated traumatic spinal injury without spinal cord injury.

METHODS

The American College of Surgeons Trauma Quality Improvement Program database was used to identify adult (18 years or older) surgically managed patients with an isolated traumatic spinal injury, without spinal cord injury admitted between 2013 and 2021. An isolated injury was defined as a spine Abbreviated Injury Scale score ≥2 and an Abbreviated Injury Scale score ≤1 in the remaining body regions, as well as corresponding International Classification of Diseases, Ninth and Tenth Revision, codes. The predictive value of demographic, clinical, and comorbidity data was evaluated using logistic regression models and ranked using the permutation importance method.

RESULTS

A total of 39,457 patients were included in the study, of whom 554 died during hospitalization. The most important variables for predicting in-hospital mortality were age, sex, Glasgow Coma Scale on admission, Orthopedic Frailty Score, and cervical spine injury. The most important variables for predicting complications were age, cervical spine injury, the need for cervical spine surgery, Revised Cardiac Risk Index, and alcohol use disorder. Finally, age, cervical spine injury, sex, Glasgow Coma Scale on admission, and Orthopedic Frailty Score had the highest relative importance when predicting failure to rescue. Models based on the five most important variables for each outcome demonstrated an excellent predictive ability for in-hospital mortality (area under the receiver operating characteristic curve [AUROC], 0.84; 95% confidence interval [CI], 0.82-0.86) and failure to rescue (AUROC [95% CI], 0.86 [0.84-0.87]) as well as an acceptable predictive ability for complications (AUROC [95% CI], 0.72 [0.71-0.73]).

CONCLUSION

The most important factors identified to predict mortality, complications, and failure to rescue in traumatic spinal injury patients without spinal cord injury who undergo surgery were patients' age, sex, frailty, cervical spine injury that necessitated surgical intervention, and cardiovascular risk.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Frailty Influence on Postoperative Surgical Site Infections After Surgery for Degenerative Spine Disease and Adult Spine Deformity. Can a Frailty Index be a Valuable Summary Risk Indicator? A Systematic Review and Metanalysis of the Current Literature

STUDY DESIGN

Metanalysis.

OBJECTIVE

Surgical site infections (SSI) is one of the commonest postoperative adverse events after spine surgery. Frailty has been described as a valuable summary risk indicator for SSI in spine surgery. The aim of this metanalysis is to evaluate the influence of frailty on postoperative SSI in this cohort and provide hints on which index can predict the risk of SSI.

METHODS

Papers describing the postoperative SSI rate in adult degenerative spine disease or adult spine deformity patients with varying degrees of frailty were included in the analysis. The SSI rate in different grades of frailty was considered for outcome measure. Meta-analysis was performed on studies in whom data regarding patients with different levels of frailty and occurrence of postoperative SSI could be pooled. P < .05 was considered significant.

RESULTS

16 studies were included. The frailty prevalence measured using mFI-11 ranged from 3% to 17.9%, these values were inferior to those measured with mFI-5. Significant difference was found between frail and non-frail patients in postoperative SSI rate at metanalysis (z = 5.9547, P < .0001 for mFI-5 and z = 3.8334, P = .0001 for mFI-11).

CONCLUSION

This is the first meta-analysis to specifically investigate the impact of frailty, on occurrence of SSI. We found a relevant statistical difference between frail and non-frail patients in SSI occurrence rate. This is a relevant finding, as the ageing of population increases alongside with spine surgery procedures, a better understanding of risk factors may advance our ability to treat patients while minimizing the occurrence of SSI.

Minimally Invasive and Navigation-Assisted Fracture Stabilization Following Traumatic Spinopelvic Dissociation

Spinopelvic dissociation is a highly unstable orthopedic injury with a growing incidence worldwide. Operative treatment classically involves an open lumbopelvic fusion and sacroiliac stabilization, which carries high perioperative morbidity and mortality in a frail patient population. Advancements in spinal navigation, robotics, and minimally invasive surgery (MIS) techniques now allow these fracture patterns to be treated entirely percutaneously through small incisions. These incisions are just large enough to accommodate pedicle screw guides and enable the placement of lumbopelvic instrumentation, with rods being passed subfascially across pedicle screws and extending caudally to iliac fixation. This contrasts with the open midline approach, which requires more extensive soft tissue dissection and results in increased blood loss compared to percutaneous techniques. Modern imaging techniques, including CT navigation and robotics, facilitate the precise placement of sacral S2AI screw instrumentation in both open and percutaneous methods, all while safely avoiding previously placed trans-sacral fixation and other existing hardware, such as acetabular screws. Trans-sacral screws are typically percutaneously inserted first by the orthopedic trauma service, utilizing inlet, outlet, and lateral sacral fluoroscopic guidance to navigate the limited available corridor. With the advent of MIS techniques, trauma patients can now benefit from faster postoperative rehabilitation, minimal blood loss, decreased pain, and quicker mobilization. This article will review current concepts on spinopelvic anatomy, fracture patterns, indications for treatment, and current concepts for minimally invasive percutaneous lumbopelvic fixation, and it will present illustrative examples.

Predictive Power of the Fried Phenotype in Assessing Postoperative Outcomes in Patients Undergoing Craniotomy for Tumor Resection

BACKGROUND AND OBJECTIVES

Compared with the modified Frailty Index-11 (mFI-11) frailty tool, reflective of patient comorbidities, the Fried phenotype weighs functional patient variables. This study examined using the Fried phenotype in predicting postoperative outcomes in craniotomy for patients with tumor.

METHODS

This retrospective cohort analysis included patients with Current Procedural Terminology codes for supratentorial/infratentorial tumor resections and preoperative frailty scores. Chart review collected the remaining variables for the primary outcome, length of stay (LOS), and secondary outcomes, discharge disposition and postoperative complications. Basic descriptive statistics summarized patient demographics, clinical parameters, and postoperative outcomes. χ 2 tests, t -tests, and ANOVA examined associations and mean differences. Logistic and Poisson regressions explored predictor-outcome relationships.

RESULTS

Over 7 years, these 153 patients underwent Fried assessments. The Fried score was biased toward females being more frail (nonfrail 38.0% female, prefrail 50.0% female and frail 65.6% female, P = .027) but not by age, body mass index, or tumor type. The mFI-11 was biased by age (nonfrail 67.8 years vs frail 72.3 years, P < .001) and body mass index (nonfrail 27.5 vs frail 30.8, P < .001) but not sex or tumor type. The Fried score was significantly correlated with increased LOS's (odds ratio [OR] = 5.92, 95% CI = 1.66-21.13, P < .001) but the mFI-11 was not (OR = 0.82, 95% CI = 0.35-1.93, P = .64). The Fried phenotype was significantly correlated with discharge disposition location ( P = .016), whereas the mFI-11 was not ( P = .749). The Fried score was significantly correlated with postoperative complications (OR = 1.36, 95% CI = 1.08-1.71, P = .01), whereas the mFI-11 was not (OR = 1.10, 95% CI = 0.86-1.41, P = .44).

CONCLUSION

The Fried phenotype more accurately correlates with postoperative outcomes including LOS, discharge disposition location, and complications than does the mFI-11 score. These findings can be used to guide preoperative planning, inform consent, and potentially identify patients who may benefit from functional optimization in the preoperative period to improve postoperative outcomes.

Prognostic Utility of Modified 5-Item Frailty Index on the Outcomes of Spine Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND

Frailty refers to a state of weakness that can arise due to age or illnesses, and frailty predisposes individuals to several adverse health outcomes. This has been postulated to prognosticate the outcome of various surgeries, including surgeries for various spine conditions; however, no meta-analysis has validated this finding.

METHODS

We conducted a systematic review and meta-analysis to investigate the prognostic utility of frailty for the outcome of spine surgeries. We performed a systematic search of the PubMed, EMBASE, and SCOPUS databases for studies investigating the ability of frailty to predict the outcome of spine surgeries. We analyzed the effect of high frailty using the 5-item Modified Frailty Index on the outcomes (extended length of stay, readmission, postoperative complications, in-hospital mortality, reoperation, and nonroutine discharge) of spine surgeries.

RESULTS

Meta-analysis of the information provided in the 11 studies included a sample size of 89,137; all studies used the 5-item Modified Frailty Index ≥2 as their cutoff for high frailty, and most studies were performed in the United States based on the American College of Surgeons National Surgical Quality Improvement Program database. The outcomes of our analysis were extended hospital length of stay (effect size 1.64; 95% confidence interval [CI]: 1.49, 1.79), postoperative complications (effect size 1.49; 95% CI: 1.10, 1.88), readmission (effect size 1.69; 95% CI: 1.40, 1.99), nonroutine discharge (effect size 2.16; 95% CI: 1.80, 2.51), postoperative in-hospital mortality (effect size 2.11; 95% CI: 1.25, 2.96), and reoperation (effect size 1.32; 95% CI: 1.19, 1.45).

