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

Enhanced Recovery After Surgery Protocol in Patients With Adult Spinal Deformity: A Systematic Review and Meta-Analysis

Study DesignSystematic review and meta-analysis.ObjectivesPerioperative interventions in Enhanced recovery after surgery (ERAS) protocols for managing adult spinal deformity (ASD) patients vary widely across institutions without widespread standardization. This study aims to evaluate the various interventions performed in ERAS protocols and the impact of these protocols on postoperative outcomes following ASD surgery.MethodsA comprehensive systematic review was conducted following PRISMA guidelines. Studies that addressed the implementation of ERAS protocol for thoraco-lumbar corrective surgery were included. We conducted a meta-analysis on postoperative outcomes, where possible, calculating the pooled standardized mean difference between conventional care (pre-ERAS) and ERAS pathways (post-ERAS).ResultsOut of 63 articles, 8 were included in the systematic review. Common interventions in the ERAS protocols included: (1) preoperative anesthesia-related risk assessment and multidisciplinary assessment, (2) intraoperative tranexamic acid (TXA) administration and continuous monitoring of lab data, and (3) postoperative early mobilization and early nutritional support. Multimodal analgesia plans were commonly observed in many of the ERAS protocols. Although meta-analysis demonstrated no significant difference in length of stay (LOS) between the groups, the post-ERAS group generally tended to exhibit lower rates of readmission and medical complications, and reductions in total opioid consumption.ConclusionsThe goals of ERAS protocols for ASD surgery often address preoperative optimization, intraoperative stress minimization, and postoperative recovery facilitation. While the implementation of the ERAS protocol has shown improvements in postoperative outcomes, further studies are required to standardize the ERAS protocol for ASD surgery and enhance the impact on multiple postoperative outcomes.

Influence of Frailty on Clinical and Radiological Outcomes in Patients Undergoing Transforaminal Lumbar Interbody Fusion-Analysis of a Controlled Cohort of 408 Patients

Background/Objectives: The concept of frailty has been recognized as an important issue which can influence postoperative outcomes. We aimed to investigate the influence of frailty on clinical and radiological outcomes in patients undergoing transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease. Methods: A single-center, retrospective cohort study was conducted involving 408 patients in whom 506 expandable interbody devices were implanted. The patients were grouped into vulnerable/frail versus well/fit according to the Canadian Frailty Index. Results: The frail patients were older and had a larger number of fused segments (3.0 vs. 2.4 segments, p = 0.009). In the univariate analysis, the frail patients were more likely to experience a postoperative adverse event (AE) until discharge (OR 1.89, 95% CI 1.22-2.92; p = 0.004), three (OR 1.57, 1.07-2.3; p = 0.021), and 12 months postoperatively (OR 3.77, 1.96-7.24; p < 0.001). Following the multivariable logistic regression analysis, frailty remained an independent risk factor for postoperative AEs at 12 months (OR 3.44, 95% CI 1.69-6.99; p = 0.001). Conclusions: Frailty negatively influenced the rate of AEs until 12 months, while the odds of having a favorable outcome at any time remained unaffected in patients undergoing posterior spinal fusion with TLIF. Future efforts are needed to evaluate whether preoperative medical optimization or prehabilitation may positively impact patient outcomes.

Effectiveness of Prehabilitation Programs in Reducing the Length of Hospital Stay and Complication Rates in Major Surgeries: A Systematic Review

Prehabilitation, involving physical, nutritional, and psychological interventions before surgery, has emerged as a promising strategy to improve postoperative outcomes. This systematic review evaluated the impact of prehabilitation programs across various surgical systems, including cardiac, abdominal, colorectal, and thoracic surgeries. Data were synthesized from meta-analyses and systematic reviews to assess the effectiveness of uni- and multimodal prehabilitation interventions. Findings demonstrate that multimodal prehabilitation, particularly combining exercise and nutrition, significantly reduces postoperative complications, enhances functional recovery, and shortens hospital length of stay (LoS). While benefits were observed across surgical systems, variability in outcomes was noted due to differences in intervention design and patient populations. The review highlights the adaptability of prehabilitation and underscores its potential as a cost-effective and scalable approach to optimize surgical outcomes. However, gaps remain in standardizing protocols and evaluating long-term benefits, particularly for underrepresented surgeries such as spine and thoracic procedures. These findings support the integration of tailored prehabilitation programs into perioperative care and emphasize the need for further high-quality research.

