The Effect of Preoperative Nutritional Intervention for Adult Spinal Deformity Patients

Preoperative Nutritional Status Screened by MNA-SF Predicts Major Complications in Elderly Patients Undergoing Lumbar Fusion Surgery

Purpose

To investigate the role of Mini Nutritional Assessment-Short Form (MNA-SF) in predicting postoperative complications in older patients (≥75 years) undergoing lumbar fusion surgery.

Patients and Methods

Patients who had undergone posterior lumbar fusion surgery between June 2019 and September 2021 were enrolled. Those with an MNA-SF score of 12 or higher were categorized as the Nourished group, while those with a score less than 12 were placed in the Malnutrition-Risk group. Preoperative, intraoperative, and postoperative variables between groups were compared. Patients were then re-classified based on the presence of major complications, univariate analysis and multivariate logistic regression was used to identify risk factors for major complications.

Results

A total of 240 patients were enrolled, with 182 in the Nourished group and 58 in the Malnutrition-Risk group. The Malnutrition-Risk group exhibited a higher incidence of major complications (46.6% vs 23.1%, p = 0.001) and comprehensive complications index (18.42 ± 18.00 vs 12.65 ± 15.87, p = 0.021), Oswestry Disability Index (27.52 ± 23.44 vs 20.45 ± 20.42, p = 0.029) and longer recovery times (12.53 days vs 10.15 days, p =0.033). Length of stay (LOS) were also increased in the Malnutrition-Risk group (19.22 ± 10.67 vs 16.04 ± 7.69, p = 0.014). Multiple regression analysis identified nutritional risk and malnutrition, as assessed by MNA-SF, as independent factors associated with postoperative major complications (OR 2.81, 95% CI 1.42-5.53, p = 0.003).

Conclusion

Preoperative nutritional risk or malnutrition is an independent risk factor for major complications among older patients undergoing posterior lumbar fusion surgery. The MNS-SF emerges as a convenient and effective tool for promptly screening the nutritional status of older patients, prompting subsequent nutritional evaluation or intervention before surgery.

Frailty and malnutrition as predictors of major complications following posterior thoracolumbar fusion in elderly patients: a retrospective cohort study

BACKGROUND CONTEXT

The number of elderly patients with degenerative spinal deformity (DSD) is increasing, and posterior thoracolumbar fusion surgery is an effective treatment option, but there are often postoperative major complications, which may hinder the benefit for elderly patients. Currently, there is no consensus on the best risk assessment technique for predicting major complications in elderly patients undergoing long-segment fusion surgery.

PURPOSE

This study constructs a risk assessment model using the Modified 5-Item Frailty Index (mFI-5) and serum albumin and evaluates its predictive value.

STUDY DESIGN

This is a retrospective analysis of a prospectively established database of DSD.

PATIENT SAMPLE

Consecutive patients (aged 65 and older) who underwent open posterior thoracolumbar fusion surgery for DSD between April 2018 and December 2023 were included.

OUTCOME MEASURES

Outcome measures included postoperative major complications, length of hospital stay [LOS], readmission and reoperation within 30 days, discharge disposition, physiological function recovery.

METHODS

The study reviewed consecutive patients who underwent open posterior thoracolumbar fusion surgery for DSD. Patients were divided into three groups based on the presence or absence of frailty or frailty combined with malnutrition. Spearman ρ analysis was used to assess the correlation between mFI-5 and serum albumin levels. Univariate analyses and multivariate logistic regression were conducted to explore the relationship between frailty and malnutrition defined by mFI-5 and serum albumin and major postoperative complications. Finally, the Receiver Operating Characteristic (ROC) curve was used to evaluate the predictive value of this model for major complications.

RESULTS

Compared to the Normal group (n=59), both the Frailty group (n=121) and the Frailty and Malnutrition group (n=50) had higher rates of major complications (21.5% vs. 8.5%, p=.035; 28% vs. 8.5%, p=.002). Multivariate logistic regression showed that frailty and malnutrition status, higher ASA score, and more bleeding were independent predictors of major postoperative complications. The ROC curve demonstrated that frailty combined with malnutrition defined by mFI-5 and serum albumin had a larger area under the curve compared to mFI-5 or serum albumin alone (AUC: 0.676; 95% CI: 1.101-14.129; p<.001).

