Pre-Operative Planning Reduces Complication Risk in Adult Spinal Deformity Surgery

Highlight From the 33rd Annual Meeting of the North American Spine Society (NASS 2018)

Peer Reviewed

Approximately 70% of patients undergoing adult spinal deformity surgery will develop perioperative or related complications, particularly patients who are older and frail, explained Christopher I. Shaffrey, MD, FACS, at a session on enhanced recovery after spine surgery (ERASS) held at NASS 2018 Meeting held September 26-29 in Los Angeles, CA.

Prehabilitation, improved nutrition, osteoporosis treatment, cardiac medications, and mental health treatments are among the many pre-operative strategies for reducing frailty and optimizing outcomes in adult spinal deformity surgery, said Dr. Shaffrey, who is Chief of the Spine Division at Duke University School of Medicine in Durham, NC.

Pre-operative risk stratification and prehabilitation benefits patients who are older and frail undergoing adult spinal surgeryPre-operative risk stratification and prehabilitation benefits patients who are older and frail undergoing adult spinal surgery. Photo Credit: 123RF.com.

What is the Best Way to Assess Frailty in Patients Undergoing Spine Surgery?
A number of studies suggest that frailty assessment is a useful tool for risk stratification in adult spinal deformity surgery, Dr. Shaffrey explained. For example, Kim et al, developed a multidimensional frailty score based on comprehensive geriatric assessment that presents a more accurate reflection of complication risk in elderly patients undergoing intermediate- or high-risk surgery than American Society of Anesthesiologists score or use of Charlson Comorbidity Index alone, Dr. Shaffrey explained.1 The multidimensional frailty score accounts includes nutritional status, physical activity, fitness, and cognitive assessment.

With a focus on adult spinal deformity surgery, the International Spine Study Group (ISSG) developed a frailty index (ASD-FI) for pre-operative risk stratification based on 40 variables that classifies patients as frail, not frail, or severely frail, Dr. Shaffrey continued.2 Greater patient frailty on the ASD-FI was associated with greater risk of major complications, proximal junctional kyphosis, pseudarthrosis, deep wound infection, wound dehiscence, reoperation, and longer hospital stay following adult spinal deformity surgery. A more recent study by ISSG (which Dr. Shaffrey is a member of) showed that despite having worse outcomes following adult spinal deformity surgery, frail patients showed greater clinical benefit than non-frail patients.3

Dr. Shaffrey and colleagues with the ISSG are developing a next generation assessment that can be used to determine if frailty can be improved prior to surgery. The new assessment will include measures such as hand grip dynamometer assessment and sit-to-stand testing, as well as other measures to accurately determine frailty, Dr. Shaffrey explained. The ISSG will begin enrolling patients using these enhanced methods of assessment during the next several months, Dr. Shaffrey told SpineUniverse.

“Another factor to consider is the relationship between frailty and surgical invasiveness,” Dr. Shaffrey said. He highlighted data from the SpineSage tool, which suggest that greater surgical invasiveness markedly increased the risk for complications in frail patients.4

Recently, the European Spine Study Group developed the Adult Deformity Surgery Complexity Index (ADSCI) for use in quantifying the invasiveness of adult spinal deformity surgery.5 “This model is extremely accurate in looking at predictive analytics to estimate which patients are going to have a post-operative complication.”

Prehabilitation Reduces Complications From Spine Surgery
At Duke University, “every patient undergoing adult spinal deformity surgery has pre-operative assessment of blood glucose level, bone density, body mass index, cardiac status, infection screening, mental health screening, nutritional status, pain medication status, prehabilitation, smoking status, and social support, and we perform a predictive analytics assessment of outcome and complications after these factors have been determined,” Dr. Shaffrey said.

The key take-home message is that prehabilitation reduces complications in major surgeries, Dr. Shaffrey said. In a study by Barakat et al, patients randomized to a 6-week structured pre-operative exercise program prior to elective abdominal aortic aneurysm repair—which is similar to adult spinal deformity in surgical complexity and severity—had a more than 50% reduced risk of complications compared to patients who received standard treatment, Dr. Shaffrey explained.6 Efficacy of prehabilitation has been demonstrated in other studies involving surgery for lumbar fusion and spinal stenosis.7,8 “We have incorporated prehabilitation into the treatment plan for all of our patients undergoing spinal deformity surgery.”

In terms of blood glucose level, “We will not operate on the patients unless their hemoglobin A1c is less than 7%,” Dr. Shaffrey said. In addition, nutrition status is assessed using serum album and transferrin level, and nutritional drink products (eg, Ensure, Sustacal, and Boost) that provide fat, protein, and multivitamin supplementation may be given pre-operatively in malnourished patients. Malnourishment—even among obese patients—increases the risk for post-operative complications, Dr. Shaffrey explained.9

Patients at risk for cardiac events are given beta-blockers and statins therapy pre-operatively, Dr. Shaffrey noted.10 Infection screening includes urinary tract infection and nasal MRSA colonization. Decolonization using topical antibiotics may help reduce the risk for post-operative wound infection following spine surgery, Dr. Shaffrey explained.11

For patients with osteoporosis, vitamin D levels are checked and supplements are given to patients with low levels. In addition, “for those patients who are able to tolerate it, we routinely use a teriparatide to improve bone quality to reduce screw loosening and improve fusion rates,” Dr. Shaffrey told attendees at NASS 2018.12 In addition, the newer agent abaloparatide has demonstrated efficacy in improving bone density, he said.

Anxiety and depression treatment are initiated before surgery in patients identified with these conditions. In addition, patients who smoke cigarettes are required to undergo a smoking cessation program with confirmation of absence of smoking byproducts before scheduling spine surgery.

Furthermore, “patients who are obese (ie, BMI >35) are referred to a structured weight loss program, and those who fail this program are sent for a bariatric surgery assessment,” Dr. Shaffrey told SpineUniverse.

Reducing Frailty Pre-Operatively Is a Top Priority in Spine Surgery
Issues related to patient frailty are a top priority in terms of reducing the risk for perioperative and post-operative complications from spine surgery, Dr. Shaffrey concluded.

“We know how to perform the surgery, but it is this fragility aspect that causes complications,” Dr. Shaffrey said. “There are a number of identified risk factors from predictive analytics, and we know which ones are the most important. By modifying these risk factors pre-operatively, we can markedly reduce the number of complications in our adult spinal deformity population.”

Disclosures
Dr. Shaffrey is a consultant and has royalties and patents from Medtronic, NuVasive and Zimmer Biomet. He is a NuVasive stock holder. He has research grants from the AO Foundation, Department of Defense, DePuy-Synthes (through ISSG), NATCN, National Institutes of Health (NIH). He has fellowship support from the AO Foundation and Neurosurgery Research & Education Foundation (NREF).

Updated on: 10/12/18
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Which Patients Undergo Pre-Surgical Psychological Evaluation Before Spine Surgery?
Christopher I. Shaffrey, MD
Chief, Spine Division
Duke University School of Medicine
Durham, NC
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