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

Effective Risk Assessment for Distal Radius Fractures: A Rigorous Multivariable Regression Analysis, Using a Novel 8-Item Modified Frailty Index

Introduction  Distal radius fractures (DRFs) are among the most common orthopaedic injuries. The prevalence of DRFs is increasing across all age groups but remains the second most common fracture in the elderly. The modified frailty index (MFI) often predicts morbidity and mortality in orthopaedic injuries. This study aims to determine the predictive value of MFI on complication rates following DRF and the patient length of stay and discharge outcomes. Methods  We utilized our MFI to perform a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Results  In a total of 22,313 patients, the average age was 46 ± 16. An increase in MFI led to an increase in the odds ratio of readmission and reoperation ( p  < 0.001). MFI predicted complications, doubling the rate as the score increased from 1 to 2 ( p  < 0.001). An MFI of 2 also led to a delayed hospital stay of 5 days ( p  < 0.001), as well as an increase in the odds of patients not being sent home at discharge ( p  < 0.001). Finally, life-threatening complications were also predicted with an increased MFI, the odds of a life-threatening complication increasing 488.20 times at an MFI of 3 ( p  < 0.001). Discussion and Conclusion  While surgical decision-making for frail patients with DRFs remains contentious, this novel 8-item MFI score was significantly associated with the probability of hospital readmission/reoperation, postoperative complications, and delayed hospital length of stay. Three new parameters were incorporated into our 8-item score compared with the conventional 5; hypoalbuminemia status (< 3.5 mg/dL), previous diagnosis of osteoporosis, and severe obesity (body mass index > 35) enhancing its sensitivity. Future studies are warranted for its prospective utility in ruling out postsurgical comorbidity.

Utility of the Modified 5-Items Frailty Index to Predict Complications and Mortality After Elective Cervical, Thoracic and Lumbar Posterior Spine Fusion Surgery: Multicentric Analysis From ACS-NSQIP Database

STUDY DESIGN

Retrospective review of multicentric data.

OBJECTIVES

The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. It has been recently shown a good predictive value after posterior lumbar fusion. We aimed to compare the predictive value of the modified 5-item frailty index in cervical, thoracic and lumbar surgery.

METHODS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database 2015-2020 was used to identify patients who underwent elective posterior cervical, thoracic, or lumbar fusion surgeries for degenerative conditions. The mFI-5 score was calculated based on the presence of 5 co-morbidities: congestive heart failure within 30 days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on the postoperative morbidity while controlling for baseline clinical characteristics.

RESULTS

53 252 patients were included with the mean age of 64.2 ± 7.2. 7946 suffered medical complications (14.9%), 1565 had surgical complications (2.9%), and 3385 were readmitted (6.3%), 363 died (.68%) within 30 days postoperative (6.3%). The mFI-5 items score was significantly associated with higher rates of complications, readmission, and mortality in cervical, thoracic, and lumbar posterior fusion surgery.

CONCLUSION

The modified 5-item frailty score is a reliable tool to predict complications, readmission, and mortality in patients planned for elective posterior spinal fusion surgery.

Frailty Influence on Postoperative Surgical Site Infections After Surgery for Degenerative Spine Disease and Adult Spine Deformity. Can a Frailty Index be a Valuable Summary Risk Indicator? A Systematic Review and Metanalysis of the Current Literature

STUDY DESIGN

Metanalysis.

OBJECTIVE

Surgical site infections (SSI) is one of the commonest postoperative adverse events after spine surgery. Frailty has been described as a valuable summary risk indicator for SSI in spine surgery. The aim of this metanalysis is to evaluate the influence of frailty on postoperative SSI in this cohort and provide hints on which index can predict the risk of SSI.

METHODS

Papers describing the postoperative SSI rate in adult degenerative spine disease or adult spine deformity patients with varying degrees of frailty were included in the analysis. The SSI rate in different grades of frailty was considered for outcome measure. Meta-analysis was performed on studies in whom data regarding patients with different levels of frailty and occurrence of postoperative SSI could be pooled. P < .05 was considered significant.

