Does Patient Frailty Status Influence Recovery Following Spinal Fusion for Adult Spinal Deformity?

An Analysis of Patients With 3-Year Follow-Up

Katherine E. Pierce, BS; Peter G. Passias, MD; Haddy Alas, BS; Avery E. Brown, BS; Cole A. Bortz, BA; Renaud Lafage, MS; Virginie Lafage, PhD; Christopher Ames, MD; Douglas C Burton, MD; Robert Hart, MD; Kojo Hamilton, MD; Michael Kelly, MD; Richard Hostin, MD; Shay Bess, MD; Eric Klineberg, MD; Breton Line, BS; Christopher Shaffrey, MD; Praveen Mummaneni, MD; Justin S Smith, MD, PhD; Frank A. Schwab, MD


Spine. 2020;45(7):E397-E405. 

In This Article

Abstract and Introduction


Study Design: Retrospective review of a prospective database.

Objective: The aim of this study was to evaluate postop clinical recovery among adult spinal deformity (ASD) patients between frailty states undergoing primary procedures

Summary of Background Data: Frailty severity may be an important determinant for impaired recovery after corrective surgery.

Methods: It included ASD patients with health-related quality of life (HRQLs) at baseline (BL), 1 year (1Y), and 3 years (3Y). Patients stratified by frailty by ASD-frailty index scale 0–1(no frailty: <0.3 [NF], mild: 0.3–0.5 [MF], severe: >0.5 [SF]). Demographics, alignment, and SRS-Schwab modifiers were assessed with χ 2/paired t tests to compare HRQLs: Scoliosis Research Society 22-question Questionnaire (SRS-22), Numeric Rating Scale (NRS) Back/Leg Pain, Oswestry Disability Index (ODI). Area-under-the-curve (AUC) method generated normalized HRQL scores at baseline (BL) and f/u intervals (1Y, 3Y). AUC was calculated for each f/u, and total area was divided by cumulative f/u, generating one number describing recovery (Integrated Health State [IHS]).

Results: A total of 191 patients were included (59 years, 80% females). Breakdown of patients by frailty status: 43.6% NF, 40.8% MF, 15.6% SF. SF patients were older (P = 0.003), >body mass index (P = 0.002). MF and SF were significantly (P < 0.001) more malaligned at BL: pelvic tilt (NF: 21.6°; MF: 27.3°; SF: 22.1°), pelvic incidence and lumbar lordosis (7.4°, 21.2°, 19.7°), sagittal vertical axis (31 mm, 87 mm, 82 mm). By SRS-Schwab, NF were mostly minor (40%), and MF and SF markedly deformed (64%, 57%). Frailty groups exhibited BL to 3Y improvement in SRS-22, ODI, NRS Back/Leg (P < 0.001). After HRQL normalization, SF had improvement in SRS-22 at year 1 and year 3 (P < 0.001), and NRS Back at 1Y. 3Y IHS showed a significant difference in SRS-22 (NF: 1.2 vs. MF: 1.32 vs. SF: 1.69, P < 0.001) and NRS Back Pain (NF: 0.52, MF: 0.66, SF: 0.6, P = 0.025) between frailty groups. SF had more complications (79%). SF/marked deformity had larger invasiveness score (112) compared to MF/moderate deformity (86.2). Controlling for baseline deformity and invasiveness, SF showed more improvement in SRS-22 IHS (NF: 1.21, MF: 1.32, SF: 1.66, P < 0.001).

Conclusion: Although all frailty groups exhibited improved postop disability/pain scores, SF patients recovered better in SRS-22 and NRS Back. Despite SF patients having more complications and larger invasiveness scores, they had overall better patient-reported outcomes, signifying that with frailty severity, patients have more room for improvement postop compared to BL quality of life.

Level of Evidence: 3


As it is known that health and age deteriorate at different rates, there is a growing interest in quantifying and interpreting one's physiologic age. Frailty, a dynamic measure transcending age, encompasses a patient's sum deficits in health. Increase in the volume of such deficits (rise in frailty status) coincides with heightened vulnerability to adverse outcomes.[1] Frailty scores and indices have been well developed in many surgical fields, successfully corresponding with mortality, prediction of postoperative outcomes, and overall risk stratification.[2–5]

Given the number of adult patients categorized as "frail" or "severely frail" undergoing elective correction of adult spinal deformity (ASD), accurate assessment of baseline (BL) impact upon postoperative recovery is very important. Previous studies have assessed patient physical recovery, noting that with increase in frailty severity, perioperative outcomes deteriorate.[6,7] Few studies exist to compare clinical patient-reported outcomes (PROs), rather than just physical recovery, among frailty statuses across follow-up time points.

Liu et al developed a novel area-under-the-curve (AUC) methodology, allowing for comparison across dissimilar patients. This proposed method normalizes follow-up health-related-quality-of-life (HRQL) follow-up scores relative to preoperative score. The scores are plotted against follow-up time points upon a graph, to compute an AUC, generating a single number, quantifying a patient's recovery trajectory across a given timespan.[8] These AUC scores consider how a patient's BL frailty status can impact recovery from the patient's point-of-view.[9] The goal of this study was to define recovery patterns of ASD patients in differing frailty groups for various patient-reported assessments.