Theprevalence of spinal metastatic disease (SMD) is increasing with the aging population and advances in medical as well as surgical care.1–3Medical, radiation, and surgical oncologists face the formidable challenge of assessing patients’ physical reserve and ability to tolerate spine surgery for metastatic disease. Prognostication of SMD-related surgical outcomes remains complicated by the need to consider numerous preoperative systemic variables known to influence postoperative outcomes, including demographics, medical comorbidities, biochemical abnormalities, poor ambulation, reduced performance status, and systemic disease burden.4An improved ability to assess patients’ systemic condition and estimate physical reserve may potentially aid risk stratification, facilitate targeted optimization or reversal of dynamic health conditions, and ease the decision-making process.
Numerous tools have been developed to aid the SMD-related decision-making process, including 1) performance scales for estimating functional status (e.g., Eastern Cooperative Oncology Group Performance Status [ECOG-PS]),52)系统accou预后nting for burden of disease (e.g., Tomita and Tokuhashi),6and 3) decision frameworks that facilitate the development of multimodal treatment plans (e.g., NOMS [neurological, oncological, mechanical, systemic]).7Furthermore, the concept of frailty is ubiquitous in medicine and is increasingly recognized among the surgical spine literature for an association with adverse events, mortality, and discharge disposition.8–12Frailty may be operationalized as either a phenotypic definition of decreased physical reserve and susceptibility to stressors13or a composite index of accumulating deficits (e.g., symptom, disease, biochemical, and radiographic abnormalities).14,15Frailty indices,16body composition analysis,17and radiographic measures of sarcopenia18have been applied in spinal oncology; however, their validity and clinical applicability have not been established.
到目前为止,脆弱在t尚未明确he context of SMD. Our overarching study purpose was to better understand how members of the AO Spine community conceptualize, define, and assess frailty in the context of SMD. To achieve this, we conducted a cross-sectional international survey of the AO Spine community. Our study objectives were to 1) assess respondents’ self-perceived level of knowledge regarding frailty in the context of SMD; 2) identify which preoperative variables were considered as surrogate markers of frailty in the context of SMD; 3) identify which postoperative clinical outcomes were perceived as being the most relevant in this population; and 4) investigate the presence of consensus on specific definitions, assessment, and cutoffs regarding the above pre- and postoperative variables.
开云体育世界杯赔率
Study Design and Population
The AO Spine Knowledge Forum Tumor (AOSKFT) is an international group of spine surgeons and oncologists seeking to advance the care of patients with SMD. We conducted a self-administered cross-sectional survey of the AO Spine community, the world’s largest society of international spine surgeons (www.aospine.org). This study was conducted and reported in adherence to the Checklist for Reporting of Survey Studies (CROSS) guidelines.19Ethics approval was not applicable because this article does not contain any studies with human subjects.
Survey Development and Testing
AOSKFT系统范围进行审查of the literature to identify preoperative systemic considerations associated with postoperative clinical outcomes in patients receiving surgery for SMD.4Subsequently, the AOSKFT performed a modified Delphi technique where members were surveyed regarding potential surrogate markers of frailty and clinically relevant outcomes in the context of SMD and survey questions were selected.20The 33-question survey (Supplementary Material A) was reviewed to reduce redundancy, optimize question clarity, and ensure face and content validity. The survey was structured to capture conceptualization, definition, and assessment of frailty in the context of SMD. The survey did not include patient data.
Survey Design
Demographics and details pertaining to practice were recorded. We assessed respondents’ preexisting perception of frailty in the context of SMD by inquiring about 1) agreement with a previously reported operational definition of frailty,14,212) self-perceived level of knowledge regarding frailty in SMD, and 3) the means by which they assess frailty and cognition in patients with SMD. Additionally, respondents were asked to indicate the degree to which 14 distinct preoperative variables represent surrogate markers of frailty in SMD. Participants indicated the degree to which 13 outcomes presented are clinically relevant.
Survey Administration
Voluntary survey responses were anonymously collected using SurveyMonkey. No financial incentive was provided. Participation in the survey was considered consent for enrollment in the study. The survey was distributed by email on January 21, 2022. A reminder email was sent on February 14, and the survey was closed on February 20, 2022. "Country of practice" was used to derive the "AO Spine region of practice." Respondents could select more than one practice focus. Respondent demographic data were used to ensure single survey participation.
Data Interpretation
Responses were summarized using descriptive statistics. A subgroup analysis was performed to stratify responses based on respondents’ subjective perceived level of knowledge regarding frailty in the context of SMD, whereby they indicated a higher (i.e., "moderate," "high") or lower (i.e., "I am not familiar," "limited") level of perceived knowledge. Respondents rated whether they considered the presented variables as surrogate markers of frailty or clinically relevant outcomes, respectively; possible rating categories included "not a frailty marker (or clinically relevant outcome)," "neutral or not sure," "yes," "yes, definitely," or "yes, most definitely." Consensus (defined as ≥ 70% agreement among respondents) was determined by collapsing the latter three groups of positive answers.20
Statistical Analysis
Categorical data were reported as frequency count (percentage) or proportion. Statistical differences were assessed for categorical variables with chi-square and Fisher’s exact tests where applicable. The Mann-Whitney U-test was used for rating questions. Quantitative analysis was performed using the open-source Pandas (version 1.4.1) package for Python (version 3.8.4) and R software (version 4.0.2, R Foundation for Statistical Computing), where applicable. Significance was defined as p < 0.05.
Results
Demographics
There were 359 respondents. The analysis was conducted for 312 responses. Forty-seven responses were excluded for only having completed the demographic section. Most respondents were male (n = 294, 94.2%) and between 35 and 54 years of age (n = 219, 70.2%) (Table 1). The practice specialties were most frequently orthopedics (n = 191, 61.2%) and neurosurgery (n = 111, 35.6%) (Table 1). Degenerative (n = 258, 82.7%), trauma (n = 234, 75.0%), and tumor (n = 233, 74.7%) were the most common practice foci. Study participants represented 71 countries spanning 6 geographic regions (Supplementary Material B). The 3 most common countries of practice were Canada (n = 37, 11.9%), the United States (n = 28, 9.0%), and Brazil (n = 20, 6.4%).
