Faculty Bibliography

STUDY DESIGN/METHODS:This was a retrospective cohort study of a national dataset. PURPOSE/OBJECTIVE:The purpose of this study was to consider the influence of frailty on the development of hospital-acquired conditions (HACs) in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA/BACKGROUND:HACs frequently include reasonably preventable complications. Eleven events are identified as HACs by the Affordable Care Act. In the surgical ASD population, factors leading to HACs are important to identify to optimize health care. METHODS:Patients 18 years and older undergoing corrective surgery for ASD identified in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). The relationship between HACs and frailty as defined by the NSQIP modified 5-factor frailty index (mFI-5) were assessed using χ2 and independent sample t tests. The mFI-5 is assessed on a scale 0-1 [not frail (NF): <0.3, mildly frail (MF): 0.3-0.5, and severely frail (SF): > 0.5]. Binary logistic regression measured the relationship between frailty throughout HACs. RESULTS:A total of 9143 ASD patients (59.1 y, 56% female, 29.3 kg/m2) were identified. Overall, 37.6% of procedures involved decompression and 100% fusion. Overall, 6.5% developed at least 1 HAC, the most common was urinary tract infection (2.62%), followed by venous thromboembolism (2.10%) and surgical site infection (1.88%). According to categorical mFI-5 frailty, 82.1% of patients were NF, 16% MF, and 1.9% SF. Invasiveness increased with mFI-5 severity groups but was not significant (NF: 3.98, MF: 4.14, SF: 4.45, P>0.05). Regression analysis of established factors including sex [odds ratio (OR): 1.22; 1.02-146; P=0.030], diabetes mellitus (OR: 0.70; 0.52-0.95; P=0.020), total operative time (OR: 1.01; 1.00-1.01; P<0.001), body mass index (OR: 1.02; 1.01-1.03; P=0.008), and frailty (OR: 8.44; 4.13-17.26; P<0.001), as significant predictors of HACs. Overall, increased categorical frailty severity individually predicted increased total length of stay (OR: 1.023; 1.015-1.030; P<0.001) and number of complications (OR: 1.201; 1.047-1.379; P=0.009). CONCLUSIONS:For patients undergoing correction surgery for ASD, the incidence of HACs increased with worsening frailty score. Such findings suggest the importance of medical optimization before surgery for ASD.

STUDY DESIGN/UNASSIGNED:Retrospective study. OBJECTIVES/UNASSIGNED:Our goal was to evaluate the rate of rod fracture and persistent pseudarthrosis in cohorts of patients treated with a dual rod or multiple-rod construct in revision surgery for pseudarthrosis. METHODS/UNASSIGNED:A dual rod construct was used in 23 patients, and a multiple rod construct in 24 patients, spanning the pseudarthrosis level. Two-year fusion grading, and rates of pseudarthrosis and implant failure, were assessed. RESULTS/UNASSIGNED:There were no differences in patient or surgical characteristics between the groups: (2- rod construct: Age 60 ± 14, Levels 10 ± 5, 3-column osteotomy:17%; multiple-rod construct: Age: 62 ± 11, Levels 9 ± 4, 3-column osteotomy:30%). Patients in the multiple rod construct were transfused a greater volume of packed red blood cells (pRBCs) intraoperatively (2.6 ± 2.9 vs. 1.1 ± 1.5 U, p < 0.0001). At 2 year follow up there was no difference in fusion grades at the previous level of pseudarthrosis, the rate of rod fracture or pseudarthrosis between the 2 groups, or rate of reoperation for pseudarthrosis, rod fracture, wound infection, hardware prominence, or PJK/PJF. CONCLUSIONS/UNASSIGNED:Our data demonstrate no difference in fusion grade, or rates of rod fracture and revision at 2 years, after utilizing a dual rod versus multiple rod construct in revision surgery for pseudarthrosis. The low complication rates seen with either configuration warrant further investigation of the optimal instrumentation configuration.

