Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?

Peter G Passias; Oluwatobi O Onafowokan; Peter Tretiakov; Tyler Williamson; Nicholas Kummer; Jamshaid Mir; Ankita Das; Oscar Krol; Lara Passfall; Rachel Joujon-Roche; Bailey Imbo; Timothy Yee; Daniel Sciubba; Carl B Paulino; Andrew J Schoenfeld; Justin S Smith; Renaud Lafage; Virginie Lafage

doi:10.1097/BRS.0000000000004981

Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?

Spine (Phila Pa 1976). 2024 Apr 9. doi: 10.1097/BRS.0000000000004981. Online ahead of print.

Authors

Peter G Passias¹, Oluwatobi O Onafowokan¹, Peter Tretiakov¹, Tyler Williamson¹, Nicholas Kummer¹, Jamshaid Mir¹, Ankita Das¹, Oscar Krol¹, Lara Passfall¹, Rachel Joujon-Roche¹, Bailey Imbo¹, Timothy Yee², Daniel Sciubba³, Carl B Paulino⁴, Andrew J Schoenfeld⁵, Justin S Smith⁶, Renaud Lafage⁷, Virginie Lafage⁷

Affiliations

¹ Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA.
² Department of Neurosurgery, University of California San Francisco, CA, USA.
³ Department of Neurosurgery, Northwell Health, New York, NY, USA.
⁴ Department of Orthopedic Surgery, SUNY Downstate-University Hospital of Brooklyn, New York, NY, USA.
⁵ Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA.
⁶ Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA.
⁷ Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA.

PMID: 38595092
DOI: 10.1097/BRS.0000000000004981

Abstract

Study design: Retrospective Single-Center Study.

Objective: To assess the influence of frailty on optimal outcome following ASD corrective surgery.

Summary of background data: Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on best possible outcome.

Methods: ASD patients with frailty measures, baseline and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on 2-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation.

Results: 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF-group had the highest rate of deterioration (16.7%, P=0.025) at the second postoperative year but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P=0.886). Improvement of SF patients was greatest at 6 months (ΔODI of -22.6±18.0, P<0.001) but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at 6 months, P<0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 years, F: 6.7±0.511 years, SF: 5.8±0.757 years; P=0.113).

Conclusions: Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery.

Level of evidence: III.