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Background: Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. Enhanced recovery after surgery (ERAS) can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains., Materials and Methods: An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes, and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay after surgery., Results: A total of 245 patients (age of 79.8±3.4 year) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between nonfrail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery., Conclusion: Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS)., Methods: This was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA., Results: After excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA., Conclusions: Delayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation., (© 2024. The Author(s).)

Background Context: Elderly patients are less likely to recover from lumbar spine fusion (LSF) as rapidly compared with younger patients. However, there is still a lack of research on the effect of early ambulation on elderly patients undergoing LSF surgery for lumbar degenerative disorders., Purpose: To evaluate the safety and benefit of ambulation within 24 hours in elderly patients who underwent LSF., Study Design: A retrospective study., Patient Sample: Consecutive patients (aged 65 and older) who underwent elective transforaminal lumbar interbody fusion surgery for degenerative disorders from January 2019 to October 2022., Outcome Measures: Outcome measures included postoperative complications, postoperative drainage (mL), laboratory test data, length of hospital stay (LOS), readmission and reoperation within 3 months., Methods: Early ambulation patients (ambulation within 24 hours after surgery) were propensity-score matched 1:1 to a delayed ambulation patients (ambulation at a minimum of 48 hours postoperatively) based on age, intraoperative blood loss, and number of fused segments. The incidence of postoperative adverse events (AEs, including rates of complications, readmission, and prolonged LOS) and the average LOS were used to assess the safety and benefit of early ambulation, respectively. Multivariable regression analysis was performed to assess the association between early ambulation and postoperative AEs. The risk factors for delayed ambulation were also determined using multivariable logistic analyses., Results: A total of 998 patients with LSF surgery were reviewed in this study. After excluding 116 patients for various reasons, 882 patients (<24 hours: N=350, 24-48 hours: N=230, and >48 hours: N= 302) were included in the final analysis. After matching, sex, BMI, preoperative comorbidities, laboratory test data and surgery-related variables were comparable between the groups. The incidence of postoperative AEs was significantly lower in the EA group (44.3% vs 64.0%, p<.001). The average postoperative LOS of the EA group was 2 days shorter than the DA group (6.5 days vs 8.5 days, p<.001). Patients in the EA group had a significantly lower rate of prolonged LOS compared with the DA group (35.1% vs 55.3%, p<.001). There was no significant difference in postoperative drainage volumes between the two groups. Multivariable analysis identified older age (odds ratio [OR] 1.07, p<.001), increased intraoperative EBL (OR 1.002, p=.001), and higher international normalization ratio (OR 10.57, p=.032) as significant independent risk factors for delayed ambulation., Conclusions: Ambulation within 24 hours after LSF surgery is independently associated fewer AEs and shorter hospital stays in elderly patients. Implementing the goal of ambulation within 24 hours after LSF surgery into enhanced recovery after surgery protocols for elderly patients seems appropriate. Older age, increased intraoperative blood loss and worse coagulation function are associated with delayed ambulation., 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 © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background and Aim: The benefits of the enhanced recovery after surgery (ERAS) program to elderly patients have not been evaluated in lumbar fusion surgery. Compliance with the ERAS program is associated with prognosis. There is currently no adequate assessment about the importance of the individual components of ERAS program in lumbar fusion surgery. The aim of the study was to analyze the effect of compliance with our ERAS program and the relative importance of the individual ERAS program components among elderly patients undergoing lumbar fusion surgery., Methods: A retrospective case-review study was conducted from March 2018 to March 2020. The ERAS program for lumbar fusion surgery at our department was implemented. Overall compliance was found to be 92.9%, and this was used as a cutoff for dividing patients into higher compliance and lower compliance groups. Patient characteristics and clinical outcomes were compared between groups., Results: The overall compliance rate was 92.9%, distributing 91 patients into the higher compliance group and 169 patients into the lower compliance group. Patients with higher compliance were younger (p=0.045). The length of stay (LOS) of patients with higher compliance was significantly shorter than that of patients with lower compliance. Patients with higher compliance had significantly fewer complications (p=0.031). A multivariate analysis showed that surgical time (p=0.029), lower compliance (p=0.034), and early oral feeding (p=0.026) were predictors of any postoperative complications. On multivariate analysis, the following items remained correlated with prolonged LOS (LOS≥12 days): older age (p=0.010), lower compliance (p<0.0001), early ambulation (p=0.018), and stick to discharge criteria (p=0.040)., Conclusion: Low compliance with ERAS program among elderly patients undergoing lumbar fusion surgery was associated with a higher incidence of complications and prolonged LOS. The failure of early oral feeding was associated with increased complications, and the failure of early ambulation or sticking to discharge criteria was significantly more influential on prolonged LOS., Competing Interests: The authors declare that they have no competing interests., (© 2020 Li et al.)

