A Simpler, Modified Frailty Index Weighted by Complication Occurrence Correlates to Pain and Disability for Adult Spinal Deformity Patients

Impact of Enhanced Recovery After Surgery Protocols on Outcomes Up to Two Years After Adult Structural Spine Disorder Surgery

STUDY DESIGN

Retrospective cohort study of prospectively enrolled database.

OBJECTIVE

We analyze the recovery pattern of patients with adult structural spine disorder (ASD) who underwent corrective surgery with enhanced recovery after surgery (ERAS+) protocol, including physical and psychological prehabilitation components, compared with a non-ERAS protocol (ERAS-) up to 2 years (2Y) after surgery.

BACKGROUND

Spine surgery for ASD is often highly invasive, which can contribute to prolonged recovery. The trajectory of recovery may be accelerated by the application of enhanced recovery principles.

MATERIALS AND METHODS

Inclusion criteria were operative patients with ASD older than 18 years with complete baseline, 90 days perioperative, and 2Y postoperative data. We assessed differences in baseline demographics, surgical details, baseline health-related quality of life (HRQL), and surgical outcomes between ERAS+ and ERAS- patients. Outcomes included adverse events, reoperations, and radiographic parameters such as sacral slope, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, lumbar lordosis, T2 to T12 kyphosis, and maximum Cobb angle. In addition, HRQL measures included the physical component summary, Oswestry Disability Index, Neck Disability Index, EuroQol 5 dimensions, Scoliosis Research Society Questionnaire 22r total and domain scores, Numeric Pain Rating Scale-back, and Numeric Pain Rating Scale-leg. We used multivariable logistic regression and analysis of covariance to adjust for confounding.

RESULTS

A total of 471 patients with ASD met the inclusion criteria, with 59 designated ERAS+. Those individuals with ERAS+ were older (64.1 ± 13.0 vs. 58.0 ± 16.0; P = 0.005), had a higher Charlson Comorbidity Index, (2.4 ± 1.8 vs. 1.4 ± 1.6; P < 0.001), and exhibited a higher modified ASD frailty index (8.2 ± 5.4 vs. 6.3 ± 4.9; P = 0.019). The adjusted analysis demonstrated the ERAS+ cohort demonstrated a lower likelihood of overall reoperations (Odds ratio (OR): 0.3; 95% CI: 0.13-0.89), and a lower likelihood of overall adverse events (OR: 0.4; 95% CI: 0.19-0.93). ERAS+ was more likely to achieve the minimal clinically important difference in the Scoliosis Research Society Questionnaire 22r total scores at 6 months (6M; OR: 3.1; 95% CI: 1.2-8.4), self-image domain at 6M (OR: 9.0; 95% CI: 1.6-50.0), in the pain domain at 6M (OR: 3.5; 95% CI: 1.01-11.9) and 1 year postoperatively (OR: 2.6; 95% CI: 1.03-6.7), and in the SF-36's physical component summary (PCS) scores at 1 year (OR: 2.1; 95% CI: 1.05-4.2). No other statistically significant differences in HRQL were observed at the remaining time points (P > 0.05).

CONCLUSION

Our work is the first to evaluate HRQL metrics and complications over 2Y following ASD correction with ERAS. Despite presenting with more severe baseline frailty and higher comorbidity profiles, patients with ASD who underwent corrective surgery with an ERAS protocol experienced fewer short-term adverse events and improved HRQL. We believe ERAS following ASD surgery leads to faster functional recovery, reduced postoperative deconditioning, and improved quality of life.

The 5-Factor Modified Frailty Index is Associated With Increased Risk of Reoperations and Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To determine the predictive capability between the 5-factor modified frailty index (mFI-5) scores and adverse clinical and radiographic outcomes following single-level transforaminal lumbar interbody fusion (TLIF).

