The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: A prospective cohort study.

BACKGROUND: Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. ERAS can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains. MATERIALS AND METHODS: An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay (LOS) after surgery. RESULTS: A total of 245 patients (age of 79.8 ± 3.4 yr) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between non-frail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery. CONCLUSION: Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

Compensation Characteristics of Spinal Sagittal Malalignment According to Pelvic Incidence in Elderly Patients with Degenerative Lumbar Spinal Stenosis.

OBJECTIVE: Compensation characteristics of spinal sagittal malalignment according to pelvic incidence (PI) have yet to be elucidated. This study aimed to investigate the difference in compensatory segments according to PI in elderly patients with degenerative lumbar spinal stenosis (DLSS). METHODS: This retrospective study included 196 patients (143 females, 53 males) suffering from DLSS with an average age of 66.73 years in our department. Sagittal parameters were obtained on the whole spinal lateral radiograph, including T1-T12 slope (T1S-T12S), Cobb angle (CA) of the functional units of the thoracic spine, thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), PI, the ratio of PT to PI (PT/PI), PI minus LL mismatch (PI-LL), sagittal vertical axis (SVA). Patients were divided into the low and high PI groups according to the median value of PI. With reference to the value of SVA and PI-LL, each PI group was further grouped into the balance subgroup (SVA < 50 mm, PI-LL ≤10°), hidden imbalance subgroup (SVA < 50 mm, PI-LL > 10°), and imbalance subgroup (SVA ≥50 mm). Independent samples t-test/Mann-Whitney U test, one-way ANOVA/Kruskal-Wallis test, and Person correlation analysis were utilized for statistical test. RESULTS: The median value of PI was 47.65°. 96 and 100 patients were assigned to low and high PI groups, respectively. Correlation analysis indicated that the T8-T12 slope and T10-T12 slope were associated with PI-LL in the high and low PI groups, respectively (all, p < 0.01). For segmental lordosis, T8-9 to T11-12 CA and T10-11 to T11-12 CA were associated with PI-LL in the high and low PI groups, respectively (all, p < 0.01). In the high PI cohort, T8-12 CA and PT increased significantly from the balance to imbalance subgroups (both, p < 0.05). In the low PI cohort, T10-12 CA and PT first increased and then decreased from the balance to imbalance subgroups (both, p < 0.05). CONCLUSION: T8-12 was the main compensatory segment of the thoracic spine in patients with high PI, while it was T10-12 in patients with low PI. In addition, the compensation potential of the lower thoracic spine and pelvis in patients with low PI was inferior to those with high PI.

The effect of sagittal alignment, coronal balance, and segmental stability on preoperative patient-reported outcomes in patients with degenerative lumbar spondylolisthesis.

OBJECTIVE: The aim of this study was to investigate the association between spinal alignment and preoperative patient-reported outcomes (PROs) in patients with degenerative lumbar spondylolisthesis (DLS) and to identify the independent risk factors for worse preoperative PROs. METHODS: In total, 101 patients suffering from DLS were retrospectively studied within a single medical center. Age, sex, height, weight, and body mass index were uniformly recorded. PRO-related indicators include the Oswestry Disability Index (ODI), the Japanese Orthopedic Association's (JOA) score, and the visual analog scale (VAS) for back and leg pain. Sagittal alignment, coronal balance, and stability of the L4/5 level were evaluated through whole-spine anteroposterior and lateral radiographs and dynamic lumbar X-ray. RESULTS: Increasing age (P = 0.005), higher sagittal vertical axis (SVA) (P < 0.001), and global coronal imbalance (GCI) (P = 0.023) were independent risk factors for higher ODI. Patients with GCI had lower JOA scores (P = 0.001) than those with balanced coronal alignment. Unstable spondylolisthesis (P < 0.001) and GCI (P = 0.009) were two vital predictors of VAS-back pain. Increasing age (P = 0.031), local coronal imbalance (LCI) (P < 0.001), and GCI (P < 0.001) were associated with higher VAS-leg pain. Moreover, patients with coronal imbalance also exhibited significant sagittal malalignment based on the subgroup analysis. CONCLUSION: DLS patients with higher SVA, unstable spondylolistheses, a combination of LCI/GCI, or increasing age were predisposed to have more severe subjective symptoms before surgery.

