Aims The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m2 (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than 'not frail' patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally.

中文翻译：

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虚弱的患者需要对更近端的椎骨进行器械操作，以便在成人脊柱畸形手术后取得成功。


目的 本研究的目的是调查上器械椎骨 （UIV） 水平对接受成人脊柱畸形 （ASD） 手术的虚弱患者的影响。方法 使用 ASD 改良衰弱指数将接受 T9 到骨盆融合的成人脊柱畸形患者分为非虚弱、虚弱和严重虚弱类别。ASD 被定义为以下至少一种：脊柱侧弯≥ 20°，矢状垂直轴 （SVA） ≥ 5 cm，或骨盆倾斜≥ 25°。均值比较检验用于评估两组之间的差异。采用 Logistic 回归分析分析衰弱类别、 UIV 和结局之间的关联。结果 共纳入 477 例患者 （平均年龄 60.3 岁 （SD 14.9），平均 BMI 27.5 kg/m2 （SD 5.8），平均查尔森合并症指数 （CCI） 1.67 （SD 1.66））。总体而言，74% 的患者为女性 （n = 353），49.6% 的患者不虚弱 （237），35.4% 的患者虚弱 （n = 169），15% 的患者严重虚弱 （n = 71）。基线时，年龄、 BMI 、 CCI 和畸形的差异显著 （均 p = 0.001）。总体而言，15.5% 的患者 （n = 74） 在两年内出现机械并发症 （8.1% 不虚弱 （n = 36），15.1% 虚弱 （n = 26），16.3% 严重虚弱 （n = 12）;p = 0.013）。组间再次手术也存在差异 （20.2% （n = 48） vs 23.3% （n = 39） vs 32.6% （n = 23）;p = 0.011）。控制骨质疏松症、基线畸形和矫正程度（通过矢状面年龄调整评分 （SAAS） 匹配），虚弱和严重虚弱的患者如果患有心力衰竭 （比值比 （OR） 6.6 （95% CI 1.6 至 26.7;p = 0.008）、抑郁 （OR 5.1 （95% CI 1.1 至 25.7）;p = 0.048） 或癌症 （OR 1.5 （95% CI 1.1 至 1.4）;p = 0.004）。 虚弱和重度虚弱患者在两年内发生机械并发症的几率高于“非虚弱”患者 （19% （n = 45） vs 11.9% （n = 29）;p = 0.003）。当控制严重虚弱和虚弱患者的基线畸形和矫正程度时，如果严重虚弱患者有更近端的 UIV，则在两年内不太可能出现临床相关的近端交界性后凸或衰竭或机械并发症。结论 虚弱患者由于合并症，成人脊柱畸形手术后有不良结局的风险。尽管明确的规定性上器械化椎骨仍然难以捉摸，但如果上器械化椎骨位于更远的地方，这些患者似乎面临更大的不良结果风险。