Association of preoperative frailty with adverse postoperative outcomes in elderly patients undergoing elective spinal surgery: A prospective cohort study

Association of preoperative frailty with adverse postoperative outcomes in elderly patients undergoing elective spinal surgery: A prospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of preoperative frailty with adverse postoperative outcomes in elderly patients undergoing elective spinal surgery: A prospective cohort study Yanhong Song, Ziyi Wu, Anqi Zhao, Jiayu Zhou, Ping Zhao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3886717/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Sep, 2025 Read the published version in BMC Geriatrics → Version 1 posted 11 You are reading this latest preprint version Abstract Background This study aims to investigate the relationship between a brief preoperative frailty assessment and the occurrence of adverse postoperative outcomes in elective spinal surgery in the elderly. Methods This is a prospective cohort study. The participants selected for the study were elderly patients undergoing elective spinal surgery at Shengjing Hospital of China Medical University. A total of 231 elderly patients aged 65 years or older were assessed for preoperative frailty using the FRAIL scale, a brief frailty screening scale that covers five main aspects: fatigue, resistance, mobility, disease status, and weight, within 1 week before surgery. Follow-up was conducted within 30 days after surgery to obtain information about postoperative recovery. The primary outcome indicator was the occurrence of postoperative complications. Complications of interest included postoperative infections (respiratory, urinary, and surgical site infections), cardiovascular complications, blood transfusions, electrolyte disturbances, and problems with postoperative feeding. Secondary outcome indicators were prolonged hospital stay and adverse postoperative course. Results A total of 207 patients were eventually analyzed in this study, of whom 101 (48.8%) were male and 106 (51.2%) were female. The median age of the cohort was 69 (67–72) years. Preoperative frailty assessment resulted in 30 (14.5%) being healthy, 121 (58.5%) being prefrail and 56 (27.1%) being frail. A total of 65 (31.4%) of the 207 patients experienced postoperative complications. In a multifactorial analysis, frailty (score ≥ 3) (OR, 4.80; 95% CI, 1.1-20.96) and ASA classification ≥ 3 (OR, 2.53; 95% CI, 1.23–5.21) were independent risk factors for the development of postoperative complications. ASA classification ≥ 3 (OR, 2.21; 95% CI, 1.046–4.69) was significantly associated with a prolonged hospital stay. Patients with frailty (score ≥ 3) (OR, 6.426; 95%CI, 1.13–36.69) or ASA classification ≥ 3 (OR, 4.10; 95% CI, 1.71–9.83) were at increased risk of adverse postoperative course (CCI above the 75th percentile). Conclusions In geriatric elective spinal surgery, preoperative assessment with the brief frailty screening scale can help identify individuals at high potential risk of postoperative adverse events. Trial registration: This study was initially registered in the Chinese Clinical Trial Registry on 8/8/2021 under the registration number ChiCTR2100049677. Frailty Spinal surgery Elderly people Adverse postoperative outcomes Figures Figure 1 Figure 2 1. Background With the advancement of medical conditions and the improvement of people's living standards, life expectancy is constantly increasing, which leads to the gradual acceleration of the population aging process. The results of the seventh national census report prompt that the total number of people over 65 years old in China is as high as 1.90 billion, accounting for 13.50 percent of the population, which is a year-on-year increase of 4.63 percent compared with the sixth population census [ 1 ] . It has been predicted in a relevant study that by 2050, the proportion of the global population aged 65 years or older will reach 17% [ 2 ] , which indicates that our social healthcare and security system will confront great challenges in the coming decades. The functional deterioration of the skeletal system associated with aging has rendered the elderly a critical population for intervertebral disc herniation and vertebral fracture, and the volume of elective spinal surgeries for the elderly has been increasing annually [ 3 , 4 ] . It has been found that the proportion of elderly patients (aged 65 years or older) in spinal surgery is up to 60% [ 5 ] . Since the 1990s, the trend of population aging has become increasingly serious. With improvements in medical technology, advanced age is no longer a contraindication to surgical intervention. However, compared with younger people, the elderly often suffer from a combination of chronic diseases (hypertension, diabetes, coronary heart disease, degenerative joint disease, and cancer). According to relevant data, the prevalence of chronic disease co-morbidity is up to 61.9% in China's middle-aged and elderly population above 50 years of age [ 6 ] . Multi-system functional decline increases the risk of surgery significantly in the elderly population. Under these circumstances, precise assessment of a patient's preoperative physiological status is particularly essential to reduce surgical and anesthetic risks. There is no accurate method to predict the occurrence of postoperative complications in elderly elective spinal surgery. In recent years, the concept of frailty is evolving in the field of geriatric research and has received extensive attention from national and international researchers [ 7 ] . Preoperative frailty is recognized as an important risk factor for adverse outcomes after surgical procedures [ 8 – 10 ] . In 2012, a panel of experts from the American College of Surgeons and the American Geriatrics Society jointly recommended that a comprehensive preoperative assessment of frailty in elderly patients should be performed [ 11 ] . The concept of frailty was first proposed in 1978 at the American Geriatrics Federal Conference, mainly for the elderly who have declining somatic functions and cumulative health problems as a result of aging [ 12 ] . The concept of frailty has not yet been standardized, but scholars both nationally and internationally generally agree that it is centered on a decline in physiological reserve and a reduction in stress resistance [ 13 , 14 ] . There are various instruments for frailty assessment, and the traditional assessment methods mainly include the frailty phenotype and the frailty index. In 2008, the International Society for Nutrition and Aging proposed the Frailty Screening Scale (the FRAIL scale) by integrating the key points of the frailty phenotype and the frailty index, which has the advantages of being brief, accurate, and easy to implement, and it is suitable for the rapid screening for clinical geriatric frailty [ 15 ] . The International Clinical Practice Guidelines published in 2019 recommended the Frailty Screening Scale as a valid measurement tool for determining the frailty status of older adults [ 16 ] . Most studies on preoperative frailty assessment have been limited to general surgical procedures such as cardiac surgery and acute abdominal surgery, and relatively few studies have been conducted on geriatric spinal surgery, which is a relatively common type of surgery performed on elderly patients, and there is still a lack of high-quality studies to improve the awareness of the elderly population undergoing elective spinal surgery. The relationship between the severity of frailty, which is assessed with the Frailty Screening Scale, and adverse postoperative outcomes in spinal surgery has rarely been reported. Therefore, we designed this study to investigate whether screening for frailty could help identify a population at high risk for poor prognosis after elective spinal surgery. 