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The impact of frailty on postoperative complications in geriatric patients undergoing multi-level lumbar fusion surgery

Abstract

Study design

Retrospective Cohort Study.

Purpose

This study evaluates the impact of patient frailty status on postoperative complications in those undergoing multi-level lumbar fusion surgery.

Methods

The Nationwide Readmission Database (NRD) was retrospectively queried between 2016 and 2017 for patients receiving multi-level lumbar fusion surgery. Demographics, frailty status, and relevant complications were queried at index admission and readmission intervals. Primary outcome measures included perioperative complications and 30-, 90-, and 180-day complication and readmission rates. Perioperative complications of interest were infection, urinary tract infection (UTI), and posthemorrhagic anemia. Secondary outcome measures included inpatient length of stay (LOS), adjusted all-payer costs, and discharge disposition. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail patients with similar diagnoses and procedures. Subgroup analysis of minimally invasive surgery (MIS) versus open surgery within frail and non-frail cohorts was conducted to evaluate differences in surgical and medical complication rates. The analysis used nonparametric Mann–Whitney U testing and odds ratios.

Results

Frail patients encountered higher rates perioperative complications including posthemorrhagic anemia (OR: 1.73, 95%CI 1.50–2.00, p < 0.0001), infection (OR: 2.94, 95%CI 2.04–4.36, p < 0.0001), UTI (OR: 2.57, 95%CI 2.04–3.26, p < 0.0001), and higher rates of non-routine discharge (OR: 2.07, 95%CI 1.80–2.38, p < 0.0001). Frail patients had significantly greater LOS and total all-payer inpatient costs compared to non-frail patients (p < 0.0001). Frailty was associated with significantly higher rates of 90- (OR: 1.43, 95%CI 1.18–1.74, p = 0.0003) and 180-day (OR: 1.28, 95%CI 1.03–1.60, p = 0.02) readmissions along with higher rates of wound dehiscence (OR: 2.21, 95%CI 1.17–4.44, p = 0.02) at 90 days. Subgroup analysis revealed that frail patients were at significantly higher risk for surgical complications with open surgery (16%) compared to MIS (0%, p < 0.0001). No significant differences were found between surgical approaches with respect to medical complications in both cohorts, nor surgical complications in non-frail patients.

Conclusions

Frailty was associated with higher odds of all perioperative complications, LOS, and all-payer costs following multi-level lumbar fusion. Frail patients had significantly higher rates of 90 and 180-day readmission and higher rates of wound disruption at 90-days. On subgroup analysis, MIS was associated with significantly reduced rates of surgical complications specifically in frail patients. Our results suggest frailty status to be an important predictor of perioperative complications and long-term readmissions in geriatric patients receiving multi-level lumbar fusions. Frail patients should undergo surgery utilizing minimally invasive techniques to minimize risk of surgical complications. Future studies should explore the utility of implementing frailty in risk stratification assessments for patients undergoing spine surgery.

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Fig. 1

Data availability

No patient identifiers were collected, as we used a publicly available nationally-representative database purchased through the Healthcare Cost and Utilization Project website. No unique code was developed, and standard statistical software (RStudio) and tests were used.

References

  1. Desa UN (2019) United Nations Department of Economic and Social Affairs. Population Division World Population Prospects

  2. Kalseth J, Halvorsen T (2020) Health and care service utilisation and cost over the life-span: a descriptive analysis of population data. BMC Health Serv Res 20:435

    PubMed  PubMed Central  Article  Google Scholar 

  3. Bressler HB, Keyes WJ, Rochon PA, Badley E (1999) The prevalence of low back pain in the elderly: a systematic review of the literature. Spine 24:1813

    CAS  PubMed  Article  Google Scholar 

  4. Rudy TE, Weiner DK, Lieber SJ et al (2007) The impact of chronic low back pain on older adults: a comparative study of patients and controls. Pain 131:293–301

    PubMed  PubMed Central  Article  Google Scholar 

  5. Dieleman JL, Baral R, Birger M et al (2016) US spending on personal health care and public health, 1996–2013. JAMA 316:2627–2646

    PubMed  PubMed Central  Article  Google Scholar 

  6. Epstein NE (2011) Spine surgery in geriatric patients: sometimes unnecessary, too much, or too little. Surg Neurol Int 2:188

    PubMed  PubMed Central  Article  Google Scholar 

  7. Wong AY, Karppinen J, Samartzis D (2017) Low back pain in older adults: risk factors, management options and future directions. Scoliosis Spinal Disord 12:14

    PubMed  PubMed Central  Article  Google Scholar 

  8. Verla T, Adogwa O, Toche U et al (2016) Impact of increasing age on outcomes of spinal fusion in adult idiopathic scoliosis. World Neurosurg 87:591–597