RESULTS

16 studies were included. The frailty prevalence measured using mFI-11 ranged from 3% to 17.9%, these values were inferior to those measured with mFI-5. Significant difference was found between frail and non-frail patients in postoperative SSI rate at metanalysis (z = 5.9547, P < .0001 for mFI-5 and z = 3.8334, P = .0001 for mFI-11).

CONCLUSION

This is the first meta-analysis to specifically investigate the impact of frailty, on occurrence of SSI. We found a relevant statistical difference between frail and non-frail patients in SSI occurrence rate. This is a relevant finding, as the ageing of population increases alongside with spine surgery procedures, a better understanding of risk factors may advance our ability to treat patients while minimizing the occurrence of SSI.

Impact of Preoperative Frailty on Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Anterior vs. Posterior Cervical Surgery

Introduction: Frailty has been shown to negatively influence patient outcomes across many disease processes, including in the cervical spondylotic myelopathy (CSM) population. The aim of this study was to assess the impact that frailty has on patients with CSM who undergo anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF). Materials and Methods: A retrospective cohort study was performed using the 2016-2019 national inpatient sample. Adult patients (≥18 years old) undergoing ACDF only or PCDF only for CSM were identified using ICD codes. The patients were categorized based on receipt of ACDF or PCDF and pre-operative frailty status using the 11-item modified frailty index (mFI-11): pre-Frail (mFI = 1), frail (mFI = 2), or severely frail (mFI ≥ 3). Patient demographics, comorbidities, operative characteristics, perioperative adverse events (AEs), and healthcare resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS) and non-routine discharge (NRD). Results: A total of 37,990 patients were identified, of which 16,665 (43.9%) were in the pre-frail cohort, 12,985 (34.2%) were in the frail cohort, and 8340 (22.0%) were in the severely frail cohort. The prevalence of many comorbidities varied significantly between frailty cohorts. Across all three frailty cohorts, the incidence of AEs was greater in patients who underwent PCDF, with dysphagia being significantly more common in patients who underwent ACDF. Additionally, the rate of adverse events significantly increased between ACDF and PCDF with respect to increasing frailty (p < 0.001). Regarding healthcare resource utilization, LOS and rate of NRD were significantly greater in patients who underwent PCDF in all three frailty cohorts, with these metrics increasing with frailty in both ACDF and PCDF cohorts (LOS: p < 0.001); NRD: p < 0.001). On a multivariate analysis of patients who underwent ACDF, frailty and severe frailty were found to be independent predictors of extended LOS [(frail) OR: 1.39, p < 0.001; (severely frail) OR: 2.25, p < 0.001] and NRD [(frail) OR: 1.49, p < 0.001; (severely frail) OR: 2.22, p < 0.001]. Similarly, in patients who underwent PCDF, frailty and severe frailty were found to be independent predictors of extended LOS [(frail) OR: 1.58, p < 0.001; (severely frail) OR: 2.45, p < 0.001] and NRD [(frail) OR: 1.55, p < 0.001; (severely frail) OR: 1.63, p < 0.001]. Conclusions: Our study suggests that preoperative frailty may impact outcomes after surgical treatment for CSM, with more frail patients having greater health care utilization and a higher rate of adverse events. The patients undergoing PCDF ensued increased health care utilization, compared to ACDF, whereas severely frail patients undergoing PCDF tended to have the longest length of stay and highest rate of non-routine discharge. Additional prospective studies are necessary to directly compare ACDF and PCDF in frail patients with CSM.

Impact of frailty on the outcomes of patients undergoing degenerative spine surgery: a systematic review and meta-analysis

BACKGROUND

Degenerative spinal diseases are common in older adults with concurrent frailty. Preoperative frailty is a strong predictor of adverse clinical outcomes after surgery. This study aimed to investigate the association between health-related outcomes and frailty in patients undergoing spine surgery for degenerative spine diseases.

METHODS

A systematic review and meta-analysis were performed by electronically searching Ovid-MEDLINE, Ovid-Embase, Cochrane Library, and CINAHL for eligible studies until July 16, 2022. We reviewed all studies, excluding spinal tumours, non-surgical procedures, and experimental studies that examined the association between preoperative frailty and related outcomes after spine surgery. A total of 1,075 articles were identified in the initial search and were reviewed by two reviewers, independently. Data were subjected to qualitative and quantitative syntheses by meta-analytic methods.

