The prevalence and impact of frailty in patients with symptomatic lumbar spinal stenosis

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

Objective

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

Patients and Methods

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

Results

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

Conclusion

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

The Impact of Frailty on Surgical Outcome of Patients with Lumbar Spinal Canal Stenosis

Introduction

Frailty is an important factor in surgical outcomes. The current study aimed to evaluate the effect of preoperative frailty on postoperative outcomes in older patients with lumbar spinal canal stenosis (LSCS).

Methods

We retrospectively examined 209 patients aged ≥65 years who underwent surgery for LSCS. Health-related quality-of-life (HRQOL) tools, including the Roland-Morris Disability Questionnaire (RDQ), Zurich Claudication Questionnaire (ZCQ), and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), were used in the assessment conducted before surgery and at 6 months and 1 year after surgery. Frailty was categorized based on the 11-item modified frailty index (mFI-11). Patients with mFI-11 of 0, <0.21, and >0.21 were classified under the robust (R), pre-frailty (P), and frailty (F) groups, respectively.

Results

According to the mFI-11, 24, 138, and 47 patients were included in the R, P, and F groups, respectively. Regarding preoperative radiographic parameters, there was a remarkable increase in the sagittal vertical axis and a significant decrease in the development of lumbar lordosis with frailty progression. The preoperative scores of RDQ and ZCQ, and lumbar function, walking ability, social life, and psychological disorder domain scores of JOABPEQ differed significantly among these groups. The frequency of revision surgery was not higher in the F group than in the other groups. After adjustment for factors have shown different distributions among the three groups, the frequency of effective surgical cases did not show a clear trend among the three groups in all domains of the JOABPEQ.

Conclusions

The preoperative HRQOL scores and the radiographic parameters of patients with LSCS worsened with frailty severity. However, frailty did not affect the rate of revision surgery and surgical efficacy in patients with LSCS. Although this study has limitations, our findings indicated that even LSCS patients with frailty can be considered for surgery if they have an indication for LSCS surgery.

Association between frailty and locomotive syndrome in elderly patients with lumbar spinal stenosis: A retrospective longitudinal analysis

AIMS

With the aging society worldwide, lumbar spinal stenosis (LSS) has become common, and its incidence has been increasing worldwide. Frailty and locomotive syndrome significantly overlap as disorders in older people. The current study aimed to validate the association between frailty and locomotive syndrome in patients with LSS. In particular, the involvement of frailty in locomotive syndrome following surgery was examined.

METHODS

We retrospectively reviewed the time-course data of consecutive patients aged ≥65 years who underwent lumbar spinal surgery for LSS. The locomotive syndrome stages were determined using the 25-Question Geriatric Locomotive Function Scale: stage 0, score ≤6; stage 1, score ≥7; stage 2, score ≥16; and Stage 3, score ≥24. Robust, pre-frailty, and frailty were defined as a modified frailty index-11 score of 0, <0.21, and >0.21, respectively.

RESULTS

This study included 234 patients. All patients except one were diagnosed with locomotive syndrome preoperatively. Approximately 24.8% of participants were diagnosed with frailty. LSS surgery improved locomotive syndrome regardless of frailty severity. Meanwhile, multivariable analysis indicated that frailty could significantly inhibit improvement in locomotive syndrome after surgery in old patients with LSS (estimated relative risk: 0.6; 95% confidence interval: 0.4-0.9).

CONCLUSIONS

This study first assessed the association between locomotive syndrome and frailty in patients with LSS. Locomotive syndrome could be managed effectively with surgery regardless of frailty severity in old patients with LSS. However, our findings emphasize the need to screen for frailty preoperatively in this patient group. Geriatr Gerontol Int 2024; 24: 116-122.

