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

Zhang Y ，Wu Q ，Han M ，Yang C ，Kang F ，Li J ，Hu C ，Chen X ... -  《Clinical Interventions in Aging》

Modified-frailty index does not independently predict complications, hospital length of stay or 30-day readmission rates following posterior lumbar decompression and fusion for spondylolisthesis.

Frailty has been associated with inferior surgical outcomes in various fields of spinal surgery. With increasing healthcare costs, hospital length of stay (LOS) and unplanned readmissions have emerged as clinical proxies reflecting overall value of care. However, there is a paucity of data assessing the impact that baseline frailty has on quality of care in patients with spondylolisthesis. The aim of this study was to investigate the impact that frailty has on LOS, complication rate, and unplanned readmission after posterior lumbar spinal fusion for spondylolisthesis. A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. All adult (≥18 years old) patients who underwent lumbar spinal decompression and fusion for spondylolisthesis were identified using ICD-9-CM diagnosis and procedural coding systems. We calculated the modified frailty index (mFI) for each patient using 5 dichotomous comorbidities - diabetes mellitus, congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, and dependent functional status. Each comorbidity is assigned 1 point and the points are summed to give a score between 0 and 5. As in previous literature, we defined a score of 0 as "not frail", 1 as "mild" frailty, and 2 or greater as "moderate to severe" frailty. Patient demographics, comorbidities, complications, LOS, readmission, and reoperation were assessed. A multivariate logistic regression analysis was used to identify independent predictors of adverse events (AEs), extended LOS, complications, and unplanned readmission. There were a total of 5,296 patients identified, of which 2,030 (38.3%) were mFI=0, 2,319 (43.8%) patients mFI=1, and 947 (17.9%) were mFI ≥2. The mFI≥2 cohort was older (p≤.001) and had a greater average BMI (p≤.001). The mFI≥2 cohort had a slightly longer hospital stay (3.7 ± 2.3 days vs. mFI=1: 3.5 ± 2.8 days and mFI=0: 3.2 ± 2.1 days,p≤.001). Both surgical AEs and medical AEs were significantly greater in the mFI≥2 cohort than the other cohorts, (2.6% vs. mFI=1: 1.8% and mFI=0: 1.2%,p=.022) and (6.3% vs. mFI=1: 4.8% and mFI=0: 2.6%,p≤.001), respectively. While there was no significant difference in reoperation rates, the mFI≥2 cohort had greater unplanned 30-day readmission rates (8;4% vs. mFI=5.6: 4.8% and mFI=0: 3.4%,p≤.001). However, on multivariate regression analysis, mFI≥2 was not a significant independent predictor of LOS (p=.285), complications (p=.667), or 30-day unplanned readmission (p=.378). Our study indicates that frailty, as measured by the mFI, does not significantly predict LOS, 30-day adverse events, or 30-day unplanned readmission in patients undergoing lumbar spinal decompression and fusion for spondylolisthesis. Further work is needed to better define variable inputs that make up frailty to optimize surgical outcome prediction tools that impact the value of care.

Elsamadicy AA ，Freedman IG ，Koo AB ，David WB ，Reeves BC ，Havlik J ，Pennington Z ，Kolb L ，Shin JH ，Sciubba DM ... -  《-》

The impact of frailty on postoperative complications in geriatric patients undergoing multi-level lumbar fusion surgery.

