Frail patients require instrumentation of a more proximal vertebra for a successful outcome after surgery for adult spine deformity.

IF 4.9 1区 医学 Q1 ORTHOPEDICS Bone & Joint Journal Pub Date : 2024-11-01 DOI:10.1302/0301-620X.106B11.BJJ-2024-0369.R2
Oluwatobi O Onafowokan, Pawel P Jankowski, Ankita Das, Renaud Lafage, Justin S Smith, Christopher I Shaffrey, Virginie Lafage, Peter G Passias
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Abstract

Aims: The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

Methods: Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes.

Results: A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m2 (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than 'not frail' patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV.

Conclusion: Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally.

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年老体弱的患者在接受成人脊柱畸形手术后,需要在较近的椎体上安装器械,以获得成功的结果。
目的:本研究旨在探讨上部器械椎体(UIV)水平对接受成人脊柱畸形(ASD)手术的体弱患者的影响:方法:对接受T9-骨盆融合术的成人脊柱畸形患者采用ASD-改良虚弱指数进行分层,将其分为不虚弱、虚弱和严重虚弱三个类别。ASD的定义是脊柱侧弯≥20°、矢状垂直轴(SVA)≥5厘米或骨盆倾斜≥25°中的至少一项。采用均数比较检验来评估两组之间的差异。逻辑回归分析用于分析虚弱类别、UIV和结果之间的关联:共纳入 477 名患者(平均年龄 60.3 岁(标清 14.9),平均体重指数 27.5 kg/m2(标清 5.8),平均夏尔森合并症指数(CCI)1.67(标清 1.66))。总体而言,74%的患者为女性(n = 353),49.6%的患者不虚弱(237),35.4%的患者虚弱(n = 169),15%的患者严重虚弱(n = 71)。基线时,年龄、体重指数、CCI 和畸形的差异显著(均为 p = 0.001)。总体而言,15.5% 的患者(n = 74)在两年前出现了机械并发症(8.1% 不虚弱(n = 36),15.1% 虚弱(n = 26),16.3% 严重虚弱(n = 12);p = 0.013)。各组间的再手术率也存在差异(20.2%(n = 48)vs 23.3%(n = 39)vs 32.6%(n = 23);P = 0.011)。在控制了骨质疏松症、基线畸形和矫正程度(通过矢状面年龄调整评分(SAAS)匹配)后,体弱和严重体弱患者如果患有心衰,则更有可能出现机械并发症(几率比(OR)6.6 (95% CI 1.6 to 26.7); p = 0.008)、抑郁症 (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048)或癌症 (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004)。与 "非虚弱 "患者相比,虚弱和严重虚弱患者在两年内发生机械并发症的比例更高(19%(n = 45)vs 11.9%(n = 29);p = 0.003)。在控制了严重虚弱患者和虚弱患者的基线畸形和矫正程度后,严重虚弱患者如果有更近端UIV,两年后出现临床相关的近端交界性脊柱后凸或失败或机械并发症的可能性较小:结论:由于合并症的存在,体弱患者在接受成人脊柱畸形手术后有可能出现不良后果。虽然上部器械椎体的确切位置仍未确定,但如果上部器械椎体的位置较远,这些患者的不良预后风险似乎更大。
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来源期刊
Bone & Joint Journal
Bone & Joint Journal ORTHOPEDICS-SURGERY
CiteScore
9.40
自引率
10.90%
发文量
318
期刊介绍: We welcome original articles from any part of the world. The papers are assessed by members of the Editorial Board and our international panel of expert reviewers, then either accepted for publication or rejected by the Editor. We receive over 2000 submissions each year and accept about 250 for publication, many after revisions recommended by the reviewers, editors or statistical advisers. A decision usually takes between six and eight weeks. Each paper is assessed by two reviewers with a special interest in the subject covered by the paper, and also by members of the editorial team. Controversial papers will be discussed at a full meeting of the Editorial Board. Publication is between four and six months after acceptance.
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