Assessing the Predictive Power of Frailty and Life-Space Mobility on Patient-Reported Outcomes of Disability in Older Adults with Low Back Pain

Background: Frailty and decreased life-space mobility are known as risk factors to develop physical limitations leading to disability in older adults with low back pain (LBP). This cross sectional study aimed to investigate the prevalence and predictive power of frailty and life-space mobility on patient-reported outcomes of disability in older adults with LBP. Methods: The sample comprised 165 older adults with LBP who visited two tertiary care hospitals between December 2021 and February 2022. The participants responded to structured standard questionnaires. Data were analyzed using descriptive statistics and robust logistic regression. Results: More than two-thirds of participants were classified as non-frail (26.67%) or pre-frail (66.67%). Mobility restrictions and minimal to severe disability were identified. Controlling other variables, frailty (OR = 1.74, 95% CI: 1.14–2.64) and restricted life-space mobility (OR = 0.42, 95% CI: 0.26–0.67) were significantly associated with disability. Integrating frailty with life-space mobility evaluations demonstrated the highest predictive power for disability-related LBP (AUC = 0.89, 95% CI: 0.84–0.93). Conclusion: Frailty and restricted life-space mobility significantly predicted disability in older adults with LBP. Healthcare professionals should recognize the critical importance of integrating patient-reported outcomes with screening for frailty and life-space mobility limitation to optimize care or tract symptom progression.

Modified Frailty Index Does Not Provide Additional Value in Predicting Outcomes in Patients Undergoing Elective Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To determine the predictive value of the modified Frailty Index (mFI) in evaluating sarcopenia and clinical outcomes in patients undergoing 1-level or 2-level transforaminal lumbar interbody fusion (TLIF).

METHODS

Patients who underwent a 1-level or 2-level TLIF between 2012 and 2020 were retrospectively identified. Frailty was compared among groups using mFI, and sarcopenia was classified by the psoas muscle cross-sectional area. Bivariate statistics compared demographics, comorbidities, and clinical outcomes. A linear regression model was developed using the Charlson Comorbidity Index (CCI) or mFI as independent variables to determine potential predictors for improvement in 1-year patient-reported outcomes.

RESULTS

Of 488 included patients, 60 were severely frail and 60 patients had sarcopenia, but sarcopenia was not associated with patient frailty (P = 0.469). Severely frail patients had worse baseline Oswestry Disability Index (ODI) (P < 0.001), Mental Component Score-12 (P = 0.001), and Physical Component Score-12 (P < 0.001), and worse improvement in ODI (P = 0.037), Physical Component Score-12 (P < 0.001), and visual analog scale (VAS) back (P = 0.007). mFI was an independent predictor of poorer improvement in VAS back and ODI, whereas age + CCI in addition predicted poorer improvement in VAS leg. Patients with higher mFI experienced longer length of stay, less frequent home discharge, and higher rates of complications, but similar readmission and reoperation rates.

CONCLUSIONS

Frailer patients experience poorer improvement in back pain, physical functioning, and disability after TLIF. mFI and the combination of age and CCI comparably predict patient-reported outcomes but do not correlate to baseline sarcopenia. Frailty increased the risk of complications, length of hospital stay, and risk of nonhome discharge.

The measurements of frailty and their possible application to spinal conditions: a systematic review

BACKGROUND CONTEXT

Frailty is associated with an increased risk of postoperative adverse events (AEs) within the surgical spine population. Multiple frailty tools have been reported in the surgical spine literature. However, the applicability of these tools remains unclear.

PURPOSE

Primary objective is to appraise the construct, feasibility, objectivity, and clinimetric properties of frailty tools reported in the surgical spine literature. Secondary objectives included determining the applicability and the most sensitive surgical spine population for each tool.

STUDY DESIGN

Systematic Review.

PATIENT SAMPLE

Studies reporting the use of a clinical frailty tool with a defined methodology in the adult surgical population (age ≥18 years).

OUTCOME MEASURES

Postoperative adverse events (AEs) including mortality, major and minor morbidity, length of stay (LOS), unplanned readmission and reoperation, admission to the Intensive Care Unit (ICU), and adverse discharge disposition; postoperative patient-reported outcomes (health-related quality of life (HRQoL), functional, cognitive, and symptomatic); radiographic outcomes; and postoperative frailty trajectory.