    PubMed  Article  Google Scholar 

  9. Polanczyk CA, Marcantonio E, Goldman L et al (2001) Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 134:637–643

    CAS  PubMed  Article  Google Scholar 

  10. Reid PC, Morr S, Kaiser MG (2019) State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease: JNSPG 75th anniversary invited review article. J Neurosurg Spine 31:1–14

    PubMed  Article  Google Scholar 

  11. Cloyd JM, Acosta FL, Ames CP (2008) Complications and outcomes of lumbar spine surgery in elderly people: a review of the literature. J Am Geriatr Soc 56:1318–1327

    PubMed  Article  Google Scholar 

  12. Raffo CS, Lauerman WC (2006) Predicting morbidity and mortality of lumbar spine arthrodesis in patients in their ninth decade. Spine 31:99–103

    PubMed  Article  Google Scholar 

  13. Shahrestani S, Ton A, Chen XT et al (2021) The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery. Eur Spine J. https://doi.org/10.1007/s00586-021-06960-8

    Article  PubMed  Google Scholar 

  14. Sun W, Lu S, Kong C et al (2020) Frailty and post-operative outcomes in the older patients undergoing elective posterior thoracolumbar fusion surgery. Clin Interv Aging 15:1141–1150

    PubMed  PubMed Central  Article  Google Scholar 

  15. The Johns Hopkins Adjusted Clinical Groups Technical Reference Guide (2009), version 9.0. Johns Hopkins University, Baltimore, MD

  16. De la Garza RR, Goodwin CR, Jain A et al (2016) Development of a metastatic spinal tumor frailty index (MSTFI) using a nationwide database and its association with inpatient morbidity, mortality, and length of stay after spine surgery. World Neurosurg 95:548-555.e4

    Article  Google Scholar 

  17. Bakhsheshian J, Shahrestani S, Buser Z et al (2021) The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine. Spine J. https://doi.org/10.1016/j.spinee.2021.11.015

    Article  PubMed  Google Scholar 

  18. Hannah TC, Neifert SN, Caridi JM et al (2020) Utility of the hospital frailty risk score for predicting adverse outcomes in degenerative spine surgery cohorts. Neurosurgery 87:1223–1230

    PubMed  Article  Google Scholar 

  19. Sirven N, Rapp T (2017) The cost of frailty in France. Eur J Health Econ 18:243–253

    PubMed  Article  Google Scholar 

  20. Gobbens RJJ, van Assen MALM, Luijkx KG, Schols JMGA (2012) The predictive validity of the Tilburg Frailty Indicator: disability, health care utilization, and quality of life in a population at risk. Gerontologist 52:619–631

    PubMed  Article  Google Scholar 

  21. García-Nogueras I, Aranda-Reneo I, Peña-Longobardo LM et al (2017) Use of health resources and healthcare costs associated with frailty: the FRADEA study. J Nutr Health Aging 21:207–214

    PubMed  Article  Google Scholar 

  22. Kim DH, Glynn RJ, Avorn J et al (2019) Validation of a claims-based frailty index against physical performance and adverse health outcomes in the health and retirement study. J Gerontol A Biol Sci Med Sci 74:1271–1276

    PubMed  Article  Google Scholar 

  23. Goldfarb M, Bendayan M, Rudski LG et al (2017) Cost of cardiac surgery in frail compared with nonfrail older adults. Can J Cardiol 33:1020–1026

    PubMed  Article  Google Scholar 

  24. De Giorgi S, De Giorgi G, Borracci C et al (2014) Adult scoliosis: age-related deformity and surgery. Eur Spine J 23(Suppl 6):597–603

    PubMed  Article  Google Scholar 

  25. Kobayashi K, Imagama S, Ando K et al (2017) Complications associated with spine surgery in patients aged 80 years or older: Japan association of spine surgeons with ambition (JASA) multicenter study. Global Spine J 7:636–641

    PubMed  PubMed Central  Article  Google Scholar 

  26. Mitnitski A, Collerton J, Martin-Ruiz C et al (2015) Age-related frailty and its association with biological markers of ageing. BMC Med 13:161

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  27. Oskutis MQ, Lauerman MH, Kufera JA et al (2016) Are frailty markers associated with serious thoracic and spinal injuries among motor vehicle crash occupants? J Trauma Acute Care Surg 81:156–161

    PubMed  Article  Google Scholar 

  28. Joseph B, Pandit V, Zangbar B et al (2014) Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. JAMA Surg 149:766–772

    PubMed  Article  Google Scholar 

  29. Bourassa-Moreau É, Versteeg A, Moskven E et al (2020) Sarcopenia, but not frailty, predicts early mortality and adverse events after emergent surgery for metastatic disease of the spine. Spine J 20:22–31

    PubMed  Article  Google Scholar 

  30. Makary MA, Segev DL, Pronovost PJ et al (2010) Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 210:901–908

    PubMed  Article  Google Scholar 

  31. Farhat JS, Velanovich V, Falvo AJ et al (2012) Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg 72:1526–1530

    PubMed  Article  Google Scholar 

  32. Robinson TN, Wu DS, Stiegmann GV, Moss M (2011) Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults. Am J Surg 202:511–514

    PubMed  PubMed Central  Article  Google Scholar 

  33. Charest-Morin R, Street J, Zhang H et al (2018) Frailty and sarcopenia do not predict adverse events in an elderly population undergoing non-complex primary elective surgery for degenerative conditions of the lumbar spine. Spine J 18:245–254

    PubMed  Article  Google Scholar 

  34. Carreon LY, Puno RM, Dimar JR 2nd et al (2003) Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85:2089–2092

    PubMed  Article  Google Scholar 

  35. Silvers HR, Lewis PJ, Asch HL, Clabeaux D (1997) Lumbar microdiscectomy in the elderly patient. Br J Neurosurg 11:16–24

    CAS  PubMed  Article  Google Scholar 

  36. Miller EK, Ailon T, Neuman BJ et al (2018) Assessment of a novel adult cervical deformity frailty index as a component of preoperative risk stratification. World Neurosurg 109:e800–e806

    PubMed  Article  Google Scholar 

  37. Zileli M, Dursun E (2020) How to improve outcomes of spine surgery in geriatric patients. World Neurosurg 140:519–526

    PubMed  Article  Google Scholar 

  38. Stenvers E, Mars RC, Zuurmond RG (2019) Frail patients benefit from less invasive procedures. Geriatr Orthop Surg Rehabil 10:2151459319885283

    PubMed  PubMed Central  Article  Google Scholar 

  39. Haque RM, Mundis GM Jr, Ahmed Y et al (2014) Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients. Neurosurg Focus 36:E13

    PubMed  Article  Google Scholar 

  40. Shabat S, Arinzon Z, Folman Y et al (2008) Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians. Eur Spine J 17:193–198

    PubMed  Article  Google Scholar 

  41. Chen C-L, Chen C-M, Wang C-Y et al (2019) Frailty is associated with an increased risk of major adverse outcomes in elderly patients following surgical treatment of hip fracture. Sci Rep 9:19135

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  42. Ko FC (2019) Preoperative frailty evaluation: a promising risk-stratification tool in older adults undergoing general surgery. Clin Ther 41:387–399

    PubMed  PubMed Central  Article  Google Scholar 

  43. Kweh B, Lee H, Tan T, et al (2020) Spinal surgery in patients aged 80 years and older: risk stratification using the modified frailty index. Global Spine J 2192568220914877

  44. Lieberman R, Abrams C, Weiner J (2003) Development and evaluation of the Johns Hopkins University risk adjustment models for Medicare+ Choice plan payment. Johns Hopkins University, Baltimore

    Google Scholar 

  45. Sternberg SA, Bentur N, Abrams C et al (2012) Identifying frail older people using predictive modeling. Am J Manag Care 18:e392–e397

    PubMed  Google Scholar 

  46. Shahrestani S, Bakhsheshian J, Solaru S et al (2021) Inclusion of frailty improves predictive modeling for postoperative outcomes in surgical management of primary and secondary lumbar spine tumors. World Neurosurg 153:e454–e463

    PubMed  Article  Google Scholar 

  47. McIsaac DI, Bryson GL, van Walraven C (2016) Association of frailty and 1-year postoperative mortality following major elective noncardiac surgery: a population-based cohort study. JAMA Surg 151:538–545

    PubMed  Article  Google Scholar 

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Correspondence to Zorica Buser.

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Conflict of interest

No conflicts of interest. Disclosures outside of submitted work: JCW—Royalties—Biomet, Seaspine, Synthes; Investments/Options—Bone Biologics, Pearldiver, Electrocore, Surgitech; Board of Directors—AO Foundation; Fellowship Funding (paid to institution): AO Foundation. ZB- consultancy: Cerapedics (past), The Scripps Research Institute (past), Xenco Medical (past), AO Spine (past); Research Support: SeaSpine (past, paid to the institution), Next Science (past, paid directly to institution), Medical Metrics (past, paid directly to institution); North American Spine Society: committee member; Lumbar Spine Society: Co-chair Educational Committee, AOSpine Knowledge Forum Degenerative: Associate member; AOSNA Research committee- committee member.

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Ton, A., Shahrestani, S., Saboori, N. et al. The impact of frailty on postoperative complications in geriatric patients undergoing multi-level lumbar fusion surgery. Eur Spine J (2022). https://doi.org/10.1007/s00586-022-07237-4

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  • DOI: https://doi.org/10.1007/s00586-022-07237-4

Keywords

  • Frailty
  • Lumbar, Fusion
  • Spine
  • Readmissions
  • Multi-level