The effect of interlaminar Coflex stabilization in the topping-off procedure on local and global spinal sagittal alignment.

PURPOSE: To investigate the effect of interlaminar Coflex stabilization (ICS) at various segments in the topping-off procedure on local and global spinal sagittal alignment. METHODS: Eighty-nine consecutive patients with degenerative lumbar spinal stenosis (DLSS) who underwent ICS and transforaminal lumbar interbody fusion (TLIF) were retrospectively reviewed. They were divided into Group A (L4-L5 ICS + L5-S1 TLIF), Group B (L3-L4 ICS + L4-S1 TLIF), and Group C (L2-L3 ICS + L3-S1 TLIF) according to their fusion levels. The measured local sagittal parameters included the implanted segmental angle (ISA), intervertebral disc angle (IDA), intervertebral foreman height (IFH), and disc height. The assessed global sagittal parameters included thoracic kyphosis, lumbar lordosis (LL), the fused segment angle (FSA), the sacral slope, the pelvic tilt, pelvic incidence, and the sagittal vertical axis. The Oswestry Disability Index (ODI) and visual analog scales (VAS) were recorded to evaluate the clinical outcomes. RESULTS: Regarding the local alignment parameters, the ISA and IDA decreased immediately after surgery in Groups A and B, followed by an increase at the last follow-up (all, P < 0.05). Conversely, the IFH of Groups A and B first increased after surgery and then decreased to approximately the original value (all, P < 0.05). No significant differences were evident between the local sagittal parameters at different time points in Group C. Regarding the global sagittal profiles, the LL and FSA exhibited a significant postoperative increase (both at P < 0.05) in all the groups. All three groups displayed significant improvements in the ODI, VAS-back pain, and VAS-leg pain. Furthermore, 4.5% (4/89) of the patients exhibited radiographic adjacent segment degeneration (ASD) at the last follow-up. CONCLUSION: ICS during topping-off surgery led to a temporary loss of local lordosis, especially in the lower lumbar segment, while the intervertebral space realigned after middle-term follow-up. The topping-off procedure with ICS is a feasible and promising surgical option of DLSS since it reduces fusion levels and prevents ASD development.

The ratio of cervical lordosis to C7 slope represents the reciprocal change between cervical sagittal alignment and global spinal alignment.

PURPOSE: This retrospective cross-sectional study investigated variations in the ratio of cervical lordosis to C7 slope (CL/C7S) at different stages of global sagittal balance to better understand how global sagittal alignment affects cervical alignment. METHODS: A total of 255 patients with the degenerative lumbar disease were retrospectively studied within a single medical center. Whole spine radiographs were used to evaluate sagittal parameters, mainly including occiput-C2 lordosis (OC2), cervical lordosis (CL), C7 slope (C7S), the ratio of cervical lordosis to C7 slope (CL/C7S), cervical sagittal vertical axis (CSVA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), PI minus LL mismatch (PI-LL), and sagittal vertical axis (SVA). Patients were divided into the balance group (SVA < 50 mm, PI-LL ≤ 10°), hidden imbalance group (SVA < 50 mm, PI-LL > 10°), and imbalance group (SVA > 50 mm). RESULTS: Significant correlations were found between CL/C7S and OC2 (r = - 0.334), CSVA (r = - 0.504), PI-LL (r = 0.189), and SVA (r = 0.309). Multivariable linear regression analysis indicated that patients in the hidden imbalance group had lower CL/C7S than those in the balance group (B = - 0.234, P < 0.001), whereas the value of CL/C7S in patients with imbalanced sagittal alignment was higher than those with balanced alignment (B = 0.164, P = 0.011). The mean value of CL/C7S was 0.71, 0.51, and 0.97 in the balance, hidden imbalance, and imbalance groups, respectively. The global spine tended to tilt forward as the LL decreased, while TK, PT, PI-LL, and SVA increased (all, P < 0.001) from the balance stage to the imbalance stage. CONCLUSIONS: CL/C7S tended to be lower when the thoracic extension increased to maintain global sagittal balance at the hidden imbalance stage. Inversely, CL/C7S increased significantly when the global spine showed severe anterior malalignment.