2. Methods Experimental design and study population It is a prospective cohort study to investigate the association between preoperative frailty and postoperative adverse outcomes after elective spine surgery. The trial was approved by the Ethics Committee of Shengjing Hospital under the ethical number 2021PS511K and registered with the China Clinical Trial Registry under the registration number ChiCTR2100049677. The study population consisted of elderly patients undergoing elective spinal surgery at Shengjing Hospital. A comprehensive assessment was performed using the FRAIL scale, and clinically relevant data were obtained through a combination of preoperative visits, intraoperative monitoring, 30-day postoperative telephone follow-up, and a review of electronic medical records. Inclusion criteria included 1) elderly patients scheduled for elective spinal surgery, 2) age ≥ 65 years, 3) anesthesia was general anesthesia, and 4) patients and family members gave informed consent and were able to cooperate with the preoperative questionnaire and postoperative follow-up. Exclusion criteria included: 1) severe hearing, reading, or speech communication disorders that prevented normal communication; 2) dementia or severe cognitive dysfunction that prevented them from cooperating with the completion of the survey; 3) a history of severe mental illness that prevented them from refusing to or being able to cooperate with the study; and 4) refusal to participate by the patient or family members. Frailty and outcome assessment Patients were assessed for frailty on admission by an anesthetist (who was not involved in the follow-up study) using the FRAIL scale, a validated measurement tool recommended by the Clinical Practice Guidelines, which provides an understanding of the patient's level of frailty by asking simple questions [ 16 ] . It consists of five main questions with scores ranging from 0–5, with a maximum score of 5. A score of ≥ 3 is defined as frailty, a score of 1–2 is defined as prefrailty, and a score of 0 is considered healthy [ 15 ] . Higher scores often indicate a greater degree of frailty (more details in supplementary file 1). The other two investigators ascertained the regression of the disease through postoperative visits, medical records, and telephone communication within 30 days after the operation. It is worth noting that these two investigators were not aware of the patient's preoperative frailty level. The primary outcome of this study was the occurrence of postoperative complications. Complications of interest included pulmonary infection, urinary tract infection, surgical incision infection, cardiovascular system complications, electrolyte disturbances, postoperative blood transfusion, and postoperative feeding difficulties. Postoperative complications were also assessed using the Comprehensive Complication Index (CCI), a new method of evaluating postoperative complications based on the Clavien-Dindo classification (CDC) system [ 17 , 18 ] . The CDC system was proposed in 2004 and divided into five grades according to the magnitude of the intervention to correct a given postoperative complication. The CDC system describes the likelihood of all complications, but in clinical studies, for ease of handling, only the highest grades of complications are usually reported. In other words, the CDC grading system focuses only on the most severe outcomes, whereas the CCI focuses on all postoperative outcomes and the number and severity of each complication. We obtained each participant's 30-day postoperative CCI through the online calculation form (available at www.assessurgery.com ). Secondary outcome indicators for this study included prolonged hospital stay and adverse postoperative course. Prolonged hospital stay was defined as the length of hospital stay exceeding the 75th percentile of the cohort. The CCI being greater than the 75th percentile of the total population was seen as a deviation from the normal postoperative outcome of regression, and therefore was taken as a surrogate for adverse postoperative course. Collection of other clinical data All patients' spinal surgeries were performed at Shengjing Hospital, and patients were managed under anaesthesia using a standardised anaesthesia protocol when they entered the operating theatre. Besides the assessment of frailty and postoperative outcome indicators, other relevant data were routinely collected during the perioperative period in this study. The main indicators collected included: age, gender, BMI, ASA classification, Basic Activities of Daily Living (BADL), albumin level, duration of surgery, invasive size of the surgery, bleeding, fluid replacement, urine output, whether or not blood was transfused intraoperatively and the amount of blood transfused. The BADL is a means of assessing the ability to perform activities necessary to maintain basic living and survival, and the main items include eating, bathing, grooming, dressing, controlling bowel movements, going to the toilet, bed, and chair mobility, walking, and walking up and down stairs. A score out of 100 is considered excellent for the ability to perform activities of daily living without dependence on others. A score greater than 60 is assessed as good, and a score less than or equal to 60 requires varying degrees of care from others. We graded the magnitude of invasiveness of spinal surgery using a rating system: grades 1 and 2 consisted mainly of microdiscectomy, lumbar laminectomy or anterior cervical surgery, and minimally invasive fusion; grades 3 and 4 consisted mainly of lumbar fusion, traumatic injury, or posterior cervical fusion, tumor, infection, deformity, or combined anterior and posterior cervical spine surgery. In the context of this study, levels 1 and 2 were defined as less invasive, and levels 3 and 4 as more invasive. Statistical analysis Statistical analyses were performed using IBM SPSS Statistics for Macintosh (version 27.0). Categorical variables were expressed as numbers (percentage), continuous variables obeying normal distribution were expressed as mean and standard deviation (SD), and continuous variables disobeying normal distribution were expressed as the median and interquartile range (IQR). The Kruskal-Wallis test and chi-square test were used to compare the variability of different frailty subtypes. Further two-by-two comparisons were performed when the p-value was < 0.05, and p-values were corrected using the Bonferroni method. In the analysis of factors influencing the postoperative-related outcome indicators, we used univariate analysis to screen out meaningful variables and then performed multifactorial logistic regression analysis to find independent risk factors associated with the occurrence of the study outcomes. The Hosmer-Lemeshow test was used to evaluate the superiority of fit of the model. When the p-value was > 0.05, it was judged that there was no significant difference between the predicted and true values. In addition, we used Graphpad Prism 8 to prepare forest plots for Logistic regression analysis. Sample size calculation: this experiment was to investigate the relationship between 3 different levels: healthy, prefrailty, and frailty, and the occurrence of postoperative complications. By reviewing the previous literature [ 19 ] , the complication rates of the healthy group, prefrailty group, and frailty group were 10.42%, 31.62%, and 47.17%, respectively. With an α of 0.05,1-β of 0.1, 173 patients were planned to be included, and the sample size was at least 204, taking into account a 15% loss-to-follow-up rate. 3. Results Study Process and Baseline Characteristics A total of 231 patients aged 65 years and older undergoing elective spinal surgery were evaluated in this study, and 15 refused to participate. Of the remaining 216 patients, 