BACKGROUND:Data on timing of complications are important for accurate quality assessments. We sought to better define pre- and postdischarge complications occurring within 90 days of adult spinal deformity (ASD) surgery and quantify the effect of multiple complications on recovery. METHODS:We performed a review of 1040 patients who underwent ASD surgery (age: 46 ± 23; body mass index: 25 ± 7, American Society of Anesthesiologists [ASA] score: 2.5 ± 0.6, levels: 10 ± 4, revision: 9%, 3-column osteotomy: 13%). We assessed pre- and postdischarge complications and risk factors for isolated versus multiple complications, as well as the impact of multiple complications. RESULTS:= .02). Patients who developed multiple complications (9.3%) had a longer length of stay, and increased risk for readmission and unplanned reoperation. CONCLUSIONS:Knowledge regarding timing of postoperative complications in relation to discharge may better inform quality improvement measures. PE and implant-related complications play a prominent role in perioperative complications and need for readmission, with several modifiable risk factors identified. LEVEL OF EVIDENCE/METHODS:Level 3. CLINICAL RELEVANCE/CONCLUSIONS:Advances in surgical techniques and instrumentation have improved postoperative radiographic and clinical outcomes after ASD surgery. The rate of complications after complex ASD surgery remains high, both at early postoperative and long term follow-up. This study reviews complications within 90 days of surgery, with an assessment of patient and surgical risk factors. We found that modifiable risk factors for early complications after ASD surgery include COPD, and current smoking. The data presented in this study also provide surgeons with knowledge of the most common complications encountered after ASD surgery, to aid in preoperative patient discussion.

Advanced age and other comorbid factors correlate with age-increased morbidity associated with spine surgery. It is crucial that spine surgeons critically assess perioperative risks versus postoperative benefits of spine surgery in the growing elderly population. Close coordination between the surgeon, anesthesia team and the patient can minimize complications, improve function and contribute to decreased costs of these complex procedures.

BACKGROUND:The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with complication risk; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's clinical utility. The present study aimed to develop a simplified, weighted frailty index for ASD patients METHODS: This study is a retrospective review of a single-center database. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Component mASD-FI factors were regressed against incidence of medical complications, and factor weights were calculated from regression of these coefficients. Total mASD-FI score ranged from 0 to 21, and was calculated by summing weights of expressed parameters. Linear regression and published ASD-FI cutoffs generated corresponding mASD-FI frailty cutoffs: not frail (NF, <7), frail (7-12), severely frail (SF, >12). Analysis of variance assessed the relationship between frailty category and validated baseline measures of pain and disability at baseline. RESULTS:= .001). CONCLUSIONS:This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and it weights component factors by their contribution to adverse outcomes. Because increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment.

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.

