Modified Frailty Index Score Helps Stratify High-Surgical Risk Patients Undergoing ALIF

Senior author Samuel K. Cho, MD and Woojin Cho, MD, PhD Comment

Peer Reviewed

High score on a modified Frailty Index (mFI) was an independent predictor of any complication and pulmonary complication in patients undergoing anterior lumbar interbody fusion (ALIF), according to findings published online ahead of print in The Spine Journal.
Flat chart. Lined Graph, Infographics elements.High score on a modified Frailty Index was an independent predictor of any complication and pulmonary complication in patients undergoing anterior lumbar interbody fusion. Photo Source: “We found that the risk of developing complications following ALIF increases as the patient’s frailty index increases,” senior author Samuel K. Cho, MD, told SpineUniverse. “This makes intuitive sense.”

“One interesting observation was that one’s physiologic health status as indicated by the number of medical and functional comorbidities was more important than simple chronical age,” said Dr. Cho, who is Associate Professor of Orthopaedics and Neurosurgery at Icahn School of Medicine at Mount Sinai. “If you are a perfectly healthy 80-year-old patient who needs spinal surgery, the odds of having a complication may not be as high as traditionally thought simply because of your age.”

Study Design

“Complications following any surgery are of tremendous concern to both surgeons and their patients,” Dr. Cho said. “We have been studying perioperative complications following spinal surgery to elicit risk factors that may have increased the chance of having an adverse event utilizing a large national surgical database called National Surgical Quality Improvement Program (NSQIP) maintained by the American College of Surgeons. We identified frailty index as a relatively simple tool that we could use to risk stratify patients and decided to study ALIF, along with other spinal procedures.”

The study was a secondary analysis of prospectively collected NSQIP data for the period of 2010 through 2014. The investigator identified 3,920 patients undergoing ALIF, and used an 11-variable assessment that mapped 16 NSQIP variables to 11 variables in the Canadian Study of Health and Ageing Frailty Index (CSHA-FI) to calculate a modified Frailty Index (mFI) score.

The majority of subjects had an mFI score of 0 (no frailty-associated variables; n=2,205), followed by 0.09 (n=1,382), 0.18 (n=464), or ≥0.27 (n=49).

Greater Frailty Index Score Linked to Higher Complication Rate

The rate of any complication increased in a stepwise fashion from a low of 10.8% for an mFI score of 0 to a high of 32.7% for an mFI score of ≥0.27.

After multivariable regression analysis, high frailty scores (mFI ≥0.27) significantly predicted the risk for any complication and pulmonary complications (odds ratio, 2.4 and 7.5 respectively; P=0.040 and P=0.001). High frailty scores were not significantly associated with the risk for blood transfusion, length of hospital stay >5 days, mortality, return to operating room, urinary tract infection, or venous thromboembolism. 

Dr. Cho and colleagues noted that mFI was more strongly associated with complication risk than age. In contrast, age was a better predictor of the risk for urinary tract infection and intra/postoperative blood transfusion.

Simple Tool May Help Stratify High-Surgical Risk Patients

“I hope that the frailty index provides a simple tool to spinal surgeons and related healthcare professionals to risk stratify their patients before a planned operation so that they can have a more informed conversation with the patients preoperatively and prepare for possible adverse events postoperatively,” Dr. Cho concluded.

“All of the related studies are intended to better identify patient and procedure-related risk factors and organize them systematically, so that we can provide our patients with information that have scientific basis and also prepare them and the medical team for possible adverse events,” Dr. Cho added. “Also, we hope to elucidate modifiable risk factors that we can work on preoperatively so that we minimize complications, eg, better control of blood glucose levels before surgery.”

Woojin Cho, MD, PhD
Chief of Orthopaedic Spine Surgery
Montefiore Medical Center, Bronx, NY.

As our life expectancy increases, more elderly people will need either medical or surgical attention. However, we know that not everyone in the same age group is the same in terms of health and physical ability to perform daily activities. Therefore, to my knowledge, this Frailty index was invented in geriatric medicine to tailor the medical and surgical treatment for each specific patient. In that regard, this article contributes one more scientific fact to our preexisting knowledge.”

So far, we have used patients’ exact age and ASA score to evaluate their peri-operative risks. Based on the findings of this article, we can use Frailty index to evaluate the risks related to ALIF. When it comes to surgical decision-making, we need to weigh the risks and benefits. Studies like this will give us the more objective and scientific tools to make the best surgical decision.

Limitations of the study include lack of diversity among the patient population. This study was performed with data from U.S. patients only. Even though Frailty index is more comprehensive than traditional tools, it does not reflect racial or ethnic differences. If more of these kind of studies can be done in different countries, the findings can be beneficial to people worldwide, who are all aging and living longer.”

It is important to remember that every patient is different. Therefore, any medical or surgical treatment should be tailored to each specific patient. We believe that there is only “one” best treatment for a specific patient. Even though we cannot be certain what that single best treatment is, we can maximize our chances by the way of “evidence-based practice,” and therefore, patient care and research should go hand in hand with each other.

Updated on: 01/08/20
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Samuel K. Cho, MD
Associate Professor
Department of Orthopaedics
Icahn School of Medicine at Mount Sinai

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