Study Design: Multivariate analysis of retrospective registry data., Objective: To report the perioperative complication in a large cohort of surgery for elderly degenerative lumbar scoliosis (DLS) patients and to analyze the risk factors., Summary of Background Data: The perioperative complication rate and risk factors for patients with DLS remain unclear, especially in elderly population., Methods: Between November 2015 and June 2018, 98 patients aged 70 or older with DLS received decompression and intervertebral fusion by one spine surgeon at Beijing Xuanwu Hospital. The medical history and comorbidities of all patients were recorded., Results: The perioperative complication rate was 34.7% in all patients, 11.2% of all patients had major complications, and 31.6% had minor complications. The major complication most commonly seen was wound infection, and the most common minor complication was hypoproteinemia. Elderly patients (>75) had longer hospital stays (17.5 ± 7.9) when compared to younger patients. Two risk factors of perioperative complications were chosen after binary logistic regression analysis: lower BMI and longer instrumented segments. The only risk factor for major complications was longer instrumented level (≥3), and the only risk factor for minor complications was lower BMI., Conclusion: Our findings indicate that in elderly patients with DLS, lower BMI is a risk factor for minor perioperative complication. Obesity is not a major problem in this population, on the contrary, BMI is a protective factor for perioperative complications. The risk factors for major perioperative complications in elderly patients with DLS are longer instrumented segments but not related to the number of decompression and intervertebral fusion levels. Preoperative comorbidities and advanced age were not associated to a higher perioperative complication rate in elderly patients. The perioperative complication rate in patients with DLS over 70 years of age is found to be acceptable with appropriate perioperative management., Competing Interests: The authors declared that they have no conflicts of interest in this work., (© 2019 Ding et al.)

Background: There were several reports describing the biomechanics and microstructure of multifidus muscles in patients with lumbar disc herniation. However, correlations between lumbar multifidus muscle atrophy (LMA), spinopelvic parameters, and severity of adult degenerative scoliosis (ADS) have not been investigated. The study evaluated the impact of LMA and spinopelvic parameters on the severity of ADS., Methods: One hundred and thirty-two patients with ADS were retrospectively reviewed. Standing whole-spine X-ray was used to evaluate the coronal (coronal Cobb angle, CA; coronal vertical axis, CVA) and sagittal (sagittal vertical axis, SVA; thoracic kyphosis, TK; lumbar lordosis, LL; pelvic incidence, PI; pelvic tilt, PT; sacral slope, SS) parameters. LMA was evaluated on axial T2-weighted magnetic resonance imaging (MRI) at intervertebral levels above and below the vertebra at the apex of the scoliotic curve. Clinical symptoms were evaluated by the Oswestry Disability Index (ODI) and the Japanese Orthopaedic Association (JOA) score. Multiple linear regression was used to assess correlations between LMA, spinopelvic parameters, and severity of scoliosis., Results: LL and PT were negatively correlated with CA (P < 0.001); LL was positively correlated with SVA (P < 0.001). PI was positively correlated with CA (P < 0.001) and CVA (P < 0.001). PT (P < 0.001) and SS (P < 0.001) were negatively correlated with CVA. SS was negatively correlated with SVA (P < 0.001). Concave LMA at the upper or lower intervertebral level of the apical vertebra was positively correlated with CA (P ≤ 0.001); convex LMA at the upper or lower intervertebral level was negatively correlated with CA (P < 0.001). Convex LMA at the upper intervertebral level and concave LMA at the lower intervertebral level of the apical vertebra were negatively correlated with the SVA (P ≤ 0.001). At the upper intervertebral level, LMA on the concave side was positively correlated with CVA (P = 0.028); LMA on the convex side was negatively correlated with CVA (P = 0.012). PI was positively correlated with ODI (P < 0.001); PT (P < 0.001) and SS (P < 0.001) were negatively correlated with ODI. At the lower intervertebral level, LMA on the concave side was positively correlated with ODI (P = 0.038); LMA on the convex side was negatively correlated with ODI (P = 0.011). PI was positively correlated with JOA (P < 0.001); PT (P < 0.001) and SS (P < 0.001) were negatively correlated with JOA., Conclusions: Spinopelvic parameters are correlated with the severity of ADS. Asymmetric LMA at both upper and lower intervertebral levels of the apical vertebra is positively correlated with CA. LMA on the diagonal through the apical vertebra is very important to maintain sagittal imbalance via parallelogram effect. LMA at lower intervertebral levels of the apical vertebra may have a predictive effect on ODI. JOA score seems to be more correlated with spinopelvic parameters than LMA.

