The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature

doi:10.1016/j.spinee.2018.07.008

The Spine Journal

Volume 18, Issue 12, December 2018, Pages 2354-2369

https://doi.org/10.1016/j.spinee.2018.07.008 Get rights and content

Abstract

STUDY DESIGN: Systematic review.

OBJECTIVES: To identify currently used measures of frailty and sarcopenia in the adult spine surgery literature. To assess their ability to predict postoperative outcomes including mortality, morbidity, in-hospital length of stay (LOS), and discharge disposition. To determine which is the best clinical measure of frailty and sarcopenia in predicting outcome after spine surgery.

SUMMARY OF BACKGROUND DATA: Frailty and sarcopenia have been identified as predictors of mortality and adverse-events (AEs) in numerous nonsurgical and nonspine populations. This topic is an emerging area of interest and study in patients undergoing spinal surgery.

METHODS: A systematic literature review using the PRISMA methodology of MEDLINE, PubMed, Ovid, EMBASE, and Cochrane databases was performed from January 1950 to August 2017. Included studies consisted of those that examined measures of frailty or sarcopenia in adult patients undergoing any spinal surgery. The literature was synthesized and recommendations are proposed based on the GRADE system.

RESULTS: The initial search yielded 210 results, 11 of which met our complete inclusion criteria. Seven reported on measures of frailty and four reported on measures of sarcopenia. Frailty, assessed using a variety of measurement tools, was a consistent predictor of mortality, major and minor morbidity, prolonged in-hospital LOS, and discharge to a center of higher care for adult patients undergoing spinal surgery. The relationship between sarcopenia and postoperative outcomes was inconsistent due to the lack of consensus regarding the definition, measurement tools, and wide variability in sarcopenia measured in the spinal population.

CONCLUSIONS: Frailty is predictive of AEs, mortality, in-hospital LOS, and discharge disposition in a number of distinct spinal surgery populations. The impact of sarcopenia on postoperative outcomes is equivocal given the current state of the literature. The relationship between spinal pathology, frailty, sarcopenia, and how they interact to yield outcome remains to be clarified. Frailty and sarcopenia are potentially useful tools for risk stratification of patients undergoing spinal surgery.

This systematic review was registered with PROSPERO, registration number 85096.

Introduction

In the modern era of spine surgery, a growing number of interventions are performed in the setting of advancing patient age and the presence of multiple comorbidities. Spine surgeons face the challenge of determining what, if any, is the appropriate surgical intervention in the aging population. Surgical intervention aims to improve the quality of life with no or acceptable additional morbidity. Patient factors such as frailty and sarcopenia may guide surgical decision-making in terms of candidacy, type, and magnitude of procedure and the specifics of informed consent.

Frailty is a cumulative age-related decline in multiple physiological reserves causing an inability to respond to provoked stress [1], [2]. Frailty can be measured through a variety of parameters using clinical, biochemical and radiological markers [3]. Clinical markers such as the accumulation of comorbid burden, reduced activities of daily living and quality of life, increased functional dependence and decreased cognition have been integrated into tools which measure and stratify frailty severity [3], [4]. Likewise, biochemical markers such as reduced serum albumin and elevated inflammatory markers (erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6) and ferritin levels) have been integrated into similar tools [5], [6]. Recently radiological markers have been introduced that quantify reductions in muscle area or density, indicative of sarcopenia, which act as a further method of measuring and stratifying frailty severity [7]. The fact that multiple measuring systems exist reflects the reality that frailty has no universally accepted definition or gold standard method of assessment [3].

Frailty may explain some of the observed heterogeneity in postoperative outcomes amongst elderly patients, particularly those who do not tolerate even a minor stressor. In multiple nonspine surgical populations, frailty is a significant independent risk factor in predicting postoperative adverse events (AEs) and mortality [8], [9], [10].

Frailty and sarcopenia, while linked, are distinctly different health and disease concepts. The hallmark of frailty is a loss of functional capacity that can occur in association with sarcopenia, which is defined as a decline in skeletal muscle mass, strength, and endurance [7]. Sarcopenia described by Cruz-Jentoft et al. is evaluated via a radiological technique known as morphometrics [2], [7]. Morphometrics is the radiological measurement of patients muscle areas on either computed-tomography (CT) or magnetic resonance imaging (MRI) modalities [7], [11]. The most common muscles groups assessed for sarcopenia are the psoas and paraspinous muscle areas and to a lesser extent the quadriceps [7], [11]. Recent literature has suggested that sarcopenia may be an independent and important risk factor in predicting mortality and adverse-events across multiple surgical and medical fields [8], [9], [10], [12], [13]. However, there is currently no consensus as to the most appropriate methodology of measuring sarcopenia or in determining sarcopenia cutoffs that may be clinically relevant [7].