Preoperative Zung depression scale predicts outcomes in older patients undergoing short-segment fusion surgery for degenerative lumbar spinal disease.

PURPOSE: To identify the relationship between depression measured by Zung depression rating scale (ZDRS) and postoperative outcomes (including the patients reported outcomes [PRO] and clinical outcomes) two years after short-segment fusion surgery for degenerative lumbar spinal disease in older patients (aged 75 years and older). METHODS: We enrolled patients who underwent short-segment fusion surgery for lumbar degenerative disease from May 2018 to June 2020. All patients were assessed for depression using the ZDRS. Patients were included in the depression group and not-depressed group based on their scores. Preoperative baseline data were collected on characteristics, comorbidities, laboratory data, pain levels (visual analogue scale [VAS]), functional status (Oswestry Disability Index [ODI]), and surgery-related variables. The primary outcomes were PRO measures, including VAS, ODI and satisfaction two years after lumbar fusion surgery. Other outcomes included postoperative complications, the length of stay, and reoperation. Univariate and multivariate analyses were performed to identify the risk factors for poor satisfaction. RESULTS: A total of 231 patients (201 in not-depressed and 30 in depressed group) were enrolled in this study. There were no significant differences between the two groups for baseline data. Depressed group had higher rates of choices for dissatisfaction (36.7% vs. 14.0%, p = 0.015), higher VAS scores of low back pain (2.8 ± 2.3 vs. 1.6 ± 1.7, p = 0.012), and worse functional status (31.5 ± 22.5 vs 21.8 ± 19.9, p = 0.015) than the not-depressed group. Depressed patients reported significantly higher rates of postoperative complications and readmissions. Multivariate regression analysis revealed that depression (p = 0.001) was independently associated with postoperative dissatisfaction. CONCLUSION: Preoperative depression was a risk factor for postoperative dissatisfaction, worse functional status, readmission, and complications in older patients undergoing lumbar fusion surgery. Preoperative screening using the Zung depression scale helps inform decision-making when considering fusion surgery for patients aged 75 and older.

Changes in T1 slope and cervical sagittal vertical axis correlate to improved neurological function recovery after cervical laminoplasty.

Purpose: To investigate the influence of changes in T1 slope (T1S) and cervical sagittal vertical axis (CSVA) on cervical laminoplasty outcomes. Methods: Eighty-one patients with cervical spondylotic myelopathy (CSM) treated with cervical laminoplasty were enrolled in this study. Demographic parameters included age and follow-up time. Imaging data included occiput-C2 lordosis (OC2), C2-C7 Cobb angle (CL), T1S, CSVA. Outcome assessment indicators included the Japanese Orthopedic Association (JOA) score, JOA recovery rate, and neck disability index (NDI). All patients were grouped based on preoperative T1S and variation in CL after surgery, respectively. Patients with decreased CL postoperatively were further grouped according to whether they were combined with T1S reduction. Results: There were no significant differences in the final JOA score, JOA recovery rate, or NDI between patients with different T1S. Patients with loss of CL postoperatively had lower JOA score and JOA recovery rate, but higher NDI than patients with sustained CL. Furthermore, patients with CL loss but compensate for it with reduction in T1S had lower CSVA, higher JOA score and JOA recovery rate than those with CL loss alone. Conclusions: Decreased T1S postoperatively prevents the tendency of the cervical spine to tilt forward by regulating CSVA and facilitates recovery of neurological function after cervical laminoplasty.