CONCLUSIONS

This study revealed that high frailty according to the modified 5-Item Frailty Index is correlated with an increased risk of readmission, extended length of hospital stay, postoperative complications, nonroutine discharge, postoperative in-hospital mortality, and reoperation following spine surgeries for any pathology of the spine.

A Critical Appraisal of the Application of Frailty and Sarcopenia in the Spinal Oncology Population

STUDY DESIGN

Systematic review and clinimetric analysis.

OBJECTIVES

Frailty and sarcopenia predict worse surgical outcomes among spinal degenerative and deformity-related populations; this association is less clear in the context of spinal oncology. Here, we sought to identify frailty and sarcopenia tools applied in spinal oncology and appraise their clinimetric properties.

METHODS

A systematic review was conducted from January 1st, 2000, until June 2022. Study characteristics, frailty tools, and measures of sarcopenia were recorded. Component domains, individual items, cut-off values, and measurement techniques were collected. Clinimetric assessment was performed according to Consensus-based Standards for Health Measurement Instruments.

RESULTS

Twenty-two studies were included (42 514 patients). Seventeen studies utilized 6 frailty tools; the three most employed were the Metastatic Spine tumor Frailty Index (MSTFI), Modified Frailty Index-11 (mFI-11), and the mFI-5. Eight studies utilized measures of sarcopenia; the three most common were the L3-Total Psoas Area (TPA)/Vertebral Body Area (VBA), L3-TPA/Height2, and L3-Spinal Muscle Index (L3-Cross-Sectional Muscle Area/Height2). Frailty and sarcopenia measures lacked or had uncertain content and construct validity. Frailty measures were objective except the Johns-Hopkins Adjusted Clinical Groups. All tools were feasible except the Hospital Frailty Risk Score (HFRS). Positive predictive validity was observed for the HFRS and in select studies employing the mFI-5, MSTFI, and L3-TPA/VBA. All frailty tools had floor or ceiling effects.

CONCLUSIONS

Existing tools for evaluating frailty and sarcopenia among patients undergoing surgery for spinal tumors have poor clinimetric properties. Here, we provide a pragmatic approach to utilizing existing frailty and sarcopenia tools, until more clinimetrically robust instruments are developed.

Full-endoscopic spine-surgery in the elderly and patients with comorbidities

Due to demographic changes, a growing number of elderly patients with comorbidities will require spine surgery in the next decades. However, age and multimorbidity have been associated with considerably worse postoperative outcomes, and is often associated with surgical invasiveness. Full-endoscopic spine-surgery (FESS), as a cornerstone of contemporary minimally invasive surgery, has the potential to mitigate some of these disparities. Thus, we conducted an analysis of all FESS cases at a national center. Utilizing the Charlson Comorbidity index (CCI) ≥ 3 as a frailty surrogate we separated patients in two groups for patients with and without comorbidities. Patients with (CCI) ≥ 3 exhibited a higher age (p < 0.001), and number of comorbidities (p < 0.001) than the control group. Thereafter, a propensity score matching was done to adjust for potential confounders. Postoperative safety measures in emergency department utilization, and clinic readmission did not significantly differ between the groups. Furthermore, patients of both groups reported similar postoperative pain improvements. However, patients with a (CCI) ≥ 3 were treated as inpatients more often (p < 0.001), had a higher length of stay (p < 0.001) and a smaller functional improvement after at a chronic postoperative timepoint (p = 0.045). The results underline safety and efficacy of FESS in patients with comorbidities. Additionally, they provide guidance for preoperative patient counselling and resource utilization when applying FESS in frail patients.

Frail patients require Longer Fusions for Success following Adult Cervical Deformity Surgery

BACKGROUND

Adult cervical deformity (ACD) surgery is more frequently being performed in frail patients. Although surgical outcomes are largely successful, there remains significant risk of poor outcomes. The ideal length of fusion constructs in these patients remains debatable.

METHODS

Patients undergoing cervical fusion for ACD with lower instrumented vertebra (LIV) at T4-or-above, with clinical and radiographic data from baseline (BL) to 2 years (2Y) were stratified by CD-modified frailty index into not frail (NF), frail (F) and severely frail (SF) categories. Deformity was classified by Kim et al. criteria. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, lower instrumented vertebra (LIV) and outcomes.

RESULTS

286 patients (Age: 57.3 ± 10.9 years, BMI: 28.9 ± 6.4 kg/m2, CCI: 0.84 ± 1.26). 47% of patients were female. 32.2% of patients were NF, 50.3% F and 17.5% SF. By deformity, 66% were focal kyphosis (FK), 12% were flatneck, and 22% were cervicothoracic. Only FK type differed between NF and F/SF patients (39.2 vs 73.6%, p = 0.005). At baseline (BL), differences in age, BMI, CCI and deformity were not significant. F/SF patients had longer LOS (p = 0.018) and higher rates of distal junctional kyphosis/failure (DJK/F) at 2 years. Controlling for baseline disability, F and SF patients were more likely to experience poor outcomes at 2 years with C7 compared with more distal LIVs. The risk for poorer outcomes was not significant when comparing LIVs within the upper thoracic spine. Similar trends were seen performing sub-analyses specifically comparing F vs SF patients.

CONCLUSIONS

Frail patients are at risk for poor outcomes following ACD surgery due to their comorbidities. These patients appear to be at even greater risk for poor outcomes with a lower instrumented vertebra proximal to T1.

Obstacles in "Time to Spine": Challenges for the Timely Delivery of Acute Surgical Care for Patients with Traumatic and Non-Traumatic Spinal Cord Injury

Over the past three decades, advancements in our understanding of the pathophysiology of spinal cord injury (SCI) have underscored the critical importance of early treatment for both traumatic and non-traumatic cases. Early surgical intervention significantly improves outcomes by limiting the extent of secondary damage. Despite numerous studies highlighting the superior outcomes associated with early decompression surgery for patients with SCIs, hospital reviews reveal that less than 60% of patients undergo surgical decompression within 24 h of injury. This occurs despite consensus among physicians regarding the benefits of early surgery. Therefore, it is important to highlight the multifactorial causes of this knowledge to action discordance. This review aims to elucidate the administrative, logistical, and technical challenges that hinder timely access to surgery for SCIs.

Frail patients require instrumentation of a more proximal vertebra for a successful outcome after surgery for adult spine deformity

Aims

The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

Methods

Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes.

Results

A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m2 (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than 'not frail' patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV.

Conclusion

Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally.

The Role of Frailty and Sarcopenia in Predicting Major Adverse Events, Length of Stay and Reoperation Following En Bloc Resection of Primary Tumours of the Spine

STUDY DESIGN

Retrospective observational cohort study.

OBJECTIVE

En bloc resection for primary tumours of the spine is associated with a high rate of adverse events (AEs). The objective was to explore the relationship between frailty/sarcopenia and major perioperative AEs, length of stay (LOS), and unplanned reoperation following en bloc resection of primary spinal tumours.

METHODS

This is a unicentre study consisting of adult patients undergoing en bloc resection for a primary spine tumor. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia was quantified with the total psoas area/vertebral body area ratio (TPA/VB) at L3 and L4. Univariable regression analysis was used to quantify the association between frailty/sarcopenia and major perioperative AEs, LOS and unplanned reoperation.

RESULTS

95 patients met the inclusion criteria. The mFI and STFI identified a frailty prevalence of 3% and 18%. Mean CT TPA/VB ratios were 1.47 (SD ± .05) and 1.83 (SD ± .06) at L3 and L4. Inter-observer reliability was .93 and .99 for CT and MRI L3 and L4 TPA/VB ratios. Unadjusted analysis demonstrated sarcopenia and mFI did not predict perioperative AEs, LOS or unplanned reoperation. Frailty defined by an STFI score ≥2 predicted unplanned reoperation for surgical site infection (SSI) (P < .05).

CONCLUSIONS

The STFI was only associated with unplanned reoperation for SSI on unadjusted analysis, while the mFI and sarcopenia were not predictive of any outcome. Further studies are needed to investigate the relationship between frailty, sarcopenia and perioperative outcomes following en bloc resection of primary spinal tumors.

Mitigating Medical Adverse Events Following Spinal Surgery: The Effectiveness of a Postoperative Quality Improvement (QI) Care Bundle

BACKGROUND AND OBJECTIVES

Spine surgery is associated with a high incidence of postoperative medical adverse events (AEs). Many of these events are considered "minor" though their cost and effect on outcome may be underestimated. We sought to examine the clinical and cost-effectiveness of a postoperative quality improvement (QI) care bundle in mitigating postoperative medical AEs in adult surgical spine patients.