6 could not cooperate with the questionnaire, and 3 surgeries were canceled. Data from the final 207 patients were included in the analysis (more details in Fig. 1 ). The median age of this study cohort was 69 years, of which 51.2% (n = 106/207) were female and 27.1% (n = 56/207) were frail. The mean BMI for all participants in this study was 24.27 (SD ± 2.82) kg/m2, and the mean albumin was 39.24 (SD ± 3.28) g/L. The percentage of participants with dependent care on BADL was 22.2% (n = 46/207), and the percentage of those with an ASA classification ≥ 3 was 37.2% (n = 77/207). The results of the preoperative frailty assessment using the Frailty Screening Scale suggested that 56 (27.1%) patients were frail, 121 (58.5%) were pre-frail and 30 (14.5%) were healthy. The median duration of surgery was 142 minutes and 87.9% (n = 187/207) of patients had surgical invasiveness greater than or equal to grade 3. The postoperative outcome metrics involved a 31.4% incidence of postoperative complications and the median total length of stay was 12 (10–16) days. Additionally, the median CCI for the study cohort was 22.9 (21.2–28.5) (more details in Table 1 ). Comparison of differences between patients with different frailty levels The results of this study revealed significant differences (p < 0.05) in age, ASA classification, BADL rating, postoperative complications, total hospital stay, and CCI among patients with different frailty subtypes. Patients in the frail group were older, with a median of 69.5 (67–74) years, and further analyses suggested that there was a significant difference in age between frail and healthy patients (p < 0.05). The proportion of patients with ASA grading ≥ 3 increased as the level of frailty progressed, and the proportion of frail patients with BADL less than or equal to 60 points was as high as 46.4%. Intraoperative monitoring indicators such as operative time, invasive size, rehydration volume, blood loss, urine volume, and the presence or absence of blood transfusion did not differ significantly between the different groups (P > 0.05). While in the analysis of postoperative-related outcome indicators, we found an increased incidence of postoperative complications (p = 0.003), prolonged hospital stay (p = 0.001), and increased CCI values (p = 0.001) in the frail compared to the healthy patients (more details in Table 2 ). Primary outcome: Postoperative complications Postoperative complications occurred in 31.4% (n = 65/207) of the patients and the common complications were postoperative feeding difficulties (8 patients), postoperative blood transfusion (20 patients), respiratory infections (9 patients), urinary tract infections (9 patients), incisional infections (13 patients), cardiovascular complications (7 patients) and electrolyte imbalance (18 patients). The results of the univariate analysis showed that the occurrence of postoperative complications was associated with frailty, ASA greater than or equal to grade 3, BADL less than or equal to a score of 60, duration of the operation, rehydration, blood loss, and the presence or absence of intraoperative blood transfusion. In a multifactorial stepwise regression analysis, frailty (score ≥ 3) (OR, 4.801; 95% CI, 1.1-20.96) was a strong independent predictor of the occurrence of postoperative complications, however, frailty (score 1 or 2) (OR, 2.243; 95% CI, 0.59–8.533) was not such a case. ASA grade ≥ 3 was associated with an increased risk of postoperative complications (more details in Fig. 2 ). Secondary outcomes: Prolonged hospitalization and adverse postoperative course. The median length of stay in the study cohort was 12 (10–16) days and prolonged hospital stay was defined as exceeding the 75th percentile with an incidence of 26.57% (n = 55/207). Results of multifactorial regression analyses found that ASA classification ≥ 3 (OR, 2.214; 95%CI, 1.046–4.685; p = 0.038) was significantly associated with a prolonged total length of stay in patients undergoing elective spinal surgery(more details in Supplementary file 2). The median value of CCI in our study cohort was 22.9 (21.2–28.5) points. By univariate analysis, we found that age, frailty, albumin level, ASA classification ≥ 3, BADL ≤ 60 points, duration of surgery, rehydration volume, blood loss, urine volume, and the presence of blood transfusion may be associated with the occurrence of adverse postoperative course (p < 0.05). Further multifactorial logistic regression results suggested that frailty (score ≥ 3) (OR, 6.426; 95%CI, 1.125–36.689; p = 0.036), as well as ASA classification ≥ 3 (OR, 4.097; 95%CI, 1.707–9.831; p = 0.002), were the independent risk factors (more details in Table 3 ). 4. discussion This study explored the association between preoperative frailty as assessed by the FRAIL scale and postoperative adverse outcomes in elderly spinal surgery patients, and the results of the study showed that frailty can help predict postoperative adverse events in elective spinal surgery, which mainly include the occurrence of postoperative complications and undesirable postoperative course. Spinal surgery is effective in the treatment of herniated discs and stenosis, but we would like to emphasize that it is more important to assess the necessity of surgery from a holistic point of view since elderly patients suffer from a decline in physiological functional reserve and stress resistance along with aging. Frailty is a non-specific state of decreased physiological reserve and dysfunctional ability to maintain homeostasis in multiple systems and is prevalent in the elderly population. Data from community-based cross-sectional studies have suggested that the prevalence of frailty ranges from 4.0-59.1% in the older population aged 65 years or older, and this variability can be attributed in part to the diversity of assessment instruments [ 20 ] . The prevalence of frailty is even higher in hospitalized elderly patients [ 21 ] . Frailty is also commonly found in elderly patients undergoing elective spinal surgery, which was assessed using the Frailty Screening Scale in an elderly population aged greater than or equal to 70 years, which found a prevalence of 24% for frailty and up to 54% for pre-frailty [ 19 ] . No uniform gold standard has been established for the assessment of frailty, and some assessment instruments require a large number of indicators to be counted, which makes the assessment more time-consuming and often limits their use in clinical practice. However, the assessment instrument used in this study is the FRAIL scale, which has the advantages of briefness, accuracy, and ease of administration. Our findings support that the FRAIL scale can predict adverse events in the postoperative period, which is consistent with the results of previous studies [ 19 , 22 , 23 ] . The results of this study suggest that patients in the frailty group were older compared to the healthy group (p = 0.036), which is in accordance with the fact that frailty is a clinical syndrome that is closely associated with advancing age. Conventional wisdom has it that advancing age is associated with increased surgical risk. This is mainly due to the multisystem functional decline and reduced resilience that often accompanies older patients. However, the prediction of surgical risk based on age alone does not appear to be reliable, and the health status of an individual is often influenced by genetic, social, and individual lifestyle factors. Therefore, indicators that can accurately reflect the health status of elderly individuals are more effective in predicting surgical risk. In recent years, frailty has received a lot of attention in the field of geriatrics, and it usually refers to a nonspecific state of decreased physiological functional reserve and stress resistance of the body. The results of the multifactorial analysis