Endoscopic and Non-endoscopic Approaches to Single-level Lumbar Spine Decompression: Propensity Score Matched Comparative Analysis and Frailty Driven Predictive Model

Introduction: The endoscopic spine surgery (ESS) approach is a promising minimally invasive surgery (MIS) technique associated with increased patient satisfaction and reduced complications. The present study reports multi-center, international data, comparing ESS and non-ESS for single-level lumbar decompression and proposes a frailty-driven predictive model for non-home discharge (NHD).

Methods: Cases of ESS and non-ESS lumbar spine decompression were queried from the National Surgical Quality Improvement Program (NSQIP, 2017-2020). Propensity score matching (1:1, nearest neighbor, 0.1 caliper) was performed on baseline frailty score (measured by Risk Analysis Index [RAI] and 5-factor modified frailty index [mFI5]). The primary outcome of interest was NHD. A frailty-driven predictive model was built with RAI as the primary driver.

Results: Single-level non-fusion spine lumbar decompression surgery was performed in 38,686 patients with 174 (0.4%) ESS cases. RAI was a reliable predictor of NHD with excellent discriminatory accuracy in ROC analysis: C-statistic: 0.80 (95% CI 0.65-0.94) in ESS cohort, C-statistic: 0.75 (95% CI 0.73-0.76) overall cohort. Propensity score matched ESS patients demonstrated a reduction in total operative time (89 vs. 103 minutes, P=0.049) and hospital length of stay (LOS) (0.82 vs. 1.37 days, P< 0.001). In ROC curve analysis, the frailty-driven predictive model demonstrated excellent diagnostic accuracy for NHD (C-statistic: 0.87, 95% CI 0.85-0.88).

Conclusion : After frailty-based propensity matching, endoscopic spine surgery is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decision making with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_dischargedispo.