Since frailty and sarcopenia appear to be useful in the surgical decision process in nonsurgical and nonspinal populations, a systematic review of the literature was performed using the PRISMA (Preferred Reporting Items of Systematic reviews and Meta-Analyses) guidelines to clarify its use in the context of adult spine surgery.

Our systematic review was designed to answer the following research questions:

1.
In adult patients undergoing spinal surgery, what clinical measure of frailty and sarcopenic measurement technique is the most appropriate that allows for the prediction of postoperative outcomes including mortality, morbidity, in-hospital length of stay (LOS) and discharge disposition?
2.
In which adult population(s) undergoing spinal surgery does frailty and/or sarcopenia have the most clinically significant role in predicting postoperative outcomes?

Section snippets

Methodology

Systematic reviews are important in health care. Clinicians read them to keep up-to-date with the most current clinical knowledge within their field of medical or surgical practice and they are used as starting points for developing clinical guidelines. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers’ ability to assess

Results

The initial literature search yielded a total of 210 articles (Figure). After the full inclusion and exclusion criteria were applied, 11 articles [[16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]] were included in the systematic review. Figure shows the overall process of article extraction and screening with the electronic search strategy used to identify relevant literature from the databases. There was 100% agreement between the two reviewers with respect to the final

Discussion

Frailty and sarcopenia have been previously recognized as independent risk factors for postoperative AEs in elderly patients undergoing surgical intervention [[8], [9]]. In the context of adult spine surgery, the relationship between baseline frailty and sarcopenia with postoperative outcomes has only recently been explored. Our review identified seven studies that implicitly assessed the impact of frailty on postoperative AEs. Although the exact definition of frailty varied between studies,

Conclusion

This systematic review identified eleven studies, seven utilizing frailty measure, and four assessing sarcopenia, which evaluated the impact of frailty and sarcopenia on postoperative outcomes. Frailty and sarcopenia were both independent risk factors associated with increased likelihood of postoperative complications including mortality, morbidity, in-hospital LOS, and discharge disposition. The mFI was the most commonly applied measure of frailty, but in terms of sarcopenia, due to a lack of

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Over the course of the study period, the mean patient age increased linearly year-over-year (ß=0.60 [0.48, 0.72], p < 0.0001, R=0.94), while the SSI rate decreased linearly (ß=−0.14 [−0.27, −0.02], p = 0.0249, R=0.56), and frailty scores did not change significantly (p = 0.8124, R=0.065). Among all patients undergoing PSF, postoperative wound infection was independently associated with number of levels fused (OR=1.104 p < 0.001), frailty as measured by mFI (OR=1.150 p = 0.006), and BMI (OR=1.041 p = 0.008). Frailty was also independently associated with postoperative ICU admission (OR=1.1080 p = 0.005), 30-day readmission (OR=1.181 p < 0.001), and 30-day reoperation (OR=1.128 p < 0.001). Among all patients, rate of postoperative wound infection increased with increasing frailty (p = 0.0002) and increasing comorbid disease burden (chi-square p = 0.0012).
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: FDA device/drug status: Not applicable

: Author disclosures: EM: Nothing to disclose. E-BM: Nothing to disclose. R-CM: Nothing to disclose. AF: Nothing to disclose. JS: Nothing to disclose.

: This systematic review was registered with PROSPERO, registration number 85096.

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Review ArticleThe impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature

Abstract

Introduction

Section snippets

Methodology

Results

Discussion

Conclusion

Ageing Res Rev

J Am Coll Cardiol

Adv Surg

J Am Coll Surg

J Am Coll Surg

Spine J

Spine J

Spine J

Spine J

Spine J

A global clinical measure of fitness and frailty in elderly people

CMAJ

Frailty in older adults: evidence for a phenotype

J Gerontol: Med Sci

Frailty in relation to the accumulation of deficits

J Gerontol: Med Sci

Interleukin-6 in aging and chronic disease: a magnificent pathway

J Gerontol A Biol Sci Med Sci

Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people

Age Ageing

Frailty in the older surgical patient: a review

Age Ageing

Review Article
The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature