Ali et al. [39] (2016) |
All spine surgeries in ACS-NSQIP between 2006–2010 |
18,294/ACSNSQIP |
mFI: significant frailty, mFI ≥0.27 |
30 Days |
30-Day rates of wound infection, any infection, Clavien-Dindo Class IV complications, and mortality |
Found a dose-respond relationship between mFI and complication rate. As mFI increased from 0 to ≥0.27: mortality rate increased 0.1% to 2.3% (p<0.001), Clavien IV complication rate increased 0.8% to 7.1% (p<0.001), wound infection rate increased 1.7% to 4.1% (p<0.001), and overall infection rate increased 8.1% to 24.3% (p<0.001). |
mFI score is independent predictor of postoperative morbidity and mortality in this population. Study failed to demonstrate predictive superiority of inferiority of mFI relative to ASA classification system, but mFI score ≥0.27 had greater odds of developing Clavien-Dindo class IV complications compared to ASA. |
Shin et al. [8] (2017) |
ACDF |
6,148/ACS-NSQIP |
mFI: significant frailty, mFI ≥0.27 |
30 Days |
30-Day rates of mortality, Clavien-Dindo grade IV complications, any complications, HAC including surgical site infection, UTI, and VTE. |
As mFI increased from 0 to ≥0.27: morality rate increased 0.1% to 3.0% (p<0.001), Clavien IV complication rate increased 0.8% to 5.6% (p<0.001), HAC rate increased 1.4% to 4.1% (p=0.003), and total complication rate increased 2.0% to 9.0% (p<0.001). |
mFI score ≥0.27, age >75 yr and ASA class >3 were all found to be independent predictors of Clavien class 4 complications. |
mFI ≥0.27 independently predicts Clavien IV complication rate (OR, 4.67; 95% CI, 2.27–9.62). |
Rates for all outcome variables assessed increased in a stepwise fashion with increasing mFI for both ACDF and PCF. |
Shin et al. [8] (2017) |
PCF |
817/ACS-NSQIP |
mFI: significant frailty, mFI ≥0.36 |
30 Days |
30-Day rates of mortality, Clavien-Dindo grade IV complications, any complications, HAC including surgical site infection, UTI, and VTE. |
As mFI increased from 0 to ≥0.36: morality rate increased 0.0% to 10.0% (p<0.001), Clavien IV complication rate increased 0.7% to 20.0% (p<0.001), HAC rate increased 3.1% to 7.7% (p=0.005), and total complication rate increased 4.1% to 35.0% (p<0.001). |
Age >75 yr and ASA class >3 were not found to be independent predictors of class 4 complications. |
mFI ≥0.36 independently predicts Clavien IV complication rate (OR, 41.26; 95% CI, 6.62–257.15). |
Medvedev et al. [41] (2016) |
PCF |
5,627/ACS-NSQIP |
Frailty Based Risk Score—comprised of 21 clinical, functional, and laboratory deficits. |
30 Days |
30-Day rates of major and minor complications, readmission, and reoperation. Major complication defined as those that result in permanent sequelae or reoperation. Minor complications resolved without consequence. |
Frailty score was a significant predictor of: ‘all complications’ (OR, 1.78; 95% CI, 1.61–1.96), readmission (OR, 1.40; 95% CI, 1.22–1.62), prolonged intubation (OR, 2.54; 95% CI, 2.00–3.22), and reintubation (OR, 2.34; 95% CI, 1.82–3.02). |
Frailty score was found to be an independent predictor of reoperation, readmission, intubation related complications, unplanned re-intubation, and allcause complication rate. |
Miller et al. [42] (2018) |
Cervical spine |
61/ISSG database |
CD-FI—uses 40 vari- |
≥1 Year |
Primary outcome: incidence of major complications, defined as complications that were potentially life-threatening, required reoperation, or created permanent injury. |
On multivariate logistic regression, odds of major complication were significantly greater for SF patients (OR, 43; 95% CI, 2.7–684) compared with NF patient. Greater frailty associated with greater odds of major complication (OR, 7.6; 95% CI, 1.5–38.4). |
Increasing frailty was associated with increasing risk of major complications. Postoperative medical complications were more highly correlated with frailty than were surgical complications. LOS and discharge disposition not related to degree of frailty in this study. |
deformity surgery |
for adult cervical spine deformity |
ables found in ISSG cervical deformity database; NF, CD- FI <0.2; frail, CD-FI 0.2–0.4; SF, CD-FI >0.4 |
Secondary outcomes: hospital LOS, discharge disposition, and medical/surgical complication rates. |
Institutional discharge and prolonged LOS did not correlate significantly with CD-FI. |
Leven et al. [31] (2016) |
ASD surgery |
1,001/ACS-NSQIP |
mFI: significant frailty, mFI ≥0.27 |
30 Days |
30-Day mortality and complications including pneumonia, sepsis, DVT, PE, wound complications, deep infection, central nervous system complication, sepsis/septic shock, cardiac arrest, acute renal failure, UTI, reoperation. |