Advancing the timing of drainage removal: a comprehensive analysis of different drainage removal criteria in patients undergoing short-level lumbar fusion surgery

OBJECTIVE

To specifically evaluate the safety and benefit of different drainage removal criteria (50 ml and 100 ml per 24 h) in patients undergoing short-level lumbar fusion surgery.

METHODS

Patients with degenerative lumbar diseases who underwent short level lumbar fusion with instrumentation between January 2021 and January 2023 were retrospectively recruited in the study. Based on the different criteria for drainage removal, the patients were divided into 2 groups (group A and group B). To control for confounding factors, a 1:1 nearest propensity score matching of significant variation, especially age, gender, BMI, number of fused levels, intraoperative blood loss, and surgical duration, were performed between groups. Perioperative outcomes were compared between groups. Multivariate logistic regression was performed to determine the risk factors for overall complications.

RESULTS

A total of 1004 eligible patients were reviewed in this study with 676 patients in group A and 328 patients in group B. After propensity score matching, 616 patients, 308 in each group were included in the final analysis. There were significantly more patients getting drainage removed on POD 2 (23.1% vs. 32.1%, p = 0.012) and POD 3 (37.0% vs., 45.1%, p = 0.041) in group B. In addition, patients in group B had earlier postoperative timing of ambulation (3.87 ± 1.12 vs. 2.41 ± 1.34, p = 0.012). No significant difference in symptomatic hematoma and surgical site infection was observed, but there were significant fewer overall complications (10.39% vs. 5.19%, p = 0.016) in the group B. Multivariate logistic regression indicated that postoperative timing of ambulation (OR 2.38, 95% CI 1.19-3.97, p < 0.001) was independently associated with overall complications.

CONCLUSION

In this study, we found that the relaxation of the criteria for drainage removal could significantly shorten the length of stay, in addition, it could promote early postoperative ambulation of patients and thus reduce the occurrence of perioperative overall complications.

Development and validation of a nomogram to predict the unfavorable outcomes in elderly patients undergoing lumbar fusion surgery for degenerative disease

OBJECTIVE

Failure to understand long-term quality of life and functional outcomes hinders effective decision making and prognostication. Therefore, the study aims to predict and analyse the unfavorable outcomes (FOs) in elderly patients undergoing lumbar fusion surgery.

METHODS

Consecutive 382 patients who underwent lumbar fusion surgery for lumbar degenerative disease from March 2019 to July 2022 were enrolled in this study. The risk factors were selected by the least absolute shrinkage and selection operator method (LASSO) regression. Then, a nomogram prediction model was established to predict unfavorable outcomes (UFOs) by using the risk factors selected from LASSO regression. The performance of the model was assessed by the calibration curve and receiver operating characteristic (ROC) curve. The decision curve analysis (DCA) and clinical impact curve (CIC) were used to evaluate the clinical utility of the model.

RESULTS

Finally, 147 of 382 patients showed UFOs. After splitting data in a 70 - 30 fashion, 267 patients were included in the training set. Ten potential risk factors were selected according to the LASSO regression, that identified the predictor to establish nomogram model. The area under the curve (AUC) value was 0.828, and the calibration curve gained from this prediction model suggested good predictive accuracy between the predicted probability and actual probability. In the validation set, the AUC for the model was 0.858. Likewise, the calibration curve gained from this prediction model suggested good predictive accuracy between the predicted probability and actual probability. And the results of DCA and CIC demonstrated that the model showed good clinical practicability in the validation set.

CONCLUSION

This nomogram model has good predictive performance and clinical practicability, which could provide a certain basis for predicting UFOs in elderly patients undergoing lumbar fusion surgery.

Hospital frailty risk score predicts high-value care outcomes following brain metastasis resection

OBJECTIVE

Brain metastases (BM) are the most common adult intracranial tumors, representing a significant source of morbidity in patients with systemic malignancy. Frailty indices, including 11- and 5-factor modified frailty indices (mFI-11 and mFI-5), American Society of Anesthesiologists (ASA) physical status classification, and Charlson Comorbidity Index (CCI), have recently demonstrated an important role in predicting high-value care outcomes in neurosurgery. This study aims to investigate the efficacy of the newly developed Hospital Frailty Risk Score (HFRS) on postoperative outcomes in BM patients.

METHODS

Adult patients with BM treated surgically at a single institution were identified (2017-2019). HFRS was calculated using ICD-10 codes, and patients were subsequently separated into low (<5), intermediate (5-15), and high (>15) HFRS cohorts. Multivariate logistic regressions were utilized to identify associations between HFRS and complications, length of stay (LOS), hospital charges, and discharge disposition. Model discrimination was assessed using receiver operating characteristic (ROC) curves.

RESULTS

A total of 356 patients (mean age: 61.81±11.63 years; 50.6 % female) were included. The mean±SD for HFRS, mFI-11, mFI-5, ASA, and CCI were 6.46±5.73, 1.31±1.24, 0.95±0.86, 2.94±0.48, and 8.69±2.07, respectively. On multivariate analysis, higher HFRS was significantly associated with greater complication rate (OR=1.10, p<0.001), extended LOS (OR=1.13, p<0.001), high hospital charges (OR=1.14, p<0.001), and nonroutine discharge disposition (OR=1.12, p<0.001), and comparing the ROC curves of mFI-11, mFI-5, ASA,and CCI, the predictive accuracy of HFRS was the most superior for all four outcomes assessed.

CONCLUSION

The predictive ability of HFRS on BM resection outcomes may be superior than other frailty indices, offering a new avenue for routine preoperative frailty assessment and for managing postoperative expectations.

Baseline Frailty Measured by the Risk Analysis Index and 30-Day Mortality After Surgery for Spinal Malignancy: Analysis of a Prospective Registry (2011-2020)

OBJECTIVE

To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection.

METHODS

SM surgery cases were queried from the American College of Surgeons - National Surgical Quality Improvement Program database (2011-2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, "mortality/hospice") were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 2,235 cases were stratified by RAI score: 0-20, 22.7%; 21-30, 11.9%; 31-40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697-0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001).

CONCLUSION

Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.

Comparison of Four Nutritional Screening Tools for Predicting Postoperative Adverse Events Following Degenerative Spinal Deformity Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

To compare the mini nutritional assessment-short form (MNA-SF), geriatric nutritional risk index, prognostic nutritional index (PNI), and preoperative serum albumin level as predictors of postoperative adverse events (AEs) in degenerative spine deformity (DSD) patients.

SUMMARY OF BACKGROUND DATA

Although various nutritional screening tools have been well evaluated in patients undergoing spinal fusion surgery, the most suitable tool for the DSD population remains uncertain at present.

PATIENTS AND METHODS

The authors reviewed consecutive patients who underwent thoracolumbar fusion surgery for DSD between August 2016 and May 2023. Four screening tools were used to assess preoperative nutritional status. Patients were divided into two categories according to each screening tool, and the four screening tools were compared regarding their predictive power for postoperative AEs, including the rates of extended length of hospital stays (LOS), complications, and readmission within three months. Physical functional indicators such as time to first ambulation, nonhome discharge, and postoperative LOS were assessed as secondary outcome measures. A multivariable logistic regression analysis was used to identify factors associated with postoperative AEs.

RESULTS

A total of 228 patients were included. The demographic characteristics, underlying disease, and magnitude of correction were not significantly different between well-nourished and malnourished groups. The nutritional risks shown by MNA-SF and albumin level were significantly associated with infectious complications ( P <0.05). The nutritional risk shown by MNA-SF was significantly associated with nonhome discharge, prolonged postoperative LOS (12.5±8.2 vs. 10.3±6.1, P =0.039), and delayed ambulation (3.7±2.1 vs. 2.2±1.8, P =0.001). Multivariable logistic regression revealed that PNI <50 was significantly associated with total AEs and minor AEs after DSD surgery.

CONCLUSIONS

PNI was significantly associated with the incidence of total AEs and minor AEs, while preoperative albumin level and MNA-SF were more effective in predicting postoperative infectious complications and delayed recovery of physical function, respectively.

LEVEL OF EVIDENCE

Level III.

Frailty as a predictor of postoperative outcomes in neurosurgery: a systematic review

INTRODUCTION

Baseline frailty status has been utilized to predict a wide range of outcomes and guide preoperative decision making in neurosurgery. This systematic review aims to analyze existing literature on the utilization of frailty as a predictor of neurosurgical outcomes.

EVIDENCE ACQUISITION

We conducted a systematic review following PRISMA guidelines. Studies that utilized baseline frailty status to predict outcomes after a neurosurgical intervention were included in this systematic review. Studies that utilized sarcopenia as the sole measure of frailty were excluded. PubMed, EMBASE, and Cochrane library was searched from inception to March 1st, 2023, to identify relevant articles.

EVIDENCE SYNTHESIS

Overall, 244 studies met the inclusion criteria. The 11-factor modified frailty index (mFI-11) was the most utilized frailty measure (N.=91, 37.2%) followed by the five-factor modified Frailty Index (mFI-5) (N.=80, 32.7%). Spine surgery was the most common subspecialty (N.=131, 53.7%), followed by intracranial tumor resection (N.=57, 23.3%), and post-operative complications were the most reported outcome (N.=130, 53.2%) in neurosurgical frailty studies. The USA and the Bowers author group published the greatest number of articles within the study period (N.=176, 72.1% and N.=37, 15.2%, respectively).

CONCLUSIONS

Frailty literature has grown exponentially over the years and has been incorporated into neurosurgical decision making. Although a wide range of frailty indices exist, their utility may vary according to their ability to be incorporated in the outpatient clinical setting.

Frailty: Implications for Neuroanesthesia

Frailty is increasingly prevalent in the aging neurosurgical population and is an important component of perioperative risk stratification and optimization to reduce complications. Frailty is measured using the phenotypic or deficit accumulation models, with simplified tools most commonly used in studies of neurosurgical patients. There are a limited number of frailty measurement tools that have been validated for individuals with neurological disease, and those that exist are mainly focused on spine pathology. Increasing frailty consistently predicts worse outcomes for patients across a range of neurosurgical procedures, including early complications, disability, non-home discharge, and mortality. Evidence for interventions to improve outcomes for frail neurosurgical patients is limited, and the role of bundled care pathways, prehabilitation, and multidisciplinary involvement requires further investigation. Surgery itself may be an intervention to improve frailty in selected patients, and future research should focus on identifying effective interventions to improve both short-term complications and long-term outcomes.

Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review

BACKGROUND

Despite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why.

METHODS

Following Pawson's realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated.

RESULTS

From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients' needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision.

CONCLUSIONS

Implementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention's goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients.

TRIAL REGISTRATION

PROSPERO (CRD42022335282).

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.

