Risk Stratification of Elderly Patients Undergoing Spinal Surgery Using the Modified Frailty Index

Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review

OBJECTIVE

Many tools have been used to assess frailty in the perioperative setting. However, no single scale has been shown to be the most effective in predicting postoperative complications. We evaluated the relationship between several frailty scales and the occurrence of complications following different non-cardiac surgeries.

METHODS

This systematic review was registered in PROSPERO (CRD42023473401). The search strategy included PubMed, Google Scholar, and Embase, covering manuscripts published from January 2000 to July 2023. We included prospective and retrospective studies that evaluated frailty using specific scales and tracked patients postoperatively. Studies on cardiac, neurosurgical, and thoracic surgery were excluded because of the impact of underlying diseases on patients' functional status. Narrative reviews, conference abstracts, and articles lacking a comprehensive definition of frailty were excluded.

RESULTS

Of the 2204 articles identified, 145 were included in the review: 7 on non-cardiac surgery, 36 on general and digestive surgery, 19 on urology, 22 on vascular surgery, 36 on spinal surgery, and 25 on orthopedic/trauma surgery. The reviewed manuscripts confirmed that various frailty scales had been used to predict postoperative complications, mortality, and hospital stay across these surgical disciplines.

CONCLUSION

Despite differences among surgical populations, preoperative frailty assessment consistently predicts postoperative outcomes in non-cardiac surgeries.

The 5-Item Modified Frailty Index as a Predictor of Postoperative Outcomes in Thoracic Metastatic Epidural Spinal Cord Compression

BACKGROUND

Patients with thoracic metastatic epidural spinal cord compression (MESCC) often undergo extensive surgical decompression to avoid functional decline. Though limited in scope, scales including the revised cardiac risk index (RCRI) are used to stratify surgical risk to predict perioperative morbidity. This study uses the 5-item modified frailty index (mFI-5) to predict outcomes following transpedicular decompression/fusion for high-grade MESCC.

METHODS

A retrospective chart review was conducted on patients who underwent transpedicular decompression and fusion for MESCC (baseline demographics, spinal instability neoplastic score, preoperative and postoperative Bilsky scores, primary cancer type, and RCRI). Primary outcomes included length of stay (LOS), intraoperative estimated blood loss, readmission/reoperation within 90 days of index surgery, 90-day mortality, and posthospitalization disposition.

RESULTS

One hundred twenty-seven patients were included in our study. Ninety percent of patients' lesions were Bilsky 2 or greater. Increasing frailty, measured by mFI-5, was a significant predictor of increased LOS (P < 0.01) and 90-day mortality (P < 0.05). Multivariate analysis adjusting for sex, body mass index , and age still showed statistical significance (P < 0.05). MFI-5 was not a significant predictor of readmission/reoperation within 90 days or estimated blood loss. Age - not mFI-5 or RCRI - was a significant predictor for posthospitalization nonhome disposition (P = 0.001).

CONCLUSIONS

The mFI-5 can serve as a useful predictor of outcomes after transpedicular decompression and fusion for thoracic MESCC as it can account for the patient's frailty. Our study demonstrated the mFI-5 as a predictor of LOS and 90-day mortality. These results provide a background to both understanding and integrating frailty into decision-making in MESCC.

Increased incidence of traumatic spinal injury in patients aged 65 years and older in the Netherlands

PURPOSE

The global population is ageing rapidly. As a result, an increasing number of older patients with traumatic spine injuries are seen in hospitals worldwide. However, it is unknown how the incidence of traumatic spinal injury has developed over the past decade. Therefore, this study aimed to determine the incidence and characteristics of traumatic spinal injury in patients aged under and above 65 years.

METHODS

During three time periods: 2009-2010, 2014-2015 and 2019-2020, all adult patients with traumatic spinal injury in the Netherlands were identified from the Dutch National Trauma Registry. Patient-related characteristics and 1-year mortality were collected from a subgroup of patients treated at a level-1 trauma centre, and patients aged ≥ 65 years were compared to patients aged < 65 years.