As mFI increased from 0 to 0.27: mortality increased 0.3% to 10%, complication rate increased 35% to 60%, blood transfusion increased 32% to 55%, and PE/DVT increased 1.3% to 5% (all p<0.01). mFI of ≥0.36 (n=10 patients) correlated with 0% mortality and all-cause complication rate of 50%. |
Patients with higher mFI scores had higher rates of mortality, blood transfusions, PE/DVT, and any postoperative complications (p<0.01). |
Risk stratifying patients using mFI score of ≥0.18 was better predictor of reoperation than patient characteristics of age ≥60 yr and obesity class ≥III. |
mFI of ≥0.27 shown to be optimal cutoff with respect to several complications, mortality, and reoperation risk. |
Miller et al. [32] (2017) |
ASD surgery |
417/ISSG–ASD prospective patient database |
ASD-FI: NF, CD-FI <0.3; frail, CD-FI 0.3–0.5; SF, CD-FI >0.5 |
≥2 Years |
Primary outcome: incidence of major complications, defined as complications that were potentially life-threatening, required reoperation, or created permanent injury. |
When compared to NF reference group: frail group had significantly greater odds of any complication (p=0.02), major complication (p=0.006), and prolonged LOS (p<0.001); SF group has significantly greater odds of any complication (p=0.03), major complication (p=0.001), reoperation (p=0.02), prolonged LOS (p<0.001), deep wound infection (p=0.03), wound dehiscence (p=0.02), pseudoarthrosis (p=0.03), and PJK (p=0.02). |
After controlling for complexity of procedure, frailty is independently associated with longer LOS and higher overall complication, major complication, and reoperation rates. Increasingly severe frailty is associated with increased postoperative incidence of PJK, pseudo-arthrosis, wound dehiscence, and deep wound infection. |
Secondary outcomes: incidence of deep wound infection rate, wound dehiscence incidence, LOS, PJK, pseudo-arthrosis incidence, and reoperation rate. |
Miller et al. [43] (2018) |
ASD surgery |
266/ESSG database |
ASD-FI (truncated to 36 variables): NF, CD-FI <0.3; frail, CD-FI 0.3–0.5; SF, CD-FI >0.5 |
≥2 Years |
Primary outcome: major perioperative complications, defined as complications that substantially changed expected path to recovery, were potentially life threatening, required reoperation, or caused permanent injury. |
Compared to NF patients, frail and SF patients had higher odds of experiencing a major complication with OR 1.8 (95% CI, 1.0–33), and OR 2.6 (95% CI, 1.3–5.5), respectively. |
Measurement of frailty using the ASD-FI in the ESSG database showed that frail and SF patients, compared to nonfrail patients, had significantly greater odds of developing a major complication, PJK, deep wound infection, and reoperation. Elevated frailty was associated with longer hospital stays. |
Secondary outcomes: length of hospital stay, reoperation, PJK, deep wound infection, and surgical/medical complications. |
On multivariable analysis SF compared to NF patients had higher odds of developing PJK (OR, 7.0; 95% CI, 1.4–34), wound infection (OR, 9.7; 95% CI, 2.3–41) and reoperation (OR, 3.9; 95% CI, 1.7–8.9). Compared to NF, frail and SF patients had significantly longer hospital LOS. |
Reid et al. [34] (2018) |
ASD surgery with ≥4 level instrumented fusion |
332/ISSG–ASD database |
ASD-FI: NF, CD-FI <0.3; frail, CD-FI 0.3–0.5; SF, CD-FI >0.5 |
≥2 Years |
Postoperative HRQoL scores including ODI scores, SF-36 PCS scores, numeric back pain scores, and numeric leg pain scores; collected at 2 years postoperatively. Primary study outcome was if patients reached SCB for aforementioned scores. |
Baseline HRQoL and pain scores were significantly worse in frail patient groups than the non-frail group (p<0.0001). At 2-year follow-up patients in all frailty categories experienced improvement in HRQoL measures. Absolute changes between baseline and postoperative ODI, PCS, and leg pain scores were significantly greater the frail group. Regarding numeric back pain scores, frail and SF patients were less likely to reach SCB than NF patients. |
Despite higher preoperative risk stratification scores, increased complication rates, and worse baseline HRQoL scores: frail patients undergoing ASD surgery were more likely to reach SCB for most HRQoL measures following compared to NF Group. SF were least likely to reach SCB for most HRQoL measures. |
Yagi et al. [44] (2018) |
Surgery for ASD, DS, and LSCS |
156 (ASD), 152 (DS), 173 (LSCS) |
mFI: NF, mFI=0; pre-frail, mFI <0.21; frail, mFI >0.21 |
≥2 Years |
Primary outcome: postoperative clinical outcomes and complication rate. |