METHODS

We collected 14-year prospective observational interrupted time series (ITS) with two historical cohorts: 2006 to 2008, pre-implementation of the postoperative QI care bundle; and 2009 to 2019, post-implementation of the postoperative QI care bundle. Adverse Events were identified and graded (Minor I and II) using the previously validated Spine AdVerse Events Severity (SAVES) system. Pearson Correlation tested for changes across patient and surgical variables. Adjusted segmented regression estimated the effect of the postoperative QI care bundle on the annual and absolute incidences of medical AEs between the two periods. A cost model estimated the annual cumulative cost savings through preventing these "minor" medical AEs.

RESULTS

We included 13,493 patients over the study period with a mean of 964 per year (SD ± 73). Mean age, mean Charlson Comorbidity Index (CCI), and mean spine surgical invasiveness index (SSII) increased from 48.4 to 58.1 years; 1.7 to 2.6; and 15.4 to 20.5, respectively (p < 0.001). Unadjusted analysis confirmed a significant decrease in the annual number of all medical AEs (p < 0.01). When adjusting for age, CCI and SSII, segmented regression demonstrated a significant absolute reduction in the annual incidence of cardiac, pulmonary, nausea and medication-related AEs by 9.58%, 7.82%, 11.25% and 15.01%, respectively (p < 0.01). The postoperative QI care bundle was not associated with reducing the annual incidence of delirium, electrolyte levels or GI AEs. Annual projected cost savings for preventing Grade I and II medical AEs were $1,808,300 CAD and $11,961,500 CAD.

CONCLUSION

Postoperative QI care bundles are effective for improving patient care and preventing medical care-related AEs, with significant cost savings. Postoperative QI care bundles should be tailored to the specific vulnerability of the surgical population for experiencing AEs.

Effects of frailty on patients with oral and maxillofacial space infection: a retrospective analysis

OBJECTIVES

To investigate the implications of frailty as a predictive factor for outcomes among patients with oral and maxillofacial space infection.

METHODS

A retrospective cohort study was conducted to analyze 348 medical records, gathering data on several key aspects. These included the etiology of infection, the location of inflamed areas, the treatment administered, and the ultimate treatment outcomes. Additionally, the study collected information on the Symptom Severity (SS) score, frailty score, age, gender, the presence of systemic diseases, alcohol consumption, and smoking history.

RESULTS

A total of 155 patients were classified as frailty, while 193 patients were classified as non-frailty. We found a significantly different in age, BMI, hospitalization expenses, length of hospital stay, SS, fibrinogen and admission to ICU between the frail group and the non- frail group.

CONCLUSIONS

Frailty serves as a valuable predictor of outcomes among patients with oral and maxillofacial space infections. By identifying high-risk patients, frailty can be employed as a clinical tool to guide perioperative care, ultimately optimizing patient outcomes. Notably, frail patients often require more ICU treatment.

Preoperative rehabilitation optimization for spinal surgery: a narrative review of assessment, interventions, and feasibility

PURPOSE

Postoperative physical therapy (PT) is a cornerstone of orthopedic and musculoskeletal rehabilitation, proven to provide various positive clinical benefits. However, there is a paucity of literature evaluating the utility of preoperative rehabilitation specific to spine surgery. Thus, this review article aims to provide an overview of previously published studies discussing the efficacy of preoperative rehabilitation programs and its role in spinal surgery. Special emphasis was given to preoperative frailty assessments, physical performance tests, interventional strategies, feasibility, and future directions.

METHODS

We performed a literature review using PubMed, Google Scholar, EMBASE, and PubMed Central (PMC) using directed search terms. Articles that examined preoperative rehabilitation in adult spine surgery were compiled for this review. Prehabilitation programs focused on exercise, flexibility, and behavioral modifications have been shown to significantly improve pain levels and functional strength assessments in patients undergoing elective spine surgery. In addition, studies suggest that these programs may also decrease hospital stays, return to work time, and overall direct health care expenditure costs. Screening tools such as the FRAIL scale can be used to assess frailty while physical function tests like the timed-up-and go (TUGT), 5 repetition sit-to-stand test (5R-STST), and hand grip strength (HGS) can help identify patients who would most benefit from prehabilitation.

CONCLUSIONS

This review illustrates that prehabilitation programs have the potential to increase quality of life, improve physical function and activity levels, and decrease pain, hospital stays, return to work time, and overall direct costs. However, there is a paucity of literature in this field that requires further study and investigation.

Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review

OBJECTIVE

Many tools have been used to assess frailty in the perioperative setting. However, no single scale has been shown to be the most effective in predicting postoperative complications. We evaluated the relationship between several frailty scales and the occurrence of complications following different non-cardiac surgeries.

METHODS

This systematic review was registered in PROSPERO (CRD42023473401). The search strategy included PubMed, Google Scholar, and Embase, covering manuscripts published from January 2000 to July 2023. We included prospective and retrospective studies that evaluated frailty using specific scales and tracked patients postoperatively. Studies on cardiac, neurosurgical, and thoracic surgery were excluded because of the impact of underlying diseases on patients' functional status. Narrative reviews, conference abstracts, and articles lacking a comprehensive definition of frailty were excluded.

RESULTS

Of the 2204 articles identified, 145 were included in the review: 7 on non-cardiac surgery, 36 on general and digestive surgery, 19 on urology, 22 on vascular surgery, 36 on spinal surgery, and 25 on orthopedic/trauma surgery. The reviewed manuscripts confirmed that various frailty scales had been used to predict postoperative complications, mortality, and hospital stay across these surgical disciplines.

CONCLUSION

Despite differences among surgical populations, preoperative frailty assessment consistently predicts postoperative outcomes in non-cardiac surgeries.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations

PURPOSE

Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations.

METHODS

Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040.

RESULTS

The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75 years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75 years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75 years or older.

CONCLUSIONS

Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75 years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

Lumbar fusion surgery in the era of an aging society: analysis of a nationwide population cohort with minimum 8-year follow-up

BACKGROUND CONTEXT

Fusions for lumbar spine diseases are widely performed and have a growing incidence, especially in elderly population.

PURPOSE

The goal of this study was to assess national trends of lumbar spinal fusions and examine the risk for reoperations after a lumbar fusion with a focus on 'epidemiologic transition' relating to age.

STUDY DESIGN/SETTING

The prospectively collected Korean Health Insurance Review and Assessment Service (HIRA) nationwide cohort database was retrospectively reviewed.

PATIENT SAMPLE

The total 278,815 patients who underwent lumbar spinal fusions for degenerative spine diseases between 2010 and 2018 were reviewed and used to assess trends in operative incidence. The 37,050 patients who underwent lumbar fusions between 1/2010 and 12/2011 were enrolled to determine 8-year reoperation rates.

OUTCOME MEASURES

The overall number of lumbar spinal fusions were analyzed for the national annual trend. Demographic data, reoperation rates, and confounding clinical factors were evaluated.

METHODS

The overall number of lumbar spinal fusions was analyzed to determine the national annual trend of operative incidence. For the reoperation rate analysis, the primary outcome measured was the cumulative incidence of revision operations within a minimum 8-year follow-up period. Additional outcomes included comparative analyses of the reoperation rate with respect to age, sex, or other underlying comorbidities.

RESULTS

Over time, elderly patients comprised a larger portion of the cohort (2010:24.2%; 2018:37.6%), while operations in younger patients decreased over time (2010:40.3%; 2018:27.0%). In the cohort of patients with a minimum 8-year follow-up (n=37,050), rates of reoperation peaked in patients aged 60-69 years (17.6 per 1000 person-years [HR 2.20 compared to <40years]) and decreased for more elderly patients (14.3 per 1000 person-years [HR 1.80 compared to <40years]). Age was the most significant risk factor for reoperation. Osteoporosis was also a risk factor for reoperation in postmenopausal females.

CONCLUSIONS

Increasing incidence of lumbar fusions in elderly patients was seen however the risk of reoperation decreased in patients aged 70 or more. Lumbar fusion for elderly patients should not be hesitated in the decision-making process because of concerns about reoperation.

Orthopedic Frailty Score and adverse outcomes in patients with surgically managed isolated traumatic spinal injury

Background

With an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility of the Orthopedic Frailty Score (OFS) in assessing the risk of adverse outcomes in patients with isolated TSI requiring surgery, with the hypothesis that frailer patients suffer from a disproportionately increased risk of these outcomes.

Methods

The Trauma Quality Improvement Program database was queried for all adult patients (18 years or older) who suffered an isolated TSI due to blunt force trauma, between 2013 and 2019, and underwent spine surgery. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The association between the OFS and in-hospital mortality, complications, and failure to rescue (FTR) was determined using Poisson regression models, adjusted for potential confounding.

