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OBJECTIVE Frailty’s role in preoperative risk assessment in spine surgery has increased in association with the increasing size of the aging population. However, previous frailty assessment tools have significant limitations. The aim of this study was to compare the predictive ability of the Risk Analysis Index (RAI) with the 5-factor modified frailty index (mFI-5) for postoperative spine surgery morbidity and mortality. METHODS Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database for adults > 18 years who underwent spine surgery between 2015 and 2019. Multivariate modeling and receiver operating characteristic curve analysis, including area under the curve/C-statistic calculations, were performed to evaluate the comparative discriminative ability of RAI and mFI-5 on postoperative outcomes. RESULTS In a cohort of 292,225 spine surgery patients, multivariate modeling showed that increasing RAI scores, and not increasing mFI-5 scores, were independent predictors of increased postoperative mortality for the trauma, tumor, and infection subcohorts. In the overall spine cohort, both increasing RAI and increasing mFI-5 scores were associated with increased mortality, but C-statistics indicated that the RAI (C-statistic 0.802 [95% CI 0.800–0.803], p < 0.0001, DeLong test) had superior discrimination compared with the mFI-5 (C-statistic 0.677 [95% CI 0.675–0.679], p < 0.0001, DeLong test). In subgroup analyses, the RAI had superior discriminative ability to mFI-5 for mortality in the trauma and infection groups (p < 0.001 and p = 0.039, respectively). CONCLUSIONS The RAI demonstrates superior discrimination to the mFI-5 for predicting postoperative mortality and morbidity after spine surgery and the RAI maintains conceptual fidelity to the frailty phenotype. Patients with high RAI scores may benefit from knowing the possibility of increased surgical risk with potential spine surgery.

Introduction The aim of this study was to evaluate the discriminative accuracy of the preoperative Risk Analysis Index (RAI) frailty score for prediction of mortality or transition to hospice within 30 days of brain tumor resection (BTR) in a large multicenter, international, prospective database. Methods Records of BTR patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program (2012–2020) database. The relationship between the RAI frailty scale and the primary end point (mortality or discharge to hospice within 30 days of surgery) was assessed using linear-by-linear proportional trend tests, logistic regression, and receiver operating characteristic (ROC) curve analysis (area under the curve as C-statistic). Results Patients with BTR (N = 31,776) were stratified by RAI frailty tier: 16,800 robust (52.8%), 7,646 normal (24.1%), 6,593 frail (20.7%), and 737 severely frail (2.3%). The mortality/hospice rate was 2.5% (n = 803) and was positively associated with increasing RAI tier: robust (0.9%), normal (3.3%), frail (4.6%), and severely frail (14.2%) (p Conclusions RAI frailty score predicts 30-day mortality after BTR and may be translated to the bedside with a user-friendly calculator (https://nsgyfrailtyoutcomeslab.shinyapps.io/braintumormortalityRAIcalc/). The findings hope to augment the informed consent and surgical decision-making process in this patient population and provide an example for future study designs.

Retrospective analysis of a prospectively maintained database.To evaluate the effects of interhospital transfer (IHT) status, age, and frailty on postoperative outcomes in patients who underwent spine surgery.The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent spine surgeries from 2015 to 2019 (N = 295,875). Univariate and multivariable analyses were utilized to analyze the effect of IHT on postoperative outcomes and the contribution of baseline frailty status (mFI-5 score stratified into "pre-frail", "frail", and "severely frail") on outcomes in IHT patients. Effect sizes were summarized by odds ratio (OR) with associated 95% confidence intervals (95% CI).Of 295,875 patients in the study, 3.3% (N = 9666) were IHT status. On multivariable analysis, controlling for covariates, IHT status was significantly associated with greater likelihood of 30-day mortality (odds ratio [OR] = 9.3), major complications (OR=5.0), Clavien-Dindo (CD) grade IV complications (OR=7.0), unplanned readmission (OR=2.1), unplanned reoperation (OR=2.6), eLOS (OR=16.1), and discharge to non-home destination (OR=12.7) (all P 0.001). Increasing frailty was significantly associated with poor outcomes in spine surgery patients with IHT status compared to chronological age.This study provides evidence that IHT status is associated with poor outcomes in spine surgery patients. Furthermore, increasing frailty more than increasing age was a robust predictor of poor outcomes among IHT spine surgical patients. Baseline frailty status, as measured by the mFI-5, may be utilized for preoperative risk stratification of patients with IHT status with anticipated spine surgery.

