Frailty and Surgical Invasiveness Are Independently Associated with Complications in Pediatric Spinal Deformity Surgery.

Background

The purposes of this study were to determine whether frailty and surgical invasiveness are independently associated with perioperative outcomes and to describe the outcome rates when these 2 risk domains are considered together in pediatric patients undergoing spinal fusion for deformity.

Methods

This was a retrospective cohort study. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database (2016 to 2023) was queried for patients who underwent spinal fusion for any spinal deformity. Frailty was classified using the Pediatric Spine Frailty Index (non-frail = 0; mildly frail = 1; frail = 2, 3, or 4, severely frail = 5 or 6). Surgical invasiveness was defined using the Pediatric Spine Surgical Invasiveness Index (low, <5; moderate, 5 to 15; high, >15). The outcomes were any adverse event, severe adverse event, unplanned reoperation, and unplanned readmission within 30 days after surgery. Multivariable logistic regression analyses were performed.

Results

A total of 46,399 patients were included (mean age, 13.8 ± 2.6 years; 67.7% female). Increasing surgical invasiveness was associated with increasingly higher rates of adverse events, severe adverse events, unplanned reoperation, and unplanned readmission across almost all frailty categories. Compared with patients who were non-frail, those who were severely frail had markedly higher odds of any adverse event (OR, 6.71; p < 0.001), severe adverse event (OR, 23.17; p < 0.001), unplanned reoperation (OR, 2.81; p < 0.001), and unplanned readmission (OR, 4.13; p < 0.001). Increasing surgical invasiveness was also independently associated with progressively higher odds of adverse outcomes. Compared with low invasiveness, high invasiveness was associated with increased odds of any adverse event (OR, 1.61; p < 0.001), severe adverse event (OR, 2.10; p < 0.001), unplanned reoperation (OR, 1.62; p < 0.001), and unplanned readmission (OR, 1.40; p < 0.001).

Conclusions

Both frailty and surgical invasiveness were independently associated with increased perioperative risk in pediatric spinal fusion. Patients with greater frailty who were undergoing more invasive procedures had the highest observed rates of adverse outcomes. Incorporating both patient vulnerability and anticipated operative magnitude into preoperative assessment may support more individualized counseling, shared decision-making, and perioperative planning. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.