Search

Background: Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms., Objective: To examine the factors associated with successful nonoperative management in patients with ASD., Methods: We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis., Results: In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P < .05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P < .05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P < .001) were significantly more likely to achieve nonoperative success., Conclusion: Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Study Design: Retrospective single-center, consecutively enrolled database of adult spinal deformity (ASD) patients., Objective: The aim of this study was to assess the performance of the mASD-FI in predicting clinical and patient-reported outcomes after ASD-corrective surgery., Summary of Background Data: The recently described modified Adult Spinal Deformity frailty index (mASD-FI) quantifies frailty of ASD patients, but the utility of this clinical prediction tool as a means of prognosticating postoperative outcomes has not been investigated., Methods: ASD patients with available mASD-FI scores and HRQL data at presentation and 2-years postop were included.Patients were stratified by mASD-FI score using published cutoffs: not frail (NF <7), frail (F, 7-12), severely frail (SF, >12). Analysis of vaiance assessed differences in patient factors across frailty groups. Linear regression assessed the relationship of mASD-FI with length of stay (LOS) and HRQLs. Multivariable logistic regression revealed how frailty category predicted odds of complications, infections and reoperation., Results: A total of 509 patients included (59 years, 79%F, 27.7 kg/m 2 ). The cohort presented with moderate baseline deformity: sagittal vertical axis (83.7 mm ± 71), PT (12.7° ± 10.8°), PI-LL (43.1° ± 21.1°). Mean preoperative mASD-FI score was 7.2, frailty category: NF (50.3%), F (34.0%), SF (15.7%).Age, BMI, and Charlson Comorbidity Index increased with frailty categories (all P < 0.001); however, fusion length ( P = 0.247) and osteotomy rate ( P = 0.731) did not. At baseline, increasing frailty was associated with inferior Oswestry Disability Index (ODI), EuroQol 5-Dimension Questionnaire (EQ-5D), SRS-22r, Pain Catastrophizing Scale, and NRS Back and Leg (all P < 0.001). Greater frailty was associated with increased LOS and reduced postoperative HRQL. Controlling for complication incidence, baseline mASD-FI predicted 2 year postop scores for year ODI (b = 0.7, 0.58-0.8, P < 0.001) SRS (b = -0.023, -0.03 to -0.02, P < 0.001), EQ-5D (b = -0.003, -0.004 to -0.002, P < 0.001). F and SF were associated with greater odds of unplanned revision surgery and complications., Conclusion: Higher preoperative mASD-FI score was associated with significantly greater complications, higher rate of unplanned reoperations and lower postoperative HRQL in this investigation. The mASD-FI provides similar prognostic utility while reducing burden for surgeons and patients., Competing Interests: Conflict of interest statement: P.G.P., MD, reports personal consulting fees for Spinewave, Zimmer Biomet, DePuy Synthes, and Medicrea outside the submitted work., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Summary of Background Data: The influence of frailty on economic burden following corrective surgery for the adult cervical deformity (CD) is understudied and may provide valuable insights for preoperative planning., Objective: To assess the influence of baseline frailty status on the economic burden of CD surgery., Study Design: Retrospective cohort., Materials and Methods: CD patients with frailty scores and baseline and two-year Neck Disability Index data were included. Frailty score was categorized patients by modified CD frailty index into not frail (NF) and frail (F). Analysis of covariance was used to estimate marginal means adjusting for age, sex, surgical approach, and baseline sacral slope, T1 slope minus cervical lordosis, C2-C7 angle, C2-C7 sagittal vertical axis. Costs were derived from PearlDiver registry data. Reimbursement consisted of a standardized estimate using regression analysis of Medicare payscales for services within a 30-day window including length of stay and death. This data is representative of the national average Medicare cost differentiated by complication/comorbidity outcome, surgical approach, and revision status. Cost per quality-adjusted life-year (QALY) at