Results

A total of 43 768 patients were included in the current investigation. After adjusting for confounding, frailty was associated with a more than doubling in the risk of in-hospital mortality (adjusted incidence rate ratio (IRR) (95% CI): 2.53 (2.04 to 3.12), p<0.001), a 25% higher overall risk of complications (adjusted IRR (95% CI): 1.25 (1.02 to 1.54), p=0.032), a doubling in the risk of FTR (adjusted IRR (95% CI): 2.00 (1.39 to 2.90), p<0.001), and a 10% increase in the risk of intensive care unit admission (adjusted IRR (95% CI): 1.10 (1.04 to 1.15), p=0.004), compared with non-frail patients.

Conclusion

The findings indicate that the OFS could be an effective method for identifying frail patients with TSIs who are at a disproportionate risk of adverse events.

Level of evidence

Level III.

Frailty as a predictor of poor outcomes in patients with chronic subdural hematoma (cSDH): A systematic review of literature

Objective

In recent years, frailty has been reported to be an important predictive factor associated with worse outcomes in neurosurgical patients. The purpose of the present systematic review was to analyze the impact of frailty on outcomes of chronic subdural hematoma (cSDH) patients.

Methods

We performed a systematic review of literature using the PubMed, Cochrane library, Wiley online library, and Web of Science databases following PRISMA guidelines of studies evaluating the effect of frailty on outcomes of cSDH published until January 31, 2023.

Results

A comprehensive literature search of databases yielded a total of 471 studies. Six studies with 4085 patients were included in our final qualitative systematic review. We found that frailty was associated with inferior outcomes (including mortality, complications, recurrence, and discharge disposition) in cSDH patients. Despite varying frailty scales/indices used across studies, negative outcomes occurred more frequently in patients that were frail than those who were not.

Conclusions

While the small number of available studies, and heterogenous methodology and reporting parameters precluded us from conducting a pooled analysis, the results of the present systematic review identify frailty as a robust predictor of worse outcomes in cSDH patients. Future studies with a larger sample size and consistent frailty scales/indices are warranted to strengthen the available evidence. The results of this work suggest a strong case for using frailty as a pre-operative risk stratification measure in cSDH patients.

Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020)

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification.

METHODS

Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.

Frailty is a Risk Factor for Postoperative Complications in Older Adults with Lumbar Degenerative Disease: A Prospective Cohort Study

Objective

Frailty, representing the physiological reserve and tolerance of the body, serves as a crucial evaluation index of the overall status of the older adults. This study aimed to investigate the prevalence of preoperative frailty and its impact on postoperative outcomes among older adults with lumbar degenerative disease in China.

Patients and Methods

In this prospective study, a total of 280 patients aged 60 and above, diagnosed with lumbar degenerative disease and scheduled for surgical intervention were enrolled. The prevalence of frailty pre-surgery was evaluated using the Tilburg Frailty Indicator (TFI) and the modified Frailty Index 11 (mFI-11). The primary outcome was postoperative complication within 30 days post-surgery. The secondary outcomes were the length of hospital stay, hospital costs, reoperation within 30 days post-surgery and unplanned readmission within 30 days post-discharge. Both univariable and multivariable logistic regression were employed to screen and identify the risk factors predisposing patients to postoperative complications.

Results

A total of 272 older adults were included in the study ultimately. The frailty detection rates of TFI and mFI-11 were 15.8% (43/272) and 10.7% (29/272) respectively. Thirty-four patients (12.5%) encountered complications. Significantly elevated rates of complications, prolonged hospital stays, increased hospital costs, and heightened readmission rates were observed in the frail group compared to the non-frail group (P<0.05). Univariable analysis showed that the potential factors related to complications are TFI, mFI-11 and albumin. Multivariable logistic regression revealed that TFI was an independent risk factor for postoperative complications (OR=5.371, 95% CI: 2.338-12.341, P < 0.001).

Conclusion

Frailty was an independent predictor of postoperative complications in older adults undergoing lumbar fusion surgery. Frailty assessment should be performed in such patients to improve preoperative risk stratification and optimize perioperative management strategies.

Surgical Outcomes in Octogenarians with Central Cord Syndrome: A Propensity-Score Matched Analysis

OBJECTIVE

Central cord syndrome (CCS) is a traumatic cervical spine injury that is treated with surgical decompression. In octogenarians (80-89), surgeons often opt for conservative management instead due to fears of postoperative complications and prolonged recovery times. This study aims to assess the in-hospital complications and outcomes in octogenarians undergoing surgery compared to those undergoing nonsurgical management for CCS.

METHODS

The National Trauma Data Bank was queried from 2017 to 2019 for octogenarians with CCS. Patients who received surgical fusion or decompression were divided into the surgery group and the remaining into the nonsurgical group. The surgery group was sampled and propensity score matched with the non-surgery group. Student t tests and Pearson χ2 tests were used to test for group differences.

RESULTS

A total of 759 octogenarians with CCS were identified. Following sampling and propensity score matching, 225 patients were identified in each group. The surgery group experienced longer intensive care unit (6.8 days vs. 3.21 days, P < 0.001) and hospital (13.79 days vs. 7.8 days, P < 0.001) lengths of stay and higher rates of deep vein thrombosis (4.89% vs. 0.44%, P = 0.02) and ventilator-associated pneumonia (4% vs. 0%, P = 0.02). Patients did not otherwise differ in mortality rate, other hospital complications, and discharge disposition.

CONCLUSIONS

Octogenarians undergoing surgery for CCS experience longer length of stay and complications consistent with prolonged hospitalization but otherwise have similar mortality, hospital complications, and discharge disposition compared to non-surgical treatment. Given the relative lack of short-term drawbacks, surgery should be considered first-line management when the long-term benefits are substantive.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma

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.

Impact of Frailty on Inpatient Outcomes of Acute Traumatic Spinal Cord Injury: Evidence From US National Inpatient Sample

OBJECTIVES

Spinal cord injury (SCI) is any spinal cord injury or affliction that results in temporary or permanent impairment of motor or sensory function. This study determined the prevalence of frailty and its impact on in-hospital outcomes of patients admitted with acute traumatic SCI (TSCI).

METHODS

This retrospective study extracted data of adults 18 to 85 years with acute TSCI from the US Nationwide Inpatient Sample (NIS) 2016 to 2018. Frailty status were assessed by the 11-factor modified Frailty Index (mFI-11) through claim codes. Patients with an mFI ≥3 were classified as frail. Associations between study variables and in-hospital mortality, discharge status, prolonged length of stay, severe infection, and hospital costs were determined by univariate and multivariable regression analyses.

RESULTS

A total of 52,263 TSCI patients were identified, where 12,203 (23.3%) patients were frail. After adjusting for relevant confounders, frailty was independently associated with increased risk for in-hospital mortality [adjusted odds ratio (aOR) = 1.25, 95% CI:1.04-1.49], unfavorable discharge (aOR =1.15, 95% CI: 1.09-1.22), prolonged length of stay (aOR =1.32, 95% CI: 1.24-1.40), and severe infection (aOR =2.52, 95% CI: 2.24-2.83), but not hospital cost. Stratified analyses revealed frailty was associated with higher unfavorable discharge and severe infection regardless of age, Charlson Comorbidity Index, and injury level.

CONCLUSIONS

In acute TSCI, frailty is independently associated with increased risk for adverse inpatient outcomes in terms of in-hospital mortality, prolonged hospital stays, unfavorable discharge, and particularly severe infection.

Posterior Instrumented Spinal Surgery Outcomes in the Elderly: A Comparison of the 5-Item and 11-Item Modified Frailty Indices

STUDY DESIGN

Retrospective Cohort.

OBJECTIVES

To validate the most concise risk stratification system to date, the 5-item modified frailty index (mFI-5), and compare its effectiveness with the established 11-item modified frailty index (mFI-11) in the elderly population undergoing posterior instrumented spine surgery.

METHODS

A single centre retrospective review of posterior instrumented spine surgeries in patients aged 65 years and older was conducted. The primary outcome was rate of post-operative major complications (Clavien-Dindo Classification ≥ 4). Secondary outcome measures included rate of all complications, 6-month mortality and surgical site infection. Multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated and compared by DeLong's test. The indices were correlated with Spearman's rho.

RESULTS

272 cases were identified. The risk of major complications was independently associated with both the mFI-5 (OR 1.89, 95% CI 1.01-3.55, P = .047) and mFI-11 (OR 3.73, 95% CI 1.90-7.30, P = .000). Both the mFI-5 and mFI-11 were statistically significant predictors of risk of all complications (P = .007 and P = .003), surgical site infection (P = .011 and P = .003) and 6-month mortality (P = .031 and P = .000). Adjusted ROC curves determined statistically similar c-statistics for major complications (.68 vs .68, P = .64), all complications (.66 vs .64, P = .10), surgical site infection (.75 vs .75, P = .76) and 6-month mortality (.83 vs .81, P = .21). The 2 indices correlated very well with a Spearman's rho of .944.

