Frailty Indexes
- General
- Frailty evaluation is a key factor for surgical planning and outcome prediction. Recognizing the effect of frailty and medical comorbidities is crucial for decision-making and treatment options.
- Numbers
- Affects
- 10% of those aged 65+ in high-income countries
- 25–50% in those aged 85+
- Up to 50% among similar-aged acute hospital inpatients
- Definition:
- As a state of low physiological reserve, which leads to a heightened risk for complications and adverse outcomes in surgery.
- The body's response to stressors (e.g., minor illness or injury) is diminished in frail individuals, increasing the likelihood of negative outcomes or dependence.
- Age-associated decline in physiological reserves and function across multiple systems
- Two broad approaches to characterisation
- Frailty index (FI): cumulative deficits/multi-morbidity
- For TL deformity
- Modified frailty index (mFI):
- mASD-FI
- Assesses frailty through functional ability, comorbidities, and cognition.
- Higher scores indicate a greater risk of postoperative issues. mFI-5
- Evaluates postoperative morbidity risk, considering factors like recent heart failure, diabetes, functional status, COPD/pneumonia, and hypertension.
- Adult spinal deformity frailty index (ASD-FI):
- Specifically designed for patients with adult spinal deformity, it includes domains such as nutrition, physical function, and comorbidity burden. It is predictive of surgical complications and outcomes, but its feasibility in clinical practice is questionable due to its length (40 items).
- For cervical deformity
- Frailty phenotype:
- Weakness, slowness, low activity, exhaustion, weight loss Rockwood score
- Fried frailty criteria:
- Measures frailty based on weight loss, exhaustion, weakness, walking speed, and activity level, and predicts the risk of falls and mortality.
- mFI (Modified Frailty Index)
- Issues with frailty indexes
- Spinal deformity causing pain and neurological deficit can be confounded as frailty
- It is not a continuous measure
- Each factor used to define frailty is a yes or no question
- Little to no use for patients below 65 years
- Strategies to Mitigate Frailty
- Preoperative Strategies (Prehabilitation):
- Aims to improve physical and mental preoperative conditions to enhance recovery outcomes.
- Four pillars of prehabilitation
- Exercise therapy
- Nutritional interventions
- Psychological interventions
- Smoking cessation interventions
- Assessment & Optimisation:
- Risk factor assessment and medication assessment.
- Nutritional status: Malnutrition increases infection risk; assess weight, BMI, and serum markers. Consider body fat distribution over BMI for surgical risks in obese patients.
- Bone density: Use DXA and other measures, vital in elderly to avoid fractures.
- Cognitive health: Check for dementia to mitigate delirium risk from anesthesia or blood loss.
- Optimise mobility and identify social support sources.
- Implementation:
- Screen all patients to provide tailored advice and escalate care for high-risk individuals.
- Customised activities involve varying intensity training based on specific patient requirements.
- Requirements for Success:
- Patient centered approach, involvement of clinical and nonclinical staff, and encouraging behavioral changes before surgery.
- Research on prehabilitation in spine surgery is limited, with practical challenges yet to be fully identified.
- Intraoperative Strategies:
- Minimizing Risks:
- Minimizing operative time
- Reduce blood loss
- Reduce procedural complexity.
- Surgical Techniques:
- Minimally Invasive Surgery (MIS):
- Reduces hospital stay, blood loss, and complications, especially beneficial for older patients.
- It can achieve satisfactory clinical and radiological outcomes for ASD with reduced complication rates.
- Simplify surgical strategy (e.g., short fusion, if possible).
- Bone Management:
- Bone augmentation: especially in elderly patients with poor bone quality.
- Polymethacrylate (PMMA) or
- larger screws can be used for anchorage,
- Screw trajectory: Altering pedicle screw paths can enhance fixation in osteoporotic bone.
- Cortical trajectory:
- Pericortical > Bicortical CBT
- Spirig 2021: The authors do not recommend placing CBT screws bicortically, as no relevant biomechanical advantage is gained while the potential risk for iatrogenic injury to structures anterior to the spine is increased.