The discrepancy between preoperative cervical sagittal vertical axis and T1 slope predisposes inferior clinical outcomes in patients with cervical spondylotic myelopathy after cervical laminoplasty.

Objective: Cervical sagittal parameters have been widely used to predict clinical outcomes in patients with cervical spondylotic myelopathy (CSM). This study aims to coin a novel cervical sagittal parameter defined as the ratio of cervical sagittal vertical axis to T1 slope (CSVA/T1S) and to investigate the correlation between CSVA/T1S and postoperative HRQOL after laminoplasty. Methods: A total of 102 CSM patients treated with cervical laminoplasty from our database were retrospectively reviewed. All patients were followed up for >12 months. Radiological parameters were measured using lateral cervical radiographs, including occiput-C2 lordosis (OC2), cervical lordosis (CL), CSVA, and T1S. Clinical parameters included the Japanese Orthopedic Association (JOA) score, neck disability index (NDI), and JOA recovery rate. Patients were grouped by preoperative T1S, T1S-CL, and CSVA/T1S value, respectively. Clinical and radiological outcomes were compared between the groups. Results: Patients with high CSVA/T1S had greater OC2 and CSVA but lower CL than those in the low CSVA/T1S group pre-and postoperatively. With respect to HRQOL results, the final NDI was 12.46 ± 9.11% in the low CSVA/T1S group, which was significantly lower than that in the high CSVA/T1S group (17.68 ± 8.81%, P = 0.040). Moreover, only CSVA/T1S was detected to be significantly correlated with final NDI (r = 0.310, P = 0.027). No significant correlation was found between clinical results and other cervical sagittal parameters, including T1S, CSVA, and T1S-CL. Conclusions: Preoperative CSVA/T1S was correlated with postoperative NDI in patients with CSM after cervical laminoplasty. Patients with low preoperative CSVA/T1S achieved better neurological function improvement after cervical laminoplasty. Cervical laminoplasty could be an appropriate choice for patients with lower preoperative CSVA/T1S.

[Improved effects of saponins from Panax japonicus on decline of cognitive function in natural aging rats via NLRP3 inflammasome pathway].

The aim of this paper was to investigate the effect of total saponins from Panax japonicus( SPJ) on cognitive decline of natural aging rats and its mechanism. Thirty male SD rats of eighteen month old were randomly divided into three groups: aged group,10 mg·kg~(-1) SPJ-treated group and 30 mg·kg~(-1) SPJ-treated group. The SPJ-treated groups were given SPJ at the dosages of 10 mg·kg~(-1) and 30 mg·kg~(-1),respectively,from the age of 18 to 24 months. Aged group were lavaged the same amount of saline,10 six-month-old rats were used as control group,with 10 rats in each group. The open field test,novel object recognition and Morris water maze were performed to detect the changes of cognitive function in each group. The changes of synaptic transmission of long-term potentiation( LTP) in hippocampal CA1 region were detected by field potential recording. Western blot was used to detect the protein levels of NLRP3,ASC,caspase-1 and the changes of Glu A1,Glu A2,CAMKⅡ,CREB and phosphorylation of CAMKⅡ,CREB in each group.The results showed that SPJ could improve the decline of cognitive function in aging rats,reduce the damage of LTP in the hippocampal CA1 region of aged rats,and decrease the expression of NLRP3,ASC,caspase-1 in aging rats. At the same time,SPJ could enhance the membrane expression of AMPA receptor( Glu A1 and Glu A2),and increase the expression of p-CAMKⅡand p-CREB in aging rats.SPJ could improve cognitive decline of natural aging rats,and its mechanism may be related to regulating NLRP3 inflammasome,thus regulating the membrane expression of AMPA receptor,and enhancing the expression phosphorylation of CAMKⅡ and CREB.