METHODS

All patients over the age of 50 undergoing single-level open or minimally invasive TLIF from 2012 to 2021 with a minimum follow-up of 1 year were identified. Deformity, trauma, emergency, and tumor cases were excluded as were patients undergoing revision surgeries. An mFI-5 score was computed for each patient using a set of five factors which included hypertension requiring medication, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and partially or fully dependent functional status. Univariate and multivariate logistic regression analysis were performed to evaluate the impact of mFI-5 scores on readmissions, reoperations, and postoperative complications.

RESULTS

156 patients were included and grouped according to their level of frailty: no-frailty (mFI = 0, n = 67), mild frailty (mFI = 1, n = 59), and severe frailty (mFI = 2+, n = 30). Multivariate analysis found high levels of frailty (mFI = 2+) to be independent predictors of reoperation (OR: 16.9, CI: 2.7 - 106.9, P = .003) and related readmissions (OR = 16.5, CI: 2.6 - 102.7, P = .003) as compared to the no-frailty group. An mFI-5 score of 2+ was also predictive of any complication (OR = 4.5, CI: 1.4 - 14.3, P = .01) and adjacent segment disease (ASD) (OR = 12.5, CI: 1.2 - 134.0, P = .037).

CONCLUSION

High levels of frailty were predictive of related readmissions, reoperations, any complications, and ASD in older adult patients undergoing single-level TLIF.

Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery

STUDY DESIGN/SETTING

Retrospective cohort study.

OBJECTIVE

Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery.

METHODS

ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility.

RESULTS

By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001).

CONCLUSIONS

The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.

Comparative Analysis of Outcomes in Adult Spinal Deformity Patients with Proximal Junctional Kyphosis or Failure Initially Fused to Upper Versus Lower Thoracic Spine

Background: Patients with proximal junctional kyphosis (PJK) or failure (PJF) may demonstrate disparate outcomes and recovery when fused to the upper (UT) versus lower (LT) thoracic spine. Few studies have distinguished the reoperation and recovery abilities of patients with PJK or PJF when fused to the upper (UT) versus lower (LT) thoracic spine. Methods: Adult spine deformity patients ≥ 18 yrs with preoperative and 5-year (5Y) data fused to the sacrum/pelvis were included. The rates of PJK, PJK revision, and radiographic PJF were compared between patients with upper instrumented vertebra (UIV) in the upper thoracic spine (UT; T1-T7) and lower thoracic spine (LT; T8-L1). Mean differences were assessed via analyses of covariance, factoring in any differences between cohorts at baseline and any use of PJF prophylaxis. Backstep logistic regressions assessed predictors of achieving Smith et al.'s Best Clinical Outcomes (BCOs) and complications, controlling for similar covariates. Results: A total of 232 ASD patients were included (64.2 ± 10.2 years, 78% female); 36.3% were UT and 63.7% were LT. Postoperatively, the rates of PJK for UT were lower than LT at 1Y (34.6 vs. 50.4%, p = 0.024), 2Y (29.5 vs. 49.6% (p = 0.003), and 5Y (48.7 vs. 62.8%, p = 0.048), with comparable rates of PJF. In total, 4.0% of UT patients underwent subsequent reoperation, compared to 13.0% of LT patients (p = 0.025). A total of 6.0% of patients had recurrent PJK, and 3.9% had recurrent PJF (both p > 0.05). After reoperation, UT patients reported higher rates of improvement in the minimum clinically important difference for ODI by 2Y (p = 0.007) and last follow-up (p < 0.001). While adjusted regression revealed that, for UT patients, the minimization of construct extension was predictive of achieving BCOs by last follow-up (model p < 0.001), no such relationship was identified in LT patients. Conclusions: Patients initially fused to the lower thoracic spine demonstrate an increased incidence of PJK and lower rates of disability improvement, but are at a lessened risk of neurologic complications if reoperation is required.