two years was calculated for NF and F patients., Results: There were 126 patients included. There were 68 NF patients and 58 classified as F. Frailty groups did not differ by overall complications, instance of distal junctional kyphosis, or reoperations (all P >0.05). These groups had similar rates of radiographic and clinical improvement by two years. NF and F had similar overall cost ($36,731.03 vs. $37,356.75, P =0.793), resulting in equivocal costs per QALYs for both patients at two years ($90,113.79 vs. $80,866.66, P =0.097)., Conclusion: F and NF patients experienced similar complication rates and upfront costs, with equivocal utility gained, leading to comparative cost-effectiveness with NF patients based on cost per QALYs at two years. Surgical correction for CD is an economical healthcare investment for F patients when accounting for anticipated utility gained and cost-effectiveness following the procedure., Level of Evidence: III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: With increasing interest in cost optimization, costs of adult spinal deformity (ASD) surgery intersections with frailty merit investigation., Objective: To investigate costs associated with ASD and frailty., Methods: Patients with ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥ 25°, or thoracic kyphosis ≥ 60°) with baseline and 2-yr radiographic data were included. Patients were severely frail (SF), frail (F), or not frail (NF). Utility data were converted from Oswestry Disability Index to Short-Form Six-Dimension. Quality-adjusted life years (QALYs) used 3% rate for decline to life expectancy. Costs were calculated using PearlDiver. Loss of work costs were based on SRS-22rQ9 and US Bureau of Labor Statistics. Accounting for complications, length of stay, revisions, and death, cost per QALY at 2 yr and life expectancy were calculated., Results: Five hundred ninety-two patients with ASD were included (59.8 ± 14.0 yr, 80% F, body mass index: 27.7 ± 6.0 kg/m2, Adult Spinal Deformity-Frailty Index: 3.3 ± 1.6, and Charlson Comorbidity Index: 1.8 ± 1.7). The average blood loss was 1569.3 mL, and the operative time was 376.6 min, with 63% undergoing osteotomy and 54% decompression. 69.3% had a posterior-only approach, 30% combined, and 0.7% anterior-only. 4.7% were SF, 22.3% F, and 73.0% NF. At baseline, 104 were unemployed losing $971.38 weekly. After 1 yr, 62 remained unemployed losing $50 508.64 yearly. With propensity score matching for baseline SVA, cost of ASD surgery at 2 yr for F/SF was greater than that for NF ($81 347 vs $69 722). Cost per QALY was higher for F/SF at 2 yr than that for NF ($436 473 vs $430 437). At life expectancy, cost per QALY differences became comparable ($58 965 vs $58 149)., Conclusion: Despite greater initial cost, F and SF patients show greater improvement. Cost per QALY for NF and F patients becomes similar at life expectancy., (Copyright © Congress of Neurological Surgeons 2021. All rights reserved.)

Study Design: Retrospective review of a single-center spine database., Objective: Investigate the intersections of chronological age and physiological age via frailty to determine the influence of surgical invasiveness on patient outcomes., Summary of Background Data: Frailty is a well-established factor in preoperative risk stratification and prediction of postoperative outcomes. The surgical profile of operative patients with adult spinal deformity (ASD) who present as elderly and not frail (NF) has yet to be investigated. Our aim was to examine the surgical profile and outcomes of patients with ASD who were NF and elderly., Methods: Patients with ASD 18 years or older, four or greater levels fused, with baseline (BL) and follow-up data were included. Patients were categorized by ASD frailty index: NF, Frail (F), severely frail (SF]. An elderly patient was defined as 70 years or older. Patients were grouped into NF/elderly and F/elderly. SRS-Schwab modifiers were assessed at BL and 1 year (0, +, ++). Logistic regression analysis assessed the relationship between increasing invasiveness, no reoperations, or major complications, and improvement in SRS-Schwab modifiers [Good Outcome]. Decision tree analysis assessed thresholds for an invasiveness risk/benefit cutoff point., Results: A total of 598 patients with ASD included (55.3 yr, 59.7% F, 28.3 kg/m2). 