CONCLUSIONS

Compared to considering frailty or malnutrition alone, the combined assessment of frailty and malnutrition using mFI-5 and serum albumin is valuable in predicting major complications in elderly patients undergoing posterior thoracolumbar fusion surgery.

Surgical Apgar Score and Controlling Nutritional Status Score can be predictors of major postoperative complications after spine surgery

Assessing intraoperative hemodynamics with Surgical Apgar Score (SAS) and preoperative nutritional status with the Controlling Nutritional Status (CONUT) score are said to be useful to predict postoperative complications in many surgical services, but little is reported in the field of spinal surgery. The purpose of this study was to assess the utility of SAS and the CONUT score for predicting the risk of major postoperative complications after spinal surgery. We included 659 people who undergone spinal surgery in our institute in eight consecutive years. The occurrence of postoperative major complications was investigated. Background clinical information, surgical information including the SAS and the CONUT score, and the length of postoperative hospital stay were collected. The risk factors of postoperative complications were assessed statistically. Complications occurred in 117 cases (17.8%). The multivariate analysis showed that history of diabetes mellitus (odds ratio [OR] 1.81: P = 0.035), coronary disease (OR 3.33; P = 0.009), American Society of Anesthesiologists Physical Status (OR 1.71; P = 0.025), use of instruments (OR 2.07; P = 0.026), operation time (OR 1.30; P < 0.001), SAS (OR 0.59; P < 0.001), and CONUT (OR 1.34; P < 0.001) were independent risk factors of major complications after spinal surgery. Assessing the intraoperative hemodynamics with SAS and preoperative nutritional status with the CONUT score was useful in predicting major postoperative complications after spinal surgery. People who are detected as high risked people should be managed carefully after spinal surgery.

Assessing the effects of prehabilitation protocols on post-operative outcomes in adult cervical deformity surgery: does early optimization lead to optimal clinical outcomes?

PURPOSE

To investigate the effect of a prehabilitation program on peri- and post-operative outcomes in adult cervical deformity (CD) surgery.

METHODS

Operative CD patients ≥ 18 years with complete baseline (BL) and 2-year (2Y) data were stratified by enrollment in a prehabilitation program beginning in 2019. Patients were stratified as having undergone prehabilitation (Prehab+) or not (Prehab-). Differences in pre and post-op factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales.

RESULTS

115 patients were included (age: 61 years, 70% female, BMI: 28 kg/m2). Of these patients, 57 (49%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI, and frailty. Surgically, Prehab+ were able to undergo longer procedures (p = 0.017) with equivalent EBL (p = 0.627), and shorter SICU stay (p < 0.001). Post-operatively, Prehab+ patients reported greater reduction in pain scores and greater improvement in quality of life metrics at both 1Y and 2Y than Prehab- patients (all p < 0.05). Prehab+ patients reported significantly less complications overall, as well as less need for reoperation (all p < 0.05).

CONCLUSION

Introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling patients to undergo longer surgeries with lessened risk of peri- and post-operative complications.

The Need for Comprehensive Medical Management in Pyogenic Spondylodiscitis: A Review Article

The incidence of spontaneous or primary spondylodiscitis has been increasing over the years, affecting the aging population with multiple comorbidities. Several conditions influencing treatment outcomes stand out, such as diabetes mellitus, renal insufficiency, cardiovascular and respiratory dysfunction, and malnutrition. Due to these, the question arises regarding properly managing their current conditions and pre-existing disease states. Treatment plans must consider all concomitant comorbidities rather than just the infectious process. This can be done with the help of multidisciplinary teams to provide comprehensive care for patients with pyogenic spondylodiscitis. To date, there is no article regarding comprehensive medicine for spontaneous pyogenic spondylodiscitis; hence, this paper reviews the evidence available in current literature, recognizes knowledge gaps, and suggests comprehensive care for treating patients with spinal infections. Pre-requisites for implementing multidisciplinary teams include leadership, administrative support, and team dynamics. This group comprises an appointed leader, coordinator, and different subspecialists, such as orthopedic surgeons, infectious disease specialists, internists, rehabilitation doctors, psychiatrists, microbiologists, radiologists, nutritionists, pharmacologists, nurses, and orthotists working together with mutual trust and respect. Employing collaborative teams allows faster time for diagnosis and improves clinical outcomes, better quality of life, and patient satisfaction. Forefront communication is clear and open between all team members to provide holistic patient care. With these in mind, the need for employing multidisciplinary teams and the feasibility of its implementation emerges, showing a promising and logical path toward providing comprehensive care in managing multimorbid patients with pyogenic spondylodiscitis.