Treatment of adult spine deformity: A retrospective comparison of bone morphogenic protein and bone marrow aspirate with bone allograft

BACKGROUND  : The use of bone morphogenic protein (BMP-2) in adult spine deformity (ASD) surgery remains controversial more than two decades following its approval for clinical application in spine surgery. This study was performed to assess outcomes in patients undergoing ASD surgery with BMP application compared with a combination of bone marrow aspirate, cancellous bone chips and i-Factor.

METHODS

This was a retrospective cohort study. ASD patients were stratified by use of intra-operative BMP (BMP +) or not (BMA + I) and surveyed for the development of complications and mechanical failure. Quality of life gained following the procedure was evaluated using quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions. Multivariable analyses (ANCOVA) and logistic regression were used to adjust for confounding.

RESULTS

512 patients were included (60% BMP +). At baseline, BMP + patients were older (62.5 vs 60.8 years, p < 0.010). Radiographic and quality-of-life metrics did not differ at follow up timepoints (all p > 0.05). BMP use was associated with higher supplemental rod use (OR: 7.0, 1.9 - 26.2, p = 0.004), greater number of levels fused (OR: 1.1, 1.03 - 1.17, p = 0.003) and greater neurological complications (OR: 5.0, 1.3 - 18.7, p = 0.017). Controlling for rod use and levels fused, BMP use was not associated with a lower risk of mechanical complications (OR 0.3, 95% CI: 0.2 - 3.0, p = 0.353), rod breakage (OR: 3.3, 0.6 - 18.7, p = 0.182) or implant failure (OR: 0.3, 0.04 - 1.51). At 2 years, the BMP + cohort exhibited higher overall costs ($108,062 vs $95,144, p = 0.002), comparable QALYs (0.163 vs 0.171, p = 0.65) and higher cost per QALY (p = 0.001) at two years.

CONCLUSIONS

In this analysis, BMP-2 application was not associated with superior outcomes when compared to a less costly biologic alternative (bone marrow aspirate + cancellous bone chips + i-Factor) following ASD surgery. The use of BMP-2 in ASD surgery appears to have reduced cost-efficacy at two years postoperatively.

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.

Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course

BACKGROUND

Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described.

STUDY DESIGN/SETTING

This is a retrospective study on a prospectively enrolled, complex ASD database.

PURPOSE

This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications.

METHODS

Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO.

RESULTS

648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086).

CONCLUSION

Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.

The more the better? Integration of vertebral pelvic angles (VPA) PJK thresholds to existing alignment schemas for prevention of mechanical complications after adult spinal deformity surgery

PURPOSE

While existing adult spinal deformity (ASD) alignment schemas acknowledge the dynamic relationship between the pelvis and spine, consideration of vertebral pelvic angles (VPA) thresholds for PJK may provide further insight into the relationship of each individual vertebra to the pelvis, which may allow for greater individualization of operative targets. Herein, we examine VPA's utility in preventing mechanical complications and its possible unification with prevalent scoring systems.

METHODS

In a retrospective cohort study of a prospectively collected database, operative ASD patients ≥ 18 years with complete baseline (BL) and two-year (Y) operative, radiographic, and health-related quality of life data were included. Descriptive analyses, means comparison, and logistic regression tests were applied to explore demographic and surgical differences, as well as the impact of alignment goals on outcomes. Cohorts were grouped as patients who met VPA non-PJK thresholds, as defined by Duvvuri et al. 2023 alone versus traditional GAP/SAAS alignment matching versus combined VPA + SAAS + GAP. The Non-PJK VPA validated mean for L1PA was 10.4 ± 7.0 and T9PA 8.9 ± 7.5.

