Worse Outcomes Associated with Frailty Among Anterior Lumbar Interbody Fusion Patients: Analysis of 25,317 Cases from ACS-NSQIP

Introduction: Anterior lumbar interbody fusion (ALIF) is a well-established surgical approach in the treatment of degenerative pathologies, trauma, infection, and neoplasia. The current study sought to improve preoperative decision-making for ALIF patients with a metric that has shown promising results in the neurosurgical literature: frailty.

Methods: Patient cases were extracted from The National Surgical Quality Improvement Program database (2012-2020). Univariable analysis was used to analyze the effects of frailty (as measured by the 5-item modified frailty index [mFI-5] and Revised Risk Analysis Index [RAI-rev]) versus age alone on 30-day mortality, extended length of stay, 30-day unplanned readmission, 30-day unplanned reoperation, non-home discharge destination (NHD), and Clavien-Dindo grade IV complications (CDIV).

Results: Increasing frailty was associated with increased likelihood of all measured postoperative outcomes among the 25,317 included ALIF patients when compared to age alone. Binary logistic regression of mFI-5 and RAI-rev, respectively, showed significant odds ratios for unplanned readmission (pre-frail 1.54, frail 1.90, severely frail 3.18; pre-frail 1.49, frail 1.88, severely frail 6.9), NHD (2.13, 3.23, 8.4; 3.22, 9.6, 23.6), and CDIV (1.77, 2.85, 6.3; 2.28, 5.9, 12.1). In all instances, a Cochran-Armitage trend test resulted in p< 0.001, indicating a significant linear association of increasing odds.

Conclusion : Frailty, as measured by mFI-5 and RAI-rev, was a more reliable predictor of poor postoperative outcomes in ALIF patients when compared to age alone. More specifically, increasing degrees of frailty by either metric was associated with increased likelihood of all outcomes measured. These findings support the recent literature in the utility of these frailty measures in the preoperative context across multiple facets of neurosurgery.