Influence of Frailty on Life Expectancy in Octogenarians After Lumbar Spine Surgery

Discriminatory Value of the Risk Analysis Index Versus the 5-Factor Modified Frailty Index for Major Outcome Measures in Degenerative Cervical Myelopathy

Study DesignObservational Retrospective Cohort Study.ObjectivesTo compare the discriminatory abilities of the Revised Risk Analysis Index (RAI-Rev) and the 5-Factor Modified Frailty Index (mFI-5) to predict major postoperative outcomes in DCM patients overall, and by anterior (ADF) or posterior (PDF) approaches for decompression and fusion.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DCM patients undergoing ADF or PDF from 2015-2020. Logistic regression and Receiver Operating Characteristic analysis were used to compare the predictive and discriminatory value of mFI-5 and RAI-Rev for 30-day outcomes.Results18,138 DCM patients were included (median age: 61 years). Both RAI-Rev and mFI-5 predicted 30-day outcomes; however, increasing frailty as measured by RAI-Rev demonstrated greater odds ratios. RAI-rev demonstrated superior discrimination for non-fatal adverse outcomes, notably non-home discharge (NHD) [C-statistic 0.72 (95% CI 0.71-0.73, P < 0.001)], and for all non-fatal measures except major complications (P < 0.05). Sub-analysis by approach showed frailty had greater predictive accuracy for adverse outcomes in ADF compared to PDF.ConclusionsThe RAI-Rev demonstrated superior discrimination predicting non-fatal outcomes following DCM when compared to the mFI-5, with equivalent mortality prediction. Further, frailty plays a stronger role in predicting mortality and morbidity in ADF compared to frailty's impact on predicting outcomes with PDF. This finding demonstrates the utility of the RAI-Rev in preoperative risk stratification with an increasingly frail patient population and provides initial evidence for selecting posterior approaches for DCM patients as frailty increases.

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.

Comparison of Pain and Functional Outcomes Among Geriatric and Nongeriatric Adults Following Full Endoscopic Spine Surgery for Degenerative Lumbar Pathology

BACKGROUND

Full endoscopic spine surgery (FESS) champions a rapid recovery and a low rate of overall complications. However, its efficacy in geriatric patients that might yield additional benefits from minimized invasiveness remains underexplored.

METHODS

A multi-institutional prospective cohort study was conducted involving patients undergoing elective lumbar FESS. Participants were categorized into nongeriatric (18-69 years old) and geriatric (≥70 years old) groups. Studied variables included demographics, medical comorbidities, operative details, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI). A mobile application was leveraged to collect real-time data pre- and postoperatively.

RESULTS

One hundred and sixty-four patients were included and divided into nongeriatric (N = 125) and geriatric (N = 39) cohorts. No group differences were observed between sex (P = 0.404), body mass index (P = 0.372), procedure duration (P = 0.350), or blood loss (P = 0.384). Nongeriatric patients received discectomy more frequently (P < 0.001), while older patients underwent more decompressive procedures (P < 0.001). Characterization of pain and functional outcome revealed that nongeriatric and geriatric patients follow a similar recovery trajectory and both appreciate significant improvements from baseline to 3 months postoperatively (P < 0.001 for VAS back, VAS leg, and ODI). There were no differences in the rate of improvement between age groups at any time point (P > 0.05 for VAS back, VAS leg, and ODI).

CONCLUSIONS

FESS significantly improves pain and function in both geriatric and nongeriatric adults with degenerative lumbar conditions, with no difference in the degree of improvement between groups.

CLINICAL RELEVANCE

These findings underscore the efficacy of FESS as a minimally invasive surgical option for elderly patients. Mobile application technology is useful for collecting patient-reported data in spine surgery clinical research.

LEVEL OF EVIDENCE: 3

MFI-11 Predicts Post-Operative Serious Complications in Patients Undergoing Surgery for Odontoid Fractures

STUDY DESIGN

Retrospective Cohort.

OBJECTIVES

The objective of this study was to analyze postoperative complications in different mFI-11 groups after surgery for odontoid fractures in a geriatric population.

METHODS

A single center retrospective review of odontoid fractures surgery (between 2013 and 2022) in patients aged 65 years and older was conducted. The primary outcome was the occurrence of a major complication (Calvien-Dindo ≥4) within 30 days post-surgery. The secondary outcome was the occurrence of a major complication within 3 months after surgery, and death within 1-month post-surgery. Survival curve, multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated.

RESULTS

There were 92 patients included in this study, with a mean age of 80.5 years. Serious complication occurred for 16 patients (17%) during hospitalization. Multivariate analysis demonstrated an mFI 11 >.27 was strongly and independently associated with serious complications within 1-month post-surgery (OR = 16.7, 95% CI = 4.50-83), as well as serious complications within 3 months post-surgery (OR = 11.8, 95% CI = 3.48-49.1) and death within 1 month post-surgery (OR = 11.7; 95% CI = 3.02-60.4). The Receiver Operator Characteristics (ROC) curves for the three models all have an Area Under the Curve (AUC) value greater than 0.7.

CONCLUSIONS

The mFI-11 is a straightforward and validated tool that can be used during the preoperative period to identify the patient's level of frailty and assess their risk of postoperative complications. Patients with mFI-11 ≥.27 are at greater risk of serious complications within 1 and 3 months' post-surgery and death within 1 month post-surgery.

Mortality in patients older than 65 years undergoing surgery for degenerative lumbar spine disease: a comparison with the general population

BACKGROUND

The increased life expectancy and prevalence of spondylarthrosis have led to a growing frequency of spinal surgery in older people. This study aims to assess whether there is an excess mortality concerning that expected in the general population associated with surgical procedures performed in patients over 65 years old for a degenerative disease of the lumbar spine.

METHODS

All patients aged 65 years or older undergoing surgery at a single center between 2009 and 2019 for lumbar spine degenerative disease were included. Standardized mortality ratios (SMRs) were estimated to compare the mortality risk with the expected in the Spanish population for the same age, gender, and calendar-period. Multivariable Cox analysis was employed to determine risk factors of mortality.

RESULTS

A total of 411 procedures were analyzed. The mean age was 72.6 years old. SMR was 0.67 (CI 95% 0.54-0.84). That benefit was significant in women after gender stratification. Patients operated on between 65-84 years old had a lower mortality rate than that expected for the general population. For patients aged 85 or older, the observed mortality was not different from that expected in the general population. Multivariable Cox analysis observed an association between higher mortality and the variables age, male, and Charlson comorbidity index score.

CONCLUSIONS

Compared with the general population, patients over 65 years old who underwent spinal surgery for degenerative disease of the lumbar spine experienced a reduction in mortality. This effect was particularly significant in women and patients aged 65-84 years. Age, male gender, and Charlson comorbidity index score were associated with higher mortality risk.

Clinical Outcomes and Complication Profile of Spine Surgery in Septuagenarians and Octogenarians: Case Series

OBJECTIVE

The aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians.

METHODS

This retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index (CCI), ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians.

RESULTS

Among the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups (P > 0.05). Notably, the septuagenarian group had a higher average number of fused levels (2.36 vs. 0.38, P = 0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures (P = 0.012), resulting in lower overall bleeding in the oldest group(P < 0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(P = 0.012). A total of 6 (5%) intraoperative complications and 12 (10%) postoperative complications were documented, with no statistically significant differences observed between the groups.

CONCLUSIONS

This case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.

A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques

OBJECTIVE

This study aimed to compare the accuracy of robotic spine surgery and conventional pedicle screw fixation in lumbar degenerative disease. We evaluated clinical and radiological outcomes to demonstrate the noninferiority of robotic surgery.

METHODS

This study employed propensity score matching and included 3 groups: robot-assisted mini-open posterior lumbar interbody fusion (PLIF) (robotic surgery, RS), c-arm guided minimally invasive surgery transforaminal lumbar interbody fusion (C-arm guidance, CG), and freehand open PLIF (free of guidance, FG) (54 patients each). The mean follow-up period was 2.2 years. The preoperative spine condition was considered. Accuracy was evaluated using the Gertzbein-Robbins scale (GRS score) and Babu classification (Babu score). Radiological outcomes included adjacent segmental disease (ASD) and mechanical failure. Clinical outcomes were assessed based on the visual analogue scale, Oswestry Disability Index, 36-item Short Form health survey, and clinical ASD rate.

RESULTS

Accuracy was higher in the RS group (p < 0.01) than in other groups. The GRS score was lower in the CG group, whereas the Babu score was lower in the FG group compared with the RS group. No significant differences were observed in radiological and clinical outcomes among the 3 groups. Regression analysis identified preoperative facet degeneration, GRS and Babu scores as significant variables for radiological and clinical ASD. Mechanical failure was influenced by the GRS score and patients' age.

CONCLUSION

This study showed the superior accuracy of robotic spine surgery compared with conventional techniques. When combined with minimally invasive surgery, robotic surgery is advantageous with reduced ligament and muscle damage associated with traditional open procedures.

What are the risk factors for a second osteoporotic vertebral compression fracture?

BACKGROUND CONTEXT

Osteoporosis is characterized by decreased bone strength and an increased risk of fracture. Osteoporosis-related fractures are associated with increased morbidity, mortality, dysfunction, access to health care, health-care costs, and reduced quality of life. Therefore, preventing osteoporotic vertebral compression fractures (OVCF) is important. Secondary OVCFs often occur after the first OVCF.

PURPOSE

This study aimed to identify risk factors for a second OVCF after a first OVCF.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

One hundred seventy-eight patients from a single institution who had their first OVCF between January 1, 2000 and December 31, 2019 were enrolled in this study.

OUTCOME MEASURES

The following data were observed for all cases: patient demographics, bone mineral density, and pelvic parameters.

METHODS

We retrospectively reviewed patients from a single institution who had their first OVCF between January 1, 2000 and December 31, 2019. Demographic factors, medication (oral bisphosphonate, zoledronic acid, denosumab), bone mineral density (BMD), body mass index (BMI), fat, and muscle amount of the trunk using dual-energy X-ray absorptiometry (DEXA), and pelvic parameters (lumbar lordosis, sacral slope, pelvic tilt, pelvic incidence minus lumbar lordosis) were investigated.

RESULTS

Of 178 patients who had an OVCF, 68 (38.2%) had a second OVCF. Patients were followed up for >2 years and wore braces for an average of 6 months. The mean age was 71.9±8.63 years, mean BMD T-score was -3.1±1.09, and mean BMI was 23.3±2.96. Comparing those with and without a second OVCF, the smaller the BMD T-score and trunk muscle mass to fat ratio, the more likely a second OVCF occurred (p<.05). There were fewer second OVCF cases in the injection medication group than in the peroral group (p<.05). There were no significant differences in radiologic parameters between these groups.

CONCLUSIONS

Patients who had a second OVCF had an average of 21.3 months after the first OVCF. Risk factors for a second OVCF are low T-scores in the femur, and low M/F ratio of the trunk, android, and gynoid regions. For patients with an OVCF, injection medications may be advisable.

Efficacy of Transforaminal Endoscopic Lumbar Discectomy in Elderly Patients Over 65 Years of Age Compared to Young Adults

OBJECTIVE

Spine surgery rates are increasing in the elderly population due to social aging, and it is known that prognoses related to surgery are worse for the elderly compared to younger individuals. However, minimally invasive surgery, such as full endoscopic surgery, is considered safe with low complication rates due to minimal damage to surrounding tissues. In this study, we compared outcomes of transforaminal endoscopic lumbar discectomy (TELD) in elderly and younger patients with disc herniation in the lumbosacral region.

METHODS

We retrospectively analyzed the data of 249 patients who underwent TELD at a single center between January 2016 to December 2019, with a minimum follow-up of 3 years. Patients were allocated to 2 groups: a young group aged ≤ 65 years (n = 202) or an elderly group aged > 65 years (n = 47). We evaluated baseline characteristics, clinical outcomes, surgery-related outcomes, radiological outcomes, perioperative complications, and adverse events during the 3-year follow-up period.