Objective: To study the predictors of postoperative aggravation of shoulder imbalance in severe and rigid thoracic or thoracolumbar scoliosis., Methods: In this study, 49 patients with severe and rigid thoracic or thoracolumbar scoliosis were analyzed retrospectively. The patients underwent whole-spine anteroposterior and lateral radiography preoperatively and postoperatively. On the radiographs, we measured parameters, including T1 tilt, radiographic shoulder height (RSH), proximal curve, middle curve, distal curve, apical vertebral translation (AVT) of the middle curve, thoracic trunk shift (TTS), coronal balance, and sagittal balance. We regarded RSH and T1 tilt as postoperative shoulder balance parameters and divided the patients into improved and aggravated groups of shoulder imbalance. Univariate analysis, receiver operating characteristic (ROC) curve, and multivariate logistic regression analyses were used in the statistical analyses., Results: The RSH was -17.01 ± 21.85 mm before surgery and 4.76 ± 18.11 mm at follow-up. The T1 tilt angle was -10.20° ± 19.53° before surgery and -2.72° ± 13.48° at follow-up. The results of the univariate analysis suggest that preoperative RSH and proximal to middle curve change ratio were significantly higher in the patients in the improved RSH group (p < 0.01). In addition, preoperative RSH, preoperative T1 tilt, and apical vertebral translation of the middle curve were significantly higher, and preoperative proximal curve, postoperative proximal curve, and preoperative distal curve were significantly lower in the patients with improved T1 tilt group (p < 0.01). In a binary logistic regression analysis, preoperative RSH [B = -0.120, odds ratio (OR) = 0.887, p = 0.006] was found to be an independent predictor of postoperative aggravation of RSH. Similarly, preoperative T1 tilt (B = -0.488, OR = 0.614, p = 0.001) was found to be an independent predictor of postoperative aggravation of T1 tilt. Moreover, the relationship between changes in RSH and T1 tilt was either concordant or discordant., Conclusion: Several radiographic parameters were found to affect postoperative aggravation of RSH and T1 tilt. In particular, preoperative RSH and T1 tilt were found to be independent predictive factors of postoperative aggravation of RSH and T1 tilt, respectively.

