• Peter G Passias, Tyler K Williamson, Oscar Krol, Peter S Tretiakov, Rachel Joujon-Roche, Bailey Imbo, Salman Ahmad, Claudia Bennett-Caso, Stephane Owusu-Sarpong, Jordan B Lebovic, Djani Robertson, Shaleen Vira, Ekamjeet Dhillon, Andrew J Schoenfeld, Muhammad B Janjua, Tina Raman, Themistocles S Protopsaltis, Constance Maglaras, Brooke O'Connell, Alan H Daniels, Carl Paulino, Bassel G Diebo, Justin S Smith, Frank J Schwab, Renaud Lafage, and Virginie Lafage.
• Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY.
• Spine. 2023 Jul 1; 48 (13): 930936930-936.

Study DesignRetrospective cohort study.ObjectiveAssess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes.Summary Of Background DataThe Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications.Materials And MethodsWe included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score.ResultsBaseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation.ConclusionThis study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity.Level Of EvidenceIII.Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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