Introduction: “Frailty”, a state of decreased homeostatic reserve, may be estimated based on the presence of preoperative comorbidities. The aim of this study was to develop a preoperative metastatic spinal tumor frailty index (MSTFI) which could predict morbidity, mortality, and length of stay.
Methods: A large inpatient hospitalization database was searched from 2002-2011 to identify 4,583 patients with spinal metastasis from breast (21.1%), lung (34.1%), thyroid (3.8%), renal (19.9%) and prostate (21.1%) cancer who underwent surgery. A multiple logistic regression model identified nine independent parameters that were used to construct the MSTFI: anemia, congestive heart failure, chronic lung disease, coagulopathy, electrolyte abnormalities, pulmonary circulation disorders, renal failure, malnutrition, and pathologic fractures. Patients with 0 comorbidities were categorized as “not frail,” 1 as “mildly frail,” 2 as “moderately frail,” and =3 as “severely frail.”
Results: The overall perioperative complication rate was 19.3% and in-patient mortality was 3.0%. Compared to patients without frailty, patients with mild (odds ratio (OR) 2.12; 95% CI, 1.74 – 2.59), moderate (OR 3.81; 95% CI, 3.05 – 4.76), and severe frailty (OR 8.11; 95% CI, 6.34 – 10.38) had significantly increased odds of complication development. Likewise, patients with mild (OR 2.73; 95% CI, 1.64 – 4.52), moderate (OR 4.10; 95% Ci, 2.39 – 7.04), and severe frailty (OR 6.34; 95% CI, 3.61 – 11.1) were more likely to die during their hospital stay. Length of stay also increased significantly by MSTFI (p<0.001).
Conclusions: In surgically treated patients with spinal metastasis, certain preoperative comorbidities may significantly increase the risk of major complications and mortality.
Patient Care: Spinal metastatic disease is increasing in incidence. Identifying risk factors for morbidity, mortality and length of stay is important in appropriately stratifying patients for treatment
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify factors that are associated with morbidity, mortality and length of stay among patients with metastatic spine tumors
References: 1. Wong DA, Fornasier VL, MacNab I. Spinal metastases: the obvious, the occult, and the impostors. Spine (Phila Pa 1976). 1990;15: 1-4.
2. Maccauro G, Spinelli MS, Mauro S, Perisano C, Graci C, Rosa MA. Physiopathology of spine metastasis. Int J Surg Oncol. 2011;2011: 107969.
3. Simmons ED, Zheng Y. Vertebral tumors: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006;443: 233-247.
4. Harrington KD. Anterior decompression and stabilization of the spine as a treatment for vertebral collapse and spinal cord compression from metastatic malignancy. Clin Orthop Relat Res. 1988: 177-197.
5. Kato S, Murakami H, Demura S, et al. Spinal metastasectomy of renal cell carcinoma: A 16-year single center experience with a minimum 3-year follow-up. J Surg Oncol. 2016.
6. Petteys RJ, Spitz SM, Rhee J, et al. Tokuhashi score is predictive of survival in a cohort of patients undergoing surgery for renal cell carcinoma spinal metastases. Eur Spine J. 2015;24: 2142-2149.
7. De la Garza-Ramos R, Kerezoudis P, Bydon A, et al. Complications in Metastatic Spinal Tumor Surgery. World Spinal Column J. 2016;7: 20-24.
8. Lau D, Leach MR, Than KD, Ziewacz J, La Marca F, Park P. Independent predictors of complication following surgery for spinal metastasis. Eur Spine J. 2013;22: 1402-1407.
9. Fedarko NS. The biology of aging and frailty. Clin Geriatr Med. 2011;27: 27-37.
10. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62: 722-727.
11. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210: 901-908.
12. Louwers L, Schnickel G, Rubinfeld I. Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: analysis of the National Surgical Quality Improvement Project database. Am J Surg. 2015.
13. HCUP Quality Control Procedures. Available from URL: http://www.hcup-us.ahrq.gov/db/quality.jsp [accessed May 17, 2016].
14. De la Garza-Ramos R, Abt NB, Kerezoudis P, Krauss W, Bydon M. Provider volume and short-term outcomes following surgery for spinal metastases. J Clin Neurosci. 2016;24: 43-46.
15. Patil CG, Lad SP, Santarelli J, Boakye M. National inpatient complications and outcomes after surgery for spinal metastasis from 1993-2002. Cancer. 2007;110: 625-630.
16. Yoshihara H, Yoneoka D. Trends in the surgical treatment for spinal metastasis and the in-hospital patient outcomes in the United States from 2000 to 2009. Spine J. 2014;14: 1844-1849.
17. Goodwin CR, Khattab MH, Sankey EW, et al. Factors Associated with Life Expectancy in Patients with Metastatic Spine Disease from Adenocarcinoma of the Lung. Global Spine J. 2015;5: 417-424.
18. Ju DG, Zadnik PL, Groves ML, et al. Factors associated with improved outcomes following decompressive surgery for prostate cancer metastatic to the spine. Neurosurgery. 2013;73: 657-666; discussion 666.
19. Sellin JN, Suki D, Harsh V, et al. Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma. J Neurosurg Spine. 2015;23: 419-428.
20. Zadnik PL, Hwang L, Ju DG, et al. Prolonged survival following aggressive treatment for metastatic breast cancer in the spine. Clin Exp Metastasis. 2014;31: 47-55.
21. Shehadi JA, Sciubba DM, Suk I, et al. Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients. Eur Spine J. 2007;16: 1179-1192.
22. Walston J, McBurnie MA, Newman A, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Intern Med. 2002;162: 2333-2341.
23. Jones D, Song X, Mitnitski A, Rockwood K. Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians. Aging Clin Exp Res. 2005;17: 465-471.
24. Rockwood K, McMillan M, Mitnitski A, Howlett SE. A Frailty Index Based on Common Laboratory Tests in Comparison With a Clinical Frailty Index for Older Adults in Long-Term Care Facilities. J Am Med Dir Assoc. 2015;16: 842-847.
25. Arrigo RT, Kalanithi P, Cheng I, et al. Charlson score is a robust predictor of 30-day complications following spinal metastasis surgery. Spine (Phila Pa 1976). 2011;36: E1274-1280.
26. Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50: 1109-1118.
27. Southern DA, Quan H, Ghali WA. Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data. Med Care. 2004;42: 355-360.
28. Schoenfeld AJ, Le HV, Marjoua Y, et al. Assessing the utility of a clinical prediction score regarding 30-day morbidity and mortality following metastatic spinal surgery: the New England Spinal Metastasis Score (NESMS). Spine J. 2015.
29. Bauer HC, Wedin R. Survival after surgery for spinal and extremity metastases. Prognostication in 241 patients. Acta Orthop Scand. 1995;66: 143-146.
30. Ghori AK, Leonard DA, Schoenfeld AJ, et al. Modeling 1-year survival after surgery on the metastatic spine. Spine J. 2015;15: 2345-2350.
31. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976). 2005;30: 2186-2191.
32. De la Garza-Ramos R, Samdani AF, Sponseller PD, et al. Visual loss after corrective surgery for pediatric scoliosis: incidence and risk factors from a nationwide database. Spine J. 2016.