METHODS

This systematic review was registered with PROSPERO: CRD42019109045. Publications from January 1950 to December 2020 were identified by a comprehensive search of PubMed, Ovid, and Embase, supplemented by manual screening. Studies reporting and validating a frailty tool in the surgical spine population with a measurable outcome were included. Each tool and its clinimetric properties were evaluated using validated criteria and definitions. The applicability of each tool and its most sensitive surgical spine population was determined by panel consensus. Bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

47 studies were included in the final qualitative analysis. A total of 14 separate frailty tools were identified, in which 9 tools assessed frailty according to the cumulative deficit definition, while 4 instruments utilized phenotypic or weighted frailty models. One instrument assessed frailty according to the comprehensive geriatric assessment (CGA) model. Twelve measures were validated as risk stratification tools for predicting postoperative AEs, while 1 tool investigated the effect of spine surgery on postoperative frailty trajectory. The modified frailty index (mFI), 5-item mFI, adult spinal deformity frailty index (ASD-FI), FRAIL Scale, and CGA had the most positive ratings for clinimetric properties assessed.

CONCLUSIONS

The assessment of frailty is important in the surgical decision-making process. Cumulative deficit and weighted frailty instruments are appropriate risk stratification tools. Phenotypic tools are sensitive for capturing the relationship between spinal pathology, spine surgery, and prehabilitation on frailty trajectory. CGA instruments are appropriate screening tools for identifying health deficits susceptible to improvement and guiding optimization strategies. Studies are needed to determine whether spine surgery and prehabilitation are effective interventions to reverse frailty.

Risk Factors that Hinder Locomotive Syndrome Improvement Following Surgery for Musculoskeletal Diseases in Older Patients: A Multicenter Prospective Study

OBJECTIVES

This study aimed to evaluate preoperative and postoperative locomotive syndrome (LS) in older adults undergoing surgical treatment for musculoskeletal diseases of the lumbar spine and lower extremities and identify risk factors that impede LS improvement after surgery.

METHODS

: The baseline evaluation included 471 patients 65 years or older (276 in the pre-old age [65-74 years] group; 195 in the old age [75 years or older] group) and examined the preoperative and postoperative LS data. The second evaluation performed to identify risk factors, including anthropometric measurements, comorbidity, and frailty, that hinder LS improvement after surgery included 378 patients with preoperative LS stage 3.

RESULTS

Preoperatively, 80% of the patients had LS stage 3; this rate decreased to 40% postoperatively. Half of the patients exhibited postoperative LS improvement. The LS improvement rate was higher in the pre-old age group than in the old age group. According to the multiple logistic regression analysis, old age, high body mass index, weak hand grip strength, and high 5-factor modified frailty index score were significant risk factors that hinder LS improvement after surgery.

CONCLUSIONS

Aging, obesity, weak muscle strength, and frailty can hinder LS improvement in older patients who undergo surgery.

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.

Frequency of vitamin d deficiency in patients with lumbar spinal stenosis and its relationship with obesity, depression, and pain intensity: a cross-sectional study

ABSTRACT Objective This study was conducted to determine the frequency of vitamin D deficiency in patients with lumbar spinal stenosis and to define the relationship between vitamin D levels and obesity, depression, and pain intensity. Methods This study was conducted with 69 patients (Male = 32, Female = 37) diagnosed with lumbar spinal stenosis. The participants’ 25(OH)D levels were measured by radioimmunoassay. In addition, bone metabolic status, including bone mineral density and bone turnover markers, was also evaluated. The Beck Depression Inventory was used to determine the depression statuses of the patients, while the McGill Melzack Pain Questionnaire was administered to measure pain intensity. The results were evaluated at a significance level of p<0.05. Results Vitamin D deficiency (<20 ng/mL) was found in 76.8% of the patients. Binary logistic regression analysis showed a significantly higher frequency of vitamin D deficiency in patients who: 1) had higher body mass indexes (OR 3.197, 95% CI 1.549-6.599); 2) fared higher in Beck’s depression score (OR 1.817, 95% CI 1.027–3.217); and 3) were female rather than male (OR 1.700, 95% CI 0.931-3.224) (p<0.05). Conclusion In this study, vitamin D deficiency was prevalent in lumbar spinal stenosis patients. In addition, obese, depressed, and female individuals have higher risks of vitamin D deficiency.

