193. Should our corrective realignments be tailored to different frailty states?

Abstract

<h3>BACKGROUND CONTEXT</h3> Adult spinal deformity is associated with severe pain and disability. Recent literature has shown that surgical intervention can significantly improve patients' quality of life and lessen disease burden. As many patients requiring spine surgery are elderly and often frail, restoration of alignment targets may differ. The literature is scarce on how different frailty states affect realignment goals. <h3>PURPOSE</h3> Modify the age-adjusted alignment goals using the Frailty Index to optimize outcomes in surgical adult spinal deformity (ASD) patients. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study of a prospective multicenter database of ASD patients. <h3>PATIENT SAMPLE</h3> This study included 245 ASD patients. <h3>OUTCOME MEASURES</h3> Complications, HRQLs (SRS-22, ODI, SF-36). <h3>METHODS</h3> Operative ASD patients (scoliosis ≥20°, SVA ≥5cm, PT ≥25°, or TK ≥60°) with available baseline and 2-year radiographic and HRQL data were included. ASD frailty index was used to stratify patients into not frail (NF) and frail (F) categories. Linear regression analysis established normative radiographic thresholds, utilizing previously published age specific US-Normative ODI values (Lafage et al) and the frailty index, based on a cohort of patients with an ideal clinical outcome (no major complications, no PJK, and an SRS-satisfaction of >4). Patients were considered "matched" if 2-year postop alignment was within 1 standard deviation (+1SD overcorrected-1SD undercorrected). <h3>RESULTS</h3> A total of 245 patients included (57±15yrs, 82% female, 26±5.14kg/m2, ASD-FI: 2.9±1.6, CCI: 1.8 ±1.7). Patients had a mean level fused of 11.1±4.4, LOS of 7.7 days±4.4, EBL of 1577 mL, operative time of 377 min, with 63% undergoing an osteotomy. In terms of surgical approach, 69.9% posterior-only, and 29.3% had a combined approach. Primary analyses demonstrated correlation between baseline frailty index, PT, PI-LL, SVA, and ODI, (p<0.05). Linear regression analysis developed age and frailty adjusted alignment threshold. Thresholds for correction were found to increase with age, as previously determined by Lafage et al, as well as, increase with a higher frailty index. Frail patients, corresponding to the same age, were found on average to have a higher alignment threshold than not frail patients in SVA, PI-LL, and PT. Controlling for age, CCI, and baseline deformity, frail patients experienced less overall PJK when undercorrected in PI-LL in the Lafage Schwab age-adjusted parameters (.28[.09-.85], p=.024). Patients who achieved a match in the newly developed age and frailty-adjusted parameters in PI-LL had lower rates of PJF (5% vs 15%, p=.014 with improved HRQLs, and those matched in SVA had improved HRQLs when compared to those who were under- or overcorrected. Matched SVA patients had a shorter LOS. <h3>CONCLUSIONS</h3> Age-adjusted alignment by Lafage et al was the first study to recognize that older age warrants a lower degree of correction, and, the original SRS-Schwab criteria was modified accordingly. Alignment targets accounting for both frailty and age were developed with larger thresholds for increasing frailty. In this study, we found patients who were matched in these age and frailty adjusted thresholds had lower rates of PJF and significantly improved HRQL outcomes. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.