RESULTS

398 patients met inclusion criteria (mean age 61 ± 14 years, 78% female, BL BMI 27 ± 6, BL CCI 2 ± 2). At baseline, mean vertebral pelvic angles were as follows: T1PA: 24 ± 14; T4PA 20 ± 13, T9PA 15 ± 12, L1PA 11 ± 10, L4PA 11 ± 6. Mean vertebral pelvic angles at 6 W postoperatively: T1PA 16 ± 10, T4PA 12 ± 10, T9PA 8 ± 9, L1PA 9 ± 8, L4PA 11 ± 5. 240 (60%) patients attained optimal L1PA, while 104 patients (26.1%) reached non-PJK mean for T9PA. 89 patients (22%) were optimal by both VPA standards. VPA-Optimal group demonstrated significantly lower rates of 1Y PJK (17% v 83%, p = 0.042) and PJF by 2Y (7% v. 93%, p = 0.038). When patients attained VPA goals in addition to GAP/SAAS goals at 6 W, they demonstrated significantly lower rates of Y1 PJK (p = 0.026) and Y1 and Y2 PJF. Those with optimal VPA registered greater SRS-22 scores across multiple domains (p < 0.02) as well as a greater rate of normal neurological examination at 6 W (p = 0.048).

CONCLUSIONS

Vertebral pelvic angles are a reliable measure of global alignment, and respecting certain targets may help prevent development of PJK/PJF. The value of VPA can be augmented through integration with GAP/SAAS frameworks to prevent complications and improve quality of life.

Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?

STUDY DESIGN

Retrospective single-center study.

OBJECTIVE

To assess the influence of frailty on optimal outcome following ASD corrective surgery.

SUMMARY OF BACKGROUND DATA

Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on the best possible outcome.

METHODS

ASD patients with frailty measures, baseline, and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on two-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation.

RESULTS

A total of 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF group had the highest rate of deterioration (16.7%, P =0.025) in the second postoperative year, but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P =0.886). Improvement of SF patients was greatest at six months (ΔODI of -22.6±18.0, P <0.001), but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at six months, P <0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 yr, F: 6.7±0.511 yr, SF: 5.8±0.757 yr; P =0.113).

CONCLUSIONS

Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery.

LEVEL OF EVIDENCE

Level III.

Assessing the Impact of Radiographic Realignment on Adult Spinal Deformity Patients with Sacroiliac Joint Pain at Presentation

Background: Adult spinal deformity (ASD) patients with concurrent sacroiliac joint (SIJ) pain are susceptible to worse postoperative outcomes. There is scarce literature on the impact of ASD realignment surgery on SIJ pain. Methods: Patients undergoing ASD realignment surgery were included and stratified by the presence of SIJ pain at the baseline (SIJP+) or SIJ pain absence (SIJP-). Mean comparison tests via ANOVA were used to assess baseline differences between both cohorts. Multivariable regression analyses analyzed factors associated with SIJ pain resolution/persistence, factoring in BMI, frailty, disability, and deformity. Results: A total of 464 patients were included, with 30.8% forming the SIJP+ cohort. At the baseline (BL), SIJP+ had worse disability scores, more severe deformity, higher BMI, higher frailty scores, and an increased magnitude of lower limb compensation. SIJP+ patients had higher mechanical complication (14.7 vs. 8.2%, p = 0.024) and reoperation rates (32.4 vs. 20.2%, p = 0.011) at 2 years. SIJP+ patients who subsequently underwent SI fusion achieved disability score outcomes similar to those of their SIJ- counterparts. Multivariable regression analysis revealed that SIJP+ patients who were aligned in the GAP lordosis distribution index were more likely to report symptom resolution at six weeks (OR 1.56, 95% CI: 1.02-2.37, p = 0.039), 1 year (OR 3.21, 2.49-5.33), and 2 years (OR 3.43, 2.41-7.12). SIJP- patients who did not report symptom resolution by 1 year and 2 years were more likely to demonstrate PI-LL > 5° (OR 1.36, 1.07-2.39, p = 0.045) and SVA > 20 mm (OR 1.62, 1.24-1.71 p = 0.017). Conclusions: SIJ pain in ASD patients may result in worsened pain and disability at presentation. Symptom resolution may be achieved in affected patients by adequate postoperative lumbar lordosis restoration.

Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact

BACKGROUND AND OBJECTIVES

Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms.

METHODS

We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes.

RESULTS

Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE.

CONCLUSION

Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.

Anesthesia and perioperative pain relief in the frail elderly patient

Demand for anesthesia and analgesia for the frail elderly is continuously increasing as the likelihood of encountering very elderly, very vulnerable, and very compromised patients has, ever so subtly, increased over the last three decades. The anesthesiologist has, increasingly, been obliged to offer professional services to frail patients. Fortunately, there has been a dramatic improvement in medications, methods of drug delivery, critical monitoring, and anesthesia techniques. Specific methodologies peculiar to the frail are now taught and practiced across all anesthesia subspecialties. However, administering anesthesia for the frail elderly is vastly different to giving an anesthetic to the older patient. Frail patients are increasingly cared for in specialized units-geriatric intensive therapy units, post-acute care services, palliative, hospices, and supportive care and aged care facilities. Several medications (e.g., morphine-sparing analgesics) more suited to the frail have become universally available in most centers worldwide so that best-practice, evidence-based anesthesia combinations of drugs and techniques are now increasingly employed. Every anesthetic and pain management techniques in the frail elderly patient are going to be discussed in this review.

Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery

BACKGROUND

While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.

OBJECTIVE

Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers.

STUDY DESIGN/SETTING

Retrospective cohort study of a prospectively collected multicenter database.

METHODS

ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility.

RESULTS

A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years.

CONCLUSIONS

Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.

Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes.

SUMMARY OF BACKGROUND DATA

The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications.

MATERIALS AND METHODS

We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score.

RESULTS

Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation.

CONCLUSION

This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity.

LEVEL OF EVIDENCE

III.

Frailty measured by risk analysis index and adverse discharge outcomes after adult spine deformity surgery: analysis of 3104 patients from a prospective surgical registry (2011-2020)

BACKGROUND CONTEXT

Measurement of frailty with the Risk Analysis Index (RAI) has demonstrated improved outcome prediction compared to other frailty indices across the surgical literature. However, the generalizability and clinical utility of preoperative RAI scoring for prediction of postoperative morbidity after adult spinal deformity surgery is presently unknown. Thus, recent studies have called for an RAI analysis of spine deformity outcomes.

PURPOSE

The present study sought to evaluate the discriminatory accuracy of preoperative frailty, as measured by RAI, for predicting postoperative morbidity among adult spine deformity surgery patients using data queried from a large prospective surgical registry representing over 700 hospitals from 49 US states and 11 countries.

STUDY DESIGN/SETTING

Secondary analysis of a prospective surgical registry.

PATIENT SAMPLE

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020).

OUTCOME MEASURES

The primary endpoint was "adverse discharge outcome" (ADO) defined as discharge to a non-home, non-rehabilitation nursing/chronic care facility.

METHODS

Adult spine deformity surgeries were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020) using diagnosis and procedure codes. The relationship between increasing preoperative RAI frailty score and increasing rate of primary endpoint (ADO) was assessed with Cochran-Armitage linear trend tests. Discriminatory accuracy was tested by computation of concordance statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 3,104 patients underwent spine deformity surgery and were stratified by RAI score: 0-10: 22%, 11-15: 11%, 16-20: 29%, 21-25: 26%, 26-30: 8.0%, 31-35: 2.4%, and 36+: 1.4%. The rate of ADO was 14% (N=439/3094). The rate of ADO increased significantly with increasing RAI score (p<.0001). RAI demonstrated robust discriminatory accuracy for prediction of ADO in ROC analysis (C-statistic: 0.71, 95% CI: 0.69-0.74, p<.001). In pairwise comparison of ROC curves (DeLong test), RAI demonstrates superior discriminatory accuracy compared to the 5-factor modified frailty index (mFI-5; p<.001).