Respondent demographics
| Demographic | Answer Options | Overall (n = 312) | High LOK (n = 160) | Low LOK (n = 152) | p Value |
|---|---|---|---|---|---|
| Perceived LOK regarding frailty in SMD (n = 312) | High | 33 (10.6) | 33 (20.6) | 0 (0.0) | |
| Moderate | 127 (40.7) | 127 (79.4) | 0 (0.0) | ||
| Limited | 123 (39.4) | 0 (0.0) | 123 (80.9) | ||
| I am not familiar | 29 (9.3) | 0 (0.0) | 29 (19.1) | ||
| AO Spine region of practice (n = 312) | Asia Pacific | 59 (18.9) | 27 (16.9) | 32 (21.1) | 0.003* |
| Europe & Southern Africa | 99 (31.7) | 54 (33.8) | 45 (29.6) | ||
| Latin America | 49 (15.7) | 27 (16.9) | 22 (14.5) | ||
| Middle East & Northern Africa | 39 (12.5) | 10 (6.2) | 29 (19.1) | ||
| North America | 66 (21.2) | 42 (26.2) | 24 (15.8) | ||
| Sex (n = 312) | Male | 294 (94.2) | 151 (94.4) | 143 (94.1) | 0.896* |
| Female | 18 (5.8) | 9 (5.6) | 9 (5.9) | ||
| Age (n = 312) | 25–34 | 28 (9.0) | 15 (9.4) | 13 (8.6) | 0.284* |
| 35–44 | 133 (42.6) | 59 (36.9) | 74 (48.7) | ||
| 45–54 | 86 (27.6) | 51 (31.9) | 35 (23.0) | ||
| 55–64 | 47 (15.1) | 25 (15.6) | 22 (14.5) | ||
| ≥65 | 18 (5.8) | 10 (6.2) | 8 (5.3) | ||
| Practice specialty (n = 312) | 开云体育app官方网站下载入口 | 111 (35.6) | 56 (35.0) | 55 (36.2) | 0.119† |
| Orthopedics | 191 (61.2) | 102 (63.8) | 89 (58.6) | ||
| Other (please specify)‡ | 10 (3.2) | 2 (1.2) | 8 (5.3) | ||
| Practice focus (n = 312)§ | Degenerative | 258 (82.7) | 137 (85.6) | 121 (79.6) | 0.209* |
| Deformities | 155(49.7) | 87 (54.4) | 68 (44.7) | 0.112* | |
| Trauma/spinal cord injury | 234 (75.0) | 114 (71.3) | 120 (78.5) | 0.150* | |
| Tumor | 233 (74.7) | 133 (83.1) | 100 (65.8) | 0.001* | |
| Other (please specify) | 15 (4.8) | 10 (6.3) | 5 (3.3) | 0.292† | |
| Practice setting (n = 312) | Academic/university affiliate | 167 (53.5) | 95 (59.4) | 72 (47.4) | 0.123† |
| Private practice | 60 (19.2) | 30 (18.8) | 30 (19.7) | ||
| Public hospital or government/military hospital | 77 (24.7) | 32 (20.0) | 45 (29.6) | ||
| Other (please specify) | 8 (2.6) | 3 (1.9) | 5 (3.3) | ||
| Estimated population served (n = 311) | <100,000 | 23 (7.4) | 5 (3.1) | 18 (11.8) | 0.009† |
| 100,000–500,000 | 71 (22.8) | 37 (23.3) | 34 (22.4) | ||
| 500,000–1,000,000 | 63 (20.3) | 32 (20.1) | 31 (20.4) | ||
| 1,000,000–2,000,000 | 51 (16.4) | 22 (13.8) | 29 (19.1) | ||
| >2,000,000 | 103 (33.1) | 63 (39.6) | 40 (26.3) | ||
| Yrs in practice (n = 311) | <5 | 57 (18.3) | 24 (15.0) | 33 (21.9) | 0.133* |
| 5–10 | 88 (28.3) | 39 (24.4) | 49 (32.5) | ||
| 11–15 | 56 (18.0) | 33 (20.6) | 23 (15.2) | ||
| 16–20 | 40 (12.9) | 23 (14.4) | 17 (11.3) | ||
| >20 | 70 (22.5) | 41 (25.6) | 29 (19.2) | ||
| Completed a spine surgery fellowship? (n = 312) | No | 105 (33.7) | 46 (28.8) | 59 (38.8) | 0.078* |
| Yes | 207 (66.3) | 114 (71.2) | 93 (61.2) | ||
| Yrs since completing a spine surgery fellowship (n = 206) | <5 | 51 (24.8) | 23 (20.4) | 28 (30.1) | 0.236* |
| 5–10 | 51 (24.8) | 27 (23.9) | 24 (25.8) | ||
| 11–15 | 50 (24.3) | 31 (27.4) | 19 (20.4) | ||
| 16–20 | 21 (10.2) | 15 (13.3) | 6 (6.5) | ||
| >20 | 33 (16.0) | 17 (15.0) | 16 (17.2) | ||
| Patient case vol (n = 312) | <100 | 77 (24.7) | 31 (19.4) | 46 (30.3) | 0.391† |
| 100–200 | 126 (40.4) | 68 (42.5) | 58 (38.2) | ||
| 201–300 | 69 (22.1) | 38 (23.8) | 31 (20.4) | ||
| 301–400 | 17 (5.4) | 10 (6.2) | 7 (4.6) | ||
| 401–500 | 11 (3.5) | 6 (3.8) | 5 (3.3) | ||
| >500 | 12 (3.8) | 7 (4.4) | 5 (3.3) | ||
| Percent of work time in clinical practice (n = 310) | 0–25% | 11 (3.5) | 3 (1.9) | 8 (5.3) | 0.078† |
| 26–50% | 40 (12.9) | 15 (9.4) | 25 (16.7) | ||
| 51–75% | 99 (31.9) | 54 (33.8) | 45 (30.0) | ||
| >75% | 160 (51.6) | 88 (55.0) | 72 (48.0) | ||
| Percent of work time on research &/or teaching (n = 312) | 0–25% | 221 (70.8) | 109 (68.1) | 112 (73.7) | 0.073† |
| 26–50% | 75 (24.0) | 45 (28.1) | 30 (19.7) | ||
| 51–75% | 12 (3.8) | 6 (3.8) | 6 (3.9) | ||
| >75% | 4 (1.3) | 0 (0.0) | 4 (2.6) |
LOK = level of knowledge.