in this study found that frailty (but not age) was an independent risk factor for poor prognosis. A comprehensive assessment of the organism's physiological status of frailty seems to be more relevant than aging alone. The results of the differential comparison of the different frailty subtypes suggested that frail patients would have a higher rate of postoperative complications (p = 0.003), a longer hospital stay (p = 0.001), and a higher CCI value (p = 0.001) compared to the healthy group. Patients in the frail group had increased postoperative complication rates and CCI values compared to the pre-frail group (p < 0.05). However, there was no similar effect in the pre-frail group compared to the healthy group. Therefore, we should pay attention and prevent the occurrence of frailty in the elderly population. In the present study, frailty (score ≥ 3) was significantly associated with the incidence of postoperative complications and adverse postoperative course; however, this was not the case for pre-frailty (scores of 1 or 2). Notably, frailty is a dynamic process that is potentially reversible, and it would make sense to implement individualized interventions in the early stages of frailty. However, as frailty progresses, the decline in reserve capacity due to massive stress injury makes it difficult for the organism to return to its initial state. Therefore, new perspectives suggest that early identification and active intervention can delay or even prevent the progression of frailty in both healthy and pre-frail patients [ 24 ] . In our findings, pre-frailty was not an independent risk factor for postoperative adverse events, but raising awareness of this stage in the elderly population is crucial. Besides postoperative complications, we also evaluated postoperative regression using the Composite Complication Index (CCI). Postoperative complications are a good indicator for evaluating surgical outcomes, but there is heterogeneity in most current studies on postoperative complications. Taking infection as an example, there are different levels of severity of postoperative infections; mild infections may only require anti-inflammatory drugs, while extremely severe infections may result in the requirement of intensive care or even death of the patient, which is unfair if all the different levels of infections are defined as just the occurrence of an infection. The CDC classification system evaluates the postoperative outcome according to the magnitude of the degree of intervention to correct a particular complication. However, in clinical studies, CDC usually reports only the highest grade. CCI was based on the CDC, which focuses not only on all postoperative outcomes but also on the number and severity of each complication [ 25 ] . Frailty and ASA grade ≥ 3 were found to be independent risk factors for the adverse postoperative course. Some studies have found that frailty is significantly associated with prolonged hospitalization [ 26 – 28 ] . However, in our findings, frailty did not predict prolonged hospital stay. Although the decision to discharge a patient is made through a joint assessment between the surgeon and anesthetist, it may still be confounded by multiple factors. The role of frailty in predicting length of stay remains to be further explored. There are some shortcomings in this study. Firstly, this is a prospective cohort study in elderly patients undergoing elective spinal surgery, revealing that preoperative frailty identified by the Frail Scale assessment was significantly associated with the occurrence of postoperative adverse events, but it may not be sufficient to accurately estimate the OR due to the limited sample size. Second, whether the results of this study can be generalized to other types of surgery remains to be explored. Third, we used multifactorial logistic regression analyses to correct for possible confounders, but failure to thoroughly and adequately adjust for some variables cannot be ruled out. 5. Conclusion and perspectives The primary outcome of this study was that frailty was an independent risk factor for the occurrence of postoperative complications and adverse postoperative course. A simple preoperative frailty screening tool was found to identify those at high risk for adverse postoperative outcomes. Advocating for preoperative frailty assessment does not make "frailty" a contraindication to surgery, but rather anticipates that early identification of frailty and timely intervention may be particularly valuable in reducing the incidence of postoperative adverse events in elective surgery. Moreover, with the aim of promoting health and longevity in elderly patients, preoperative frailty assessment may support decision-making about whether surgery is truly beneficial to the patient. Abbreviations Abbreviation Full name Alb Albumin ASA American society of anesthesiologists BADL Basic Activities of Daily Living BMI Body mass index CCI Comprehensive Complication Index CDC Clavien-Dindo classification CI Confidence interval IQR Interquartile range SD Standard deviation Declarations Ethics approval and consent to participate: The study was approved by the Ethics Committee of Shengjing Hospital of China Medical University, and elderly patients who agreed to participate were enrolled in the study Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that there is no conflict of interest regarding the publication of this article. Funding: This work was supported by the National Nature Science Foundation of China (No.81870838 to Ping Zhao; No. 82001154 to Ziyi Wu). Authors' contributions: Yanhong Song conducted the experimental design, data collection and collation, statistical analysis, and drafted the first draft of the paper. Ziyi Wu, Anqi Zhao, and Jiayu Zhou made significant contributions to the experimental implementation and data collection. In addition, they also provided significant assistance in experimental design, data analysis, first draft writing, and revision. The whole process of designing, implementing, analyzing, writing, and revising the paper was completed under the supervision and guidance of Ping Zhao. The five of them agreed on the final submitted version. Acknowledgements: We sincerely appreciate the staff of the Department of Anesthesiology and the Department of Spine and Joint Surgery at Shengjing Hospital for their support and assistance in the study. References National Bureau of Statistics. Seventh National Population Census Bulletin (No. 5) [EB/OL](2021-05-11)[2020-12-25]. http://www.stats.gov.cn/tjsj/tjgb/rkpcgb/qgrkpcgb/202106/t20210628_1818827.html . He W, Goodkind D, Kowal P. An Aging World: 2015. 2016. Kobayashi K, Imagama S, Ando K, et al. Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study. Global Spine J. 2017. 7(6): 560-566. Huang Q, Liu S, Liang G. Research progress on risk factors, clinical prevention and treatment of postoperative delirium in patients undergoing spinal surgery. Zhonghua Wai Ke Za Zhi. 2019. 57(6). Zeng X, Wang L, Bao R. Nursing procedure intervention on falls and bed-drops in elderly patients. CHINA MODERN DOCTOR. 2019. 57(02): 142-144+148. Zhao Y, Atun R, Oldenburg B, et al. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data. Lancet Glob Health. 2020. 8(6): e840-e849. Gottesman D, McIsaac DI. Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults. Anaesthesia. 2022. 77(12): 1430-1438. Panayi AC, Orkaby AR, Sakthivel D, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019. 218(2): 393-400. Song Y, Wu Z, Huo H, Zhao P. The Impact of Frailty on Adverse Outcomes in Geriatric Hip Fracture Patients: A Systematic Review and Meta-Analysis. Front Public Health. 2022. 10: 890652. Hewitt J, Long S, Carter B, Bach S, McCarthy K, Clegg A. The prevalence of frailty and its association with clinical outcomes in general surgery: a systematic review and meta-analysis. Age Ageing. 