CONCLUSION

Preoperative frailty, as measured by RAI, is a robust predictor of postoperative morbidity (measured by ADO) after adult spine deformity surgery. The frailty score may be translated directly to the bedside with a user-friendly risk calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spineDeformity.

Performance of the Modified Adult Spinal Deformity Frailty Index in Preoperative Risk Assessment

STUDY DESIGN

Retrospective single-center, consecutively enrolled database of adult spinal deformity (ASD) patients.

OBJECTIVE

The aim of this study was to assess the performance of the mASD-FI in predicting clinical and patient-reported outcomes after ASD-corrective surgery.

SUMMARY OF BACKGROUND DATA

The recently described modified Adult Spinal Deformity frailty index (mASD-FI) quantifies frailty of ASD patients, but the utility of this clinical prediction tool as a means of prognosticating postoperative outcomes has not been investigated.

METHODS

ASD patients with available mASD-FI scores and HRQL data at presentation and 2-years postop were included.Patients were stratified by mASD-FI score using published cutoffs: not frail (NF <7), frail (F, 7-12), severely frail (SF, >12). Analysis of vaiance assessed differences in patient factors across frailty groups. Linear regression assessed the relationship of mASD-FI with length of stay (LOS) and HRQLs. Multivariable logistic regression revealed how frailty category predicted odds of complications, infections and reoperation.

RESULTS

A total of 509 patients included (59 years, 79%F, 27.7 kg/m 2 ). The cohort presented with moderate baseline deformity: sagittal vertical axis (83.7 mm ± 71), PT (12.7° ± 10.8°), PI-LL (43.1° ± 21.1°). Mean preoperative mASD-FI score was 7.2, frailty category: NF (50.3%), F (34.0%), SF (15.7%).Age, BMI, and Charlson Comorbidity Index increased with frailty categories (all P < 0.001); however, fusion length ( P = 0.247) and osteotomy rate ( P = 0.731) did not. At baseline, increasing frailty was associated with inferior Oswestry Disability Index (ODI), EuroQol 5-Dimension Questionnaire (EQ-5D), SRS-22r, Pain Catastrophizing Scale, and NRS Back and Leg (all P < 0.001). Greater frailty was associated with increased LOS and reduced postoperative HRQL. Controlling for complication incidence, baseline mASD-FI predicted 2 year postop scores for year ODI (b = 0.7, 0.58-0.8, P < 0.001) SRS (b = -0.023, -0.03 to -0.02, P < 0.001), EQ-5D (b = -0.003, -0.004 to -0.002, P < 0.001). F and SF were associated with greater odds of unplanned revision surgery and complications.

CONCLUSION

Higher preoperative mASD-FI score was associated with significantly greater complications, higher rate of unplanned reoperations and lower postoperative HRQL in this investigation. The mASD-FI provides similar prognostic utility while reducing burden for surgeons and patients.

The Clinical Impact of Failing to Achieve Ideal Proportional Realignment in Adult Spinal Deformity Patients

SUMMARY OF BACKGROUND DATA

The impact of not achieving ideal realignment in the global alignment and proportion (GAP) score in adult spinal deformity (ASD) correction on clinical outcomes is understudied at present.

OBJECTIVE

To identify the clinical impact of failing to achieve GAP proportionality in ASD surgery.

STUDY DESIGN

Retrospective cohort.

METHODS

Operative ASD patients with fusion to S1/pelvis and with pre-(BL) and 2-year (2Y) data were included. Patients were assessed for matching their 6-week (6W) age-adjusted alignment goals. 1 Patients were stratified by age-adjusted match at 6W postoperatively (Matched) and 6W GAP proportionality (proportioned: GAP-P; moderately disproportioned: GAP-MD; severely disproportioned: GAP-SD). Groups were assessed for differences in demographics, surgical factors, radiographic parameters, and complications occurring by 2Y. Multivariable logistic regression was used to assess independent effects of not achieving GAP proportionality on postoperative outcomes for Matched and Unmatched patients.

