Elsevier

The Spine Journal

Volume 18, Issue 2, February 2018, Pages 245-254
The Spine Journal

Clinical Study
Frailty and sarcopenia do not predict adverse events in an elderly population undergoing non-complex primary elective surgery for degenerative conditions of the lumbar spine

https://doi.org/10.1016/j.spinee.2017.07.003Get rights and content

Abstract

Background Context

Sarcopenia measured by normalized total psoas area (NTPA) has been shown to predict mortality and adverse events (AEs) in numerous surgical populations. The relationship between sarcopenia and postoperative outcomes after surgery for degenerative spine disease (DSD) has not been investigated.

Purpose

This study aimed to determine the relationships between sarcopenia, frailty, and postoperative AEs in the elderly DSD population. Secondary objectives were to describe the distribution and predictors of NTPA and to determine the relationship between sarcopenia, frailty, and length of stay, discharge to a facility, and in-hospital mortality.

Study Design

This is an ambispective study from a quaternary care academic center.

Patient Sample

A total of 102 patients over 65 years old who underwent elective thoracolumbar surgery for DSD between 2009 and 2013 were included in this study.

Outcome Measures

The primary outcome was a composite of perioperative AEs; the secondary outcomes were length of stay, discharge disposition, and in-hospital mortality.

Methods

Total psoas area (TPA) at mid-L3 level on preoperative computed tomography scan adjusted for height (NTPA) defined sarcopenia. The modified frailty index (mFI) of 11 clinical variables defined frailty. The distribution and predictors of sarcopenia (NTPA) were determined. The association of NTPA with AEs, length of stay, discharge disposition to care facility, and mortality was analyzed, including adjusting for known and suspected confounders using multivariate regression.

Results

Median Spine Surgical Invasiveness Index was 8 (interquartile range 2–10), and mean NTPA was 674 mm2/m2 (293.21–1636.25). Using the mFI, 20.6% were pre-frail and 19.6% were frail. Inter- and intraobserver reliability for determining NTPA were near perfect with kappa 0.95–0.97 and 0.94–1.00, respectively. The NTPA was independently associated with patient gender and body mass index (BMI) but not frailty (mFI). Age, BMI, mFI, and American Anesthesiologists' Society score were not associated with incidence of postoperative AEs. The NTPA did not predict the occurrence of AE (odds ratio [OR] 1.06 per 100 mm2/m2, 95% confidence interval [CI] 0.91–1.23, p=.45). Similarly, NTPA was not predictive of length of stay (rho=−0.04, p=.67), discharge home (OR 0.95 (95% CI 0.76–1.20) per 100 mm2/m2, p=.70), or death (OR 1.12 (95% CI 0.83–1.53) per 100 mm2/m2, p=.47). In contrast, increasing mFI was associated with increased risk of mortality (OR 3.12 (95% CI 1.21–8.03) per 0.1 increase in frailty score, p=.006).

Conclusions

In contrast to other surgical groups, sarcopenia (NTPA) or frailty (mFI) did not predict acute care complications in a selected population of elderly patients undergoing simple lumbar spine surgery for DSD. Although NTPA can be reliably measured in this population, it may be an inappropriate surrogate for sarcopenia given its anatomical relationship to spinal function.

Introduction

Sarcopenia is defined as a progressive loss of skeletal muscle mass, strength, and power associated with adverse outcomes and is a manifestation of musculoskeletal frailty [1], [2]. Psoas muscle size has been used as a measure of sarcopenia and has been shown to predict perioperative outcomes and mortality following major abdominal surgery [3], [4], [5], [6]. Frailty is similar but distinct from sarcopenia and is defined as “a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, which increases the risk of adverse outcomes.” [1] Frailty represents a state of weakened reserve against even minor stressors and may not correlate to chronological age [1], [7]. The prevalence of frailty increases with age, is associated with increasing disability, admission to hospital, and death [8]. Its prevalence is higher in the overall surgical population (42%–50%) than the non-surgical elderly population (4%–10%) [1]. Frailty has been shown to independently predict postoperative complications in some surgical populations [9], [10], [11], [12], [13], including a subgroup of patients undergoing elective spine surgery [14], although the relationship between sarcopenia and outcomes has not been reported. As patients undergoing spine surgery experience a high rate of perioperative complications [15], frailty and sarcopenia may play an important role in risk prediction.

The population presenting for lumbar degenerative spine surgery is aging and presents challenges in perioperative risk stratification [16], [17]. In addition, traditional measures of frailty and strength may not discriminate well, given associated functional limitations. Defining the appropriate measurement tool and role of frailty in this population will not only facilitate appropriate patient selection but may offer opportunities for risk modification [7]. The primary objective of this study was to determine the relationship between sarcopenia, frailty, and postoperative adverse events (AEs). Secondary objectives were to determine the prevalence and distribution of sarcopenia as measured by psoas muscle area on computed tomography (CT) imaging and the relationship between sarcopenia, frailty, and postoperative outcomes such as length of stay, discharge to a facility, and in-hospital mortality in elderly patients undergoing primary elective thoracolumbar degenerative spine surgery.

Section snippets

Methods

We performed this ambispective cohort study with ethics approval from our Institutional Research Ethics Board (H14-02983) with a waiver for informed consent.

Results

A total of 425 patients met the inclusion criteria of which 323 were excluded based on the exclusion criteria, leaving 102 patients for final analysis (Fig. 2). The study population characteristics are provided in Table 1. The NTPA distribution was positively skewed in the population, particularly in women (Fig. 3).

Discussion

In this study, we investigated the use of NTPA and mFI as predictors of postoperative outcomes in a selected population of elderly patients undergoing routine surgery for lumbar degenerative disease. The mean NTPA was 674 (SD 278) mm2/m2, and 40% of our population was pre-frail or frail. We demonstrated that NTPA can be reliably and easily assessed in this population, assuming preoperative CT imaging is available. Body mass index and gender were independent predictors of the NTPA, but not

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    Author disclosures: RCM: Nothing to disclose. JS: Fellowship Support: Medtronic and AOSpine (E, Paid directly to institution/employer), outside the submitted work. HZ: Nothing to disclose. TR: Nothing to disclose. TA: Nothing to disclose. MB: Nothing to disclose. MD: Royalties: Medtronic (H); Consulting: Medtronic (E); Endowments: Paetzold Chair (E, Paid to institution); Fellowship Support: BC Government, Medtronic, and AOSpine (F, Paid to institution), outside the submitted work. BK: Nothing to disclose. SP: Nothing to disclose. ND: Nothing to disclose. CGF: Royalties: Medtronic (G); Consulting: Medtronic and NuVasive (F); Grants: OREF (E, Paid to institution); Fellowship Support: BC Government, Medtronic, and AOSpine (F, Paid to institution), outside the submitted work. AMF: Nothing to disclose.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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