RESULTS

Thirty-eight articles on 474,651 patients who underwent degenerative spine surgeries were included and 17 papers were quantitatively synthesized. The health-related outcomes were divided into clinical outcomes and patient-reported outcomes; clinical outcomes were further divided into postoperative complications and supportive management procedures. Compared to the non-frail group, the frail group was significantly associated with a greater risk of high mortality, major complications, acute renal failure, myocardial infarction, non-home discharge, reintubation, and longer length of hospital stay. Regarding patient-reported outcomes, changes in scores between the preoperative and postoperative Oswestry Disability Index scores were not associated with preoperative frailty.

CONCLUSIONS

In degenerative spinal diseases, frailty is a strong predictor of adverse clinical outcomes after spine surgery. The relationship between preoperative frailty and patient-reported outcomes is still inconclusive. Further research is needed to consolidate the evidence from patient-reported outcomes.

Predictive Ability of Comorbidity Indices for Surgical Morbidity and Mortality: a Systematic Review and Meta-analysis

BACKGROUND

Several contemporary risk stratification tools are now being used since the development of the Charlson Comorbidity Index (CCI) in 1987. The purpose of this systematic review and meta-analysis was to compare the utility of commonly used co-morbidity indices in predicting surgical outcomes.

METHODS

A comprehensive review was performed to identify studies reporting an association between a pre-operative co-morbidity measurement and an outcome (30-day/in-hospital morbidity/mortality, 90-day morbidity/mortality, and severe complications). Meta-analysis was performed on the pooled data.

RESULTS

A total of 111 included studies were included with a total cohort size 25,011,834 patients. The studies reporting the 5-item Modified Frailty Index (mFI-5) demonstrated a statistical association with an increase in the odds of in-hospital/30-day mortality (OR:1.97,95%CI: 1.55-2.49, p < 0.01). The pooled CCI results demonstrated an increase in the odds for in-hospital/30-day mortality (OR:1.44,95%CI: 1.27-1.64, p < 0.01). Pooled results for co-morbidity indices utilizing a scale-based continuous predictor were significantly associated with an increase in the odds of in-hospital/30-day morbidity (OR:1.32, 95% CI: 1.20-1.46, p < 0.01). On pooled analysis, the categorical results showed a higher odd for in-hospital/30-day morbidity (OR:1.74,95% CI: 1.50-2.02, p < 0.01). The mFI-5 was significantly associated with severe complications (Clavien-Dindo ≥ III) (OR:3.31,95% CI:1.13-9.67, p < 0.04). Pooled results for CCI showed a positive trend toward severe complications but were not significant.

CONCLUSION

The contemporary frailty-based index, mFI-5, outperformed the CCI in predicting short-term mortality and severe complications post-surgically. Risk stratification instruments that include a measure of frailty may be more predictive of surgical outcomes compared to traditional indices like the CCI.

Sarcopenia Best Predicts Complications in Free Flap Breast Reconstruction

Breast reconstruction remains a major component of the plastic surgeon's repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes.

Methods

All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed.

Results

In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model.

Conclusions

Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

Sense of Coherence at End of Life in Older People: An Interpretive Description

As people age, losses accumulate (ie, the death of family and friends, the loss of agility, and the loss of independence). Such losses have an impact on one's Sense of Coherence, that is, one's ability to see the world as comprehensible, manageable, and meaningful. Antonovsky deemed Sense of Coherence as a mostly stable state by the age of 30 years. Until now, there has not been an investigation into how serial loss of resources affects older people as they near the end of life. Sense of Coherence was used as the theoretical framework for this study to answer the question of how older people maintain or regain a Sense of Coherence in the presence of serious illness as they near death. Data were gathered using semistructured interviews and guided by interpretive description. This investigation found new concepts that contribute to Antonovsky's midlevel theory of salutogenesis and the construct of Sense of Coherence. Those are Incomprehensibility and Serial Loss of General Resistance Resources. The results indicate that the crux of a strong Sense of Coherence for this population is excellent communication and a coherent "big-picture" conversation.