5-year outcomes of surgical intervention in patients with adult spine deformity according to preoperative 5-item modified frailty index scores

PURPOSE

Frailty increases vulnerability to dependency and/or death, and is important in predicting the risk for adverse effects following adult spinal deformity (ASD) surgery. For easy determination of frailty, the 5-item modified frailty index (mFI-5) was established. However, there are few reports that show the relationship between frailty and mid-term operative outcomes after ASD surgery. The objective of this retrospective study is to determine the correlation of frailty using mFi-5 scores with postoperative medical complications, patient reported outcome measures (PROMs), and radiographic alignment 5 years after ASD surgery.

METHODS

208 patients were divided into robust (R), pre-frail (PF), and frail (F) groups based on mFI-5 scores. Postoperative medical complications, preoperative and 5-year follow-up PROMs and radiographic alignment were evaluated.

RESULTS

The study included 91, 79, and 38 patients in group R, PF, and F, respectively. There was no significant difference in age and sex. Discharge to care facility (16 (18%):21 (27%):16 (42%), p = 0.014) and postoperative cardiac complications (2 (2%):0 (0%):3 (8%), p = 0.031) were higher in frail patients. Preoperative ODI (38.3:45.3:54.7, p < 0.001) and SRS-22 (2.7:2.5:2.3, p = 0.004), 5-year postoperative ODI (27:27.2:37.9, p = 0.015), 5-year postoperative SVA (57.8°:78.5°:86.4°, p = 0.039) and 5-year postoperative TPA (23.9°:29.4°:29.5°, p = 0.011) were significantly worse in group F compared to group R.

CONCLUSION

Postoperatively, frail patients are more likely to have cardiac complications, inferior PROMs and deterioration of post-correction global spinal alignment. Preoperative assessment using mFI-5 is beneficial to individualize risks, optimize patients, and manage postoperative expectations.

LEVEL OF EVIDENCE: 3

Prognostic Nutritional Index and the Risk of Postoperative Complications After Spine Surgery: A Meta-Analysis

BACKGROUND

A low prognostic nutritional index (PNI) may reflect malnutrition, which has been associated with poor prognosis in patients with various clinical conditions. The aim of the systematic review and meta-analysis was to investigate the association between preoperative PNI and risk of postoperative complications in adult patients after spine surgery.

METHODS

An extensive search was conducted on PubMed, Embase, and Web of Science to identify relevant cohort studies. Random-effects models were employed to combine the findings, taking into account the potential influence of heterogeneity.

RESULTS

Ten cohort studies involving 3,249 patients receiving spine surgeries were included. Pooled results showed that a low preoperative prognostic nutritional index (PNI) was associated with an increased risk of overall postoperative complications in these patients (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.42 to 2.34, P < 0.001; I2 = 49%). Specifically, a preoperative malnutrition as evidenced by a low PNI was associated with a higher incidence of postoperative delirium (OR: 2.36, 95% CI: 1.52 to 3.66, P < 0.001; I2 = 38%) and surgical site infection (OR: 1.41, 95% CI: 1.15 to 1.73, P = 0.001; I2 = 0%). Sensitivity analyses by excluding one study at a time did not significantly change the results (P all <0.05).

CONCLUSIONS

A preoperative low prognostic nutritional index (PNI) may be a risk factor of increased incidence of overall postoperative complications, postoperative delirium, and surgical site infection in adult patients after spine surgeries.

Comparison of Postoperative Results With Prognostic Nutritional Index for Lumbar Disc Herniation

INTRODUCTION

The prognostic nutritional index (PNI) is an immune-nutritional index simply provided by a blood test. We retrospectively compared the postoperative outcomes of patients with lumbar disc herniation divided into two groups according to the PNI.

MATERIALS AND METHODS

Seventy-three patients who underwent surgery at our hospital were included in the study. All patients had herniation between one of the L3/4, L4/5, or L5/S intervertebral discs and underwent one posterior lumbar interbody fusion. These patients were divided into two groups: patients with a PNI of <50 (poorly nourished (PN) group) and patients with a PNI of ≥50 (well-nourished (WN) group). Evaluation items included patient background characteristics, operative time, blood loss, postoperative complications, and length of hospital stay.