RESULTS

Baseline characteristics, including age, general condition based on American Society of Anesthesiologist physical status classification grade, age-Charlson Comorbidity Index, and disc degeneration, were worse in elderly group (p < 0.001). However, except for leg pain at 4 weeks after surgery, overall outcomes, including pain improvement, radiological change, operation time, blood loss, and hospital stay, were not different between the 2 groups. Furthermore, the rates of perioperative complications (9 patients [4.46%] in the young group and 3 patients [6.38%] in the elderly group, p = 0.578) and adverse events over the 3-year follow-up period (32 patients [15.84%] in the young group and 9 patients [19.15%] in the elderly group, p = 0.582) were comparable in the 2 groups.

CONCLUSION

Our findings suggest that TELD produces similar outcomes in both elderly and younger patients with a herniated disc in the lumbosacral region. TELD can be considered a safe option for appropriately selected elderly patients.

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.

Central Sarcopenia, Frailty and Comorbidity as Predictor of Surgical Outcome in Elderly Patients with Degenerative Spine Disease

Objective

People are living longer and the elderly population continues to increase. The incidence of degenerative spinal diseases (DSDs) in the elderly population is quite high. Therefore, we are facing more cases of DSD and offering more surgical solutions in geriatric patients. Understanding the significance and association of frailty and central sarcopenia as risk factors for spinal surgery in elderly patients will be helpful in improving surgical outcomes. We conducted a retrospective cohort analysis of prospectively collected data to assess the impact of preoperative central sarcopenia, frailty, and comorbidity on surgical outcome in elderly patients with DSD.

Methods

We conducted a retrospective analysis of patients who underwent elective spinal surgery performed from January 1, 2019 to September 30, 2020 at our hospital. We included patients aged 65 and over who underwent surgery on the thoracic or lumbar spine and were diagnosed as DSD. Central sarcopenia was measured by the 50th percentile of psoas : L4 vertebral index (PLVI) using the cross-sectional area of the psoas muscle. We used the Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight (K-FRAIL) scale to measure frailty. Comorbidity was confirmed and scored using the Charlson Comorbidity Index (CCI). As a tool for measuring surgical outcome, we used the Clavien-Dindo (CD) classification for postoperative complications and the length of stay (LOS).

Results

This study included 85 patients (35 males and 50 females). The mean age was 74.05±6.47 years. Using the K-FRAIL scale, four patients were scored as robust, 44 patients were pre-frail and 37 patients were frail. The mean PLVI was 0.61±0.19. According to the CD classification, 50 patients were classified as grade 1, 19 as grade 2, and four as grade 4. The mean LOS was 12.35±8.17 days. Multivariate stepwise regression analysis showed that postoperative complication was significantly associated with surgical invasiveness and K-FRAIL scale. LOS was significantly associated with surgical invasiveness and CCI. K-FRAIL scale showed a significant correlation with CCI and PLVI.

Conclusion

The present study demonstrates that frailty, comorbidity, and surgical invasiveness are important risk factors for postoperative complications and LOS in elderly patients with DSD. Preoperative recognition of these factors may be useful for perioperative optimization, risk stratification, and patient counseling.

Surgical treatment of senile spinal diseases

Advanced age is a well-known risk factor for spinal surgery-related complications. Decisions on spine surgery in the elderly are difficult due to higher morbidity and mortality than in younger age groups. In addition, spine surgery is a kind of ‘functional surgery’ which does not directly affect the survival of patients. In recent years, individualized risk stratification has gained ground over simple chronological age-based assessment. In the elderly, frailty is one of the strongest factors which affect surgical outcomes for both cervical and thoracolumbar spine surgery, regardless of the surgical technique used. Spine surgery in the elderly have worse surgical outcomes in terms of duration of hospital stay, degree of functional recovery, and complication, readmission, and mortality rates. However, the benefit of spine surgery even in the very-elderly is substantial. In conclusion, surgical decisions should be made based on both personalized risk assessment and benefits of surgery. Recent advanced surgical techniques such as minimally invasive surgical techniques and robotics assistance are likely to be helpful in minimizing surgical complications. Therefore, advanced age in itself should not be considered as a contraindication for spine surgery.