A retrospective study on the relationship between 5 modified frailty index (5-mFI) and postoperative complications of gynecological elderly patients undergoing abdominal surgery

INTRODUCTION

Aim to evaluate the application of 5 modified frailty index (5-mFI) in predicting postoperative complications in elderly gynecological patients undergoing abdominal surgery.

METHODS

A total of 294 elderly gynecological patients who were hospitalized in the affiliated Hospital of North Sichuan Medical College and underwent abdominal surgery from November 2019 to May 2022 were collected from the Union Digital Medical Record (UniDMR) Browser of the hospital. According to whether postoperative complications (infection, hypokalemia, hypoproteinemia, poor wound healing and intestinal obstruction) occurred, the patients were divided into complication group (n = 98) and non-complication group (n = 196). Univariate and multivariate logistic regression analysis were used to analyze the risk factors of complications in elderly gynecological patients undergoing abdominal surgery. The receiver operating characteristic (ROC) curve was used to determine the predictive value of the frailty index score in elderly gynecological patients with postoperative complications after abdominal surgery.

RESULTS

Postoperative complications occurred in 98 of 294 elderly gynecological patients undergoing abdominal surgery, accounting for 33.3%, 5-mFI (OR1.63, 95%CI 1.07-2.46,P = 0.022), age (OR1.08,95%CI 1.02-1.15, P = 0.009), operation time (OR 1.01, 95%CI 1.00-1.01). P < 0.001) were independent risk factors for postoperative complications in elderly patients undergoing abdominal surgery, and the area under the curve of postoperative complications in elderly gynecological patients was 0.60. (95%CI: 0.53-0.67, P = 0.005) CONCLUSION: Five modified frailty index can effectively predict the occurrence of postoperative complications in elderly gynecological patients.

Risk Factors for 30-day Unplanned Readmission following Surgery for Lumbar Degenerative Diseases: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Surgical procedures for lumbar degenerative diseases (LDD), which have emerged in the 21-century, are commonly practiced worldwide. Regarding financial burdens and health costs, readmissions within 30days following surgery are inconvenient. We performed a systematic review to integrate real-world evidence and report the current risk factors associated with 30-day readmission following surgery for LDD.

METHODS

The Cochrane Library, Embase, and Medline electronic databases were searched from inception to April 2022 to identify relevant studies reporting risk factors for 30-day readmission following surgery for LDD.

RESULTS

Thirty-six studies were included in the review. Potential risk factors were identified in the included studies that reported multivariate analysis results, including age, race, obesity, higher American Society of Anesthesiologists score, anemia, bleeding disorder, chronic pulmonary disease, heart failure, dependent status, depression, diabetes, frailty, malnutrition, chronic steroid use, surgeries with anterior approach, multilevel spinal surgeries, perioperative transfusion, presence of postoperative complications, prolonged operative time, and prolonged length of stay.

CONCLUSIONS

There are several potential perioperative risk factors associated with unplanned readmission following surgery for LDD. Preoperatively identifying patients that are at increased risk of readmission is critical for achieving the best possible outcomes.

The 5-factor modified Frailty Index (mFI-5) predicts adverse outcomes after elective Anterior Lumbar Interbody Fusion (ALIF)

Background

The 5-factor modified frailty index (mFI-5) has been shown to be a concise and effective tool for predicting adverse events following various spine procedures. However, there have been no studies assessing its utility in patients undergoing anterior lumbar interbody fusion (ALIF). Therefore, the aim of this study was to analyze the predictive capabilities of the mFI-5 for 30-day postoperative adverse events following elective ALIF.

Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2010 through 2019 to identify patients who underwent elective ALIF using Current Procedural Terminology (CPT) codes in patients over the age of 50. The mFI-5 score was calculated using variables for hypertension, congestive heart failure, comorbid diabetes, chronic obstructive pulmonary disease, and partially or fully dependent functional status which were each assigned 1 point. Univariate analysis and multivariate logistic regression models were utilized to identify the associations between mFI-5 scores, and 30-day rates of overall complications, readmissions, reoperations, and mortality.