Values are given as number of respondents (%) unless otherwise indicated. Boldface type indicates statistical significance (p < 0.05).
Chi-square test.
Fisher’s exact test.
Spine surgery (n = 4; 1.3%), trauma surgery (n = 2; 0.64%), general surgery (n = 1; 0.32%), radiation oncology (n = 2; 0.64%), and perioperative nursing (n = 1; 0.32%), where the two high level-of-knowledge respondents include one from radiation oncology and one from trauma surgery.
Respondents could select multiple options.
Defining Frailty in the Context of SMD
Consensus (n = 263, 84.3%) was reached among respondents regarding the following definition of frailty for patients with spine metastases (adapted from the definition given by Shin et al.21): "a patient phenotype of multi-system diminished physical reserve or capacity predisposing to worse outcomes."
Perceived Level of Knowledge Regarding Frailty in the Context of SMD
Respondents indicated whether their perceived level of knowledge of frailty as it relates to SMD was high (n = 160, 51.3%) or low (n = 152, 48.7%) (Table 1). There were statistically significant differences identified across the 5 AO Spine regions of practice (p = 0.003) (Table 1) and according to estimated population served (p = 0.009) (Table 1). A high perceived level of knowledge was reported by a greater frequency of respondents who indicated "tumor" as their practice focus (42.6% vs 32.1%, p = 0.001). Perceived level of knowledge was not related to respondents’ age; sex; fellowship training; practice specialty; practice setting; years in practice; patient case volume; or time spent in clinical practice, research, and/or teaching.
Assessment of Frailty and Cognition in the Clinical Setting
Most respondents assess frailty by forming a general perception based on clinical condition and history provided by the patient (n = 201, 64.4%) (Table 2). Respondents with a high perceived level of knowledge were more likely to use a frailty index (p < 0.001). Respondents with a low perceived level of knowledge were more likely to not regularly assess frailty (p = 0.008).
Assessing frailty and cognition in patients with SMD
| Question | Answer Options | Overall (n = 312) | High LOK (n = 160) | Low LOK (n = 152) | p Value | Consensus |
|---|---|---|---|---|---|---|
| How do you currently assess frailty in metastatic spine tumor patients? (n = 312)* | I use a comorbidity scale, e.g., the American Society of Anesthesiologists (ASA) classification system or Charlson Comorbidity Index (CCI) | 128 (41) | 71 (44.4) | 57 (37.5) | 0.263† | No |
| I use a frailty index, e.g., the mFI or MSTFI | 83 (26.6) | 70 (43.8) | 13 (8.6) | <0.001† | ||
| I get a general perception based on the condition and history of the patient | 201 (64.4) | 103 (64.4) | 98 (64.5) | 0.920† | ||
| I do not assess frailty regularly | 19 (6.1) | 4 (2.5) | 15 (9.9) | 0.008‡ | ||
| Not sure | 5 (1.6) | 1 (0.6) | 4 (2.6) | 0.204‡ | ||
| Which cognitive scale would you use to assess metastatic spine tumor patients’ cognitive performance in daily clinical practice, including the emergency department? (n = 281) | 5-minute Montreal Cognitive Assessment (MOCA) test | 19 (6.8) | 10 (6.9) | 9 (6.6) | 0.053‡ | No |
| Mini-Mental State Exam (MMSE) | 74 (26.3) | 31 (21.4) | 43 (31.6) | |||
| Mini-Cog | 3 (1.1) | 2 (1.4) | 1 (0.7) | |||
| I do not use a formal cognitive test but I assess cognition by direct communication and/or input from family/caregivers | 139 (49.5) | 84 (57.9) | 55 (40.4) | |||
| I would not assess cognitive performance | 24 (8.5) | 9 (6.2) | 15 (11.0) | |||
| Not sure/other (please specify) | 22 (7.8) | 9 (6.2) | 13 (9.6) |
Values are given as number of respondents (%) unless otherwise indicated. Boldface type indicates statistical significance (p < 0.05).
Respondents could select multiple options.
Chi-square test.
Fisher’s exact test.
Most respondents, regardless of perceived level of knowledge, informally assess cognition by means of direct communication and/or input from family and caregivers (overall cohort, n = 139, 49.5%) (Table 2).
Perceived Surrogate Markers of Frailty in SMD
Among the overall cohort, we identified consensus regarding the association between 14 preoperative variables and frailty in SMD (Supplementary Material C); few differences were identified when stratifying based on respondents’ perceived level of knowledge. Low BMI did not reach consensus among respondents reporting a lower level of knowledge (n = 145, 67.6%). Weighted averages were derived for each surrogate marker to facilitate ranking based on the degree of perceived association with frailty (Table 3). For the overall cohort, the top 3 surrogate markers of frailty were severe comorbidities, extensive systemic disease burden, and poor performance status. Rank lists were similar when stratifying by perceived level of knowledge of frailty and SMD. Respondents with a high perceived level of knowledge, however, were more likely to indicate an association between frailty and poor performance status (p < 0.001).