CONCLUSIONS

The mFI-5 and mFI-11 are equally effective predictors of postoperative morbidity and mortality in this population. The brevity of the mFI-5 is advantageous in facilitating its daily clinical use.

Implications of Frailty on Postoperative Health Care Resource Utilization in Ankylosing Spondylitis Patients Undergoing Spine Surgery for Spinal Fractures

OBJECTIVE

The rise of spinal surgery for ankylosing spondylitis (AS) necessitates balancing health care costs with quality patient care. Frailty has been independently associated with adverse outcomes and increased costs. This study investigates whether frailty is an independent predictor of poor outcomes after elective surgery for AS.

METHODS

Using the National Inpatient Sample (NIS) database, a retrospective study was conducted on adult patients with AS who underwent posterior spinal fusion for fracture between 2016 and 2019. Each patient was assigned a modified frailty index (mFI) score and categorized as prefrail (mFI = 0 or 1), moderately frail (mFI = 2), and highly frail (mFI≥3). Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay, non-routine discharge (NRD), and exorbitant admission costs.

RESULTS

Of the 1910 patients, 35.3% were prefrail, 31.2% moderately frail, and 33.5% highly frail. Age was significantly different across groups (P < 0.001), and frailty was associated with increased comorbidities (P < 0.001). Mean length of stay (P = 0.007), NRD rate (P < 0.001), and mean cost of admission (P = 0.002) all significantly increased with increasing frailty. However, frailty was not an independent predictor of extended hospital stay, NRD, or higher costs on multivariate analysis. Instead, predictors included multiple adverse events, number of comorbidities, and race.

CONCLUSIONS

While frailty in patients with AS is associated with older age, greater comorbidities, and increased adverse events, it was not an independent predictor of extended hospital stay, NRD, or higher hospital costs. Further research is required to understand the full impact of frailty on surgical outcomes and develop effective interventions.

Impact of Frailty and Cervical Radiographic Parameters on Postoperative Dysphagia Following Anterior Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively collected registry.

OBJECTIVE

The purpose of the present study was to investigate the impact of frailty and radiographical parameters on postoperative dysphagia after anterior cervical spine surgery (ACSS).

SUMMARY OF BACKGROUND DATA

There is a growing body of literature indicating an association between frailty and increased postoperative complications following various surgeries. However, few studies have investigated the relationship between frailty and postoperative dysphagia after anterior cervical spine surgery.

MATERIALS AND METHODS

Patients who underwent anterior cervical spine surgery for the treatment of degenerative cervical pathology were included. Frailty and dysphagia were assessed by the modified Frailty Index-11 (mFI-11) and Eat Assessment Tool 10 (EAT-10), respectively. We also collected clinical demographics and cervical alignment parameters previously reported as risk factors for postoperative dysphagia. Multivariable logistic regression was performed to identify the odds ratio (OR) of postoperative dysphagia at early (2-6 weeks) and late postoperative time points (1-2 years).

RESULTS

Ninety-five patients who underwent ACSS were included in the study. Postoperative dysphagia occurred in 31 patients (32.6%) at the early postoperative time point. Multivariable logistic regression identified higher mFI-11 score (OR, 4.03; 95% CI: 1.24-13.16; P =0.021), overcorrection of TS-CL after surgery (TS-CL, T1 slope minus C2-C7 lordosis; OR, 0.86; 95% CI: 0.79-0.95; P =0.003), and surgery at C3/C4 (OR, 12.38; 95% CI: 1.41-108.92; P =0.023) as factors associated with postoperative dysphagia.

CONCLUSIONS

Frailty, as assessed by the mFI-11, was significantly associated with postoperative dysphagia after ACSS. Additional factors associated with postoperative dysphagia were overcorrection of TS-CL and surgery at C3/C4. These findings emphasize the importance of assessing frailty and cervical alignment in the decision-making process preceding ACSS.

Elderly Patients Show Substantial Improvement in Health-Related Quality of Life After Surgery for Degenerative Cervical Myelopathy Despite Medical Frailty: An Ambispective Analysis of a Multicenter, International Data Set

BACKGROUND AND OBJECTIVES

We assessed the relationship between Modified Frailty Index-5 (mFI-5) and neurological outcomes, as well as health-related quality of life (HRQoL) measures, in elderly patients with degenerative cervical myelopathy (DCM) after surgery.

METHODS

Data from 3 major DCM trials (the Arbeitsgemeinschaft für Osteosynthesefragen Spine Cervical Spondylotic Myelopathy-North America, Cervical Spondylotic Myelopathy-International, and CSM-PROTECT studies) were combined, involving 1047 subjects with moderate to severe myelopathy. Patients older than 60 years with 6-month and 1-year postoperative data were analyzed. Neurological outcome was assessed using the modified Japanese Orthopaedic Association score, while HRQoL was measured using the 36-Item Short Form Health Survey (SF-36) (both Physical Component Summary [SF-36 PCS] and Mental Component Summary [SF-36 MCS] scores) and the Neck Disability Index. Frail (mFI ≥2) and nonfrail (mFI = 0-1) cohorts were compared using univariate paired statistics.

RESULTS

The final analysis included 261 patients (62.5% male), with a mean age of 71 years (95% CI 70.7-72). Frail patients (mFI ≥2) had lower baseline modified Japanese Orthopaedic Association scores (10.45 vs 11.96, P < .001), SF-36 PCS scores (32.01 vs 36.51, P < .001), and SF-36 MCS scores (39.32 vs 45.24, P < .001). At 6-month follow-up, SF-36 MCS improved by a mean (SD) of 7.19 (12.89) points in frail vs 2.91 (11.11) points in the nonfrail group (P = .016). At 1 year after surgery, frail patients showed greater improvement in both SF-36 PCS and SF-36 MCS composite scores compared with nonfrail patients (7.81 vs 4.49, P = .038, and 7.93 vs 3.01, P = .007, respectively). Bivariate regression analysis revealed that higher mFI-5 scores correlated with more substantial improvement in overall mental status at 6 months and 1 year (P = .024 and P = .009, respectively).

CONCLUSION

mFI-5 is a clinically helpful signature to reflect the HRQoL status among elderly patients with DCM. Despite preoperative medical frailty, elderly patients with DCM experience significant HRQoL improvement after surgery. These findings enable clinicians to identify elderly patients with modifiable comorbidities and provide informed counseling on anticipated outcomes.

LEVEL OF EVIDENCE

II.

Appropriateness of specialized care referrals for LBP: a cross-sectional analysis

Background

Low back pain (LBP) accounts for a significant proportion of primary care visits. Despite the development of evidence-based guidelines, studies point to the inefficient use of healthcare resources, resulting in over 60.0% of patients with LBP being referred to spine surgeons without any surgical indication. Centralized waiting lists (CWLs) have been implemented to improve access to specialized care by managing asymmetry between supply and demands. To date, no study has provided data on patients' clinical profiles and referral patterns to medical specialists for LBP in the context of a publicly funded healthcare system operating a prioritization model. The objective of this study was to evaluate the appropriateness of specialized care referrals for LBP after the implementation of a CWL.

Methods

A retrospective cross-sectional analysis of 500 randomly selected electronic health records of patients who attended the outpatient neurosurgery clinic of the administrative Mauricie-et-Centre-du-Québec region was performed. Inclusion criteria were neurosurgery consultation referrals for adults ≥18 years suffering from a primary complaint of LBP, and performed between September 1st, 2018, and September 1st, 2021. Data relevant for drawing a comprehensive portrait of patients referred to the neurosurgery service and for judging referrals appropriateness were manually extracted.

Results

Of the 500 cases analyzed, only 112 (22.4%) were surgical candidates, while 221 (44.2%) were discharge from the neurosurgery service upon initial assessment. Key information was inconsistently documented in medical files, thus preventing the establishment of a comprehensive portrait of patients referred to the neurosurgery service for LBP. Nevertheless, over 80.0% of referrals made during the study period were deemed inappropriate. Inappropriate referrals were characterized by higher proportion of patients symptomatically improved, presenting a back-dominant chief complaint, exhibiting no objective neurological symptoms, and diagnosed with non-specific LBP.

Conclusion

This study reveals a significant proportion of inappropriate referrals to specialized care for LBP. Further research is needed to better understand the factors that prompt referrals to medical specialists for LBP, and the criteria considered by neurosurgeons when selecting the appropriate management strategy. Recent studies suggest that triaging approaches led by musculoskeletal experts may improve referral appropriateness to specialized care.