Purpose: To report our 11-year minimum clinical and radiological outcomes, as well as complications of the Charite III total disc replacement (TDR)., Methods: A total of 35 patients indicated for total disc replacement were implanted with the Charite III prosthesis. Clinical evaluation included visual analog scale (VAS) for back pain and the Oswestry disability index (ODI). Radiological parameters of intervertebral disc height (IDH), range of motion (ROM), lumbar lordosis, lumbar scoliosis and prosthesis position were evaluated. Complications and reoperation rates were also assessed., Results: Thirty-two patients had a minimum 11-year follow-up, and 33 prostheses were implanted. The mean follow-up time was 11.8 years, ranging from 11.3 to 13.8 years. Twenty-eight patients (87.5 %) had a successful outcome, as defined by the FDA. Reoperation was performed in 2 patients for adjacent segment degeneration and pedicle fracture (1 case each). Both VAS and ODI scores showed significant improvement compared to baseline. At the final follow-up, the ROM of both the index- and adjacent-level showed an obvious decrease. The IDH of the index level showed a tendency to decrease, but the difference was not significant. The IDH of adjacent levels were not significantly affected by the surgery. Mean lumbar lordosis was increased at the final follow-up, and lumbar scoliosis over 3° was observed in 12 patients (37.5%), with a mean angle of 5.6° (range 3°-12°). Of all 35 prostheses, 15 were left-shifted, 3 were right-shifted and 14 were just in the middle. In the coronal plane, 25 were rated as ideally placed, 5 were discretely shifted, 4 were slightly shifted and 1 was markedly shifted. In the sagittal plane, only 12 prostheses were rated as ideally placed, 14 were discretely shifted and 9 were suboptimally placed. Prosthesis subsidence was noted in 3 (9.4%) patients (the subsidence distances were 3.1, 4.2 and 2.8 mm, respectively). Heterotopic ossification was detected in 25 segments (71.4%), consisting of Class-I heterotopic ossification in 7 segments (20.0%), Class-II in 9 segments (25.7%), and Class-III in 9 segments (25.7%). Class-IV heterotopic ossification was not observed., Conclusion: The cumulative survival was 100% at a mean follow-up of 11.8 years. Clinical and radiological results were satisfactory and long-term clinical results were maintained for a mean follow-up of 11.8 years. Reoperation and complication rates are acceptable, and our study does not substantiate the fear of reoperation or late complications. The results of our long-term follow-up indicate that, with strict indication, TDR is a safe and effective procedure as an alternative to lumbar fusion.

Background: Coflex, a type of interspinous process implant, can provide intervertebral dynamic stability for surgical segments and effectively relieve lumbocrural pain. However, few studies have described therapeutic strategies and the avoidance of Coflex implant complications., Methods: Coflex implant complications in this study included intraoperative or postoperative spinous process fracture, aggravated postoperative lumbocrural pain, dislodgment and malposition. The complications were analyzed, and therapeutic strategies were applied according to the specific complication. The Visual Analogue Scale and Oswestry Disability Index scores were evaluated by using the paired-samples test from SPSS 12.0., Results: Conservative treatment was provided to seven patients who experienced aggravated lumbocrural pain even though their devices remained in the correct position, and pedicle screw treatment was used as an alternative in four cases. The Visual Analogue Scale and Oswestry Disability Index scores showed evident improvement in these patients. The Visual Analogue Scale and Oswestry Disability Index scores of two patients who underwent revision were also improved., Conclusions: Coflex implants should be avoided in patients with osteoporosis, a narrow interspinous space and intervertebral coronal spondylolysis, or sagittal instability. Furthermore the device choice, depth of implantation, and clamping intensity should be appropriate. Conservative treatment can be provided to patients with symptoms if the device remains in the correct position; however, revisions and salvages should be undertaken with internal fixation of pedicle screws for patients with device malposition, intraoperative implantation failure, or device intolerance.