Assessment of surrogate frailty variables for the overall cohort and stratified by respondents’ perceived level of knowledge
| Variable | Overall | High LOK | Low LOK | p Value* | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Rank | Median | Q1 | Q3 | Mean | SD | Rank | Median | Q1 | Q3 | Mean | SD | Rank | Median | Q1 | Q3 | ||
| Severe comorbidities | 2.19 | 0.90 | 1† | 2 | 2 | 3 | 2.23 | 0.88 | 2† | 2 | 2 | 3 | 2.15 | 0.93 | 2† | 2 | 1.75 | 3 | 0.234 |
| Extensive systemic disease burden | 2.16 | 0.90 | 2† | 2 | 2 | 3 | 2.17 | 0.90 | 3† | 2 | 2 | 3 | 2.15 | 0.91 | 1† | 2 | 2 | 3 | 0.441 |
| Poor performance status | 2.11 | 1.01 | 3† | 2 | 2 | 3 | 2.31 | 0.92 | 1† | 3 | 2 | 3 | 1.90 | 1.06 | 3† | 2 | 1 | 3 | <0.001 |
| Recent unplanned hospitalization secondary to complications of the underlying cancer | 1.61 | 0.90 | 4 | 2 | 1 | 2 | 1.65 | 0.89 | 6 | 2 | 1 | 2 | 1.57 | 0.91 | 6 | 2 | 1 | 2 | 0.248 |
| Ongoing cytotoxic chemotherapy &/or targeted therapy | 1.61 | 0.99 | 5 | 2 | 1 | 2 | 1.61 | 0.93 | 7 | 2 | 1 | 2 | 1.60 | 1.06 | 5 | 2 | 1 | 2 | 0.415 |
| Unintentional weight loss | 1.60 | 0.97 | 6 | 2 | 1 | 2 | 1.68 | 0.93 | 4 | 2 | 1 | 2 | 1.51 | 1.00 | 9 | 2 | 1 | 2 | 0.102 |
| Ineligibility to any further medical cancer therapy | 1.56 | 1.19 | 7 | 2 | 1 | 3 | 1.56 | 1.20 | 10 | 2 | 1 | 3 | 1.55 | 1.18 | 8 | 2 | 1 | 3 | 0.447 |
| Inability to walk secondary to spinal cord compression | 1.55 | 1.22 | 8 | 2 | 1 | 2.75 | 1.66 | 1.17 | 5 | 2 | 1 | 3 | 1.44 | 1.27 | 12 | 2 | 1 | 2 | 0.069 |
| Age | 1.55 | 0.98 | 9 | 2 | 1 | 2 | 1.54 | 1.01 | 11 | 2 | 1 | 2 | 1.56 | 0.95 | 7 | 2 | 1 | 2 | 0.488 |
| Poor cognitive performance | 1.54 | 1.17 | 10 | 2 | 1 | 2 | 1.61 | 1.11 | 8 | 2 | 1 | 2 | 1.47 | 1.22 | 10 | 2 | 1 | 2 | 0.204 |
| Moderate or severe thrombocytopenia (regardless of successful correction w/ transfusion) | 1.52 | 1.07 | 11 | 2 | 1 | 2 | 1.57 | 1.00 | 9 | 2 | 1 | 2 | 1.46 | 1.13 | 11 | 2 | 1 | 2 | 0.281 |
| Histology of the primary site of the cancer | 1.50 | 1.25 | 12 | 2 | 1 | 3 | 1.39 | 1.27 | 13 | 2 | 1 | 2 | 1.62 | 1.21 | 4 | 2 | 1 | 3 | 0.063 |
| Moderate or severe anemia (regardless of successful correction w/ transfusion) | 1.44 | 0.97 | 13 | 1 | 1 | 2 | 1.53 | 0.87 | 12 | 2 | 1 | 2 | 1.35 | 1.05 | 13 | 1 | 1 | 2 | 0.055 |
| Low BMI | 1.13 | 1.04 | 14 | 1 | 0 | 2 | 1.16 | 1.00 | 14 | 1 | 0 | 2 | 1.10 | 1.07 | 14 | 1 | 0 | 2 | 0.301 |
Q1 = quarter 1; Q3 = quarter 3.
Boldface type indicates statistical significance (p < 0.05).
Mann-Whitney U-test.
Top 3 ranked variables.
Respondents indicated whether they considered specific comorbidities significant with respect to frailty in the context of SMD (Table 4); consensus was identified for high-risk cardiopulmonary disease (85.8%), renal failure (84.8%), liver failure (79.0%), and malnutrition (81.0%). Most respondents indicated an association between frailty and past medical history of deep vein thrombosis and pulmonary embolism (62.3%), diabetes mellitus (55.5%), and stroke (50.3%).
Medical comorbidities as surrogate markers of frailty
| Question | Answer Options | Overall (n = 310) | High LOK (n = 158) | Low LOK (n = 152) | p Value | Consensus* |
|---|---|---|---|---|---|---|
| Which comorbidities do you consider significant with respect to frailty, concerning patients with spine metastases? (n = 310)† | High-risk cardiopulmonary diseases | 266 (85.8) | 139 (88.0) | 127 (83.6) | 0.504‡ | Yes |
| Diabetes mellitus | 172 (55.5) | 93 (58.9) | 79 (52.0) | 0.328‡ | No | |
| Stroke | 156 (50.3) | 87 (55.1) | 69 (45.4) | 0.141‡ | No | |
| Renal failure | 263 (84.8) | 138 (87.3) | 125 (82.2) | 0.413‡ | Yes | |
| Liver failure | 245 (79.0) | 132 (83.5) | 113 (74.3) | 0.106‡ | Yes | |
| Deep vein thrombosis/pulmonary embolism | 193 (62.3) | 101 (63.9) | 92 (60.5) | 0.722‡ | No | |
| Malnutrition | 251 (81.0) | 136 (86.1) | 115 (75.7) | 0.053‡ | Yes | |
| Other (please specify)§ | 12 (3.9) | 4 (2.5) | 8 (5.3) | 0.247¶ | No | |
| Not sure | 2 (0.6) | 1 (0.6) | 1 (0.7) | >0.999¶ | No |
Consensus was defined as ≥ 70% agreement.
Multiple answer options possible.
Chi-square test.
High perceived level of knowledge (osteoporosis, dementia, BMI, cachexia, pleural effusion, and low pulmonary reserve); low perceived level of knowledge (psychiatric disease, histology of primary cancer, tobacco use, sarcopenia, obesity, osteoporosis, inability to function independently, and neurological deficit).
Fisher’s exact test.
Respondents were queried regarding definitions and cutoff thresholds for surrogate markers of frailty (Supplementary Material D). Consensus was identified regarding quantification of systemic disease burden, which included the presence of metastases to major internal organs (85.0%). Metastases to the brain reached consensus among only respondents reporting with a high perceived level of knowledge (72.2%). Consensus was attained for the definition of unintentional weight loss as > 5% of one’s body weight over the past 3 months (80.6%).