Results

11,711 patients were included (mFI-5=0: 4,026 patients, mFI-5=1: 5,392, mFI-5=2: 2,102, mFI-5=3+: 187. Multivariate logistic regression revealed that mFI-5 scores of 1 (OR: 2.2, CI: 1.2-4.2, p=0.02), 2 (OR: 3.6, CI: 1.8-7.3, p<0.001), and 3+ (OR: 7.0, CI: 2.5-19.3, p<0.001) versus a score of 0 were significant predictors of pneumonia. An mFI-5 score of 2 (OR: 1.3; CI: 1.01-1.6, p=0.04), and 3+ (OR: 1.9; CI: 1.1-3.1; p=0.01) were both independent predictors of related readmissions. An mFI score of 3+ was an independent predictor of any complication (OR: 1.5, CI: 1.01-2.2, p=0.004), UTI (OR: 2.4, CI: 1.1-5.2, p=0.02), and unplanned intubation (OR: 4.5, CI: 1.3-16.1, p=0.02).

Conclusions

The mFI-5 is an independent predictor for 30-day postoperative complications, readmissions, UTI, pneumonia, and unplanned intubations following elective ALIF surgery in adults over the age of 50.

Comparison of Perioperative Outcomes in Patients Undergoing Short-Level Lumbar Fusion Surgery After Implementing Enhanced Recovery After Surgery: A Propensity Score Matching Analysis Focusing on Young-Old and Old-Old

Background

There were exponentially increased studies focused on revealing the satisfactory outcomes after implementing enhanced recovery after surgery (ERAS) in patients undergoing lumbar fusion surgery. However, little attention has been paid to the impact of chronologic age alone on perioperative outcomes.

Methods

In the present study, patients were dichotomized into two groups: young-old (65-79 years), and old-old (80 years and older). Given the heterogeneity and age-related comorbidities in this population and the need to compare similar groups, we performed propensity score matching for gender, body mass index (BMI), operation time, American Society of Anesthesiologists (ASA) grade, Charlson Comorbidity Index (CCI), fusion levels and frail status. Perioperative outcomes were compared between two groups.

Results

In our study, we found there were significant discrepancies in length of stay (LOS) (7.17 ± 2.81 vs 8.11 ± 3.57 days, p = 0.031) and postoperative nausea and vomiting (3.7% vs 11.0%, p = 0.038); however, there were no significant differences in C-reactive protein (21.50 ± 26.52 vs 19.22 ± 22.04 mg/L, p = 0.490), overall complication rates (24.8% vs 33.0%, p = 0.179), ambulation time (2.89 ± 1.34 vs 2.55 ± 1.49 days, p = 0.078) or removal of urinary catheter time (2.47 ± 1.44 vs 2.32 ± 1.40 days, p = 0.446).

Conclusion

There were few differences in perioperative outcomes between young-old and old-old groups. Despite similar postoperative complication rates, the old-old group might experience longer LOS when complications occur. More importantly, current outcomes suggested that chronologic age alone does not appear to have the capacity to reflect the tolerance of elderly patients to surgery.

Frailty and Sarcopenia: Impact on Outcomes Following Elective Degenerative Lumbar Spine Surgery

STUDY DESIGN

This is a retrospective review of prospectively collected data.

OBJECTIVE

The aim was to evaluate the impact of frailty and sarcopenia on outcomes after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Elderly patients are commonly diagnosed with degenerative spine disease requiring surgical intervention. Frailty and sarcopenia result from age-related decline in physiological reserve and can be associated with complications after elective spine surgery. Little is known about the impact of these factors on patient-reported outcomes (PROs).

METHODS

Patients older than 70 years of age undergoing elective lumbar spine surgery were included. The modified 5-item frailty index (mFI-5) was calculated. Sarcopenia was defined using total psoas index, which is obtained by dividing the mid L3 total psoas area by VB area (L3-TPA/VB). PROs included Oswestry disability index (ODI), EuroQual-5D (EQ-5D), numeric rating scale (NRS)-back pain, NRS leg pain (LP), and North American Spine Society (NASS) at postoperative 12 months. Clinical outcomes included length of stay (LOS), 90-day readmission and complications. Univariate and multivariable regression analyses were performed.

