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

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.

A Multivariate Analysis of a Modified Frailty Index on Perioperative Morbidity and Mortality Following Nonemergent Endovascular Aortic Aneurysm Repair

BACKGROUND

Frailty has become an increasingly recognized perioperative risk stratification tool. While frailty has been strongly correlated with worsening surgical outcomes, the individual determinants of frailty have rarely been investigated in the setting of aortic disease. The aim of this study was to examine the determinants of an 11-factor modified Frailty Index (mFI-11) on mortality and postoperative complications in patients undergoing endovascular aortic aneurysm repair (EVAR).

METHODS

Data from the National Surgical Quality Improvement Program database were queried for all patients undergoing nonemergent EVAR between 2005 and 2019. Univariate logistic regression was used to assess associations between mFI-11 variables and complications occurring within 30 days of surgery. Significant variables were then used for multivariate analysis. Variables included in mFI-11 scoring are diabetes, nonindependent functional status, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction (MI), previous percutaneous coronary intervention, cardiac surgery or angina, hypertension requiring medication, peripheral vascular disease, impaired sensorium, and previous transient ischemic attack or cerebrovascular accident. Overall complications included superficial surgical site infection, deep incisional surgical site infection, deep vein thrombosis, readmission, reintervention, bleeding requiring transfusions, major adverse events (MAEs), and mortality. MAEs included those classified as Clavien-Dindo grade IV, defined as life-threatening complications requiring intensive care unit-level management and single or multiple organ failure. Odds ratios (ORs) were calculated using SPSS 29.

RESULTS

A total of 50,798 patients were identified, resulting in a cohort that was 81% male with an average age of 73.3 ± 8.5 years. Binary regression revealed a significant increase in 30-day mortality (OR = 1.49; 95% confidence interval [CI]: 1.34-1.66; P < 0.001), overall complications (OR = 1.30; 95% CI: 1.25-1.35; P < 0.001), MAEs (OR = 1.55; 95% CI: 1.45-1.65; P < 0.001), stroke (OR = 1.41; 95% CI: 1.15-1.72; P < 0.001), prolonged mechanical ventilation (OR = 1.63; 95% CI: 1.47-1.81; P < 0.001), acute kidney injury (OR = 1.37; 95% CI: 1.20-1.57; P < 0.001), cardiac arrest (OR = 1.71; 95% CI: 1.44-2.04; P < 0.001), and MI (OR = 1.54; 95% CI: 1.35-1.75; P < 0.001) per 1-point increase in mFI-11 score. Multivariate analysis demonstrated that functional dependency was highly associated with increased odds of all outcomes except stroke, cardiac arrest, and MI, and impaired sensorium was highly associated with 30-day mortality.

CONCLUSION

The mFI-11 is a strong predictor for postoperative complications and mortality in patients undergoing nonemergent EVAR. Measurement of frailty should be considered in the preoperative assessment of patients being evaluated for EVAR, with particular attention to the risk/benefit of aortic repair in those with dependent functional status or impaired sensorium.

Assessing a revised-risk analysis index for morbidity and mortality after spine surgery for metastatic spinal tumors

BACKGROUND

Risk Analysis Index (RAI) has been increasingly used to assess surgical frailty in various procedures, but its effectiveness in predicting mortality or in-patient hospital outcomes for spine surgery in metastatic disease remains unclear. The aim of this study was to compare the predictive values of the revised RAI (RAI-rev), the modified frailty index-5 (mFI-5), and advanced age for extended length of stay, 30-day readmission, complications, and mortality among patients undergoing spine surgery for metastatic spinal tumors.

METHODS

A retrospective cohort study was performed using the 2012-2022 ACS NSQIP database to identify adult patients who underwent spinal surgery for metastatic spinal pathologies. Using receiver operating characteristic (ROC) and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI-rev, mFI-5, and greater patient age with extended length of stay (LOS), 30-day complications, hospital readmission, and mortality.

