Department of Orthopedics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; Department of Orthopaedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan; Department of Orthopaedic Surgery, National Defense Medical College, 3-2, Namniki, Tokorozawa, Saitama, 359-8513, Japan.
Department of Orthopedics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; Department of Research, Sint Maartenskliniek, P.O. Box 9011, 6500 GM Nijmegen, The Netherlands.
Spine J. 2022 Jul;22(7):1191-1204. doi: 10.1016/j.spinee.2022.01.017. Epub 2022 Feb 3.
Frailty as a concept is not yet fully understood, and is not the same as comorbidity. It is associated with an increased risk of adverse events and mortality after surgery, which makes its preoperative assessment significant. Despite its relevance, it still remains unclear which scales are appropriate for use in patients with spinal pathology.
To evaluate the feasibility and measurement properties of frailty scales for spine patients, specifically with adult spinal deformity (ASD), and to propose adequate scales for primary triage to prevent surgery in too frail patients and for preoperative assessment to modify patients' condition and surgical plans.
STUDY DESIGN/SETTING: Systematic review.
Systematic search was performed between 2010 and 2021 including terms relating to spinal disorders, frailty scales, and methodological quality. Characteristics of the studies and frailty scales and data describing relation to treatment outcomes were extracted. The risk of bias was determined with the QAREL score.
Of the 1993 references found, 88 original studies were included and 23 scales were identified. No prospective interventional study was found where the preoperative frailty assessment was implemented. Predictive value of scales for surgical outcomes varied, dependent on spinal disorders, type of surgeries, patients' age and frailty at baseline, and outcomes. Seventeen studies reported measurement properties of eight scales but these studies were not free of bias. In 30 ASD studies, ASD-Frailty Index (ASD-FI, n=14) and 11-item modified Frailty Index (mFI-11, n=11) were most frequently used. These scales were mainly studied in registry studies including young adult population, and carry a risk of sample bias and make their validity in elderly population unclear. ASD-FI covers multidisciplinary concepts of frailty with 40 items but its feasibility in clinical practice is questionable due to its length. The Risk Analysis Index, another multidisciplinary scale with 14 items, has been implemented for preoperative assessment in other surgical domains and was proven to be feasible and effective in interventional prospective studies. The FRAIL is a simple questionnaire with five items and its predictive value was confirmed in prospective cohort studies in which only elderly patients were included.
No adequate scale was identified in terms of methodological quality and feasibility for daily practice. Careful attention should be paid when choosing an adequate scale, which depends on the setting of interest (eg triage or preoperative work-up). We recommend to further study a simple and predictive scale such as FRAIL for primary triage and a comprehensive and feasible scale such as Risk Analysis Index for preoperative assessment for patients undergoing spine surgery, as their adequacy has been shown in other medical domains.
虚弱是一个尚未被充分理解的概念，它与合并症不同。它与手术后不良事件和死亡率的增加相关，这使得术前评估变得非常重要。尽管它很重要，但仍然不清楚哪些量表适用于脊柱疾病患者。
评估虚弱量表在脊柱患者中的可行性和测量特性，特别是在成人脊柱畸形（ASD）患者中，并提出适当的量表用于初步分诊，以防止过于虚弱的患者接受手术，并进行术前评估以改善患者的状况和手术计划。
研究设计/设置：系统评价。
系统检索了 2010 年至 2021 年期间与脊柱疾病、虚弱量表和方法学质量相关的术语。提取了研究和虚弱量表的特征以及描述与治疗结果关系的数据。使用 QAREL 评分确定偏倚风险。
在 1993 条参考文献中，纳入了 88 项原始研究，并确定了 23 个量表。未发现前瞻性干预研究实施了术前虚弱评估。量表对手术结果的预测价值因脊柱疾病、手术类型、患者年龄和基线时的虚弱程度以及结果而异。17 项研究报告了 8 个量表的测量特性，但这些研究并非没有偏倚。在 30 项 ASD 研究中，ASD 虚弱指数（ASD-FI，n=14）和 11 项改良虚弱指数（mFI-11，n=11）最常被使用。这些量表主要在包括年轻成年人的注册研究中进行研究，存在样本偏倚的风险，使其在老年人群中的有效性不明确。ASD-FI 涵盖了虚弱的 40 个项目的多学科概念，但由于其长度，其在临床实践中的可行性值得怀疑。另一个多学科量表 Risk Analysis Index，有 14 个项目，已在其他外科领域的前瞻性研究中用于术前评估，在干预性前瞻性研究中被证明是可行和有效的。FRAIL 是一个简单的五项目问卷，其预测价值在仅纳入老年人的前瞻性队列研究中得到了证实。
就方法学质量和日常实践的可行性而言，没有确定合适的量表。在选择合适的量表时应谨慎，这取决于感兴趣的设置（例如分诊或术前检查）。我们建议进一步研究一种简单且具有预测性的量表，如 FRAIL，用于初步分诊，以及一种全面且可行的量表，如 Risk Analysis Index，用于接受脊柱手术的患者的术前评估，因为它们在其他医学领域的适用性已得到证实。