29.8% of patients were older than 70 years. At BL, 51.3% of patients were NF, 37.5% F, and 11.2% SF. Sixty-sis (11%) patients were NF and elderly. About 24.2% of NF-elderly patients improved in SRS-Schwab by 1 year and had no reoperation or complication postoperatively. Binary regression analysis found a relationship between worsening SRS-Schwab, postop complication, and reoperation with invasiveness score (odds ratio: 1.056 [1.01-1.102], P = 0.011). Risk/benefit cut-off was 10 (P = 0.004). Patients below this threshold were 7.9 (2.2-28.4) times more likely to have a Good Outcome. 156 patients were elderly and F/SF with 16.7% having good outcome, with a risk/benefit cut-off point of less than 8 (4.4 [2.2-9.0], P < 0.001)., Conclusion: Frailty status impacted the balance of surgical invasiveness relative to operative risk in an inverse manner, whereas the opposite was seen amongst elderly patients with a frailty status less than their chronologic age. Surgeons should perhaps consider incorporation of frailty status over age status when determining realignment plans in patients of advanced age.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database., Objective: Investigate invasiveness and outcomes of ASD surgery by frailty state., Summary of Background Data: The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied., Methods: ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality-of-life measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05., Results: Overall, 195 of 322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all P < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any health-related quality of life at 3Y established an invasiveness cutoff of 63.9. Patients below this threshold were 1.8[1.38-2.35] (P < 0.001) times more likely to achieve favorable outcome. For NF patients, the cutoff was 79.3 (2.11[1.39-3.20] (P < 0.001), 111 for F (2.62 [1.70-4.06] (P < 0.001), and 53.3 for SF (2.35[0.78-7.13] (P = 0.13)., Conclusion: Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery., Summary of Background Data: The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions., Methods: Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes., Results: After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P < 0.001). Each index established significant (all P < 0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P < 0.001), whereas MF increased (9.2% to 16.2%, P < 0.001), and SF remained constant (2% to 1.6%, P > 0.05). With increase in severity, postoperative rates of morbidities and complications increased., Conclusion: The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Frailty severity may be an important determinant for impaired recovery after cervical spine deformity (CD) corrective surgery., Objective: To evaluate postop clinical recovery among CD patients between frailty states undergoing primary procedures., Methods: Patients >18 yr old undergoing surgery for CD with health-related quality of life (HRQL) data at baseline, 3-mo, and 1-yr postoperative were identified. Patients were stratified by the modified CD frailty index scale from 0 to 1 (no frailty [NF] <0.3, mild/severe fraily [F] >0.3). Patients in NF and F groups were propensity score matched for TS-CL (T1 slope [TS] minus angle between the C2 inferior end plate and the C7 inferior end plate [CL]) to control for baseline deformity. Area under the curve was calculated for follow-up time intervals determining overall normalized, time-adjusted HRQL outcomes; Integrated Health State (IHS) was compared between NF and F groups., Results: A total of 106 CD patients were included (61.7 yr, 66% F, 27.7 kg/m2)-by frailty group: 52.8% NF, 47.2% F. After propensity score matching for TS-CL (mean: 38.1°), 38 patients remained in each of the NF and F groups. IHS-adjusted HRQL outcomes from baseline to 1 yr showed a significant difference in Euro-Qol 5 Dimension scores (NF: 1.02, F: 1.07, P = .016). No significant differences were found in the IHS Neck Disability Index (NDI) and modified Japanese Orthopedic Association between frailty groups (P > .05). F patients had more postop major complications (31.3%) compared to the NF (8.9%), P = .004, though DJK occurrence and reoperation between the groups was not significant., Conclusion: While all groups exhibited improved postop disability and pain scores, frail patients experienced greater amount of improvement in overall health state compared to baseline disability. This signifies that with frailty severity, patients have more room for improvement postop compared to baseline quality of life., (© Congress of Neurological Surgeons 2021.)