RESULTS

A total of 1,796 patients were identified, of which 1,116 (62.1%) were male and 1,008 (70.7%) were non-Hispanic White. RAI-rev identified 1,291 (71.9%) frail and 208 (11.6%) very frail patients, while mFI-5 identified 272 (15.1%) frail and 49 (2.7%) very frail patients. In the ROC analysis for extended LOS, both RAI-rev and mFI-5 showed modest predictive capabilities with area under the curve (AUC) values of 0.5477 and 0.5329, respectively, and no significant difference in their predictive abilities (p = 0.446). When compared to age, RAI-rev demonstrated superior prediction (p = 0.015). With respect to predicting 30-day readmission, no significant difference was observed between RAI-rev and mFI-5 (AUC 0.5394 l respectively, p = 0.354). However, RAI-rev outperformed age (p = 0.001). When assessing the risk of 30-day complications, RAI-rev significantly outperformed mFI-5 (AUC: 0.6016 and 0.5542 respectively, p = 0.022) but not age. Notably, RAI-rev demonstrated superior ability for predicting 30-day mortality compared to mFI-5 and age (AUC: 0.6541, 0.5652, and 0.5515 respectively, p < 0.001). Multivariate analysis revealed RAI-rev as a significant predictor of extended LOS [aOR: 1.96, 95% CI: 1.13-3.38, p = 0.016] and 30-day mortality [aOR: 5.27, 95% CI: 1.73-16.06, p = 0.003] for very frail patients. Similarly, the RAI-rev significantly predicted 30-day complications for frail [aOR: 2.63, 95% CI: 1.21-5.72, p = 0.015] and very frail [aOR: 3.69, 95% CI: 1.60-8.51, p = 0.002] patients. However, the RAI did not significantly predict 30-day readmission [Very Frail aOR: 1.52, 95% CI: 0.75-3.07, p = 0.245; Frail aOR: 1.46, 95% CI: 0.79-2.68, p = 0.225].

CONCLUSION

Our study demonstrates the utility of RAI-rev in predicting morbidity and mortality in patients undergoing spine surgery for metastatic spinal pathologies. Particularly, the superiority that RAI-rev has in predicting 30-day mortality may have significant implications in multidisciplinary decision making.

The Prediction of Postoperative Delirium Using the Preoperative Assessments of Frailty and Cognitive Impairment in Aged Patients

Purpose

Frailty and cognitive impairment are closely associated with postoperative delirium. The purpose of this study was to compare the ability of screening tools assessing preoperative frailty and cognitive impairment to predict Postoperative delirium (POD) and the association with prevalence of postoperative complications, Intensive Care Unit (ICU) admission, and the hospital length of stay.

Patients and Methods

Two hundred and ninety-nine patients aged ≥60 years presenting for elective major thoracic or abdominal surgery were divided into preoperative frailty and no frailty groups or cognitive impairment and no cognitive impairment groups. The primary outcome was the incidence of postoperative delirium. The secondary outcomes included postoperative complications, ICU admission, and hospital lengths of stay.

Results

Frailty (25.6% VS 14.6%, P = 0.017) and cognitive impairment (32.7% VS 13.4%, P < 0.001) were associated with POD. However, the area under the receiver operating characteristic curve (AUC-ROC) between frailty (0.657 [95% CI 0.60-0.71]) and cognitive impairment (0.661 [95% CI 0.60-0.71]) for POD was not different (P = 0.9) and both lower than the integrated predictive model of age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, duration of surgery, morphine equivalent, surgical risk, frailty and cognitive impairment (0.814 [95% CI 0.77-0.86], P < 0.0001, P < 0.0001). Besides, frailty (15.6% vs 6.3%, P = 0.010) and cognitive impairment (16.3% vs 8.0%, P = 0.029) was associated with the incidence of postoperative complications.

Conclusion

Preoperative frailty and cognitive impairment were associated with POD. However, preoperative frailty or cognitive impairment by themselves were comparably poor predictors of POD. A comprehensive predictive model including age, BMI, ASA status, duration of surgery, morphine equivalent, surgical risk, frailty and cognitive impairment was more useful to predict POD.

Utility of Risk Analysis Index for Assessing Morbidity in Patients Undergoing Posterior Spinal Fusion for Adult Spinal Deformity

BACKGROUND

This study investigates the predictive values of the Risk Analysis Index (RAI), the modified 5-item Frailty Index (mFI-5), and advanced age for predicting 30-day extended length of stay (LOS), 30-day complications, and readmissions in patients undergoing posterior spinal fusion (PSF) for adult spinal deformity (ASD).

METHODS

A retrospective cohort study was performed using the 2012-2021 American College of Surgeons National Surgical Quality Improvement Program database. Adults undergoing PSF for ASD were identified using Current Procedural Terminology and International Classification of Diseases codes. Using receiver operating characteristic and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI, mFI-5, and greater patient age for extended LOS, 30-day complications, and readmissions.

RESULTS

In this cohort of 3814 patients, RAI identified 90.7% as Robust, 6.0% as Normal, and 3.3% as Frail/Very frail, while mFI-5 classified 47.1% as Robust, 37.5% as Normal, and 15.3% as Frail/Very frail. Multivariable analysis revealed both RAI and mFI-5 as significant predictors of extended LOS for Normal (RAI: P < 0.001; mFI-5: P = 0.013) and Frail/Very frail patients (RAI: P < 0.001; mFI-5: P = 0.003). Additionally, RAI was a significant predictor of 30-day complication risk for Normal patients (P = 0.005). Furthermore, mFI-5 was a significant predictor of 30-day readmission among Frail/Very frail patients (P = 0.002).