PurposeTo evaluate the discriminative prognostic utility of the Risk Analysis Index-Administrative (RAI-A) as compared to the modified frailty index-5 (mFI-5) and patient age for postoperative outcomes of brain tumor resection (BTR) patients. MethodsPatients with BTR were queried from the National Surgical Quality Improvement Program (NSIQP) for the years 2015 to 2019. Multivariable logistic regression was performed to evaluate the association between frailty tools and postoperative complications and discharge outcomes.ResultsWe identified 30,951 patients that underwent craniotomy for BTR; the median age of our study sample was 59 (IQR 47-68) years old and 47.8% of patients were male. Overall, increasing RAI-A score, in an overall stepwise fashion, was associated with increased post-operative outcomes including in-hospital mortality, non-routine discharge, major complications, Clavien-Dindo Grade IV complication, and extended length of stay. The RAI-A tiers 41-45 and >45 were ~4 (Odds Ratio [OR]: 4.3, 95% CI: 2.1-8.9) and ~9 (OR: 9.5, 95% CI: 3.9-22.9) more times more likely to have mortality compared to RAI-A 0-20. Multivariable regression analysis (adjusting for age, sex, BMI, non-elective surgery status, race, and ethnicity) demonstrated that RAI-A was an independent predictor of all BTR outcomes.Conclusions and RelevanceIncreasing RAI-A score is a better predictor than the mFI-5 and increasing patient age for in-hospital complications and discharge outcomes in BTR patients. The RAI-A may help providers present better preoperative risk assessment for patients and families weighing the risks and benefits of potential BTR.

Increasing patient age has been associated with worse outcomes after pituitary adenoma resection in previous studies, but the prognostic value of frailty compared with advancing age on pituitary adenoma resection outcomes has not been clearly evaluated.The National Surgical Quality Improvement Program from 2015 to 2019 was queried for data for patients aged18 years who underwent pituitary adenoma resection (n = 1454 identified patients). Univariate and multivariate analyses of age and frailty (5-factor modified frailty index [mFI-5]) were performed on 30-day mortality, major complications, extended length of stay (eLOS), discharge destination, and readmission and reoperation. The receiver operating characteristic curve analysis was performed to compare effect of age and mFI-5.On univariate analysis, increasing frailty was significantly associated with greater risk of unplanned readmission (frail: odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-3.2; severely frail: OR, 6.9; 95% CI, 2.4-19.8) and a major complication (frail: OR, 3.6; 95% CI, 2.1-6.1). Severe frailty was also associated with nonhome discharge (OR, 10.6; 95% CI, 3.2-35.8) and eLOS (OR, 4.5; 95% CI, 1.5-13.4). Increasing age was not associated with any of these outcome measures. Multivariate analysis also demonstrated similar trends. In receiver operating characteristic curve analysis, the mFI-5 score showed higher discrimination for major complications compared with age (area under the curve: 0.624 vs. 0.503; P0.001).Increasing frailty, and not advancing age, was an independent predictor for major complications, unplanned readmissions, eLOS, and nonhome discharge after pituitary adenoma resection, suggesting frailty to be superior to age in preoperative risk stratification in this patient population.

BACKGROUND: Anterior lumbar interbody fusion (ALIF) is commonly utilized in lumbar degenerative pathologies. Standalone ALIF (ST-ALIF) systems were developed to avoid added morbidity, surgical time, and cost of anterior and posterior fusion (APF). Controversy exists in the literature about which of these two techniques yields superior clinical and radiographic outcomes, and few studies have directly compared them. This study seeks to compare ST-ALIF and APF in terms of sagittal correction and surgical complications. METHODS: Ninty-two consecutive ALIF cases performed from 2013–2018 were retrospectively reviewed and separated into 2 groups. Radiographic measurements were performed on pre- and post-operative radiographs, including segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL). Surgical complications were determined. Statistical analysis was performed using chi-square test of homogeneity, Fisher’s exact test, and independent sample t-test. Comparisons between groups were deemed statistically significant at the P