Association of frailty with regional sagittal spinal alignment in the elderly

The degenerative changes in the spine of the frail elderly gradually exacerbate the alignment of the spine as the degeneration progresses. This study was conducted to assess the relationship between frailty and spine sagittal alignment measured in terms of global, cervical, thoracic, and lumbo-pelvic parameters. In total, 101 patients aged 75 years and older hospitalized for spine surgery were prospectively enrolled. We evaluated spinal sagittal parameters by dividing them into global (C7 sagittal vertical axis [SVA] and T1 pelvic angle [T1PA]), cervical (the C2-7 Cobb angle, Jackson line, and C2-7 plumb line), thoracic (thoracic kyphosis [TK]), and lumbo-pelvic (pelvic tilt [PT] and pelvic incidence minus lumbar lordosis value [PI-LL]). Patient characteristics; the Fatigue, Resistance, Ambulation, Illness, Loss of Weight (FRAIL) scale; and sagittal spinal parameters were included in the analysis. Multiple regression analysis was performed to identify associations between the FRAIL scale and sagittal spinal parameters. The FRAIL scale showed correlations with global sagittal parameters (C7 SVA [β = 0.225, p = 0.029] and T1PA [β = 0.273, p = 0.008]) and lumbo-pelvic parameters (PT [β = 0.294, p = 0.004] and PI-LL [β = 0.323, p = 0.001). Cervical and thoracic parameters were not directly associated with the FRAIL scale. LL and PI-LL were associated with TK, and TK was associated with cervical parameters (the C2-7 Cobb angle, Jackson line and C2-7 plumb line). In conclusion, frailty status could be an important factor that influences sagittal spinal alignment in the elderly. In this study, it was found that frailty mainly affected the balance of lumbo-pelvic alignment, and consequently affected the balance of the whole spine.

Frailty measurements in hospitalised orthopaedic populations age 65 and older: A scoping review

Aims and Objectives

To identify and compare frailty instruments used with hospitalised orthopaedic patients aged over 65.

Background

Frailty predicts clinical events in orthopaedic patients aged over 65. However, the strengths and limitations of different approaches to measuring frailty in this population are rarely discussed. As such, a comprehensive review to address the gap is needed.

Design

Scoping review using Arksey and O’Malley framework.

Methods

PubMed, CINAHL, PsycINFO, Scopus and EMBASE databases were searched to identify studies published from 2006 to 2020 regarding frailty instruments in older orthopaedic patients. The Preferred Reporting Items for Systematic Reviews and Meta‐analyses were followed.

Results

The initial search resulted in 1,471 articles. After review against inclusion and exclusion criteria, a final set of 31 articles containing 15 unique frailty instruments were evaluated. Most of the articles were from Western countries. Fried's phenotype and Frailty Index were commonly used. The frailty index was mostly modified to measure frailty. In hip fracture, physical function items were frequently modified in the measurement of frailty. Trained physicians and nurses administered most frailty instruments. Frailty screening was commonly conducted at hospital admission and used to prognosticate both postoperative complications and hospital outcomes. Most instruments could be completed within 10 min. Reported psychometrics had acceptable reliability and validity.

Conclusion

Many reliable frailty measures have been used in the inpatient orthopaedic settings; however, evidence is still lacking for a gold standard frailty instrument. More research is needed to identify the best‐performing measure. Frailty evaluation in patients with physical limitations is challenging with existing instruments. Clinical context, resources required and instrument quality are essential factors in selecting a frailty instrument.

Relevance to clinical practice

Musculoskeletal symptoms in older patients may bias frailty assessment. Proactive frailty screening with valid and practical instruments is vital to strengthen preoperative risk stratification and improve post‐surgical outcomes.

The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery

PURPOSE

This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery.

METHODS

The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals.

CONCLUSIONS

Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

Association of Lumbar Spinal Stenosis with Severe Disability and Mortality Among Community-Dwelling Older Adults: The Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study

STUDY DESIGN

This prospective cohort study analyzed data from the Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study.