Perceived Clinically Relevant Outcomes in SMD
Consensus was identified regarding the relevance of 11 clinical outcome measures in the setting of SMD (Supplementary Material E). The top 3 outcomes based on ranked weighted averages were major complications, neurological recovery, and change in performance status (Table 5). Respondents with a high perceived level of knowledge were more likely to consider change in health-related quality of life (HRQOL) (p = 0.006), change in performance status (p = 0.006), unintended delay in cancer treatment (p = 0.014), unplanned spinal reoperation (p = 0.015), local control at the surgical site (p = 0.045), neurological recovery (p = 0.014), and major complications (p = 0.013) as clinically relevant outcomes compared with those with a low perceived level of knowledge.
Assessment of variables as clinically relevant outcomes for the overall cohort and stratified by respondents’ perceived level of knowledge
| Variable | Overall | High LOK | Low LOK | p Value* | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Rank | Median | Q1 | Q3 | Mean | SD | Rank | Median | Q1 | Q3 | Mean | SD | Rank | Median | Q1 | Q3 | ||
| Major complications | 2.10 | 0.86 | 1† | 2 | 2 | 3 | 2.21 | 0.79 | 1† | 2 | 2 | 3 | 1.97 | 0.91 | 1† | 2 | 1 | 3 | 0.013 |
| Neurological recovery | 1.90 | 0.97 | 2† | 2 | 1 | 3 | 2.01 | 0.98 | 2† | 2 | 1 | 3 | 1.78 | 0.96 | 2† | 2 | 1 | 3 | 0.014 |
| Change in performance status | 1.73 | 0.94 | 3† | 2 | 1 | 2 | 1.87 | 0.92 | 3† | 2 | 1 | 3 | 1.59 | 0.95 | 4 | 2 | 1 | 2 | 0.006 |
| Overall survival | 1.70 | 1.13 | 4 | 2 | 1 | 3 | 1.68 | 1.10 | 5 | 2 | 1 | 3 | 1.72 | 1.16 | 3† | 2 | 1 | 3 | 0.344 |
| Time-to-event regarding mortality | 1.61 | 1.03 | 5 | 2 | 1 | 2 | 1.68 | 1.00 | 6 | 2 | 1 | 2 | 1.54 | 1.06 | 5 | 2 | 1 | 2 | 0.116 |
| Unplanned reop related to recent spine surgery | 1.58 | 1.01 | 6 | 2 | 1 | 2 | 1.72 | 0.92 | 4 | 2 | 1 | 2 | 1.44 | 1.09 | 6 | 1 | 1 | 2 | 0.015 |
| Change in HRQOL | 1.51 | 1.03 | 7 | 2 | 1 | 2 | 1.66 | 0.99 | 7 | 2 | 1 | 2 | 1.35 | 1.04 | 7 | 1 | 1 | 2 | 0.006 |
| Local control at surgical site concerning spine surgery | 1.46 | 1.04 | 8 | 1 | 1 | 2 | 1.58 | 0.96 | 8 | 2 | 1 | 2 | 1.35 | 1.11 | 8 | 1 | 1 | 2 | 0.045 |
| Unplanned readmission for any reason following spine surgery | 1.31 | 0.92 | 9 | 1 | 1 | 2 | 1.37 | 0.88 | 9 | 1 | 1 | 2 | 1.24 | 0.95 | 9 | 1 | 1 | 2 | 0.141 |
| Unintended change or delay in cancer treatment plan | 1.22 | 0.97 | 10 | 1 | 1 | 2 | 1.35 | 0.93 | 10 | 1 | 1 | 2 | 1.08 | 0.99 | 10 | 1 | 0 | 2 | 0.014 |
| Nonhome discharge | 1.07 | 1.08 | 11 | 1 | 0 | 2 | 1.15 | 1.06 | 11 | 1 | 1 | 2 | 0.98 | 1.10 | 11 | 1 | 0 | 2 | 0.084 |
| Minor complications | 0.78 | 1.01 | 12 | 1 | 0 | 1 | 0.78 | 1.07 | 12 | 1 | 0 | 1 | 0.78 | 0.94 | 12 | 1 | 0 | 1 | 0.344 |
| Cost-effectiveness | 0.66 | 1.13 | 13 | 1 | 0 | 1 | 0.63 | 1.11 | 13 | 1 | 0 | 1 | 0.69 | 1.16 | 13 | 1 | 0 | 1 | 0.387 |
Boldface type indicates statistical significance (p < 0.05).
Mann-Whitney U-test.
Top 3 ranked variables.
We identified consensus regarding potential "major postoperative complications" following surgery for SMD, including neurological deterioration ≥ 1 American Spinal Injury Association (ASIA) grade (72.2%), new nonambulatory status (80.8%), deep surgical site infection or wound dehiscence requiring reoperation (72.6%), major organ failure (80.8%), myocardial infarction or arrythmia (70.1%), and pulmonary embolism (74.0%) (Supplementary Material F). Respondents with a perceived high level of knowledge were more likely to consider systemic infection (71.7%, p = 0.035) and pneumonia requiring ICU transfer (71.0%, p = 0.007) as major complications. Consensus was reached (n = 104, 72.2%) among respondents with a high perceived level of knowledge regarding the definition of a major complication according to the grading proposed by the Spinal Adverse Events Severity System, version 2 (Supplementary Material G).
Discussion
This is the first international assessment of perceptions of frailty in the context of SMD. Respondents recognized that frailty is important, but they most commonly evaluate it based on general clinical impression rather than using objective frailty assessment tools. Severe comorbidities, extensive systemic disease burden, and poor performance status were considered the most important surrogate markers of frailty in this patient population. Major complications, neurological recovery, and change in performance status were considered the most clinically relevant outcomes in SMD. This study represents an important first step toward objectively defining the multidimensional nature of frailty in SMD.
