Endoscopic and Nonendoscopic Approaches to Single-Level Lumbar Spine Decompression: Propensity Score-Matched Comparative Analysis and Frailty-Driven Predictive Model

Full-endoscopic spine-surgery in the elderly and patients with comorbidities

Due to demographic changes, a growing number of elderly patients with comorbidities will require spine surgery in the next decades. However, age and multimorbidity have been associated with considerably worse postoperative outcomes, and is often associated with surgical invasiveness. Full-endoscopic spine-surgery (FESS), as a cornerstone of contemporary minimally invasive surgery, has the potential to mitigate some of these disparities. Thus, we conducted an analysis of all FESS cases at a national center. Utilizing the Charlson Comorbidity index (CCI) ≥ 3 as a frailty surrogate we separated patients in two groups for patients with and without comorbidities. Patients with (CCI) ≥ 3 exhibited a higher age (p < 0.001), and number of comorbidities (p < 0.001) than the control group. Thereafter, a propensity score matching was done to adjust for potential confounders. Postoperative safety measures in emergency department utilization, and clinic readmission did not significantly differ between the groups. Furthermore, patients of both groups reported similar postoperative pain improvements. However, patients with a (CCI) ≥ 3 were treated as inpatients more often (p < 0.001), had a higher length of stay (p < 0.001) and a smaller functional improvement after at a chronic postoperative timepoint (p = 0.045). The results underline safety and efficacy of FESS in patients with comorbidities. Additionally, they provide guidance for preoperative patient counselling and resource utilization when applying FESS in frail patients.

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations

OBJECTIVE

Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR).

METHODS

This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD.

RESULTS

One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2 years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N = 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics.

CONCLUSIONS

Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020)

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification.

METHODS

Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.

Trends in degenerative lumbar spinal surgery during the early COVID-19 pandemic in Republic of Korea: A national study utilizing the national health insurance database

During the first year of the COVID-19 pandemic, the Republic of Korea (ROK) experienced three epidemic waves in February, August, and November 2020. These waves, combined with the overarching pandemic, significantly influenced trends in spinal surgery. This study aimed to investigate the trends in degenerative lumbar spinal surgery in ROK during the early COVID-19 pandemic, especially in relation to specific epidemic waves. Using the National Health Information Database in ROK, we identified all patients who underwent surgery for degenerative lumbar spinal diseases between January 1, 2019 and December 31, 2020. A joinpoint regression was used to assess temporal trends in spinal surgeries over the first year of the COVID-19 pandemic. The number of surgeries decreased following the first and second epidemic waves (p<0.01 and p = 0.34, respectively), but these were offset by compensatory increases later on (p<0.01 and p = 0.05, respectively). However, the third epidemic wave did not lead to a decrease in surgical volume, and the total number of surgeries remained comparable to the period before the pandemic. When compared to the pre-COVID-19 period, average LOH was reduced by 1 day during the COVID-19 period (p<0.01), while mean hospital costs increased significantly from 3,511 to 4,061 USD (p<0.01). Additionally, the transfer rate and the 30-day readmission rate significantly decreased (both p<0.01), while the reoperation rate remained stable (p = 0.36). Despite the impact of epidemic waves on monthly surgery numbers, a subsequent compensatory increase was observed, indicating that surgical care has adapted to the challenges of the pandemic. This adaptability, along with the stable total number of operations, highlights the potential for healthcare systems to continue elective spine surgery during public health crises with strategic resource allocation and patient triage. Policies should ensure that surgeries for degenerative spinal diseases, particularly those not requiring urgent care but crucial for patient quality of life, are not unnecessarily halted.

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/.

The Effectiveness of Vertebral Height Restoration Based on the Vertebroplasty Procedure Used to Treat Osteoporotic Vertebral Fractures

OBJECTIVE

Whether the use of a balloon or stent in vertebroplasty for vertebral fractures, such as balloon kyphoplasty (BKP) or vertebral body stenting (VBS), actually contributes to the restoration of postoperative vertebral height is unclear. The aim of the current study was to compare the effectiveness of percutaneous vertebroplasty (PVP), BKP, and VBS in the correction of collapsed vertebrae in patients with painful vertebral fractures.

METHODS

The cases studied involved 34 vertebrae in 28 patients treated with PVP, 43 vertebrae in 38 patients treated with BKP, and 20 vertebrae in 20 patients treated with VBS at Izinkai Takeda General Hospital. Changes in the vertebral height and local kyphosis angle were measured based on standing lumbar radiographs before and after surgery and were compared among the treatment groups.

RESULTS

There were no differences in changes in the height of the anterior wall, middle body, or posterior wall of the treated vertebrae among the 3 treatment groups. The same was true for changes in the local kyphosis angle. The effectiveness of vertebral height restoration depended heavily upon preoperative vertebral instability in all the treatment groups. Correction loss due to balloon deflation effect or balloon sinking was noted with VBS or BKP.

CONCLUSION

BKP and VBS have the advantage of reducing the risk of extravertebral leakage of injected bone cement, but they have a disadvantage in that they are no more effective than PVP in restoring collapsed vertebrae despite the use of a balloon or metal stent.

RAI-measured frailty predicts non-home discharge following metastatic brain tumor resection: national inpatient sample analysis of 20,185 patients

PURPOSE

Preoperative risk stratification for patients undergoing metastatic brain tumor resection (MBTR) is based on established tumor-, patient-, and disease-specific risk factors for outcome prognostication. Frailty, or decreased baseline physiologic reserve, is a demonstrated independent risk factor for adverse outcomes following MBTR. The present study sought to assess the impact of frailty, measured by the Risk Analysis Index (RAI), on MBTR outcomes.

METHODS

All MBTR were queried from the National Inpatient Sample (NIS) from 2019 to 2020 using diagnosis and procedural codes. The relationship between preoperative RAI frailty score and our primary outcome - non-home discharge (NHD) - and secondary outcomes - complication rates, extended length of stay (eLOS), and mortality - were analyzed via univariate and multivariable analyses. Discriminatory accuracy was tested by computation of concordance statistics in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

There were 20,185 MBTR patients from the NIS database from 2019 to 2020. Each patient's frailty status was stratified by RAI score: 0-20 (robust): 34%, 21-30 (normal): 35.1%, 31-40 (very frail): 13.9%, 41+ (severely frail): 16.8%. Compared to robust patients, severely frail patients demonstrated increased complication rates (12.2% vs. 6.8%, p < 0.001), eLOS (37.6% vs. 13.2%, p < 0.001), NHD (52.0% vs. 20.6%, p < 0.001), and mortality (9.9% vs. 4.1%, p < 0.001). AUROC curve analysis demonstrated good discriminatory accuracy of RAI-measured frailty in predicting NHD after MBTR (C-statistic = 0.67).

CONCLUSION

Increasing RAI-measured frailty status is significantly associated with increased complication rates, eLOS, NHD, and mortality following MBTR. Preoperative frailty assessment using the RAI may aid in preoperative surgical planning and risk stratification for patient selection.