OBJECTIVE

To investigate the association between lumbar spinal stenosis (LSS) and severe disability and mortality among community-dwelling older adults.

SUMMARY OF BACKGROUND DATA

Only a few studies have investigated LSS longitudinally, and the study participants were limited to selected patients diagnosed with LSS during a hospital visit. Additionally, the prognosis of LSS remains unclear.

METHODS

We enrolled independent community-dwelling older adults aged 65 years or older at the time of a baseline health checkup in 2008. LSS was diagnosed using a validated diagnostic support tool for LSS. The primary endpoint was a composite of severe disability (long-term care insurance certification grade 4 or 5) and mortality. We used 1 minus Kaplan-Meier failure estimates and the log-rank test to compare the interval between baseline and the predetermined endpoint as well as a Cox proportional hazards model to estimate hazard ratios (HRs) for the LSS group with adjustment for possible confounders. Multiple imputation by chained equations was performed for sensitivity analysis.

RESULTS

Of 2058 subjects enrolled, 1560 did not have missing covariates; 269 (17%) were diagnosed with LSS. After a median follow-up of 5.8 years, the rates of severe disability and mortality were 0.022 per year in subjects with LSS and 0.012 per year in those without (P = 0.006). The adjusted HR for the composite endpoint in the LSS group was 1.55 (95% confidence interval [CI], 1.01-2.38). A similar association was observed after multiple imputation of missing covariates (adjusted HR, 1.51 [95% CI, 1.06-2.16]).

CONCLUSION

LSS was associated with severe disability and mortality in community-dwelling older adults. Detection of adults with LSS in the community may contribute to local health promotion.Level of Evidence: 2.

Evaluation of Effectiveness of Treatment Strategies for Degenerative Lumbar Spinal Stenosis: A Systematic Review and Network Meta-Analysis of Clinical Studies

OBJECTIVE

Lumbar spinal stenosis (LSS) is a common disease in spinal surgery. Many related treatment methods have been reported, but their effectiveness still lacks a systematic comparison. We aimed to evaluate the clinical outcomes related to the efficacy and safety of these treatment strategies via a network meta-analysis.

METHODS

Relevant clinical studies were retrieved from the databases of PubMed, Embase, Web of Science, and Cochrane library updated to July 29, 2020. The data were extracted from the eligible literature and the results were presented as standardized mean differences with 95% confidence intervals (CIs). A network meta-analysis was executed using the netmeta, rjags, and gemtc packages in R software, and Begg and Egger tests were used to assess the publication bias within the included studies.

RESULTS

A total of 21 eligible studies based on 2890 patients with degenerative LSS were included. The newer microdecompression technique (bilateral decompression via unilateral laminotomy [BDUL]) performed better in decreasing the visual analog scale (VAS) score compared with conventional decompressive laminectomy (VAS score back pain, 1.22; 95% CI, 0.28-2.17; VAS score leg pain, 1.39; 95% CI, 0.82-1.96), but its Oswestry Disability Index improvement was slightly inferior to that of posterolateral fusion.

CONCLUSIONS

BDUL could effectively alleviate VAS pain of patients, and had a lower incidence of complications. Although BDUL was slightly inferior to posterolateral fusion in terms of Oswestry Disability Index improvement, the postoperative quality of life of patients treated with BDUL had been significantly improved compared with that before surgery.

Risk factors for acute proximal junctional kyphosis after adult spinal deformity surgery in preoperative motion analysis

OBJECTIVE

This study aimed to examine which motion analysis parameters regarding the dynamic aspects and/or balance affect the development acute proximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery.

METHODS

A total of 90 consecutive patients were recruited prospectively, who underwent a corrective surgery for ASD with sagittal imbalance. According to the development of acute PJK within 6 months after surgery, the patients were divided into the PJK+ and PJK- groups. Before surgery, three-dimensional gait analyses were performed using a motion analysis system. The preoperative continuous and categorical variables were compared between the PJK+ and PJK- groups using independent t tests and chi-square tests, respectively. Finally, a multivariate logistic regression model was used to identify the risk factors and calculate the odds ratio (OR) for acute PJK.