The Impact of Multimodal Prehabilitation on Patient-Reported Outcomes for a Frail Octogenarian Undergoing Multilevel Lumbar Spinal Fusion Surgery: A Case Report

This case report presents the perioperative optimization pathway of a frail octogenarian who underwent multilevel lumbar spinal fusion surgery. This patient was enrolled in a multimodal prehabilitation program for frail older adults. The multimodal prehabilitation program includes preoperative interventions that prevent further decline in physiological functions before spine surgery. The program focuses on physical exercise, nutritional intervention, and pain neuroscience education. Six weeks postoperatively, clinical and patient-reported outcomes improved in the categories targeted by the preoperative interventions and surgery. This report suggests that prehabilitation is feasible for preoperatively optimizing frail older adults undergoing complex spine surgery.

Neurosurgical perioperative management of frail elderly patients

With the rapid increase in global aging, the prevalence of frailty is increasing and frailty has emerged as an emerging public health burden. Frail elderly patients suffer from reduced homeostatic reserve capacity, which is associated with a disproportionate decline in physical status after exposure to stress and an increased risk of adverse events. Frailty is closely associated with changes in the volume of the white and gray matter of the brain. Sarcopenia has been suggested to be an important component of frailty, and reductions in muscle strength and muscle mass lead to reductions in physical function and independence, which are critical factors contributing to poor prognosis. Approximately 10-32% of patients undergoing neurological surgery are frail, and the risk of frailty increases with age, which is significantly associated with the occurrence of adverse postoperative events (major complications, total duration of hospitalization, and need for discharge to a nursing facility). The postoperative mortality rate in severely frail patients is 9-11 times higher than that in non-frail individuals. Therefore, due attention must be paid to neurosurgical frailty and muscle assessment in elderly patients. Specialized interventions in the perioperative period of neurosurgery in frail elderly patients may improve their postoperative prognosis.

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.

Nutritional Optimization for Post-Spinal Surgery Recovery

Adequate nutritional intake is a key component of uncomplicated recovery from spinal surgery. Though much in the literature exists regarding its importance, specific dietary regimens for spinal surgery remain understudied, and little is available in compiling both preoperative and postoperative nutritional recommendations for patients. The complexity that may exist with these recommendations -- especially in the context of patients with diabetes or those who use substances -- has led in recent years to the development of protocols such as Enhanced Recovery After Surgery (ERAS), which gives providers a guideline upon which to base their nutritional counselling. More innovative regimens, such as the use of bioelectrical impedance analyses to assess nutritional status, have also emerged, resulting in a vast array of dietary recommendations and protocols for spinal surgery. In the following paper, we aim to compile a few of these guidelines, comparing various preoperative and postoperative nutritional strategies as well as making note of special considerations, like patients with diabetes or those who use substances. We also work to overview several such dietary "protocols" available in the literature, with a special focus on ERAS and more recent regimens like the Northwestern High-Risk Spine Protocol. We briefly mentioned preclinical work on novel nutritional recommendations as well. Ultimately, we hope to highlight the importance of nutrition in spinal surgery and address the need for greater cohesion of dietary strategies already in existence.

Does Preoperative Cognitive Optimization Improve Postoperative Outcomes in the Elderly?

Perioperative neurocognitive disorder (PND) is a growing concern, affecting several million elderly patients each year in the United States, but strategies for its effective prevention have not yet been established. Humeidan et al. recently demonstrated that preoperative brain exercise resulted in a decrease in postoperative delirium incidence in elderly surgical patients, suggesting the potential of presurgical cognitive optimization to improve postoperative cognitive outcomes. This brief review summarizes the current knowledge regarding preoperative cognitive optimization and highlights landmark studies, as well as current ongoing studies, as the field is rapidly growing. This review further discusses the benefit of cognitive training in non-surgical elderly populations and the role of cognitive training in patients with preexisting cognitive impairment or dementia. The review also examines preclinical evidence in support of cognitive training, which can facilitate understanding of brain plasticity and the pathophysiology of PND. The literature suggests positive impacts of presurgical cognitive optimization, but further studies are encouraged to establish effective cognitive training programs for elderly presurgical patients.