2018. 47(6): 793-800. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012. 215(4): 453-66. Rockwood K, Fox RA, Stolee P, Robertson D, Beattie BL. Frailty in elderly people: an evolving concept. CMAJ. 1994. 150(4): 489-95. Strandberg TE, Pitkälä KH. Frailty in elderly people. Lancet. 2007. 369(9570): 1328-1329. Friedman SM, Shah K, Hall WJ. Failing to Focus on Healthy Aging: A Frailty of Our Discipline. J Am Geriatr Soc. 2015. 63(7): 1459-62. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012. 16(7): 601-8. Dent E, Morley JE, Cruz-Jentoft AJ, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging. 2019. 23(9): 771-787. Staiger RD, Cimino M, Javed A, et al. The Comprehensive Complication Index (CCI®) is a Novel Cost Assessment Tool for Surgical Procedures. Ann Surg. 2018. 268(5): 784-791. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013. 258(1): 1-7. Susano MJ, Grasfield RH, Friese M, et al. Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery. Anesthesiology. 2020. 133(6): 1184-1191. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012. 60(8): 1487-92. Hammami S, Zarrouk A, Piron C, Almas I, Sakly N, Latteur V. Prevalence and factors associated with frailty in hospitalized older patients. BMC Geriatr. 2020. 20(1): 144. Gong S, Qian D, Riazi S, et al. Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis. Anesth Analg. 2023. 136(2): 251-261. Kunz V, Wichmann G, Wald T, et al. Frailty Assessed with FRAIL Scale and G8 Questionnaire Predicts Severe Postoperative Complications in Patients Receiving Major Head and Neck Surgery. J Clin Med. 2022. 11(16). Geriatrics CSo, Geriatrics EBoCJo. Chinese expert consensus on prevention of frailty in the elderly(2022). Chinese Journal of Geriatrics. 2022. 41(05): 503-511. Schopmeyer L, El Moumni M, Nieuwenhuijs-Moeke GJ, Berger SP, Bakker S, Pol RA. Frailty has a significant influence on postoperative complications after kidney transplantation-a prospective study on short-term outcomes. Transpl Int. 2019. 32(1): 66-74. Erne F, Wallmeier V, Ihle C, et al. The modified 5-item frailty index determines the length of hospital stay and accompanies with mortality rate in patients with bone and implant-associated infections after trauma and orthopedic surgery. Injury. 2023 . Liu EX, Kuhataparuks P, Liow ML, et al. Clinical Frailty Scale is a better predictor for adverse post-operative complications and functional outcomes than Modified Frailty Index and Charlson Comorbidity Index after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2023 . Elsamadicy AA, Koo AB, Reeves BC, et al. Prevalence and Influence of Frailty on Hospital Outcomes after Surgical Resection of Spinal Meningiomas. World Neurosurg. 2023 . Tables Tables 1-3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.pdf Table1.docx Table2.docx Table3.docx Cite Share Download PDF Status: Published Journal Publication published 24 Sep, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 01 Apr, 2025 Reviews received at journal 27 Feb, 2025 Reviewers agreed at journal 27 Feb, 2025 Reviews received at journal 29 Jun, 2024 Reviews received at journal 29 Jun, 2024 Reviewers agreed at journal 19 Jun, 2024 Reviewers invited by journal 05 Jun, 2024 Editor assigned by journal 28 May, 2024 Editor invited by journal 19 Feb, 2024 Submission checks completed at journal 19 Feb, 2024 First submitted to journal 21 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3886717","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":273718377,"identity":"0218631e-d035-41a0-aeca-a0723667941a","order_by":0,"name":"Yanhong Song","email":"","orcid":"","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yanhong","middleName":"","lastName":"Song","suffix":""},{"id":273718378,"identity":"e720fe95-da39-4263-b919-fe253bed0b44","order_by":1,"name":"Ziyi Wu","email":"","orcid":"","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ziyi","middleName":"","lastName":"Wu","suffix":""},{"id":273718379,"identity":"b16c8d8a-04a2-4177-95dd-ca4a65855c3a","order_by":2,"name":"Anqi Zhao","email":"","orcid":"","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Anqi","middleName":"","lastName":"Zhao","suffix":""},{"id":273718380,"identity":"9767c107-c3c3-4bf3-916a-686d8eacd80e","order_by":3,"name":"Jiayu Zhou","email":"","orcid":"","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiayu","middleName":"","lastName":"Zhou","suffix":""},{"id":273718381,"identity":"18e8cde3-0a7b-4f85-a219-2f46af59e3cb","order_by":4,"name":"Ping Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACCRBhAGYmPkioqCFNS7LBgzPHiNUCAWySD1uYCeuQn9388HFBwR27Bv4DzyoSG9gY+Nu7E/BqYZxzzNh4hsGz5AaJhLQbiTtkGCTOnN2AVwuzRIKZNI/B4WSgC4FazrAxGEjk4tfCJpH+DaKF/0BaQWIbM2EtPBI5YFvsGBgS0hiI0iIhkVMM9MvhBAaJhGSJhDPHeAj6RX5G+sbHBX8O2zPwn0n8+KOiRo6/vRe/FhAAxUXi/gM8CWCXElQO02LPwMB+gCjVo2AUjIJRMPIAAGzwRMiAdGd5AAAAAElFTkSuQmCC","orcid":"","institution":"Shengjing Hospital of China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Ping","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2024-01-22 02:44:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3886717/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3886717/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-06352-3","type":"published","date":"2025-09-24T15:56:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51445706,"identity":"2761cc34-b3f2-4df1-b31e-9b4790b8c3e0","added_by":"auto","created_at":"2024-02-21 18:11:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130017,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Flowchart\u003c/p\u003e","description":"","filename":"Figure1StudyFlowchart.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/a489d0f3c491620b1e116ffd.jpg"},{"id":51445710,"identity":"89ac586c-b502-4e3b-9dbd-82efe9051a11","added_by":"auto","created_at":"2024-02-21 18:11:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97175,"visible":true,"origin":"","legend":"\u003cp\u003eUnivariate and multivariate logistic regression analyses of Postoperative complications\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/db115078d42b4182086d34fd.jpg"},{"id":92430403,"identity":"6697cde1-50c0-42e4-a7c8-3d83a7d0650b","added_by":"auto","created_at":"2025-09-29 15:59:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":913302,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/2d21bb39-20b5-4613-9a8d-6230d8dbf530.pdf"},{"id":51445707,"identity":"75c85720-8792-43f0-9c90-8f68258d8711","added_by":"auto","created_at":"2024-02-21 18:11:13","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":381283,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/a86f3d7538a9b22d83fc264d.pdf"},{"id":51447037,"identity":"f447896e-f4b7-44fc-bf3f-ac537201c9ba","added_by":"auto","created_at":"2024-02-21 18:19:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":111156,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/0c2b575a5bc885f5d8832ca9.docx"},{"id":51445712,"identity":"a0df96ca-d4db-4cb7-a696-4966279d75a7","added_by":"auto","created_at":"2024-02-21 18:11:14","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":129689,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/255e7b370c4f8a2c87631233.docx"},{"id":51445708,"identity":"52c37927-d806-4d08-a062-c477f98e1592","added_by":"auto","created_at":"2024-02-21 18:11:14","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":104037,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-3886717/v1/b0e54f981cccf79d1b1f0627.