RESULTS

The results showed that the body mass index was significantly higher in the WN group than in the PN group (p=0.0221). The rates of collagen disease, steroid use, and postoperative complications were significantly higher (p=0.0475, p=0.0073, and p=0.0211, respectively) and the length of hospital stay was significantly longer (p=0.021) in the PN group than in the WN group.

CONCLUSION

In conclusion, this study indicates that postoperative complications and the length of hospital stay are significantly worse in PN patients than in WN patients.

Incidence and Potential Risk Factors of Superior Mesenteric Artery Syndrome After Spinal Corrective Surgery in Patients with Adult Spinal Deformity

OBJECTIVE

This study aimed to determine the incidence and potential risk factors of superior mesenteric artery syndrome (SMAS) after corrective spinal surgery in patients with adult spinal deformity (ASD).

METHODS

In total, 102 patients (67.6 ± 8.4 years; 8 male/94 female; body mass index (BMI); 22.4 ± 3.6 kg/m2) with ASD treated by spinal correction surgery were enrolled. Preoperative and postoperative spinal parameters, including thoracolumbar kyphosis (TLK: T10-L2) and upper lumbar lordosis (ULL: L1-L4) were measured. To evaluate the potential risk factors of SMAS, the angle and the distance between the superior mesenteric artery and aorta, the aortomesenteric angle (AMA) and aortomesenteric distance (AMD), were evaluated pre- and postoperatively. Based on the postoperative AMA, AMD, and abdominal symptoms, the patients were diagnosed with SMAS. Correlations between demographic data or spinal parameters and AMA and AMD were assessed.

RESULTS

Two (2.0%) patients were diagnosed with SMAS. Postoperative TLK significantly correlated with postoperative AMA (P = 0.013, 0.046). Postoperative ULL was significantly correlated with postoperative AMD (β = -0.27; P = 0.014).

CONCLUSION

The incidence of SMAS after corrective spinal surgery in patients with ASD was 2.0%. Postoperative smaller TLK and greater ULL can be risk factors for developing SMAS. Spine surgeons should avoid overcorrection of the upper lumbar spine in the sagittal plane to prevent SMAS.

Prognostic Nutritional Index Is a Predictive Marker for Health-Related Quality of Life in Patients with Adult Degenerative Scoliosis

Our aim was to ascertain whether the prognostic nutritional index (PNI), could predict the health-related quality of life (HRQOL) in patients with adult degenerative scoliosis (ADS) undergoing corrective surgery. We conducted a retrospective analysis of consecutive patients diagnosed with ADS between January 2013 and June 2021. Three nutritional parameters were employed for analysis (PNI, anemia, and hypoalbuminemia). We utilized the Scoliosis Research Society-22 (SRS-22) questionnaire and the Oswestry Disability Index (ODI) questionnaire to assess clinical outcomes. Following the epidemiology guidelines, we presented results from three different models: the crude model, minimally adjusted model, and fully adjusted model. A total of 316 ADS patients were included in the statistical analysis. There was no significant difference in sagittal plane radiographic parameters between the two groups. After adjusting for important confounding factors, PNI was an independent predictor of postoperative HRQOL. Specifically, for each one-unit increase in PNI, there was an approximately 20% higher likelihood of patients achieving a better HRQOL. Furthermore, we did not observe an association between hemoglobin levels or albumin levels and HRQOL. In this study, PNI has been demonstrated to be correlated with the postoperative HRQOL in patients with ADS undergoing corrective surgery.

Association of preoperative prognostic nutritional index with risk of postoperative delirium: A systematic review and meta-analysis

Study objective

To assess the association between prognostic nutritional index (PNI) and risk of postoperative delirium (POD) in adult patients.

Methods

MEDLINE, Google scholar, EMBASE, and Cochrane library databases were searched from inception till April 2022. The primary outcome was the association between PNI and the risk of POD, while the secondary outcomes were correlations of other prognostic factors with POD risk. The correlation between PNI and the incidence of POD was assessed with three approaches: Difference in preoperative PNI between POD and non-POD groups (Model 1) as well as the association of PNI as a continuous parameter (Model 2) or as a binary variable (i.e., low vs. high using a PNI cut-off value of 50) (Model 3) with POD risk.