The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Little is known of how frailty, a dynamic measure of physiological age, progresses relative to age or disability status. Operative treatment of adult spinal deformity (ASD) may play a role in frailty remediation and maintenance., Purpose: Compare frailty status, severe frailty development, and factors influencing severe frailty development among ASD patients undergoing operative or nonoperative treatment., Design: Retrospective review with maximum follow-up of 3 years., Setting: Prospective, multicenter, ASD database., Participants: Patients were consecutively enrolled from 13 participating centers., Inclusion Criteria: ≥18 years undergoing either operative or nonoperative treatment for ASD, exclusion criteria: spinal deformity of neuromuscular etiology, presence of active infection, or malignancy. The mean age of the participants analyzed were 54.9 for the operative cohort and 55.0 for the nonoperative cohort., Outcomes Measures: Frailty status, severe frailty development, and factors influencing severe frailty development., Methods: ASD patients (coronal scoliosis ≥20°, sagittal vertical axis (SVA) ≥5 cm, Pelvic Tilt (PT) ≥25°, or thoracic kyphosis ≥60°) >18 y/o, with Base Line (BL) frailty scores were included. Frailty was scored from 0 to 1 (not frail: <0.3, frail 0.3-0.5, severe frailty >0.5) through the use of ASD-frailty index (FI) which has been validated using the International Spine Study Group (ISSG) ASD database, European Spine Study Group ASD database, and the Scoli-RISK-1 Patient Database. The ISSG is funded through research grants from DePuy Synthes and individual donations and supported the current work. Operative (Op) and Nonoperative (Non-Op) patients were propensity matched. T-tests compared frailty among treatment groups and BL, 1, 2, and ≥3 years. An actuarial Kaplan-Meier survivorship analysis with log-rank (Mantel-Cox) test, adjusting for patients lost to follow-up, determined probability of severe frailty development. Multivariate Cox Regressions gauged the effect of sagittal malalignment, patient and surgical details on severe frailty development., Results: The analysis includes 472 patients (236 Op, 236 Non-Op) selected by propensity score matching from a cohort of 1,172. Demographics and comorbidities were similar between groups (p>.05). Op exhibited decreased frailty at all follow-up intervals compared with BL (BL: 0.22 vs Y1: 0.18; Y2: 0.16; Y3: 0.15, all p<.001). Non-Op displayed similar frailty from BL to 2Y follow up, and increased frailty at 3Y follow up (0.23 vs 0.25, p=.014). Compared with Non-Op, Op had lower frailty at 1Y (0.18 vs 0.24), 2Y (0.16 vs 0.23), and 3Y (0.15 vs 0.25; all p<.001). Cumulative probability of maintaining nonsevere frailty was (Op: 97.7%, Non-Op: 94.5%) at 1Y, (Op: 95.1%, Non-Op: 90.4%) at 2Y, and (Op: 95.1%, Non-Op: 89.1%) at ≥3Y, (p=.018). Among all patients, baseline depression (hazard ratio: 2.688[1.172-6.167], p=.020), Numeric Rating Scale (NRS) back pain scores (HR: 1.247[1.012-1.537], p=.039), and nonoperative treatment (HR: 2.785[1.167-6.659], p=.021) predicted severe frailty development with having a HR>1.0 and p value<.05. Among operative patients, 6-week postoperative residual SVA malalignment (SRS-Schwab SVA+modifier) (HR: 15.034[1.922-116.940], p=.010) predicted severe frailty development indicated by having a HR>1.0 and p value <.05., Conclusions: Non-Op patients were more likely to develop severe frailty, and at a quicker rate. Baseline depression, increased NRS back pain scores, nonoperative treatment, and postoperative sagittal malalignment at 6-week follow-up significantly predicted severe frailty development. Operative intervention and postoperative sagittal balance appear to play significant roles in frailty remediation and maintenance in ASD patients. Frailty is one factor, in a multifactorial conservation, that may be considered when determining operative or nonoperative values for ASD patients. Operating before the onset of severe frailty, may result in a lower complication risk and better long-term clinical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Investigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation., Methods: Patients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes., Results: 116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention., Conclusions: Operative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality., (Copyright © 2020. Published by Elsevier Ltd.)