Not Frail and Elderly: How Invasive Can We Go in This Different Type of Adult Spinal Deformity Patient?

Peter G. Passias, MD; Katherine E. Pierce, BS; Lara Passfall, BS; Ammar Adenwalla, BS; Sara Naessig, BS; Waleed Ahmad, MS; Oscar Krol, BA; Nicholas A. Kummer, BS; Nicholas O'Malley, BS; Constance Maglaras, PhD; Brooke O'Connell, MS; Shaleen Vira, MD; Frank J. Schwab, MD; Thomas J. Errico, MD; Bassel G. Diebo, MD; Burhan Janjua, MD; Tina Raman, MD; Aaron J. Buckland, MBBS; Renaud Lafage, MS; Themistocles Protopsaltis, MD; Virginie Lafage, PhD


Spine. 2021;46(22):1559-1563. 

In This Article

Abstract and Introduction


Study Design: Retrospective review of a single-center spine database.

Objective: Investigate the intersections of chronological age and physiological age via frailty to determine the influence of surgical invasiveness on patient outcomes

Summary of Background Data: Frailty is a well-established factor in preoperative risk stratification and prediction of postoperative outcomes. The surgical profile of operative patients with adult spinal deformity (ASD) who present as elderly and not frail (NF) has yet to be investigated. Our aim was to examine the surgical profile and outcomes of patients with ASD who were NF and elderly.

Methods: Patients with ASD 18 years or older, four or greater levels fused, with baseline (BL) and follow-up data were included. Patients were categorized by ASD frailty index: NF, Frail (F), severely frail (SF]. An elderly patient was defined as 70 years or older. Patients were grouped into NF/elderly and F/elderly. SRS-Schwab modifiers were assessed at BL and 1 year (0, +, ++). Logistic regression analysis assessed the relationship between increasing invasiveness, no reoperations, or major complications, and improvement in SRS-Schwab modifiers [Good Outcome]. Decision tree analysis assessed thresholds for an invasiveness risk/benefit cutoff point.

Results: A total of 598 patients with ASD included (55.3 yr, 59.7% F, 28.3 kg/m2). 29.8% of patients were older than 70 years. At BL, 51.3% of patients were NF, 37.5% F, and 11.2% SF. Sixty-sis (11%) patients were NF and elderly. About 24.2% of NF-elderly patients improved in SRS-Schwab by 1 year and had no reoperation or complication postoperatively. Binary regression analysis found a relationship between worsening SRS-Schwab, postop complication, and reoperation with invasiveness score (odds ratio: 1.056 [1.01–1.102], P = 0.011). Risk/benefit cut-off was 10 (P = 0.004). Patients below this threshold were 7.9 (2.2–28.4) times more likely to have a Good Outcome. 156 patients were elderly and F/SF with 16.7% having good outcome, with a risk/benefit cut-off point of less than 8 (4.4 [2.2–9.0], P < 0.001).

Conclusion: Frailty status impacted the balance of surgical invasiveness relative to operative risk in an inverse manner, whereas the opposite was seen amongst elderly patients with a frailty status less than their chronologic age. Surgeons should perhaps consider incorporation of frailty status over age status when determining realignment plans in patients of advanced age.

Level of Evidence: 3


Frailty is well-established as a dynamic medical syndrome characterized by increased vulnerability to adverse health outcomes and a decline in functional status as a consequence of various disease processes.[1] Although frailty was initially assessed as a substitute for physiologic age and a determinant of morbidity and mortality, it has since proven to be an important factor in preoperative risk stratification and an effective independent predictor of postoperative clinical outcomes.[2–5]

While surgical management of adult spinal deformity (ASD) can provide significant improvement in pain, functional status, and health-related quality of life measures, it is known to be technically complex and associated with high complications rates.[6–10] Both chronologic age and frailty have previously been established as risk factors for complications, morbidity, and mortality in surgical patients with ASD.[5,11–14] A retrospective study of a prospective, multicenter database by Smith et al[15] reported that patients with ASD aged 65 and above had significantly higher rates of major complication, including estimated blood loss of more than 4 L, need for reoperation, and rod fracture, compared to younger patients both perioperatively and at 2 years postoperatively.

Despite such increased risks, it is also widely recognized that surgical intervention improves clinical outcomes in ASD, including in an elderly population.[16,17] It has been shown that elderly patients with ASD undergoing surgical correction had more significant improvements in various health-related quality of life measures, including Oswestry Disability Index, 12-Item Short Form (SF-12), Scoliosis Research Society-22 (SRS-22), and numerical rating scale (NRS) for back pain, compared to younger patients, irrespective of their greater baseline (BL) disability and more severe pain.[16] However, there remains a paucity in the literature investigating the surgical profile and outcomes of operative ASD patients who are elderly and not frail (NF). Given the lack of thorough understanding of postoperative outcomes in this particular patient population and the lack of specific recommendations on how to manage them appropriately, this study aimed to investigate the surgical profile and outcomes of patients with ASD who present at an advanced age but are not categorized as being frail. We hypothesize that more so than chronologic age, physiologic age as measured by frailty index should guide surgeon decision making in terms of planning surgical invasiveness and assessing postoperative risk.