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Neurosurg Focus. 2017 Dec;43(6):E3. doi: 10.3171/2017.10.FOCUS17472.

An assessment of frailty as a tool for risk stratification in adult spinal deformity surgery.

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Departments of 1 Orthopaedic Surgery and.
Department of Orthopaedic Surgery, The Alpert Medical School of Brown University, Providence, Rhode Island.
Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
Neurosurgery, The Johns Hopkins University, Baltimore, Maryland.
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
University of California San Diego School of Medicine, San Diego, California.
Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia.
Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and.
Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, California.


OBJECTIVE The goal of this study was to analyze the value of an adult spinal deformity frailty index (ASD-FI) in preoperative risk stratification. Preoperative risk assessment is imperative before procedures known to have high complication rates, such as ASD surgery. Frailty has been associated with risk of complications in trauma surgery, and preoperative frailty assessments could improve the accuracy of risk stratification by providing a comprehensive analysis of patient factors that contribute to an increased risk of complications. METHODS Using 40 variables, the authors calculated frailty scores with a validated method for 417 patients (enrolled between 2010 and 2014) with a minimum 2-year follow-up in an ASD database. On the basis of these scores, the authors categorized patients as not frail (NF) (< 0.3 points), frail (0.3-0.5 points), or severely frail (SF) (> 0.5 points). The correlation between frailty category and incidence of complications was analyzed. RESULTS The overall mean ASD-FI score was 0.33 (range 0.0-0.8). Compared with NF patients (n = 183), frail patients (n = 158) and SF patients (n = 109) had longer mean hospital stays (1.2 and 1.6 times longer, respectively; p < 0.001). The adjusted odds of experiencing a major intraoperative or postoperative complication were higher for frail patients (OR 2.8) and SF patients ( 4.1) compared with NF patients (p < 0.01). For frail and SF patients, respectively, the adjusted odds of developing proximal junctional kyphosis (OR 2.8 and 3.1) were higher than those for NF patients. The SF patients had higher odds of developing pseudarthrosis (OR 13.0), deep wound infection (OR 8.0), and wound dehiscence (OR 13.4) than NF patients (p < 0.05), and they had 2.1 times greater odds of reoperation (p < 0.05). CONCLUSIONS Greater patient frailty, as measured by the ASD-FI, was associated with worse outcome in many common quality and value metrics, including greater risk of major complications, proximal junctional kyphosis, pseudarthrosis, deep wound infection, wound dehiscence, reoperation, and longer hospital stay.


ASD-FI = adult spinal deformity frailty index; ISSG = International Spine Study Group; LOS = length of hospital stay; NF = not frail; PJK = proximal junctional kyphosis; SF = severely frail; SVA = sagittal vertical axis; adult spinal deformity; complications; frailty index; personalized preoperative risk stratification

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