Decision-Making in SMD: A Persistent Challenge
Despite clear surgical indications for patients with SMD,22decision-making remains complicated by numerous preoperative oncological and systemic variables.4Tools capturing systemic condition and oncological disease burden have been independently used to estimate survival and guide SMD-related decision-making.5,23–25Most of these tools are outdated, suffer from poor accuracy, and lack systemic variables known to influence clinical outcomes in this patient population.4,26–29Our group summarized emerging evidence relating systemic considerations to clinical outcomes following surgery for SMD.4Older age, low BMI, weight loss, comorbidity burden, nonambulatory status, biochemical abnormalities, malnutrition, and systemic disease burden predicted worse survival, increased complications, and worse HRQOL.4Systemic condition is a consideration in the NOMS decision-making framework for SMD.7However, NOMS lacks granularity regarding the role of systemic condition, vaguely stratifying based on patients’ ability to tolerate surgery. To date, there is no widely accepted tool for evaluating patients’ systemic condition, stratifying patients’ surgical risk, or determining the appropriate degree of surgical invasiveness in the context of SMD. The latter represents an important area for future studies given advancements in minimally invasive surgical techniques,2providing benefit to patients that previously would have been considered unable to tolerate surgery.30–32
Frailty in the SMD Population: Limitations of Current Assessment Tools
Conceptually, frailty is an attractive surrogate for systemic condition. Frailty has been widely studied in medicine13and surgery.33In spine surgery, frailty predicts postoperative adverse events, mortality, hospital length of stay, and discharge disposition.8This trend is observed across various pathologies (e.g., degenerative,9,21,34deformity,35and SMD).16,36Most survey respondents indicated they subjectively assess frailty and cognition by forming a general clinical impression, direct communication, and/or input from family and caregivers. Only a minority of respondents use an objective frailty index; this may reflect a juxtaposition between emergency decision-making regarding early surgical intervention and the time necessary to complete a comprehensive frailty index, particularly in the after-hours setting.
Objective tools used to assess frailty in spine surgery include the modified frailty index (mFI)9,21,34,35and Metastatic Spine Tumor Frailty Index (MSTFI).16The limitations of these and other existing tools include the absence of clearly defined cutoff values, heterogeneous cohorts, poor generalizability, and inconsistent endpoint outcomes limiting comparability across studies.8Moskven et al. critically appraised the literature regarding frailty tools utilized in spinal surgery and found these these tools have been applied without formal evaluation of clinimetric properties, have poor objectivity, and may not be clinically applicable (e.g., lengthy questionnaires that cannot be reasonably completed in clinical practice).10There remains a need for clinically robust, objective tools for assessing frailty in the context of spine surgery.
Although the mFI performs well in the general spine surgery population, results have varied in the context of SMD. Bourassa-Moreau et al. found neither the mFI nor the MSTFI predicted postoperative adverse events in patients undergoing urgent surgery for SMD.18This may relate to the mFI containing general comorbidities but not oncological variables. The MSTFI contains components related to surgical approach and case acuity, which should not be included in frailty tools as they are not influenced by physiological reserve.8,16,37The construct, content, and predictive validity of the MSTFI are unclear. The values used to stratify frailty are dichotomous, are not weighted for strength of association, and were arbitrarily chosen without formal assessment. Furthermore, Massaad et al. found that the MSTFI demonstrated poor discrimination for predicting complications and in-hospital mortality.38Objective measures of frailty may simplify decision-making, reduce bias in patient evaluation, guide risk stratification, and improve the accuracy of clinical outcome prognostication,13but they remain to be developed for SMD. In the absence of a clinimetrically sound frailty tool, the AOSKFT suggests an approach to the evaluation of frailty in spinal oncology that includes an awareness of the phenotypic consensus definition of frailty in patients with SMD (defined herein),21in combination with careful consideration of surrogate markers of frailty (Table 3) and medical comorbidities (Table 4) considered most important by the AO Spine community.
Toward the Development of an Objective Measure of Frailty in SMD
Given the clinimetric constraints of existing frailty tools in the SMD population, the objective of this survey was to formally assess perceptions of frailty, identify surrogate markers, and define relevant cutoff thresholds for such markers. We attained consensus regarding 14 preoperative surrogate markers of frailty. Severe comorbidities, extensive systemic disease burden, poor performance status, recent unplanned hospitalization secondary to complications of the underlying cancer, and ongoing chemotherapy and/or targeted therapy were most associated with frailty. Consensus was also attained regarding specific severe comorbidities associated with frailty, including high-risk cardiopulmonary disease, renal and liver failure, and malnutrition. While tumor histology is an important prognostic consideration, respondents considered it less important in relation to the evaluation of frailty (Table 3). We also identified clinically relevant outcomes that might be the focus of future study. Major complications, neurological recovery, change in performance status, overall survival, and time to event regarding mortality were considered the most clinically relevant outcomes. Historically, outcomes of interest in this population have been postoperative survival and adverse event rates. Recently, there has been a shift in the SMD literature toward the impact of surgery on HRQOL.4,39Despite this, improved HRQOL was ranked 7 of 13.
我们的调查结果可以用来开发一个clinimetrically sound frailty tool for use in patients with SMD. During the SMD-related decision-making process, surgeons often collaborate with internists and medical and radiation oncologists to optimize patients preoperatively, assess their ability to tolerate surgery, and predict clinical outcome. An appropriately validated and clinimetrically sound tool for assessing frailty in this patient population would likely be of use to the entire collaborative, multidisciplinary decision-making team.
Strengths and Limitations
本研究得益于广泛代表性,我ncluding 71 countries around the world. The stratification of responses based on perceived level of knowledge is subjective and self-reported but accompanies findings for the overall cohort. This subgroup analysis was conducted to tease out any potential differences based on prior knowledge. The survey study design used herein was methodologically strengthened using a modified Delphi approach with the input of numerous expert spinal oncologists, similar to the initial development of other widely accepted tools used in spinal oncology.40
Conclusions
Here, we surveyed the international AO Spine community regarding perceptions of frailty in the context of SMD. This study represents a first step toward defining the multidimensional nature of frailty in this patient population and may guide the future development of a clinimetrically robust tool for assessing frailty in patients with SMD.
Acknowledgments
This study was organized by the AO Spine Knowledge Forum Tumor, a group of international spine oncology experts. AO Spine is a clinical division of the AO Foundation, which is an independent medically guided not-for-profit organization.