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of preoperative frailty with adverse postoperative outcomes in elderly patients undergoing elective spinal surgery: A prospective cohort study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eWith the advancement of medical conditions and the improvement of people's living standards, life expectancy is constantly increasing, which leads to the gradual acceleration of the population aging process. The results of the seventh national census report prompt that the total number of people over 65 years old in China is as high as 1.90\u0026nbsp;billion, accounting for 13.50 percent of the population, which is a year-on-year increase of 4.63 percent compared with the sixth population census \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. It has been predicted in a relevant study that by 2050, the proportion of the global population aged 65 years or older will reach 17% \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, which indicates that our social healthcare and security system will confront great challenges in the coming decades. The functional deterioration of the skeletal system associated with aging has rendered the elderly a critical population for intervertebral disc herniation and vertebral fracture, and the volume of elective spinal surgeries for the elderly has been increasing annually \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. It has been found that the proportion of elderly patients (aged 65 years or older) in spinal surgery is up to 60% \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSince the 1990s, the trend of population aging has become increasingly serious. With improvements in medical technology, advanced age is no longer a contraindication to surgical intervention. However, compared with younger people, the elderly often suffer from a combination of chronic diseases (hypertension, diabetes, coronary heart disease, degenerative joint disease, and cancer). According to relevant data, the prevalence of chronic disease co-morbidity is up to 61.9% in China's middle-aged and elderly population above 50 years of age \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Multi-system functional decline increases the risk of surgery significantly in the elderly population. Under these circumstances, precise assessment of a patient's preoperative physiological status is particularly essential to reduce surgical and anesthetic risks. There is no accurate method to predict the occurrence of postoperative complications in elderly elective spinal surgery. In recent years, the concept of frailty is evolving in the field of geriatric research and has received extensive attention from national and international researchers \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Preoperative frailty is recognized as an important risk factor for adverse outcomes after surgical procedures \u003csup\u003e[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. In 2012, a panel of experts from the American College of Surgeons and the American Geriatrics Society jointly recommended that a comprehensive preoperative assessment of frailty in elderly patients should be performed \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The concept of frailty was first proposed in 1978 at the American Geriatrics Federal Conference, mainly for the elderly who have declining somatic functions and cumulative health problems as a result of aging \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The concept of frailty has not yet been standardized, but scholars both nationally and internationally generally agree that it is centered on a decline in physiological reserve and a reduction in stress resistance \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. There are various instruments for frailty assessment, and the traditional assessment methods mainly include the frailty phenotype and the frailty index. In 2008, the International Society for Nutrition and Aging proposed the Frailty Screening Scale (the FRAIL scale) by integrating the key points of the frailty phenotype and the frailty index, which has the advantages of being brief, accurate, and easy to implement, and it is suitable for the rapid screening for clinical geriatric frailty \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The International Clinical Practice Guidelines published in 2019 recommended the Frailty Screening Scale as a valid measurement tool for determining the frailty status of older adults \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMost studies on preoperative frailty assessment have been limited to general surgical procedures such as cardiac surgery and acute abdominal surgery, and relatively few studies have been conducted on geriatric spinal surgery, which is a relatively common type of surgery performed on elderly patients, and there is still a lack of high-quality studies to improve the awareness of the elderly population undergoing elective spinal surgery. The relationship between the severity of frailty, which is assessed with the Frailty Screening Scale, and adverse postoperative outcomes in spinal surgery has rarely been reported. Therefore, we designed this study to investigate whether screening for frailty could help identify a population at high risk for poor prognosis after elective spinal surgery.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003eExperimental design and study population\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIt is a prospective cohort study to investigate the association between preoperative frailty and postoperative adverse outcomes after elective spine surgery. The trial was approved by the Ethics Committee of Shengjing Hospital under the ethical number 2021PS511K and registered with the China Clinical Trial Registry under the registration number ChiCTR2100049677.\u003c/p\u003e \u003cp\u003eThe study population consisted of elderly patients undergoing elective spinal surgery at Shengjing Hospital. A comprehensive assessment was performed using the FRAIL scale, and clinically relevant data were obtained through a combination of preoperative visits, intraoperative monitoring, 30-day postoperative telephone follow-up, and a review of electronic medical records. Inclusion criteria included 1) elderly patients scheduled for elective spinal surgery, 2) age\u0026thinsp;\u0026ge;\u0026thinsp;65 years, 3) anesthesia was general anesthesia, and 4) patients and family members gave informed consent and were able to cooperate with the preoperative questionnaire and postoperative follow-up. Exclusion criteria included: 1) severe hearing, reading, or speech communication disorders that prevented normal communication; 2) dementia or severe cognitive dysfunction that prevented them from cooperating with the completion of the survey; 3) a history of severe mental illness that prevented them from refusing to or being able to cooperate with the study; and 4) refusal to participate by the patient or family members.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFrailty and outcome assessment\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatients were assessed for frailty on admission by an anesthetist (who was not involved in the follow-up study) using the FRAIL scale, a validated measurement tool recommended by the Clinical Practice Guidelines, which provides an understanding of the patient's level of frailty by asking simple questions \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. It consists of five main questions with scores ranging from 0\u0026ndash;5, with a maximum score of 5. A score of \u0026ge;\u0026thinsp;3 is defined as frailty, a score of 1\u0026ndash;2 is defined as prefrailty, and a score of 0 is considered healthy \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Higher scores often indicate a greater degree of frailty (more details in supplementary file 1).\u003c/p\u003e \u003cp\u003eThe other two investigators ascertained the regression of the disease through postoperative visits, medical records, and telephone communication within 30 days after the operation. It is worth noting that these two investigators were not aware of the patient's preoperative frailty level. The primary outcome of this study was the occurrence of postoperative complications. Complications of interest included pulmonary infection, urinary tract infection, surgical incision infection, cardiovascular system complications, electrolyte disturbances, postoperative blood transfusion, and postoperative feeding difficulties.