RESULTS

Total 448 patients were included. The mean mFI-5 index was 1.6±1.0 and mean total psoas index was 1.7±0.5. There was a significant improvement in all PROs from baseline to 12 months ( P <0.0001). After adjusting for age, body mass index, smoking status, levels fused, and baseline PROs, higher mFI-5 index was associated with higher 12-month ODI ( P <0.001), lower 12-month EQ-5D ( P =0.001), higher NRS-L P ( P =0.039), and longer LOS ( P =0.007). Sarcopenia was not associated with 12-month PROs or LOS. Neither sarcopenia or mFI-5 were associated with 90-day complication and readmission.

CONCLUSIONS

Elderly patients demonstrate significant improvement in PROs after elective lumbar spine surgery. Frailty was associated with worse 12 months postoperative ODI, EQ-5D, NRS-LP scores, and longer hospital stay. While patients with sarcopenia can expect similar outcomes compared with those without, the mFI-5 should be considered preoperatively in counseling patients regarding expectations for disability, health-related quality of life, and leg pain outcomes after elective lumbar spine surgery.

LEVEL OF EVIDENCE

3.

Development and validation of a risk-based algorithm for preoperative type and screen testing in spine surgery

BACKGROUND CONTEXT

With improvements in surgical techniques and perioperative management, transfusion rates after spine surgery have decreased over time. Given this trend, routine preoperative ABO/Rh type and antibody screen (T&S) laboratory testing may not be warranted in all patients undergoing spine surgery.

PURPOSE

The aim of the current study is to evaluate risk factors for intra/postoperative transfusion in patients undergoing a variety of spine procedures and to develop an algorithm for selectively ordering preoperative T&S testing in appropriate patients.

STUDY DESIGN/SETTING

This is a single institution, retrospective observational study of patients undergoing emergent or elective spine surgery. External validation of the algorithm was performed on a national sample of patients undergoing spine surgery from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) national database.

PATIENT SAMPLE

A total of 5,947 surgeries from January 1, 2016 to December 31, 2019 at a single institution, and 166,113 surgeries from the 2016 to 2018 ACS-NSQIP database.

OUTCOME MEASURES

The primary outcome measure was performance of intraoperative or postoperative transfusion.

METHODS

Using the institutional sample, univariate statistics (chi-square tests, fisher's exact test, 2-sided independent sample tests) were performed to compare demographics, comorbidities, and surgical details (case type, number of levels treated, etc.) between patients who did and did not require intra- or postoperative transfusion. Transfusion rates were calculated and compared across procedure types. Multivariate logistic regression was performed to identify independent predictors of transfusion and the model's accuracy was evaluated using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. A risk-based algorithm suggesting no preoperative T&S in low transfusion risk procedures, routine preoperative T&S in high-risk procedures, and further assessment in medium risk thoracolumbar fusion procedures was created. The algorithm's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated when it was applied to both the institutional and national samples. Potential cost savings from reducing T&S orders were calculated.

RESULTS

In the institutional sample, 120 patients (2.0%) required intraoperative or postoperative transfusion. The highest rates of transfusion were found in corpectomy (10.5%) and anterior/posterior cervical fusion (6.9%) procedures. In the multivariate logistic regression model, the presence of a preoperative coagulation defect or hemorrhagic condition (OR: 7.149, p<.001) and 6+ level surgery (OR: 7.511, p<.001) were the strongest predictors of transfusion. Overall, the model generated an AUC of 0.882, indicating excellent predictive accuracy. When applied to the institutional cohort, the risk-based algorithm had a sensitivity of 78.3%, specificity of 80.5%, PPV of 7.6%, and NPV of 99.4% for evaluating likelihood of transfusion. Using the algorithm 4,717 T&S tests would have been eliminated (79.3%), resulting in a cost savings of $179,246. Application of the model to the ACS-NSQIP cohort resulted in a sensitivity of 61.9%, specificity of 84.6%, PPV of 15.6%, and NPV of 98.0%.

CONCLUSIONS

The routine use of preoperative ABO/Rh type and antibody screen testing does not appear to be warranted in patients undergoing spine surgery. A risk-based approach to preoperative type and screen testing may eliminate unnecessary tests and generate significant cost savings with minimal disruption to clinical care.