RESULTS

In the Dutch National Trauma Registry 25,737 patients with traumatic spinal injury were identified. The incidence of spine injury in patients > 65 years was 49.5/100,000/yr in 2009-2010, 68.8 in 2014-2015 and 65.9 in 2019-2020. The percentage of patients ≥ 65 years increased from 37% in 2009-2010, to 43% in 2014-2015, and to 47% in 2019-2020. In the subgroup of 1054 patients treated in a level-1 trauma centre, a similar increasing incidence was seen in patients aged ≥ 65 years. In these patients low energy falls were the most common trauma mechanism and the cervical spine was the most commonly injured region. Moreover, patients ≥ 65 years had significantly higher 1-year mortality compared with patients aged < 65 years, 22.7% versus 9.2%.

CONCLUSION

The incidence of traumatic spinal injury in older patients in the Netherlands has increased over the last 12 years. Almost half of the patients with traumatic spinal injury are currently aged ≥ 65 years. The increasing incidence and the high 1-year mortality highlight the need to modify existing treatment protocols for these patients.

Baseline Frailty Measured by the Risk Analysis Index and 30-Day Mortality After Surgery for Spinal Malignancy: Analysis of a Prospective Registry (2011-2020)

OBJECTIVE

To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection.

METHODS

SM surgery cases were queried from the American College of Surgeons - National Surgical Quality Improvement Program database (2011-2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, "mortality/hospice") were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 2,235 cases were stratified by RAI score: 0-20, 22.7%; 21-30, 11.9%; 31-40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697-0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001).

CONCLUSION

Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success

BACKGROUND

The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA).

METHODS

There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours).

RESULTS

In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer.

CONCLUSIONS

Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Can modified frailty index predict postoperative complication after lung cancer surgery?

PURPOSE

The impact of the modified frailty index (mFI) on postoperative complications after lung cancer surgery was investigated.

METHODS

Patients who underwent lung cancer surgery in 2017 were included. 30-day postoperative mortality and morbidity were evaluated according to their Clavien-Dindo classification. mFI values are presented as the sum of values of 11 included items. Logistic regression was used to assess the effect of mFI on postoperative severe complication incidence.

RESULTS

Among 190 patients considered, severe postoperative complications (Grade 3 or more) were observed in 30 (16%). No patients died within 30 days of surgery. The incidence of severe complications was 3.6% in patients with mFI of 0, 16.2% in patients with mFI of 1, 23.4% in patients with mFI of 2, and 31.6% in patients with mFI of 3 or more, and was correlated with the grade of mFI. Univariate and multivariate analyses showed that the high mFI was significantly predictive of postoperative complications. Frail patients of mFI ≥ 2 were at 3.0-fold greater risk of severe complications than non-frail patients of mFI 0 or 1.

CONCLUSION

mFI was associated with morbidity after lung cancer surgery. Preoperative frailty assessment and appropriate intervention to frail patients would be required to improve postoperative outcomes.

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.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

A comprehensive analysis of the triad of frailty, aging, and obesity in spine surgery: the risk analysis index predicted 30-day mortality with superior discrimination

BACKGROUND CONTEXT

The United States has experienced substantial shifts in its population dynamics due to an aging population and increasing obesity rates. Nonetheless, there is limited data about the interplay between the triad of frailty, aging, and obesity.

PURPOSE

To investigate discriminative thresholds and independent associations of the Risk Analysis Index (RAI), Modified Frailty Index-5 (mFI-5), and greater patient age.

STUDY DESIGN

An observational retrospective cohort study.

PATIENT SAMPLE

We analyzed 49,754 spine surgery patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020.

OUTCOME MEASURE

A total of 30-day postoperative mortality.

METHODS

Using receiver operating characteristic (ROC) and multivariable (odds ratios [OR] and 95% confidence intervals [CI]) analyses, we compared the discriminative thresholds and independent associations of RAI, mFI-5, and greater patient age in elderly obese patients who underwent spine surgery.