Results

Analysis of nine observational studies published from 2010 to 2021 recruiting 3,743 patients showed a POD incidence of 6.4-35%. Our meta-analysis demonstrated a lower PNI among patients in the POD group (MD: -3.78, 95% CI: -4.85 to -2.71, p < 0.0001, I ² = 54.2%) compared to the non-POD group (Model 1). Pooled results revealed a negative association between PNI and POD risk for both Model 2 (OR: 0.91, 95% CI: 0.86-0.97, p = 0.002, I ² = 71%) and Model 3 (OR: 1.68, 95% CI: 1.26-2.23, p < 0.0001, I ² = 0%). Besides, while our results supported an age-dependent increase in POD risk, other factors including body-mass index, surgical time, health status, hypertension, diabetes mellitus, and male gender were non-significant predictors of POD.

Conclusion

Our results demonstrated a negative association between PNI and POD, which warrant further large-scale studies for validation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022323809.

Association between hypoalbuminemia and complications after degenerative and deformity-correcting spinal surgeries: A systematic review and meta-analysis

Objective

The current review was designed to explore if hypoalbuminemia is associated with increased complications in patients undergoing spinal degenerative and deformities surgeries.

Methods

The search for eligible studies was conducted on the databases of PubMed, Embase, Web of Science, and CENTRAL up to 20th June 2022. Complication rates were pooled to obtain odds ratio (OR) and 95% confidence intervals.

Results

Thirteen studies were included. We found that hypoalbuminemia was significantly associated with increased risk of all complications (OR: 2.72 95% CI: 2.04, 3.63 I ²= 58% p < 0.00001), mortality (OR: 7.73 95% CI: 3.81, 15.72 I ²= 0% p < 0.00001), revision surgery (OR: 3.15 95% CI: 1.53, 6.48 I ²= 87% p = 0.002), readmissions (OR: 1.96 95% CI: 1.29, 2.98 I ²= 23% p = 0.02), surgical site infections (OR: 2.97 95% CI: 1.90, 4.63 I ²= 38% p < 0.00001), wound complications (OR: 2.31 95% CI: 1.17, 4.56 I ²= 48% p = 0.02), pulmonary complications (OR: 3.74 95% CI: 2.66, 5.26 I ²= 0% p < 0.00001), renal complications (OR: 3.04 95% CI: 1.22, 7.54 I ²= 0% p = 0.02), cardiac complications (OR: 4.33 95% CI: 2.14, 8.77 I ²= 0% p < 0.0001), urinary tract infections (OR: 2.08 95% CI: 1.80, 2.41 I ²= 0% p < 0.00001), and sepsis (OR: 4.95 95% CI: 1.87, 13.08 I ²= 64% p = 0.01) as compared to those with normal albumin.

Conclusion

Hypoalbuminemia is a significant risk factor for complications after spinal degenerative and deformity surgeries. Research is also needed on the role of nutritional support in improving outcomes after spinal degenerative and deformity surgeries.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022340024.

Preoperative Malnutrition-Associated Spinal Malalignment with Patient-Reported Outcome Measures in Adult Spinal Deformity Surgery: A 2-Year Follow-Up Study

Introduction

Malnutrition could lead to additional medical complications, and the prognostic nutrition index (PNI) is evaluated to assess the nutritional status of patients. However, the midterm postoperative outcomes of malnutrition in patients with adult spinal deformity (ASD) are unclear. This study aims to investigate postoperative midterm spinal alignment and patients' reported outcome measures (PROMs) in malnourished patients with ASD.

Methods

This study recruited 303 ASD patients who underwent surgery. Adult patients ≥50 years old were categorized into the PNI <50 (L group) and the PNI ≥50 (H group) groups. Demographic data, medical complications, mechanical complications, radiographic parameters, Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22) were analyzed.

Results

In this study, 303 patients participated, with 132 and 171 patients in the L and H groups, respectively. Significant differences were noted between the L and H groups in body mass index (22.5 vs. 23.6 kg/m², p=0.011), autoimmune disease (9.8% vs. 2.3%, p=0.005), and total number of medical complications (47.7% vs. 33.3%, p=0.011). The T1 slope was significantly higher in the L group than in the H group preoperatively (36.5 vs. 32.8°, p=0.042). However, no significant differences were noted in mechanical complications, ODI, SRS-22 scores, or radiographic parameters 2 years postoperatively between the L and H groups, except for the sagittal vertical axis (73.1 vs. 55.7 mm, p=0.014).

Conclusions

No significant difference was noted in the incidence of mechanical complications and PROMs 2 years postoperatively. Malnourished status was related to medical complications and global malalignment. However, good surgical outcomes can be expected even for malnourished patients.