\u003c/p\u003e \u003cp\u003ePostoperative complications were also assessed using the Comprehensive Complication Index (CCI), a new method of evaluating postoperative complications based on the Clavien-Dindo classification (CDC) system \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The CDC system was proposed in 2004 and divided into five grades according to the magnitude of the intervention to correct a given postoperative complication. The CDC system describes the likelihood of all complications, but in clinical studies, for ease of handling, only the highest grades of complications are usually reported. In other words, the CDC grading system focuses only on the most severe outcomes, whereas the CCI focuses on all postoperative outcomes and the number and severity of each complication. We obtained each participant's 30-day postoperative CCI through the online calculation form (available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.assessurgery.com\u003c/span\u003e\u003cspan address=\"http://www.assessurgery.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Secondary outcome indicators for this study included prolonged hospital stay and adverse postoperative course. Prolonged hospital stay was defined as the length of hospital stay exceeding the 75th percentile of the cohort. The CCI being greater than the 75th percentile of the total population was seen as a deviation from the normal postoperative outcome of regression, and therefore was taken as a surrogate for adverse postoperative course.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCollection of other clinical data\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll patients' spinal surgeries were performed at Shengjing Hospital, and patients were managed under anaesthesia using a standardised anaesthesia protocol when they entered the operating theatre. Besides the assessment of frailty and postoperative outcome indicators, other relevant data were routinely collected during the perioperative period in this study. The main indicators collected included: age, gender, BMI, ASA classification, Basic Activities of Daily Living (BADL), albumin level, duration of surgery, invasive size of the surgery, bleeding, fluid replacement, urine output, whether or not blood was transfused intraoperatively and the amount of blood transfused.\u003c/p\u003e \u003cp\u003eThe BADL is a means of assessing the ability to perform activities necessary to maintain basic living and survival, and the main items include eating, bathing, grooming, dressing, controlling bowel movements, going to the toilet, bed, and chair mobility, walking, and walking up and down stairs. A score out of 100 is considered excellent for the ability to perform activities of daily living without dependence on others. A score greater than 60 is assessed as good, and a score less than or equal to 60 requires varying degrees of care from others. We graded the magnitude of invasiveness of spinal surgery using a rating system: grades 1 and 2 consisted mainly of microdiscectomy, lumbar laminectomy or anterior cervical surgery, and minimally invasive fusion; grades 3 and 4 consisted mainly of lumbar fusion, traumatic injury, or posterior cervical fusion, tumor, infection, deformity, or combined anterior and posterior cervical spine surgery. In the context of this study, levels 1 and 2 were defined as less invasive, and levels 3 and 4 as more invasive.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics for Macintosh (version 27.0). Categorical variables were expressed as numbers (percentage), continuous variables obeying normal distribution were expressed as mean and standard deviation (SD), and continuous variables disobeying normal distribution were expressed as the median and interquartile range (IQR). The Kruskal-Wallis test and chi-square test were used to compare the variability of different frailty subtypes. Further two-by-two comparisons were performed when the p-value was \u0026lt;\u0026thinsp;0.05, and p-values were corrected using the Bonferroni method.\u003c/p\u003e \u003cp\u003eIn the analysis of factors influencing the postoperative-related outcome indicators, we used univariate analysis to screen out meaningful variables and then performed multifactorial logistic regression analysis to find independent risk factors associated with the occurrence of the study outcomes. The Hosmer-Lemeshow test was used to evaluate the superiority of fit of the model. When the p-value was \u0026gt;\u0026thinsp;0.05, it was judged that there was no significant difference between the predicted and true values. In addition, we used Graphpad Prism 8 to prepare forest plots for Logistic regression analysis.\u003c/p\u003e \u003cp\u003eSample size calculation: this experiment was to investigate the relationship between 3 different levels: healthy, prefrailty, and frailty, and the occurrence of postoperative complications. By reviewing the previous literature \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, the complication rates of the healthy group, prefrailty group, and frailty group were 10.42%, 31.62%, and 47.17%, respectively. With an α of 0.05,1-β of 0.1, 173 patients were planned to be included, and the sample size was at least 204, taking into account a 15% loss-to-follow-up rate.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cb\u003eStudy Process and Baseline Characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 231 patients aged 65 years and older undergoing elective spinal surgery were evaluated in this study, and 15 refused to participate. Of the remaining 216 patients, 6 could not cooperate with the questionnaire, and 3 surgeries were canceled. Data from the final 207 patients were included in the analysis (more details in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median age of this study cohort was 69 years, of which 51.2% (n\u0026thinsp;=\u0026thinsp;106/207) were female and 27.1% (n\u0026thinsp;=\u0026thinsp;56/207) were frail. The mean BMI for all participants in this study was 24.27 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;2.82) kg/m2, and the mean albumin was 39.24 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28) g/L. The percentage of participants with dependent care on BADL was 22.2% (n\u0026thinsp;=\u0026thinsp;46/207), and the percentage of those with an ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3 was 37.2% (n\u0026thinsp;=\u0026thinsp;77/207). The results of the preoperative frailty assessment using the Frailty Screening Scale suggested that 56 (27.1%) patients were frail, 121 (58.5%) were pre-frail and 30 (14.5%) were healthy. The median duration of surgery was 142 minutes and 87.9% (n\u0026thinsp;=\u0026thinsp;187/207) of patients had surgical invasiveness greater than or equal to grade 3. The postoperative outcome metrics involved a 31.4% incidence of postoperative complications and the median total length of stay was 12 (10\u0026ndash;16) days. Additionally, the median CCI for the study cohort was 22.9 (21.2\u0026ndash;28.5) (more details in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eComparison of differences between patients with different frailty levels\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe results of this study revealed significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in age, ASA classification, BADL rating, postoperative complications, total hospital stay, and CCI among patients with different frailty subtypes. Patients in the frail group were older, with a median of 69.5 (67\u0026ndash;74) years, and further analyses