Objective: To investigate device implanted complications and corresponding therapeutic strategies of Coflex interspinous dynamic stabilization system for lumbar spine intraoperatively and postoperatively., Methods: From September 2008 to August 2010, 133 cases of degenerative disease of lumbar spine including 62 males and 71 females, ranging from 35 to 81 years of age (mean 60.8 years), underwent or planed to be underwent decompression with Coflex interspinous dynamic stabilization system were reviewed retrospectively, and 13 cases including 6 males and 7 females, ranging from 41 to 71 years of age (mean 58.6 years), occurred device implanted complications. The Coflex implanted complications were analyzed, and therapeutic strategies according to different character were carried out, scores of visual analogue scale (VAS), Oswestry disability index(ODI) and effect-related data preoperatively, postoperatively, after conservative treatment and in final follow-up were evaluated with paired-samples t test., Results: Thirteen cases of Coflex implanted complications and treatment applied included: 3 cases occurred fracture of spinous processes intraoperatively were treated by pedicle screws instead; 2 cases occurred fracture of spinous processes postoperatively or during follow-up, including 1 case underwent revision with pedicle screws, another 1 case treated with conservative treatment; 4 cases with degenerative coronal spondylolysis in surgical segments, 1 case with sagittal instability preoperatively, and 1 case with device dislodgment in follow-up all suffered aggravated pain and received conservative treatment; 1 case suffered implanted malposition intraoperatively was underwent internal fixation with pedicle screws instead; at length, 1 case with aggravated pain postoperatively and without definite reason received revision with internal fixation of pedicle screws demolishing the Coflex. The follow-up time of 13 cases ranged from 20 to 38 months (mean 27.6 months); and 7 cases implanted Coflex with aggravated pain of lumbar and lower limb, but the position of device can still maintained, were received conservative treatment, and whose score of VAS and ODI in the final follow-up were 1.9 ± 0.7 and 23.2 ± 3.4, and comparing to 6.1 ± 1.1 and 58.1 ± 3.0 preoperatively, evident improvement was got finally (t = 8.2 and 18.2, P < 0.01). Scores of VAS and ODI of 2 cases with Coflex implanted complications underwent revision with pedicle screws were also improved correspondingly., Conclusions: Coflex interspinous dynamic stabilization system implanted should be avoided to cases who suffered with osteoporosis, too narrow interspinous space and intervertebral coronal spondylolysis or sagittal instability; and choice of device, depth of implantation and intensity of clumping should be appropriate. For patients with symptom but device still in right position, conservative treatment can be carried out; but for patients subjected to malposition of device, failure of implantation intraoperatively or intolerance to device, revisions and salvages should be underwent with internal fixation of pedicle screws.

Objective: To evaluate the clinical and radiographic results of total lumbar disc replacement with SB Charité III prosthesis., Methods: From Dec 1999 to Dec 2006, total lumbar disc replacement with SB Charité III prosthesis was performed in 65 patients affected with degenerative lumbar disc disorders. Among these patients, 48 (52 prosthesis) were followed up for more than two years (from 2.0 to 7.5 years). There were 22 males and 26 females with an average age of 43 years old (from 36 to 58 years). The diagnosis was lumbar disc herniation with low back pain in 34 patients, discogenic low back pain in 9 patients and failed lumbar disc surgery in 5 patients. All patients underwent standard anterior procedure under general anesthesia. One level replacement was done in 44 patients (L3,4 in 3, L4,5 in 23 and L5-S1 in 18), and two level procedures in 4 patients (L3,4/L4,5 in 1 and L4,5/L5-S1 in 3). Clinical and radiographic results of these patients were evaluated at each follow-up time (1, 3, 6, 12, 24 months after operation and the latest)., Results: The average visual analogue scales score for pain was 9.3 before operation, changed to 4.3 one month after operation, further declined to 2.6 two years after operation and finally to 1.8 at the latest follow-up evaluation. Meanwhile, the average Oswestry Disability Index was 45.8 before operation, 28.6 one month after operation, 12.5 two years after operation and 8.2 at the latest followup evaluation. All operated levels but one maintained mobile and there was no significant loss of range of motion observed. Complications such as implant dislocation or significant subsidence of the prosthesis occurred in none case of this group. All patients but one (98%) were satisfied with the surgery at the latest follow-up evaluation., Conclusions: Total lumbar disc replacement is an effective method for the treatment of degenerative disc disorders. Its long-term outcome remains to be verified.

Objective: To prove the biological characteristics of spinal intervertebral fusion with allograft cortical ring plus autogenous cancellus from iliac bone (called as composite ring)., Methods: Eight hybrid dogs were adopted in the study. The composite ring and autogenous tri-cortical blocks were implanted into the intervertebral space of dogs respectively. The intervertebral discs were removed before implantation. The fusion segments were evaluated by x-ray, histological examinations at 1, 2, 4 and 6 months after operation to compare the healing status of two implants., Results: The X-ray film and histological examination showed the lumbar interbody was fused after 4 months of operation in composite ring group, while the autogenous iliac bone blocks fused with peripheral bone tissue after 6 months of operation. Composite ring healed more quickly and completely, showed different osteogenesis behavior compared with that of massive allografts., Conclusion: Composite ring can promote the fusion of intervertebral body and can be used as a potential material for spinal surgery.