The 5-Item Modified Frailty Index Independently Predicts Morbidity in Patients Undergoing Instrumented Fusion following Extradural Tumor Removal

Introduction

The management of spinal neoplasia consists of surgical, radiation, and systemic options. Little data exist to guide management based on overall health status, which is particularly challenging when patients who could benefit from surgery may be too frail for it. This study's objective was to evaluate the 5-Item Modified Frailty Index (mFI-5) as a predictor of 30-day morbidity in patients undergoing instrumented resection for metastatic extradural spinal tumors.

Methods

Adults undergoing extradural tumor resection from the 2011 to 2019 National Surgical Quality Improvement Program datasets were identified by Current Procedural Terminology codes 63275-63278 with an adjunct instrumentation code (22840-22843). Patients were classified into frailty levels 0, 1, or 2+ based on mFI-5 scores of 0, 1, or 2-5, respectively. The primary outcome was morbidity. Secondary outcomes were readmission and reoperation. Multivariate modeling was utilized to analyze mFI-5 as a predictor of outcomes. The Akaike information criterion (AIC) was used to compare relative-model-fit based on frailty versus individual comorbidity variables to determine the optimal model. Chi-squared and Fisher's exact tests were used to establish significance between individual complications and frailty.

Results

There were 874 patients. Readmission, reoperation, and morbidity rates were 19.5%, 5.0%, 52.3%, respectively. In multivariate analyses, mFI-5=1 (OR: 1.45, SE: 0.31, p=0.036), mFI-5=2+ (OR: 1.41, SE: 0.40, p=0.036), operative time (OR: 1.18, SE: 0.03, p≤0.001), and chronic steroid use (OR: 1.56, SE: 0.42, p=0.037) independently predicted morbidity. Elective surgery (OR: 0.61) was protective. Frailty did not predict readmission or reoperation. Frailty was found to be significantly associated with respiratory complications, urinary tract infections, cardiac events, and sepsis/septic shock specifically.

Conclusions

mFI-5=1 independently predicted 45% increased odds of morbidity. mFI-5=2+ independently predicted 41% increased odds of morbidity. Further, every 30 additional minutes of operative time predicted 18% increased odds of morbidity, suggesting an increased risk of site-related complication events. Taken together, the mFI-5 serves as a valid predictor of morbidity in patients with extradural tumor undergoing instrumented excision.

The Impact of Frailty on Perioperative Outcomes in Patients Receiving Short-Level Posterior Lumbar Interbody Fusion: A Stepwise Propensity Score Matching Analysis

Background

There are many studies on the impact of frailty on postoperative complications; however, there are few studies focusing on stepwise propensity score matching (PSM) to offset the influence of age.

Methods

We gathered data for patients undergoing short-level posterior lumbar interbody fusion from January to December 2021. According to the Fried frailty phenotype, we categorized patients into non-frail, pre-frail, and frail groups, then, stepwise PSM for age, sex, American Society of Anesthesiologists (ASA) and fusion levels were performed to keep comparable clinical data between groups. Univariate and multivariate logistic regressions were used to determine the impact of clinical demographics on postoperative complications.

Results

A total of 559 consecutive patients with complete medical records were enrolled (237 males and 322 females; mean age 72.55 ± 5.86 years). After PSM, we found that pre-frail patients were more vulnerable to develop urinary retention (p = 0.031) and surgical site infections (p = 0.021) than non-frail patients. Longer length of stay (LOS), delayed ambulation and removal of urinary catheter times were observed in pre-frail patients. However, there was a significant difference only in LOS between pre-frail and frail patients. Binary logistic regression revealed that C-reactive protein (CRP) and frail status were independently associated with postoperative complications between non-frail and pre-frail patients, while only CRP was independently correlated with complications between pre-frail and frail patients.

Conclusion

After PSM, we found higher rates of urinary retention and surgical site infections in pre-frail patients than in non-frail patients. CRP was independently related to postoperative complications, while frail status was only independently associated with postoperative complications between pre-frail and non-frail patients. Pre-frail/frail patients tended to have more severe stress responses than non-frail patients.