Disclosures
Charest-Morin博士报道授予从AO脊柱d the North American Spine Society paid to institutions outside the submitted work. Dr. Goodwin reported grants from NIH/NINDS, FDA, and Robert Wood Johnson; and personal fees from Medtronic outside the submitted work. Dr. Goodwin is also the deputy editor forSpine。从脊柱Wav Laufer博士报道个人费用e and Globus outside the submitted work. Dr. Dea reported personal fees from Medtronic, Cerapedics, and Stryker outside the submitted work. Dr. O’Toole reported consulting for Globus Medical and stock ownership in Viseon Inc. outside the submitted work. Dr. Sciubba reported personal fees from DePuy-Synthes, Medtronic, Stryker, and Baxter outside the submitted work. Dr. Stephens reported grants from NuVasive and Stryker outside the submitted work. Dr. Bettegowda reported consulting for DePuy-Synthes, Bionaut Labs, Haystack Oncology, Privo Technologies, and Galectin Therapeutics; and is the co-founder of OrisDX and Belay Diagnostics. Dr. Myrehaug reported personal fees from AAA/Novartis outside the submitted work. Dr. Sahgal reported personal fees from Varian (travel/accommodations/speaking engagements/educational lectures), Elekta AB (accommodations/speaking engagements/educational lectures/consulting), AstraZeneca and Brainlab (accommodations/speaking engagements/educational lectures), Seagen and Merck (speaking engagements/educational lectures), and the International Stereotactic Radiosurgery Society (ISRS) and AO Spine Knowledge Forum Tumor (AOSKFT) (travel/accommodation funding) outside the submitted work; consulting for Varian, Elekta (Gamma Knife Icon), Brainlab, Merck, AbbVie, and Roche; research grants from Elekta AB, Varian, Seagen Inc., and Brainlab; honoraria from AstraZeneca, Elekta AB, Varian, Brainlab, Accuray, Seagen, and Merck (for past educational seminars); and travel accommodations/expenses from Elekta, Varian, and Brainlab. Dr. Sahgal is also vice president of the ISRS, co-chair of the AOSKFT, member of the Elekta MR Linac Research Consortium, and Clinical Steering Committee member and chair of the Elekta Oligometastases Group and Elekta Gamma Knife Icon Group. Ms. Germscheid reported personal fees (employee) from the AO Foundation during the conduct of the study.
Author Contributions
Conception and design: MacLean, Georgiopoulos, Charest-Morin, Goodwin, Laufer, Dea, Shin, O’Toole, Sciubba, Stephens, Myrehaug, Disch, Kumar, Sahgal, Germscheid. Acquisition of data: MacLean, Georgiopoulos, Dea, Rhines, Fehlings, Myrehaug, Sahgal, Germscheid, Weber. Analysis and interpretation of data: MacLean, Georgiopoulos, Charest-Morin, Goodwin, Laufer, Dea, Shin, O’Toole, Sciubba, Stephens, Bettegowda, Sahgal, Germscheid. Drafting the article: MacLean, Goodwin, Disch, Kumar, Sahgal. Critically revising the article: MacLean, Georgiopoulos, Charest-Morin, Goodwin, Laufer, Dea, Shin, Gokaslan, O’Toole, Fehlings, Stephens, Bettegowda, Myrehaug, Disch, Kumar, Sahgal, Germscheid. Reviewed submitted version of manuscript: MacLean, Georgiopoulos, Goodwin, Laufer, Dea, Shin, Gokaslan, Rhines, O’Toole, Sciubba, Fehlings, Stephens, Myrehaug, Disch, Netzer, Kumar, Sahgal, Germscheid. Approved the final version of the manuscript on behalf of all authors: MacLean. Statistical analysis: Sahgal, Germscheid. Administrative/technical/material support: Fehlings, Sahgal, Germscheid. Study supervision: Charest-Morin, Goodwin, Sahgal.
Supplemental Information
Online-Only Content
Supplemental material is available with the online version of the article.
Supplementary Material A–G.//www.prize-show.com/doi/suppl/10.3171/2023.1.SPINE221433。
Abstract Presentations
This paper will be presented at the 39th Annual AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves 2023 Spine Summit Meeting, Miami, Florida, March 19, 2023.
References
-
1 ↑
ColbySL,OrtmanJM。Projections of the Size and Composition of the U.S. Population: 2014-2060。United States Census Bureau。March 3, 2015. Accessed February 3, 2023.https://www.census.gov/library/publications/2015/demo/p25-1143.html
-
2 ↑
BarzilaiO,FisherCG,BilskyMH。State of the art treatment of spinal metastatic disease。开云体育app官方网站下载入口。2018;82(6):757–769。
-
3 ↑
RothrockRJ,BarzilaiO,ReinerAS,et al.Survival trends after surgery for spinal metastatic tumors: 20-year cancer center experience。开云体育app官方网站下载入口。2021;88(2):402–412。
-
4 ↑
MacLeanMA,TouchetteCJ,GeorgiopoulosM,et al.Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review。Lancet Oncol。2022;23(7):e321–e333。
-
5 ↑
AzamF,LatifMF,FarooqA,et al.Performance status assessment by using ECOG (Eastern Cooperative Oncology Group) score for cancer patients by oncology healthcare professionals。Case Rep Oncol。2019;12(3):728–736。
-
6 ↑
ChoiD,RicciardiF,艺术M,et al.Prediction accuracy of common prognostic scoring systems for metastatic spine disease: results of a prospective international multicentre study of 1469 patients。Spine (Phila Pa 1976)。2018;43(23):1678–1684。
-
7 ↑
LauferI,RubinDG,LisE,et al.The NOMS framework: approach to the treatment of spinal metastatic tumors。Oncologist。2013;18(6):744–751。
-
8 ↑
MoskvenE,Bourassa-MoreauÉ,Charest-MorinR,FlexmanA,StreetJ。The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature。Spine J。2018;18(12):2354–2369。
-
9 ↑
FlexmanAM,Charest-MorinR,StobartL,StreetJ,RyersonCJ。Frailty and postoperative outcomes in patients undergoing surgery for degenerative spine disease。Spine J。2016;16(11):1315–1323。
-
10 ↑
MoskvenE,Charest-MorinR,FlexmanAM,StreetJT。The measurements of frailty and their possible application to spinal conditions: a systematic review。Spine J。2022;22(9):1451–1471。