RESULTS

There were 49,754 spine surgery patients, with a median age of 71 years (IQR: 68-75), largely white (82.6%) and male (51.9%). The ROC analysis for 30-day postoperative mortality demonstrated superior discrimination for RAI (C-statistic 0.779, 95%CI 0.54-0.805) compared to mFI-5 (C-statistic 0.623, 95% CI 0.594-0.651) and greater patient age (C-statistic 0.627, 95% CI 0.598-0.656). Multivariable analyses revealed a dose-dependent association and a larger effect magnitude for RAI: frail patients OR: 19.52 (95% CI 18.29-20.82) and very frail patients OR: 65.81 (95% CI 62.32-69.50). A similar trend was observed in the interaction evaluating RAI-age-obesity (p<.001).

CONCLUSION

Our study highlights a strong association between frailty and 30-day postoperative mortality in elderly obese spine patients, revealing a dose-dependent relationship. The RAI has superior discrimination than the mFI-5 and greater patient age in predicting 30-day postoperative mortality after spine surgery. Using the RAI in preoperative assessments may improve outcomes and help healthcare providers effectively communicate accurate surgical risks and potential benefits, set realistic recovery expectations, and enhances patient satisfaction.

Emergency Colon Resection in the Geriatric Population: the Modified Frailty Index as a Risk Factor of Early Mortality

BACKGROUND

Surgical interventions in the elderly are becoming more frequent given the aging of the population. Due to their increased vulnerability in an emergent context, we aimed to evaluate various risk factors associated with an early mortality and an unfavorable postoperative trajectory.

METHODS

We performed a retrospective, single-center cohort study including patients over the age of 75 who underwent emergency colon resection between January 2016 and December 2020.

RESULTS

Among 299 patients included, the type of resection most frequently encountered was right hemicolectomy (34%). Large bowel obstruction was the surgical indication for 61% of patients (n = 182). The mortality rate within 30 days of primary surgery was 14% (n = 42). The main factors having a significant impact on early mortality were the modified Frailty Index (mFI) (26% vs 4%; p < 0.001), Charlson comorbidity index (CCI) (20 vs 0%; p = 0.03) and surgical indication (36% vs 11%; p = 0.03). No statistically significant difference was observed according to the age of the patients. Patients with a higher mFI ([Formula: see text] 3) had an increased risk of early mortality with an odds ratio (OR) of 11.94 (95%CI: 2.38-59.88; p < 0.001) in multivariate analysis. This association was also observed for the secondary outcomes, as patients with a higher mFI were less likely to return home (59% vs 32%; p = 0.009) and have their stoma closured at the end of the follow-up period (94% vs 33%; p < 0.001).

CONCLUSION

In the geriatric population, the use of mFI is a good predictor of early mortality following an emergency colon resection. This accessible tool could be used to guide the surgical decision-making.

Sarcopenia and frailty as predictors of surgical morbidity and oncologic outcomes in retroperitoneal sarcoma

BACKGROUND

Retroperitoneal sarcomas (RPS) are rare tumors for which surgical resection is the principal treatment. There is no established model to predict perioperative risks for RPS. We evaluated the association between preoperative sarcopenia, frailty, and hypoalbuminemia with surgical and oncological outcomes.

METHODS

We performed a prospective cohort analysis of 65 RPS patients who underwent surgical resection. Sarcopenia was defined as Total Psoas Area Index ≤ 1st quintile by sex. Frailty was estimated using the modified frailty index (mFI). Logistic regression models were used to assess predictors of 30-day postoperative morbidity. The Kaplan-Meier method with log-rank test was utilized to assess factors associated with overall (OS) and recurrence-free survival (RFS).

RESULT

Sarcopenia was associated with worse OS with a median of 54 compared with 158 months (p = 0.04), but no differences in RFS (p > 0.05). Hypoalbuminemia was associated with worse OS with a median of 72 compared with 158 months (p < 0.01). MFI scores were not associated with OS or RFS (p > 0.05). Sarcopenia, mFI, and hypoalbuminemia were not associated with postoperative morbidity (p > 0.05).

CONCLUSION

This study suggests that sarcopenia may be utilized as a measure of overall fitness, rather than a cancer-specific risk, and the mFI is a poor predictive measure of outcomes in RPS.