CONCLUSIONS

This study suggests that the utility of RAI and mFI-5 in predicting extended LOS patients undergoing PSF for ASD. RAI was found to be superior to mFI-5 for predicting 30-day readmissions, while mF-5 was greater for 30-day complications. These findings highlight the need for future studies to identify optimal methods in incorporating frailty assessments into preoperative surgical planning and patient discussions.

External Validation of the Spinal Orthopedic Research Group Index for Spinal Epidural Abscess 90-Day Mortality in a Geographically Remote Population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To externally validate the Spinal Orthopaedic Research Group (SORG) index for predicting 90-day mortality from spinal epidural abscess and compare its utility to the 11-item modified frailty index (mFI-11) and Charlson comorbidity index (CCI).

SUMMARY OF BACKGROUND DATA

Providing a mortality estimate may guide informed patient and clinician decision-making. A number of prognostic tools and calculators are available to help predict the risk of mortality from spinal epidural abscess, including the SORG index, which estimates 90-day postdischarge mortality. External validation is essential before wider use of any clinical prediction tool.

MATERIALS AND METHODS

Patients were identified using hospital coding. Medical and radiologic records were used to confirm the diagnosis. Mortality data and data to calculate the SORG index, mFI-11, and CCI were collected. Area under the curve and calibration plots were used to analyze.

RESULTS

One hundred and fifty patients were included: 58 were female (39%), with a median age of 63 years. Fifteen deaths (10%) at 90 days postdischarge and 20 (13%) at one year. The mean SORG index was 13.6%, the mean CCI 2.75, and the mean mFI-11 was 1.34. The SORG index ( P =0.0006) and mFI-11 ( P <0.0001) were associated with 90-day mortality. Area under the curve for SORG, mFI-11, and CCI were 0.81, 0.84, and 0.49, respectively. The calibration slope for the SORG index showed slight overestimation in the middle ranges of the predicted probability, more so than mFI-11, and was not well-calibrated over the higher ranges of predicted probability.

CONCLUSIONS

This study externally validated the SORG index, demonstrating its utility in our population at predicting 90-day mortality; however, it was less well calibrated than the mFI-11. Variations in algorithm performance may be a result of differences in socioethnic composition and health resources between development and validation centres. Continued multicenter data input may help improve such algorithms and their generalisability.

Impact of Age on the Occurrence of Vascular Complications in Patients Undergoing Anterior Lumbar Approach Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the impact of age on the incidence of vascular complications in patients undergoing anterior lumbar approach surgery.

BACKGROUND

Anterior approach lumbar spinal surgery may facilitate the use of intervertebral devices with larger endplate coverage and increased lordosis. Despite the advantages of this approach, risks related to vascular injury in older patients have been described in the literature.

PATIENTS AND METHODS

In total, 751 consecutive patients with degenerative spinal pathology who underwent stand-alone anterior lumbar interbody fusion (ALIF), ALIF combined with posterior fusion and/or instrumentation (360), total disc replacement, or hybrid procedures (ALIF and total disc replacement) were included. Data collected included general patient descriptive data, surgery details, intraoperative vascular injury, and postoperative vascular complications (deep vein thrombosis and/or pulmonary embolism). Rates of vascular complications were compared across age groups. In addition, the mean age of patients was compared between those with versus without vascular complications.

RESULTS

Overall mean age was 50.4 years (range: 20-83 yr). The mean estimated blood loss was 91.3 mL (range: 10-2800 mL). A total of 15 patients, 2.0%, had vascular complications. There were 10 cases (1.3%) of intraoperative injury to iliac arteries or iliolumbar veins (mean blood loss was 721 mL, and all were repaired intraoperatively). Postoperatively, 6 patients (0.8%) developed deep vein thrombosis and/or pulmonary embolism (one patient had both). With respect to age, there were no significant differences in rates of intraoperative, postoperative, or combined vascular complication rates across the age group ( P > 0.38). In addition, there were no statistically significant differences in the mean ages of patients with versus those without vascular complications ( P > 0.17).

CONCLUSION

Overall incidence of vascular complications was 2.0%. No relationship between vascular complications and age was demonstrated. These data suggest that increased age may not necessarily be an absolute contraindication for anterior lumbar approach surgery.

LEVEL OF EVIDENCE

Level III.

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.

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.

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.

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.