- Other Considerations:
- Optimise anesthesia. Ensure interdisciplinary team communication for discussing when to halt surgery or opt for a staged approach.
- Postoperative Strategies:
- Early Recovery:
- Early mobilization, effective pain management, and cautious medication use reduce complications and improve recovery.
- Pain Management:
- Multimodal adjuvant analgesia can help patients manage pain.
- Pain medications include NSAIDs, opioids, muscle relaxants, antidepressants, and neuropathics.
- Complication Prevention:
- Delirium prevention.
- Team Involvement:
- Include a geriatric inpatient team and other specialists such as geriatricians in postoperative care.
- Support Services:
- Pharmacy review, education, integrative support service, rehabilitation, and an osteoporosis treatment protocol.
- Rehabilitation focuses on decreasing swelling, preventing chronic pain, accelerating healing, and helping patients return to daily activities through exercises.
- Its "five pillars" include
- Controlling pain/swelling
- Improving range of motion/flexibility
- Improving strength/proprioception/balance
- Specific training
- Gradual return to activity
- Multidisciplinary Approach
- Team Involvement:
- Preoperative:
- Geriatrician (for assessment), Internist, Rehabilitation specialist, Anaesthesiologist, Surgeon, Nurses, Primary care nursing staff, General practitioner, Behavioural psychologist, Psychologist, Alcohol counsellor.
- Intraoperative:
- Surgeon, Nurses.
- Postoperative:
- Intensivist for post-operative care, Acute pain service, Physiotherapist, Geriatrician.
- Key Activities:
- Team Review:
- Regular interdisciplinary meetings to discuss surgical and medical aspects can benefit patient management.
- Preoperative Evaluations:
- Integrating multiple specialists in preoperative evaluations can enhance patient outcomes.
- Intraoperative Protocol:
- Adherence to standardized procedures by a cohesive surgical team is crucial.
- Preliminary studies suggest that this comprehensive approach reduces surgical complications and readmissions.
7. Prevention of Frailty
- Planned surgery can potentially prevent the development of frailty in ASD patients. An International Spine Study Group (ISSG) study observed improvement in frailty scores in operative groups compared to worsening in nonoperative groups over three years.
- Proper postoperative alignment is considered crucial, as misalignment has been shown to increase the risk of severe frailty.
- Severe frailty was predicted by depression, pain scores, and nonsurgical treatment in the study.
Biological clocks
- 1st generation clocks
- use methylation to estimate chronological age
- 2nd generation clocks
- not to predict chronological age
- predicts age related deficits and outcomes
- Eg:
Osteosarcopenia
- How to test
- Timed up-down from chair, five repetitions:
- Hopefully less than 10 seconds
- Timed up and go (TUG) over 4 m:
- More than 6 seconds is concerning
- Grip dynamometer:
- Average of three max.
- Men: ~30 kg/66 lb
- Women: ~20 kg/44 |b
- Gait speed:
- > 6 seconds to walk 4 m
Radiomics
- Bone density and quality
Muscle quality and integrity
Paraspinal muscle health (Goutallier classification)
- Evaluation of fatty infiltration in paraspinal muscles
- Jun 2016
- Fatty degeneration (FD) of paraspinal muscles was significantly correlated with:
- Higher age (r = 0.393)
- Increased pelvic tilt (r = 0.430)
- Increased sagittal vertical axis (SVA) (r = 0.488)
- Greater PI–LL mismatch (r = 0.479)
- More kyphotic thoracic alignment (r = −0.559; negative correlation)
- Less lumbar lordosis (LL) (r = −0.505)
- Muscle mass (LM) was positively correlated with LL (r = 0.342), and negatively with PI–LL mismatch (r = −0.283).
Comorbidities
American Society of Anesthesiologists (ASA) score
Category | Physical Status |
ASA 1 | Normal healthy patient2 |
ASA 2 | Patient with mild systemic disease4 |
ASA 3 | Patient with severe systemic disease that is not a constant threat to life6 |
ASA 4 | Patient with severe systemic disease that is a constant threat to life8 |
ASA 5 | Moribund patient not expected to survive with or wi10thout surgery |
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