-
11
FlexmanAM,StreetJ,Charest-MorinR。The impact of frailty and sarcopenia on patient outcomes after complex spine surgery。Curr Opin Anaesthesiol。2019;32(5):609–615。
-
12 ↑
Beauchamp-ChalifourP,FlexmanAM,StreetJT,et al.The impact of frailty on patient-reported outcomes after elective thoracolumbar degenerative spine surgery。J Neurosurg Spine。2021;35(5):607–615。
-
13 ↑
CleggA,YoungJ,IliffeS,RikkertMO,RockwoodK。Frailty in elderly people。Lancet。2013;381(9868):752–762。
-
14 ↑
RockwoodK,SongX,MacKnightC,et al.A global clinical measure of fitness and frailty in elderly people。CMAJ。2005;173(5):489–495。
-
15 ↑
SearleSD,MitnitskiA,GahbauerEA,GillTM,RockwoodK。A standard procedure for creating a frailty index。BMC Geriatr。2008;8(1):24。
-
16 ↑
De la Garza RamosR,GoodwinCR,JainA,et al.Development of a metastatic spinal tumor frailty index (MSTFI) using a nationwide database and its association with inpatient morbidity, mortality, and length of stay after spine surgery。World Neurosurg。2016;95:548–555.e4。
-
17 ↑
MassaadE,BridgeCP,KiapourA,et al.Evaluating frailty, mortality, and complications associated with metastatic spine tumor surgery using machine learning-derived body composition analysis。J Neurosurg Spine。2022;37(2):263–273。
-
18 ↑
Bourassa-MoreauÉ,VersteegA,MoskvenE,et al.Sarcopenia, but not frailty, predicts early mortality and adverse events after emergent surgery for metastatic disease of the spine。Spine J。2020;20(1):22–31。
-
19 ↑
SharmaA,Minh DucNT,Luu Lam ThangT,et al.A consensus-based Checklist for Reporting of Survey Studies (CROSS)。J Gen Intern Med。2021;36(10):3179–3187。
-
20 ↑
KellySE,MoherD,CliffordTJ。Defining rapid reviews: a modified Delphi consensus approach。Int J Technol Assess Health Care。2016;32(4):265–275。
-
21 ↑
ShinJI,KothariP,PhanK,et al.Frailty index as a predictor of adverse postoperative outcomes in patients undergoing cervical spinal fusion。Spine (Phila Pa 1976)。2017;42(5):304–310。
-
22 ↑
LauferI,ZuckermanSL,BirdJE,et al.Predicting neurologic recovery after surgery in patients with deficits secondary to MESCC: systematic review。Spine (Phila Pa 1976)。2016;41(suppl 20):S224-S230。
-
23 ↑
TomitaK,KawaharaN,KobayashiT,YoshidaA,MurakamiH,AkamaruT。Surgical strategy for spinal metastases。Spine (Phila Pa 1976)。2001;26(3):298–306。
-
24
TokuhashiY,MatsuzakiH,OdaH,OshimaM,RyuJ。A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis。Spine (Phila Pa 1976)。2005;30(19):2186–2191。
-
25 ↑
deKockI,MirhosseiniM,LauF,et al.Karnofsky转换性能状态(KPS)nd Eastern Cooperative Oncology Group Performance Status (ECOG) to Palliative Performance Scale (PPS), and the interchangeability of PPS and KPS in prognostic tools。J Palliat Care。2013;29(3):163–169。
-
26 ↑
ChoiD,BilskyM,FehlingsM,FisherC,GokaslanZ。Spine oncology—metastatic spine tumors。开云体育app官方网站下载入口。2017;80(3S):S131–S137。
-
27
BollenL,WibmerC,Van der LindenYM,et al.Predictive value of six prognostic scoring systems for spinal bone metastases: an analysis based on 1379 patients。Spine (Phila Pa 1976)。2016;41(3):E155–E162。
-
28
LeithnerA,RadlR,GruberG,et al.Predictive value of seven preoperative prognostic scoring systems for spinal metastases。Eur Spine J。2008;17(11):1488–1495。
-
29 ↑
NaterA,TetreaultLA,KopjarB,et al.Predictive factors of survival in a surgical series of metastatic epidural spinal cord compression and complete external validation of 8 multivariate models of survival in a prospective North American multicenter study。Cancer。2018;124(17):3536–3550。
-
30 ↑
KumarN,TanJH,ThomasAC,et al.The utility of ‘minimal access and separation surgery’ in the management of metastatic spine disease。Global Spine J。Published online February 28,2022. doi:10.1177/21925682211049803
-
31
PapalexisN,ParmeggianiA,PetaG,SpinnatoP,MiceliM,FacchiniG。Minimally invasive interventional procedures for metastatic bone disease: a comprehensive review。Curr Oncol。2022;29(6):4155–4177。
-
32 ↑
TannouryC,BeeramI,SinghV,SaadeA,BhaleR,TannouryT。The role of minimally invasive percutaneous pedicle screw fixation for the management of spinal metastatic disease。World Neurosurg。2022;159:e453–e459。
-
33 ↑
ShinallMCJr,AryaS,YoukA,et al.Association of preoperative patient frailty and operative stress with postoperative mortality。JAMA Surg。2020;155(1):e194620。
-
34 ↑
PhanK,KimJS,LeeNJ,et al.Frailty is associated with morbidity in adults undergoing elective anterior lumbar interbody fusion (ALIF) surgery。Spine J。2017;17(4):538–544。
-
35 ↑
LevenDM,LeeNJ,KothariP,et al.Frailty index is a significant predictor of complications and mortality after surgery for adult spinal deformity。Spine (Phila Pa 1976)。2016;41(23):E1394–E1401。
-
36 ↑
MedvedevG,WangC,CyriacM,AmdurR,O’BrienJ。Complications, readmissions, and reoperations in posterior cervical fusion。Spine (Phila Pa 1976)。2016;41(19):1477–1483。
-
37 ↑
DeaN,VersteegA,FisherC,et al.Adverse events in emergency oncological spine surgery: a prospective analysis。J Neurosurg Spine。2014;21(5):698–703。
-
38 ↑
MassaadE,WilliamsN,HadzipasicM,et al.Performance assessment of the metastatic spinal tumor frailty index using machine learning algorithms: limitations and future directions。Neurosurg Focus。2021;50(5):E5。
-
39 ↑
Paulino PereiraNR,GrootOQ,VerlaanJJ,et al.Quality of life changes after surgery for metastatic spinal disease: a systematic review and meta-analysis。Clin Spine Surg。2022;35(1):38–48。
-
40 ↑
FisherCG,DiPaolaCP,RykenTC,et al.A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group。Spine (Phila Pa 1976)。2010;35(22):E1221–E1229。