RESULTS

A total of 20 and 70 patients were classified into the PJK+ and PJK- groups, respectively. There were no differences in the spinopelvic radiologic parameters pre- and postoperatively between the PJK+ and PJK- groups. The PJK+ group showed a significantly higher mean anterior pelvic tilt (Ant-PT) angle in preoperative motion analysis than the PJK- group (P = 0.001 for both sides). Multivariate analysis identified the mean Ant-PT angle (P = 0.047; OR 1.127; 95% CI 1.002-1.267) as a significant risk factor for acute PJK.

CONCLUSION

Preoperative Ant-PT angle during walking was associated with a higher OR in acute PJK after surgery.

The Impact of Frailty on Spine Surgery: Systematic Review on 10 years Clinical Studies

Frailty is a condition characterized by a high vulnerability to low-power stressor. Frailty increases with age and is associated with higher complications and mortality. Several indexes have been used to quantify frailty. Spine diseases, both degenerative and oncologic, frequently require surgery which is related to complications and mortality. Aim of the present systematic review was to collect the most frequently used frailty indexes in clinics to predict surgical outcomes in patients affected by spine diseases, taking into account gender differences. Three databases were employed, and 29 retrospective clinical studies were included in this systematic review. The identified spine pathologies were primary and metastatic spine tumors, adult spine deformity (ASD), degenerative spine disease (DSD), cervical deformity (CD) and other pathologies that affected lumbar spine or multiple spine levels. Eleven indexes were identified: modified Frailty Index (mFI), Adult spinal deformity frailty index (ASD-FI), mFI-5, Metastatic Spinal Tumor Frailty Index (MSTFI), Fried criteria, Cervical deformity frailty index (CD-FI), Spinal tumor frailty index (STFI), Frailty Phenotype criteria (FP), Frailty Index (FI), FRAIL scale and Modified CD-FI (mCD-FI). All these indexes correlated well with minor and major postoperative complications, mortality and length of stay in hospital. Results on gender differences and frailty are still conflicting, although few studies show that women are more likely to develop frailty and more complications in the post-operative period than men. This systematic review could help the surgeon in the adoption of frailty indexes, before the operation, and in preventing complications in frail patients.

Development of Korean Frailty Index for Primary Care (KFI-PC) and Its Criterion Validity

BACKGROUND

The objective of this study was to develop and validate the Korean Frailty Index for Primary Care (KFI-PC) based on a comprehensive geriatric assessment.

METHODS

We developed a 54-item KFI-PC comprising 10 standard domains: cognitive status including delirium or dementia; mood; communication including vision, hearing, and speech; mobility; balance; bowel function; bladder function; ability to carry out activities of daily living; nutrition; and social resources. To test its validity, we applied KFI-PC to participants of the Korean Frailty Aging and Cohort Study (KFACS). We analyzed 1,242 participants (mean age, 77.9±3.9 years; 47.2% men) from the KFACS who visited 10 study centers in 2018, after excluding 32 participants with missing data required to assess Fried's physical frailty phenotype.

RESULTS

The mean KFI-PC score was 0.17±0.08, ranging from 0.02 to 0.52. The median KFI-PC score was higher in women than in men, and there was a trend toward higher values in older age groups. The prevalence of frailty when applying a generally used frailty index cutoff point of >0.25 was 17.5% in the whole study sample. As a construct validation of KFI-PC, the area under the receiver operating characteristic curve for Fried's physical frailty was 0.921, and the optimal cutoff value to predict frailty phenotype was 0.23. The KFI-PC score also correlated well with physical, cognitive, and psychological functions; nutritional status; disability in activities of daily living; and instrumental activities of daily living. The Cronbach's alpha coefficient of the 54 total items was 0.737.

CONCLUSION

We developed KFI-PC with 53 deficits, including comprehensive geriatric assessment components, and demonstrated the acceptable construct validity and internal consistency of KFI-PC.