Postoperative ODI scores in ASD subjects deteriorated as mFI increased. In DS and LSCS subjects, clinical outcome scores improved regardless of CCI severity. In ASD surgery, major complication rate significantly increased with increasing mFI (36% in non-frail to 81% in frail group). In DS group, complication rate tended to increase with mFI and CCI, but increase was not significant. |
Postsurgical clinical outcomes improved regardless of frailty score for DS and LSCS groups but declined significantly in ASD subjects with elevated frailty scores. |
CCI: no comorbidities, CCI £1; minor comorbidities, CCI 2–3; severely comorbidities, CD-FI ≥4 |
Secondary outcomes: sagittal alignments and incidence of PJK and failure. |
Complication rate in ASD surgery worsened with increases in m랴 and CCI. |
Ondeck et al. [33] (2018) |
PLF |
16,495/ACS-NSQIP |
ASA; mFI; mCCI—truncated version of the CCI |
30 Days |
30-Day rates of any AE, severe AEs (coma, cardiac arrest, death, DVT, myocardial infarction), minor AEs (acute kidney injury, anemia requiring transfusion, pneumonia, surgical site infection, UTI, dehiscence), infectious AEs, extended hospital LOS, and discharge to higher level of care. |
Both ASA and mFI outperformed the mCCI in discriminative ability across all adverse outcomes. ASA and mFI had statistically similar predictive value in 5 of 6 outcomes, but regarding LOS ASA outperformed mFI. |
For PLF, the ASA and age have better discriminative abilities for perioperative adverse outcomes than the mFI and the mCCI. |
Phan et al. [35] (2017) |
Anterior lumbar interbody fusion |
3,920/ACS-NSQIP |
mFI |
30 Days |
Death and any postoperative complication within 30 days. Complications categorized into larger cohorts such as: death, pulmonary complications, renal complications, etc. Other outcomes measured include LOS >5 days and return to operating room. |
As mFI increased from 0 to 0.27, there was significant stepwise increase in overall complication rate from 10.8% to 32.7%. Risk of any complication increases by odds ratio of 2.4 between mFI of 0 vs. 0.27. |
High mFI scores were independently associated with all-cause complication rate and pulmonary complication rate. |
High frailty scores significant associated with greater risk of pulmonary complications but no significant association between high mFI score and UTI, VTE, LOS>5 days, return to operating room, nor mortality could be found. |
Flexman et al. [7] (2016) |
DSD |
52,671/ACS-NSQIP |
mFI: significantly frail: mFI ≥0.27 |
30 Days |
30-Day rates of death and major complications within 30 days (Clavien–Dindo grade ≥2), LOS, and discharge to facility. |
The mFI was in independent predictor of 30-day rate of major complications (p<0.0005), infection (p=0.04), prolonged LOS (p<0.0005), discharge to higher level of care (p<0.0005), and death (p=0.05). The OR for death was 1.44 for every 0.1 increase in frailty score. |
Frailty is an important predictor of clinically relevant outcomes in patients undergoing surgery for DSD. Also, the need for reoperation due to surgical site infection was strongly predicted by presence of frailty. |
Charest-Morin et al. [40] (2018) |
Primary elective thoracolumbar surgery for non-complex DSD |
102/Spine Adverse Events Severity System ver. 2 |
mFI: frail, mFI ≥0.21 |
Not provided |
Occurrence of any perioperative AE including, but not limited to, dural tear, instrumentation failure, positioning-related complications; postoperative anemia, cardiac complications, wound infection, delirium, electrolyte abnormalities, pneumonia, neuropathic pain, UTI, and urinary retention. All AEs graded on scale of 1–6, with major events defined as grade 3 or higher. Secondary outcomes include hospital LOS, discharge to facility, and inhospital mortality. |
After controlling for invasiveness of procedure (using Spine Surgical Invasiveness Index, no relationship between NTPA and AEs (adjusted OR, 1.06; 95% CI, 0.91–1.23) nor between mFI and AEs (OR, 0.85 per 0.1 increase in mFI; 95% CI, 0.58–1.24) could be found. |
Both mFI and NTPA were not predictive of AEs, LOS, or discharge to higher level of care. mFI, but not NTPA, predictive of death. |
Sarcopenia measured by NTPA—obtained via computed tomography during preoperative assessment |
mFI, but not NTPA, was associated with increased risk of death (OR, 3.12 per 0.1 increase in mFI score; 95% CI, 1.21–8.03). Neither mFI nor NTPA predicted LOS or discharge to facility. |
Based on relatively low sample size, lack of surgical complexity, and low prevalence of frailty in study population, study is likely underpowered to detect relationship with respect to frailty and rate of AEs. |