BACKGROUND CONTEXT: Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE: To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES: Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores.
METHOD(S): Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] <0.3, mild frailty [MF] 0.3-0.5, severe frailty [SF] >0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between 'optimized' and 'non-optimized' frailty status in the cohort. Level of significance was set to P<0.05.
RESULT(S): A total of 196,523 patients (57+/-14.2 years, 30.4 kg/m², 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p<0.001). Rates of all individual postoperative HACs assessed also increased with greater baseline frailty severity: SSI (NF: 1.14%, MF: 1.93%, SF: 2.39%, p<0.001), UTI (NF: 0.91%, MF: 1.66%, SF: 2.85%, p<0.001), VTE (NF: 0.68%, MF: 0.80%, SF: 1.16%, p=0.002). Stepwise linear regression models determined that diabetes mellitus (beta = 0.493) and hypertension (beta = 0.679) were the most significant predictors for increased baseline frailty by way of the mFI-5 NSQIP index (Final model: R2= 0.897). Of total patients, 47.2% had the optimal modifiable frailty factors (no history of diabetes or hypertension). The optimal frailty patients had significantly less overall incidence of SSI (2.03% vs 2.5%, p<0.001), UTI (0.65% vs 1.4%, p<0.001), DVT (0.56% vs 0.84%, p<0.001), and any overall HAC (2.18% vs 3.56%, p<0.001).
CONCLUSION(S): Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The International Spine Study Group (ISSG) and the European Spine Study Group (ESSG) developed an adult spinal deformity (ASD) specific risk calculator based on the largest and most granular, prospective ASD database. The calculators utilize preoperative radiographic, surgical, and patient-specific variables in order to predict patient-reported outcomes and complication rates at 2 years. PURPOSE: Assess the ISSG-ESSG risk calculator usability in a single institution ASD population. STUDY DESIGN/SETTING: Retrospective cohort study- single surgeon institution. PATIENT SAMPLE: ASD pts: A total of 631 patients undergoing surgery for adult spinal deformity. OUTCOME MEASURES: Improvement from BL SRS-22 [Pain, Function, total], major complications, Oswestry Disability Index (ODI).
METHOD(S): ASD pts were isolated in the single-center ASD Database 2013-2020. Frail pts were isolated (Frail[F] 0.3>0.5). Basic demographics were assessed for these F pts via chi-squared and t-tests. Each F patient was inputted into the ESSG risk calculator to identify individual predictive rates for postoperative 2-year HRQL outcomes as well as major complications. These calculated predicted outcomes were analyzed against those identified from the ASD database in order to validate the calculator predictability in a single center institution via Brier scores. Having a score closer to 1 means the EESG calculator is not predictive of that specific outcome. A score closer to 0 meant the EESG calculator was a predictive tool for that factor.
RESULT(S): A total of 631 ASD pts were isolated (55.8;16.8yrs, 26.68kg/m², 0.95+/-1.3CCI). Of these patients, 7.8% were frail. Fifty percent of frail pts received an interbody fusion, 58.3% received a decompression, and 79.2% had an osteotomy. Surgical details: mean operative time 342.9+/-94.3minutes, mean estimated blood loss 2131.82+/-1011mL, and an average length of stay 7.12+/-2.5days. The EESG calculator predicted the likelihood of improvement for the following HRQL's ODI(86%), SRS-22 Mental Health (71.1%), SRS-22 Total (87.6%), major complication (53.4%). The single institution had lower percentages of improvement in ODI (24.6%), SRS-22 Mental Health (21.3%), SRS-22 Total (25.1%), and lower presence of major complication (34.8%). The calculated Brier scores identified the calculator's predictability for each factor: ODI (0.24), SRS-22 Mental Health (0.21), SRS-22 Total (0.25), major complication (0.28).
CONCLUSION(S): The newly developed ESSG-ISSG risk-assessment tool has a wide application in single institutions as it accurately predicts 2-year outcomes for various SRS-22 questionnaires and development of major complications. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Frailty is a baseline measure of disability that transcends age alone and has been determined a strong predictor of outcomes following adult spinal deformity (ASD) surgery. This postop impact calls for investigation of unique adjustment of Global Alignment and Proportion (GAP) scores accounting for frailty. This adjustment in spinal proportion may help surgical planning for individualized, optimal postop outcomes. PURPOSE: Modify the GAP score with frailty to optimize outcomes in surgical ASD patients. STUDY DESIGN/SETTING: Retrospective review of a single-surgeon comprehensive ASD database PATIENT SAMPLE: A total of 140 ASD patients OUTCOME MEASURES: Frailty-adjusted GAP scores; Health Related Quality of Life scores (HRQLs): ODI, SRS-22 METHODS: Surgical ASD patients (SVA>=5cm, PT>=25degree, or TK >=60degree, >3 levels fused) >=18 years old with available baseline (BL) radiographic data were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were dichotomized by the ASD frailty index, F (Not Frail, Frail). Linear regression analysis established radiographic equations for frailty-adjusted GAP Scores at baseline and 2-years involving relative pelvic version, relative lumbar lordosis, lordosis distribution index, relative spinopelvic alignment, and an age factor to formulate a sagittal plane score. Patients were restratified into frailty-adjusted proportionality groups: Proportional (<5.8), Moderately Disproportional (MD) (5.8-7), Severely Disproportional (SD) (>7). Frailty-adjusted GAP proportionality at 2-years were compared to adjusted-BL to determine whether patients improved, deteriorated or remained the same in their spine proportion.
RESULT(S): A total of 140 patients were included (55.5+/-16.4 yrs, 77.5% female, 25.2+/-4.7 kg/m2). BL frailty: 32.8% not frail, 67.2% frail. Primary analyses demonstrated correlation between BL frailty score and BL and 2-year GAP scores(P<0.001). Linear regression analysis(p<0.001) developed a frailty-adjusted GAP threshold equation: 4.4 + 0.93*(frailty score). Adjusted-baseline scores were taken and re-stratified based distribution and placed 26.4% of patients in Proportional, 26.6% MD, and 44% SD. BL adjusted GAP scores by frailty group: 5.3 Not Frail, 7.5 Frail; p<0.001. At 2-years, GAP scores were grouped into the frailty-adjusted proportionality groups: 66.2% Proportional, 10.8% MD, and 23.1% SD. Patients who were 2-year MD/SD underwent significantly more reoperations (>33.5%) compared to Proportional (12.8%), p=0.015. SD 2-year patients developed increased PJK at the 1-year mark (40%, Proportional: 13.9%, MD:7.1%, p=0.003), as well as had worse 2-year ODI and SRS-22 satisfaction scores(p<0.050). 47.5% improved in GAP (63.4% of frail patients), 12.3% deteriorated, and 40.2% remained in the same proportionality group at 2-year follow up.
CONCLUSION(S): Significant associations exist between frailty and spinal proportion. By adjusting the GAP proportionality groups accounting for baseline frailty contributed to improved outcomes and minimized reoperations. The adjusted GAP groups appeal for less rigorous spine proportion goals in severely frail patients. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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