RESULTS

Included: One hundred twenty three ASD patients. At baseline, 39.8% were GAP-SD, and 12.2% GAP-SD at 6W. Of 123 patients, 51.2% (n =63) had more than or equal to one match at 6W. GAP-SD rates did not differ by being Matched or Unmatched ( P = 0.945). GAP-SD/Unmatched patients had higher rates of reoperation, implant failure, and PJF by 2Y postop (all P <0.05). Regressions controlling for age at BL, levels fused, and CCI, revealed 6W GAP-SD/Unmatched patients had higher odds of reoperation (OR: 54 [3.2-899.9]; P =0.005), implant failure (OR: 6.9 [1.1-46.1]; P =0.045), and PJF (OR: 30.1 [1.4-662.6]; P =0.031). Compared to GAP-P or GAP-MD patients, GAP-SD/ Matched patients did not have higher rates of reoperation, implant failure, or junctional failure (all P >0.05). The regression results for both Matched and Unmatched cohorts were consistent when proportionality was substituted by the continuous GAP score.

CONCLUSION

In ASD patients who meet age-adjusted realignment goals, GAP proportionality does not significantly alter complication rates. However, GAP proportionality remains an important consideration in patients with sub-optimal age- adjusted alignment. In these cases, severe global disproportion is associated with higher rates of reoperation, implant failure, rod fracture, and junctional failure.

Which frailty scales for patients with adult spinal deformity are feasible and adequate? A systematic review

BACKGROUND CONTEXT

Frailty as a concept is not yet fully understood, and is not the same as comorbidity. It is associated with an increased risk of adverse events and mortality after surgery, which makes its preoperative assessment significant. Despite its relevance, it still remains unclear which scales are appropriate for use in patients with spinal pathology.

PURPOSE

To evaluate the feasibility and measurement properties of frailty scales for spine patients, specifically with adult spinal deformity (ASD), and to propose adequate scales for primary triage to prevent surgery in too frail patients and for preoperative assessment to modify patients' condition and surgical plans.

STUDY DESIGN/SETTING

Systematic review.

METHODS

Systematic search was performed between 2010 and 2021 including terms relating to spinal disorders, frailty scales, and methodological quality. Characteristics of the studies and frailty scales and data describing relation to treatment outcomes were extracted. The risk of bias was determined with the QAREL score.

RESULTS

Of the 1993 references found, 88 original studies were included and 23 scales were identified. No prospective interventional study was found where the preoperative frailty assessment was implemented. Predictive value of scales for surgical outcomes varied, dependent on spinal disorders, type of surgeries, patients' age and frailty at baseline, and outcomes. Seventeen studies reported measurement properties of eight scales but these studies were not free of bias. In 30 ASD studies, ASD-Frailty Index (ASD-FI, n=14) and 11-item modified Frailty Index (mFI-11, n=11) were most frequently used. These scales were mainly studied in registry studies including young adult population, and carry a risk of sample bias and make their validity in elderly population unclear. ASD-FI covers multidisciplinary concepts of frailty with 40 items but its feasibility in clinical practice is questionable due to its length. The Risk Analysis Index, another multidisciplinary scale with 14 items, has been implemented for preoperative assessment in other surgical domains and was proven to be feasible and effective in interventional prospective studies. The FRAIL is a simple questionnaire with five items and its predictive value was confirmed in prospective cohort studies in which only elderly patients were included.

CONCLUSIONS

No adequate scale was identified in terms of methodological quality and feasibility for daily practice. Careful attention should be paid when choosing an adequate scale, which depends on the setting of interest (eg triage or preoperative work-up). We recommend to further study a simple and predictive scale such as FRAIL for primary triage and a comprehensive and feasible scale such as Risk Analysis Index for preoperative assessment for patients undergoing spine surgery, as their adequacy has been shown in other medical domains.