Changes in frailty among patients hospitalized for spine pathologies during the COVID-19 pandemic in Germany-a nationwide observational study

PURPOSE

In spine care, frailty is associated with poor outcomes. The aim of this study was to describe changes in frailty in spine care during the coronavirus disease 2019 (COVID-19) pandemic and their relation to surgical management and outcomes.

METHODS

Patients hospitalized for spine pathologies between January 1, 2019, and May 17, 2022, within a nationwide network of 76 hospitals in Germany were retrospectively included. Patient frailty, types of surgery, and in-hospital mortality rates were compared between pandemic and pre-pandemic periods.

RESULTS

Of the 223,418 included patients with spine pathologies, 151,766 were admitted during the pandemic and 71,652 during corresponding pre-pandemic periods in 2019. During the pandemic, the proportion of high-frailty patients increased from a range of 5.1-6.1% to 6.5-8.8% (p < 0.01), while the proportion of low frailty patients decreased from a range of 70.5-71.4% to 65.5-70.1% (p < 0.01). In most phases of the pandemic, the Elixhauser comorbidity index (ECI) showed larger increases among high compared to low frailty patients (by 0.2-1.8 vs. 0.2-0.8 [p < 0.01]). Changes in rates of spine surgery were associated with frailty, most clearly in rates of spine fusion, showing consistent increases among low frailty patients (by 2.2-2.5%) versus decreases (by 0.3-0.8%) among high-frailty patients (p < 0.02). Changes in rates of in-hospital mortality were not associated with frailty.

CONCLUSIONS

During the COVID-19 pandemic, the proportion of high-frailty patients increased among those hospitalized for spine pathologies in Germany. Low frailty was associated with a rise in rates of spine surgery and high frailty with comparably larger increases in rates of comorbidities.

Baseline Frailty and Discharge to Advanced Care Facilities in Patients Undergoing Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Multicenter Registry Analysis of 7153 Patient Cases Comparing the Risk Analysis Index to the 5-Factor Modified Frailty Index

OBJECTIVE

To evaluate the impact of frailty, as measured by the 5-factor modified Frailty Index (mFI-5) and the Risk Analysis Index (RAI), on advanced care facility discharge (FD) in patients who underwent lumbar fusion for lumbar degenerative spine disease.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (2012-2020) was queried for adults (≥18 years) undergoing lumbar fusion for lumbar degenerative disease. Descriptive statistics and univariate crosstabulation were used to assess baseline demographics, preoperative comorbidities, and postoperative outcomes. Receiver operating characteristic curve analysis was used to assess the discriminative threshold of the mFI-5 and RAI on FD within this population.

RESULTS

The median patient age in this study cohort (N = 7153) was 56 years and FD occurred in 7.3% of cases. Receiver operating characteristic curve analysis demonstrated that both the mFI-5 and the RAI accurately predicted FD (C-statistics: mFI-5: 0.627; RAI: 0.746). DeLong's test found that the RAI had superior discrimination when compared to the mFI-5 (P < 0.0001).

CONCLUSIONS

RAI is a reliable predictor of FD in lumbar degenerative disease patients who underwent lumbar interbody fusion and demonstrated superior discrimination compared to the mFI-5. Identification of patients at risk for FD may facilitate more precise risk stratification to enable better preoperative decision-making and help set more realistic expectations of care.

A Predictive Model of Failure to Rescue After Thoracolumbar Fusion

OBJECTIVE

Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients.

METHODS

Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011-2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR.

RESULTS

The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21-25, 1.3 [0.8-2.2]; RAI 26-30, 4.0 [2.4-6.6]; RAI 31-35, 7.0 [3.8-12.7]; RAI 36-40, 10.0 [4.9-20.2]; RAI 41- 45, 21.5 [9.1-50.6]; RAI ≥ 46, 45.8 [14.8-141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89-0.95).

CONCLUSION

Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication.

Impact of frailty on the outcomes of patients undergoing degenerative spine surgery: a systematic review and meta-analysis

BACKGROUND

Degenerative spinal diseases are common in older adults with concurrent frailty. Preoperative frailty is a strong predictor of adverse clinical outcomes after surgery. This study aimed to investigate the association between health-related outcomes and frailty in patients undergoing spine surgery for degenerative spine diseases.

METHODS

A systematic review and meta-analysis were performed by electronically searching Ovid-MEDLINE, Ovid-Embase, Cochrane Library, and CINAHL for eligible studies until July 16, 2022. We reviewed all studies, excluding spinal tumours, non-surgical procedures, and experimental studies that examined the association between preoperative frailty and related outcomes after spine surgery. A total of 1,075 articles were identified in the initial search and were reviewed by two reviewers, independently. Data were subjected to qualitative and quantitative syntheses by meta-analytic methods.

RESULTS

Thirty-eight articles on 474,651 patients who underwent degenerative spine surgeries were included and 17 papers were quantitatively synthesized. The health-related outcomes were divided into clinical outcomes and patient-reported outcomes; clinical outcomes were further divided into postoperative complications and supportive management procedures. Compared to the non-frail group, the frail group was significantly associated with a greater risk of high mortality, major complications, acute renal failure, myocardial infarction, non-home discharge, reintubation, and longer length of hospital stay. Regarding patient-reported outcomes, changes in scores between the preoperative and postoperative Oswestry Disability Index scores were not associated with preoperative frailty.

CONCLUSIONS

In degenerative spinal diseases, frailty is a strong predictor of adverse clinical outcomes after spine surgery. The relationship between preoperative frailty and patient-reported outcomes is still inconclusive. Further research is needed to consolidate the evidence from patient-reported outcomes.

The 5-item modified frailty index predicts spinal osteotomy outcomes better than age in adult spinal deformity patients: an ACS - NSQIP analysis

PURPOSE

To evaluate the utility of 5-Item Modified Frailty Index (mFI-5) as compared to chronological age in predicting outcomes of spinal osteotomy in Adult Spinal Deformity (ASD) patients.

METHODS

Using Current Procedural and Terminology (CPT) codes, the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database was queried for adult patients undergoing spinal osteotomy from 2015 to 2019. Multivariate regression analysis was performed to evaluate the effect of baseline frailty status, measured by mFI-5 score, and chronological age on postoperative outcomes. Receiver-operating characteristic (ROC) curve analysis was performed to analyze the discriminative performance of age versus mFI-5.

RESULTS

A total of 1,789 spinal osteotomy patients (median age 62 years) were included in the analysis. Among the patients assessed, 38.5% (n = 689) were pre-frail, 14.6% frail (n = 262), and 2.2% (n = 39) severely frail using the mFI-5. Based on the multivariate analysis, increasing frailty tier was associated with worsening outcomes, and higher odds ratios (OR) for poor outcomes were found for increasing frailty tiers as compared to age. Severe frailty was associated with the worst outcomes, e.g., unplanned readmission (OR 9.618, [95% CI 4.054-22.818], p < 0.001) and major complications (OR 5.172, [95% CI 2.271-11.783], p < 0.001). In the ROC curve analysis, mFI-5 score (AUC 0.838) demonstrated superior discriminative performance than age (AUC 0.601) for mortality.

CONCLUSIONS

The mFI5 frailty score was found to be a better predictor than age of worse postoperative outcomes in ASD patients. Incorporating frailty in preoperative risk stratification is recommended in ASD surgery.

Projections From Surgical Use Models in Germany Suggest a Rising Number of Spinal Fusions in Patients 75 Years and Older Will Challenge Healthcare Systems Worldwide

BACKGROUND

Spinal fusion is a well-established procedure in the treatment of degenerative spinal diseases. Previous research shows that the use of this operative treatment has been growing in recent decades in industrialized countries and has become one of the most cost-intensive surgical procedures. It seems that in some countries such as Germany-with its large, industrialized, European population-this increase is mainly driven by demographic changes with low fertility rates, increasing life expectancy, and an aging population. Based on current projections, however, Germany faces a population trend that many other countries are likely to follow within a few decades. An increasingly shrinking and aging working population may eventually put the healthcare system under enormous pressure, with greater demands for spinal fusions and associated higher costs. Thus, we aimed to provide reliable projections regarding the future demand for posterior spinal fusion procedures including age- and gender-related trends up to 2060, which will be necessary for future resource planning and possible improvements in actual treatment strategies.

QUESTIONS/PURPOSES

(1) How is the use of posterior spinal fusions in Germany expected to change from 2019 through 2060, if currents trends continue? (2) How is the use of posterior spinal fusions in Germany expected to change depending on patients' age and gender during this time period?