The composite risk index based on frailty predicts postoperative complications in older patients recovering from elective digestive tract surgery: a retrospective cohort study

Background

Limitations exist in available studies investigating effect of preoperative frailty on postoperative outcomes. This study was designed to analyze the association between composite risk index, an accumulation of preoperative frailty deficits, and the risk of postoperative complications in older patients recovering from elective digestive tract surgery.

Methods

This was a retrospective cohort study. Baseline and perioperative data of older patients (age ≥ 65 years) who underwent elective digestive tract surgery from January 1, 2017 to December 31, 2018 were collected. The severity of frailty was assessed with the composite risk index, a composite of frailty deficits including modified frailty index. The primary endpoint was the occurrence of postoperative complications during hospital stay. The association between the composite risk index and the risk of postoperative complications was assessed with a multivariable logistic regression model.

Results

A total of 923 patients were included. Of these, 27.8% (257) developed postoperative complications. Four frailty deficits, i.e., modified frailty index ≥0.27, malnutrition, hemoglobin < 90 g/L, and albumin ≤30 g/L, were combined to generate a composite risk index. Multivariable analysis showed that, when compared with patients with composite risk index of 0, the odds ratios (95% confidence intervals) were 2.408 (1.714–3.383, P <  0.001) for those with a composite risk index of 1, 3.235 (1.985–5.272, P <  0.001) for those with a composite risk index of 2, and 9.227 (3.568–23.86, P <  0.001) for those with composite risk index of 3 or above. The area under receiver-operator characteristic curve to predict postoperative complications was 0.653 (95% confidence interval 0.613–0.694, P <  0.001) for composite risk index compared with 0.622 (0.581–0.663, P <  0.001) for modified frailty index.

Conclusion

For older patients following elective digestive tract surgery, high preoperative composite risk index, a combination of frailty deficits, was independently associated with an increased risk of postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01549-6.

Effects of preoperative nutritional status on complications and readmissions after posterior lumbar decompression and fusion for spondylolisthesis: A propensity-score analysis

INTRODUCTION

Malnutrition, common in the elderly, may adversely affect healthcare outcomes. In spine surgery, malnutrition is associated with higher rates of perioperative complications, unplanned readmission, and prolonged length of stay (LOS). The aim of this study was to determine the effect of malnutrition on adverse events (AEs), unplanned readmission, and LOS in patients undergoing spine surgery for spondylolisthesis.

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2016. Adult patients who underwent posterior decompression or fusion for spondylolisthesis were identified using the ICD-9-CM coding systems. Patients were divided into two cohorts based on preoperative serum albumin levels. propensity-score (PS) matching was used to create an age- and sex-matched Nourished cohort. Patient demographics, comorbidities, LOS, and postoperative complications were collected. Multivariate logistic regression analysis was performed to identify predictors of prolonged LOS, unplanned readmission, and AEs.

RESULTS

Of the 2196 patients identified, 4.5% were malnourished. Patients in the Malnourished cohort were found to have significantly longer average LOS (Malnourished: 4.51 ± 3.1 days vs PS-Matched Not Nourished: 3.7 ± 3.7, p = 0.002), higher rates of AEs (Malnourished: 14.3% vs PS-Matched Nourished: 5.8%, p = 0.007), reoperation (Malnourished: 8.4% vs PS-Matched Nourished: 3.2%, p = 0.026), and unplanned readmission (Malnourished: 15.3% vs PS-Matched Nourished: 6.1%, p = 0.003). On multivariate analysis considering only preoperative data, malnutrition was a significant independent predictor of AEs [OR: 2.13, CI (1.02, 4.46), p = 0.045]. However, after correcting for the occurrence of AEs, malnutrition was not associated with total LOS [aRR: 0.29, CI (-0.37, 0.95), p = 0.392] or 30-day unplanned readmissions [aOR: 2.24, CI (0.89, 5.60), p = 0.086].

CONCLUSION

Our study found that malnourished patients undergoing lumbar fusion for spondylolisthesis have significantly higher rates of AEs, unplanned readmission, and prolonged LOS than nourished patients. Further studies are necessary to corroborate our findings.