Retrospective Cohort Study. This study evaluates the impact of patient frailty status on postoperative complications in those undergoing multi-level lumbar fusion surgery. The Nationwide Readmission Database (NRD) was retrospectively queried between 2016 and 2017 for patients receiving multi-level lumbar fusion surgery. Demographics, frailty status, and relevant complications were queried at index admission and readmission intervals. Primary outcome measures included perioperative complications and 30-, 90-, and 180-day complication and readmission rates. Perioperative complications of interest were infection, urinary tract infection (UTI), and posthemorrhagic anemia. Secondary outcome measures included inpatient length of stay (LOS), adjusted all-payer costs, and discharge disposition. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail patients with similar diagnoses and procedures. Subgroup analysis of minimally invasive surgery (MIS) versus open surgery within frail and non-frail cohorts was conducted to evaluate differences in surgical and medical complication rates. The analysis used nonparametric Mann-Whitney U testing and odds ratios. Frail patients encountered higher rates perioperative complications including posthemorrhagic anemia (OR: 1.73, 95%CI 1.50-2.00, p < 0.0001), infection (OR: 2.94, 95%CI 2.04-4.36, p < 0.0001), UTI (OR: 2.57, 95%CI 2.04-3.26, p < 0.0001), and higher rates of non-routine discharge (OR: 2.07, 95%CI 1.80-2.38, p < 0.0001). Frail patients had significantly greater LOS and total all-payer inpatient costs compared to non-frail patients (p < 0.0001). Frailty was associated with significantly higher rates of 90- (OR: 1.43, 95%CI 1.18-1.74, p = 0.0003) and 180-day (OR: 1.28, 95%CI 1.03-1.60, p = 0.02) readmissions along with higher rates of wound dehiscence (OR: 2.21, 95%CI 1.17-4.44, p = 0.02) at 90 days. Subgroup analysis revealed that frail patients were at significantly higher risk for surgical complications with open surgery (16%) compared to MIS (0%, p < 0.0001). No significant differences were found between surgical approaches with respect to medical complications in both cohorts, nor surgical complications in non-frail patients. Frailty was associated with higher odds of all perioperative complications, LOS, and all-payer costs following multi-level lumbar fusion. Frail patients had significantly higher rates of 90 and 180-day readmission and higher rates of wound disruption at 90-days. On subgroup analysis, MIS was associated with significantly reduced rates of surgical complications specifically in frail patients. Our results suggest frailty status to be an important predictor of perioperative complications and long-term readmissions in geriatric patients receiving multi-level lumbar fusions. Frail patients should undergo surgery utilizing minimally invasive techniques to minimize risk of surgical complications. Future studies should explore the utility of implementing frailty in risk stratification assessments for patients undergoing spine surgery.

Ton A ，Shahrestani S ，Saboori N ，Ballatori AM ，Chen XT ，Wang JC ，Buser Z ... -  《-》

The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: a prospective cohort study.

Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. Enhanced recovery after surgery (ERAS) can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains. An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes, and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay after surgery. A total of 245 patients (age of 79.8±3.4 year) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between nonfrail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery. Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

Wang SK ，Wang QJ ，Wang P ，Li XY ，Cui P ，Wang DF ，Chen XL ，Kong C ，Lu SB ... -  《-》

Frailty and postoperative outcomes in patients undergoing surgery for degenerative spine disease.

Frailty is defined as a state of decreased reserve and susceptibility to stressors. The relationship between frailty and postoperative outcomes after degenerative spine surgery has not been studied. This study aimed to (1) determine prevalence of frailty in the degenerative spine population; (2) describe patient characteristics associated with frailty; and (3) determine the association between frailty and postoperative complications, mortality, length of stay, and discharge disposition. This is a retrospective analysis on a prospectively collected cohort from the National Surgical Quality Improvement Program (NSQIP). A total of 53,080 patients who underwent degenerative spine surgery between 2006 and 2012 were included in the study. A modified frailty index (mFI) with 11 variables derived from the NSQIP dataset was used to determine prevalence of frailty and its correlation with a composite outcome of perioperative complications as well as hospital length of stay, mortality, and discharge disposition. After calculating the mFI for each patient, the prevalence and predictors of frailty were determined for our cohort. The association of frailty with postoperative outcomes was determined after adjusting for known and suspected confounders using multivariate logistic regression. Frailty was present in 2,041 patients within the total population (4%) and in 8% of patients older than 65 years. Frailty severity increased with increasing age, male sex, African American race, higher body mass index, recent weight loss, paraplegia or quadriplegia, American Society of Anesthesiologists (ASA) score, and preadmission residence in a care facility. Frailty severity was an independent predictor of major complication (OR 1.15 for every 0.10 increase in mFI, 95%CI 1.09-1.21, p<.0005) and specifically predicted reoperation for postsurgical infection (OR 1.3, 95%CI 1.16-1.46, p<.0005). Prolonged length of stay and discharge to a new facility were also independently predicted by frailty severity (p<.0005). Frailty severity predicted 30-day mortality on unadjusted (OR 2.05, 95%CI 1.70-2.48, p<.0005) and adjusted analyses (OR 1.48, 95%CI 1.18-1.86, p<.0005). Frailty is an important predictor of postoperative outcomes following degenerative spine surgery. Preoperative recognition of frailty may be useful for perioperative optimization, risk stratification, and patient counseling.

Flexman AM ，Charest-Morin R ，Stobart L ，Street J ，Ryerson CJ ... -  《-》