METHODS

Comprehensive nationwide data provided by the Federal Statistical Office, the official institution for documenting all data on operations and procedures performed in Germany, were used to quantify posterior spinal fusion rates as a function of calendar year, age, and gender. Because there is a lack of evidence regarding future trends in the use of posterior spinal fusions, an autoregressive integrated moving average model on historical procedure rates from 2005 to 2019 in relation to official population projections from 2020 to 2060 was chosen to forecast future absolute numbers and incidence rates of this procedure in Germany. Long-term forecasting is more prone to unexpected disruptions than forecasting over short-term periods; however, longer spans facilitate estimates of how trends may challenge future healthcare systems if those trends continue, and thus are useful for research and planning.

RESULTS

The incidence rate of posterior spinal fusion was projected to increase by approximately 83% (95% CI 28% to 139%) to 102% per 100,000 inhabitants (95% CI 71% to 133%) in 2060, with a 1.3-fold higher rate of women undergoing surgery in terms of absolute numbers. The highest increase identified by the model occurred in patients 75 years and older with 38,974 (95% CI 27,294 to 50,653) posterior spinal fusions in 2060, compared with 14,657 in 2019. This trend applied for both women and men, with a 246% (95% CI 138% to 355%) increase in the total number of posterior spinal fusions for women 75 years and older and a 296% (95% CI 222% to 370%) increase for men 75 years and older. At the same time, posterior spinal fusions in all age groups younger than 55 years were projected to follow a constant or even negative trend up to 2060.

CONCLUSION

Our findings suggest that increasing use of posterior spinal fusion, particularly in patients 75 years and older, will challenge healthcare systems worldwide if current trends persist. This study may serve as a model for many other industrialized countries facing similar demographic and procedure-specific developments in the future. This emphasizes the need to focus on frailty research as well as appropriate financial and human resource management. Effective perioperative medical management, multidisciplinary treatment, and interinstitutional protocols are warranted, especially in older patients as we attempt to manage these trends in the future.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

The 5-Factor Modified Frailty Index Score Predicts Return to the Operating Room for Patients Undergoing Posterior Spinal Fusion for Traumatic Spine Injury

OBJECTIVE

Within the trauma spine surgery literature, the effect of patient frailty on postoperative outcomes for posterior spinal fusion (PSF) remains clear. In this study, the authors quantified the influence of the 5-factor modified frailty index (mFI-5) score on hospital length of stay, diagnosis of a postoperative infection, 30-day readmission, and 90-day return to operating room (OR).

METHODS

The authors retrospectively reviewed the records of all patients with traumatic spine injury undergoing PSF by a single surgeon at our institution from 2016 to 2021. Data were extracted using manual chart review and the mFI-5 score was calculated using data on comorbidities. Bivariate (Mann-Whitney U test and Fisher exact test) and multivariate regressions (linear and logistic) revealed whether there was an independent relationship between patient frailty and postoperative outcomes.

RESULTS

The patient cohort included 263 patients (52.00 ± 19.04), 67 (25.5) were classified as frail, defined as having an mFI-5 score ≥2. Patients who were classified as frail were significantly more likely to have diabetes (odds ratio = 21.53; P < 0.001) and active cancer (odds ratio = 10.03; P = 0.004). Patients with mFI-5 scores ≥2 were also significantly older (P < 0.001) and had higher body mass index (BMI) (P = 0.007). Patients with mFI-5 scores >2 were more likely to return to the OR (odds ratio = 2.43; P = 0.037) on bivariate analysis. When controlling for demographics and clinical characteristics, mFI-5 score independently predicted return to OR (odds ratio = 1.294; P = 0.041).

CONCLUSIONS

Patient frailty independently predicted a return to OR in patients undergoing PSF for traumatic spine injury. Future studies can investigate methods for patient risk optimization to reduce morbidity and mortality.

Assessment of the impact of frailty on adverse surgical outcomes in patients undergoing surgery for intracranial tumors using modified frailty index: A systematic review and meta-analysis

BACKGROUND

Modified frailty index (MFI) is an emerging quantitative measure of frailty; however, the quantified risk of adverse outcomes in surgeries for intracranial tumors associated with increasing MFI scores has not been thoroughly reviewed in a comprehensive manner.

METHODS

MEDLINE (PubMed), Scopus, Web of Science, and Embase were searched to identify observational studies on the association between 5 and 11 item-modified frailty index (MFI) and perioperative outcomes for neurosurgical procedures including complications, mortality, readmission, and reoperation rate. Primary analysis pooled all comparisons with MFI scores greater than or equal to 1 versus non-frail participants using mixed-effects multilevel model for each outcome.

RESULTS

In total, 24 studies were included in the review and 19 studies with 114,707 surgical operations were included in the meta-analysis. While increasing MFI scores were associated with worse prognosis for all included outcomes, reoperation rate was only significantly higher in patients with MFI ≥ 3. Among surgical pathologies, glioblastoma was influenced by a greater extent to the impact of frailty on complications and mortality that most other etiologies. In agreement with qualitative evaluation of the included studies, meta-regression did not reveal association between mean age of the comparisons and complications rate.

CONCLUSION

The results of this meta-analysis provides quantitative risk assessment of adverse outcomes in neuro-oncological surgeries with increased frailty. The majority of literature suggests that MFI is a superior and independent predictor of adverse outcomes compared to age.

The Impact of Frailty on Postoperative Complications in Total En Bloc Spondylectomy for Spinal Tumors

Total en bloc spondylectomy (TES) is an effective treatment for spinal tumors. However, its complication rate is high, and the corresponding risk factors remain unclear. This study aimed to clarify the risk factors for postoperative complications after TES, including the patient's general condition, such as frailty and their levels of inflammatory biomarkers. We included 169 patients who underwent TES at our hospital from January 2011-December 2021. The complication group comprised patients who experienced postoperative complications that required additional intensive treatments. We analyzed the relationship between early complications and the following factors: age, sex, body mass index, type of tumor, location of tumor, American Society of Anesthesiologists score, physical status, frailty (categorized by the 5-factor Modified Frailty Index [mFI-5]), neutrophil-to-lymphocyte ratio, C-reactive protein/albumin ratio, preoperative chemotherapy, preoperative radiotherapy, surgical approach, and the number of resected vertebrae. Of the 169 patients, 86 (50.1%) were included in the complication group. Multivariate analysis showed that high mFI-5 scores (odds ratio [OR] = 2.99, p < 0.001) and an increased number of resected vertebrae (OR = 1.87, p = 0.018) were risk factors for postoperative complications. Frailty and the number of resected vertebrae were independent risk factors for postoperative complications after TES for spinal tumors.

Determination of the 95% effective dose of remimazolam tosylate in anesthesia induction inhibits endotracheal intubation response in senile patients

Background and Purpose: The prevalence of elderly patients prompts anesthesiologists to determine the optimal dose of medication due to the altered pharmacokinetics and pharmacodynamics of this population. The present study aimed to determine the 95% effective dose (ED₉₅) of remimazolam tosylate in anesthesia induction to inhibit endotracheal intubation-related cardiovascular reaction in frail and non-frail senile patients. Methods: A prospective sequential allocation dose-finding study of remimazolam tosylate was conducted on 80 elderly patients who received general anesthesia between May and June 2022 at the First Affiliated Hospital of Nanchang University. The initial dose was 0.3 mg/kg. The blood pressure and heart rate fluctuations during intubation were either <20% (negative cardiovascular response) or ≥20% (positive cardiovascular response). If positive, the dose of the next patient was increased by 0.02 mg/kg, while if negative, it was reduced by 0.02 mg/kg according to the 95:5 biased coin design (BCD). The ED₉₅ and 95% confidence intervals (CIs) were determined using R-Foundation isotonic regression and bootstrapping methods. Results: The ED₉₅ of remimazolam tosylate to inhibit the response during tracheal intubation was 0.297 mg/kg (95% CI: 0.231-0.451 mg/kg) and 0.331 mg/kg (95% CI: 0.272-0.472 mg/kg) in frail and non-frail senile patients, respectively. Conculation and Implications: The CI of the two groups overlap, and no difference was detected in the ED₉₅ of remimazolam tosylate in inhibiting endotracheal intubation-related cardiovascular response in frail and non-frail senile patients. These results suggested that remimazolam tosylate is an optimal anesthesia inducer for all elderly patients. Clinical Trial Registration: https://www.chictr.org.cn, identifier ChiCTR2200055709.

Association of frailty with healthcare resource utilization after open thoracic/thoracolumbar posterior spinal fusion for adult spinal deformity

PURPOSE

The Hospital Frailty Risk Score (HFRS) is a frailty-identifying metric developed using ICD-10-CM codes. While other studies have examined frailty in adult spinal deformity (ASD), the HFRS has not been assessed in this population. The aim of this study was to utilize the HFRS to investigate the impact of frailty on outcomes in ASD patients undergoing posterior spinal fusion (PSF).

METHODS

A retrospective study was performed using the 2016-2019 National Inpatient Sample database. Adults with ASD undergoing elective PSF were identified using ICD-10-CM codes. Patients were categorized into HFRS-based frailty cohorts: Low (HFRS < 5) and Intermediate-High (HFRS ≥ 5). Patient demographics, comorbidities, intraoperative variables, and outcomes were assessed. Multivariate regression analyses were used to determine whether HFRS independently predicted extended length of stay (LOS), non-routine discharge, and increased cost.

RESULTS

Of the 7500 patients identified, 4000 (53.3%) were in the Low HFRS cohort and 3500 (46.7%) were in the Intermediate-High HFRS cohort. On average, age increased progressively with increasing HFRS scores (p < 0.001). The frail cohort experienced more postoperative adverse events (p < 0.001), greater LOS (p < 0.001), accrued greater admission costs (p < 0.001), and had a higher rate of non-routine discharge (p < 0.001). On multivariate analysis, Intermediate-High HFRS was independently associated with extended LOS (OR: 2.58, p < 0.001) and non-routine discharge (OR: 1.63, p < 0.001), though not increased admission cost (OR: 1.01, p = 0.929).

CONCLUSION

Our study identified HFRS to be significantly associated with prolonged hospitalizations and non-routine discharge. Other factors that were found to be associated with increased healthcare resource utilization include age, Hispanic race, West hospital region, large hospital size, and increasing number of AEs.

Three-Column Osteotomy for Frail Versus Nonfrail Patients with Adult Spinal Deformity: Assessment of Medical and Surgical Complications, Revision Surgery Rates, and Cost

BACKGROUND

Three-column osteotomy (3-CO) is a powerful tool for spinal deformity correction but has been associated with substantial risk and surgical invasiveness. It is incompletely understood how frailty might affect patients undergoing 3-CO.

METHODS

The PearlDiver database was used to examine spinal deformity patients with a diagnosis of frailty who had undergone 3-CO. Frail and nonfrail patients were matched, and the revision surgery rates, complications, and hospitalization costs were calculated. Logistic regression was used to account for possible confounding variables. Of the 2871 included patients, 1460 had had frailty and 1411 had had no frailty.

RESULTS

The frail patients were older, had had more comorbidities (P < 0.001), and were more likely to have undergone posterior interbody fusion (P < 0.05), without differences in the anterior interbody fusion rates. No differences were found in the reoperation rates for ≤5 years. At 30 days, the frail patients were more likely to have experienced acute kidney injury (P = 0.018), bowel/bladder dysfunction (P = 0.014), cardiac complications (P = 0.006), and pneumonia (P = 0.039). At 2 years, the frail patients were also more likely to have experienced bowel/bladder dysfunction (P = 0.028), cardiac complications (P < 0.001), deep vein thrombosis (P = 0.027), and sepsis (P = 0.033). The cost for the procedures was also higher for the frail patients than for the nonfrail patients ($24,544.79 vs. $21,565.63; P = 0.043).

CONCLUSIONS

We found that frail patients undergoing 3-CO were more likely to experience certain medical complications and had had higher associated costs but similar reoperation rates compared with nonfrail patients. Careful patient selection and surgical strategy modification might alter the risks of medical and surgical complications after 3-CO for frail patients.

Hospital-acquired infection following spinal tumor surgery: A frailty-driven pre-operative risk model

BACKGROUND

Hospital-acquired infection (HAI) after spinal tumor resection surgery contributes to adverse patient outcomes and excess healthcare resource utilization. This study sought to develop a predictive model for HAI occurrence following surgery for spinal tumors.

METHODS

The National Surgical Quality Improvement Program (NSQIP) 2015-2019 database was queried for spinal tumor resections. Baseline demographics and preoperative clinical characteristics, including frailty, were analyzed. Frailty was measured by modified frailty score 5 (mFI-5) and risk analysis index (RAI). Univariate and multivariable analyses were performed to identify independent risk factors for HAI occurrence. A logit-based predictive model for HAI occurrence was designed and discriminative power was assessed via receiver operating characteristic (ROC) analysis.

RESULTS

Of 5883 patients undergoing spinal tumor surgery, HAI occurred in 574 (9.8 %). The HAI (vs. non-HAI) cohort was older and frailer with higher rates of preoperative functional dependence, chronic steroid use, chronic lung disease, coagulopathy, diabetes, hypertension, tobacco smoking, unintentional weight loss, and hypoalbuminemia (all P < 0.05). In multivariable analysis, independent predictors of HAI occurrence included severe frailty (mFI-5, OR: 2.3, 95 % CI: 1.1-5.2, P = 0.035), nonelective surgery (OR: 1.7, 95 % CI: 1.1-2.4, P = 0.007), and hypoalbuminemia (OR: 1.5, 95 % CI: 1.1-2.2, P = 0.027). A logistic regression model with frailty score alongside age, race, BMI, elective vs. non-elective surgery, and pre-operative labs have predicted HAI occurrence with a C-statistic of 0.68 (95 % CI: 0.64-0.72).

CONCLUSIONS

HAI occurrence after spinal tumor surgery can be predicted by standardized frailty metrics, mFI-5 and RAI-rev, alongside routinely measured preoperative characteristics (demographics, comorbidities, pre-operative labs).

Morphology of paraspinal muscles in frail and non-frail older adults evaluated through FRAIL scale

BACKGROUND

Frailty is a condition characterized by the progressive deterioration of physiological functioning, which is closely related to adverse events. Multiple previous investigations applied frailty scales for spine research, and the purpose of this study is to investigate the differences in the morphology of the paraspinal muscles in frail and non-frail older adults evaluated through FRAIL scale.

METHODS

The sample of this retrospectively cross-sectional study consisted of individuals who were ≥ 60 years of age and with lumbar degenerative disease. We divided patients into two groups (0-2 = non-Frail, 3-5 = Frail) according to the FRAIL scale. The cross-sectional area (CSA) and percentage of the fatty infiltration (FI%) of the paraspinal muscles were compared between the two groups.

RESULTS

The fCSA (functional cross-sectional area) of the non-Frail group (32.78 [28.52, 38.28]) (cm²) was significantly greater than that of the Frail group (28.50 [24.11, 34.77]) (p < 0.001). The ES FI% (erector spinae fatty infiltration rate) (24.83 ± 6.61 vs. 29.60 ± 7.92, p < 0.001) and MF FI% (multifidus fatty infiltration rate) (31.68 ± 5.63 vs. 41.12 ± 7.04, p < 0.001) of the non-Frail group were significantly lower than that of Frail group.

CONCLUSIONS

The paraspinal muscles of elderly Frail patients screened by the FRAIL scale are worse than those of the non-Frail patients, and the ability of the FRAIL scale to distinguish paraspinal muscle morphology has important clinical significance.

Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review

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.

Risk Analysis Index and Its Recalibrated Version Predict Postoperative Outcomes Better Than 5-Factor Modified Frailty Index in Traumatic Spinal Injury

OBJECTIVE

To assess the discriminative ability of the Risk Analysis Index-administrative (RAI-A) and its recalibrated version (RAI-Rev), compared to the 5-factor modified frailty index (mFI-5), in predicting postoperative outcomes in patients undergoing surgical intervention for traumatic spine injuries (TSIs).

METHODS

The Current Procedural Terminology (CPT) and International Classification of Disease-9 (ICD-9) and ICD-10 codes were used to identify patients ≥ 18 years who underwent surgical intervention for TSI from National Surgical Quality Improvement Program (ACS-NSQIP) database 2015-2019 (n = 6,571). Multivariate analysis and receiver operating characteristic (ROC) curve analysis were conducted to evaluate the comparative discriminative ability of RAI-Rev, RAI-A, and mFI-5 for 30-day postoperative outcomes.

RESULTS

Multivariate regression analysis showed that with all 3 frailty scores, increasing frailty tiers resulted in worse postoperative outcomes, and patients identified as frail and severely frail using RAI-Rev and RAI-A had the highest odds of poor outcomes. In the ROC curve/C-statistics analysis for prediction of 30-day mortality and morbidity, both RAI-Rev and RAI-A outperformed mFI-5, and for many outcomes, RAI-Rev showed better discriminative performance compared to RAI-A, including mortality (p = 0.0043, DeLong test), extended length of stay (p = 0.0042), readmission (p < 0.0001), reoperation (p = 0.0175), and nonhome discharge (p < 0.0001).

CONCLUSION

Both RAI-Rev and RAI-A performed better than mFI-5, and RAI-Rev was superior to RAI-A in predicting postoperative mortality and morbidity in TSI patients. RAI-based frailty indices can be used in preoperative risk assessment of spinal trauma patients.