suggested that there was a significant difference in age between frail and healthy patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The proportion of patients with ASA grading\u0026thinsp;\u0026ge;\u0026thinsp;3 increased as the level of frailty progressed, and the proportion of frail patients with BADL less than or equal to 60 points was as high as 46.4%. Intraoperative monitoring indicators such as operative time, invasive size, rehydration volume, blood loss, urine volume, and the presence or absence of blood transfusion did not differ significantly between the different groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). While in the analysis of postoperative-related outcome indicators, we found an increased incidence of postoperative complications (p\u0026thinsp;=\u0026thinsp;0.003), prolonged hospital stay (p\u0026thinsp;=\u0026thinsp;0.001), and increased CCI values (p\u0026thinsp;=\u0026thinsp;0.001) in the frail compared to the healthy patients (more details in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003cb\u003ePrimary outcome: Postoperative complications\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications occurred in 31.4% (n\u0026thinsp;=\u0026thinsp;65/207) of the patients and the common complications were postoperative feeding difficulties (8 patients), postoperative blood transfusion (20 patients), respiratory infections (9 patients), urinary tract infections (9 patients), incisional infections (13 patients), cardiovascular complications (7 patients) and electrolyte imbalance (18 patients). The results of the univariate analysis showed that the occurrence of postoperative complications was associated with frailty, ASA greater than or equal to grade 3, BADL less than or equal to a score of 60, duration of the operation, rehydration, blood loss, and the presence or absence of intraoperative blood transfusion. In a multifactorial stepwise regression analysis, frailty (score\u0026thinsp;\u0026ge;\u0026thinsp;3) (OR, 4.801; 95% CI, 1.1-20.96) was a strong independent predictor of the occurrence of postoperative complications, however, frailty (score 1 or 2) (OR, 2.243; 95% CI, 0.59\u0026ndash;8.533) was not such a case. ASA grade\u0026thinsp;\u0026ge;\u0026thinsp;3 was associated with an increased risk of postoperative complications (more details in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary outcomes: Prolonged hospitalization and adverse postoperative course.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe median length of stay in the study cohort was 12 (10\u0026ndash;16) days and prolonged hospital stay was defined as exceeding the 75th percentile with an incidence of 26.57% (n\u0026thinsp;=\u0026thinsp;55/207). Results of multifactorial regression analyses found that ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (OR, 2.214; 95%CI, 1.046\u0026ndash;4.685; p\u0026thinsp;=\u0026thinsp;0.038) was significantly associated with a prolonged total length of stay in patients undergoing elective spinal surgery(more details in Supplementary file 2). The median value of CCI in our study cohort was 22.9 (21.2\u0026ndash;28.5) points. By univariate analysis, we found that age, frailty, albumin level, ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3, BADL\u0026thinsp;\u0026le;\u0026thinsp;60 points, duration of surgery, rehydration volume, blood loss, urine volume, and the presence of blood transfusion may be associated with the occurrence of adverse postoperative course (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Further multifactorial logistic regression results suggested that frailty (score\u0026thinsp;\u0026ge;\u0026thinsp;3) (OR, 6.426; 95%CI, 1.125\u0026ndash;36.689; p\u0026thinsp;=\u0026thinsp;0.036), as well as ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (OR, 4.097; 95%CI, 1.707\u0026ndash;9.831; p\u0026thinsp;=\u0026thinsp;0.002), were the independent risk factors (more details in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e "},{"header":"4. discussion","content":"\u003cp\u003eThis study explored the association between preoperative frailty as assessed by the FRAIL scale and postoperative adverse outcomes in elderly spinal surgery patients, and the results of the study showed that frailty can help predict postoperative adverse events in elective spinal surgery, which mainly include the occurrence of postoperative complications and undesirable postoperative course. Spinal surgery is effective in the treatment of herniated discs and stenosis, but we would like to emphasize that it is more important to assess the necessity of surgery from a holistic point of view since elderly patients suffer from a decline in physiological functional reserve and stress resistance along with aging.\u003c/p\u003e \u003cp\u003eFrailty is a non-specific state of decreased physiological reserve and dysfunctional ability to maintain homeostasis in multiple systems and is prevalent in the elderly population. Data from community-based cross-sectional studies have suggested that the prevalence of frailty ranges from 4.0-59.1% in the older population aged 65 years or older, and this variability can be attributed in part to the diversity of assessment instruments \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. The prevalence of frailty is even higher in hospitalized elderly patients \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Frailty is also commonly found in elderly patients undergoing elective spinal surgery, which was assessed using the Frailty Screening Scale in an elderly population aged greater than or equal to 70 years, which found a prevalence of 24% for frailty and up to 54% for pre-frailty \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. No uniform gold standard has been established for the assessment of frailty, and some assessment instruments require a large number of indicators to be counted, which makes the assessment more time-consuming and often limits their use in clinical practice. However, the assessment instrument used in this study is the FRAIL scale, which has the advantages of briefness, accuracy, and ease of administration. Our findings support that the FRAIL scale can predict adverse events in the postoperative period, which is consistent with the results of previous studies \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe results of this study suggest that patients in the frailty group were older compared to the healthy group (p\u0026thinsp;=\u0026thinsp;0.036), which is in accordance with the fact that frailty is a clinical syndrome that is closely associated with advancing age. Conventional wisdom has it that advancing age is associated with increased surgical risk. This is mainly due to the multisystem functional decline and reduced resilience that often accompanies older patients. However, the prediction of surgical risk based on age alone does not appear to be reliable, and the health status of an individual is often influenced by genetic, social, and individual lifestyle factors. Therefore, indicators that can accurately reflect the health status of elderly individuals are more effective in predicting surgical risk. In recent years, frailty has received a lot of attention in the field of geriatrics, and it usually refers to a nonspecific state of decreased physiological functional reserve and stress resistance of the body. The results of the multifactorial analysis in this study found that frailty (but not age) was an independent risk factor for poor prognosis. A comprehensive assessment of the organism's physiological status of frailty seems to be more relevant than aging alone. The results of the differential comparison of the different frailty subtypes suggested that frail patients would have a higher rate of postoperative complications (p\u0026thinsp;=\u0026thinsp;0.003), a longer hospital stay (p\u0026thinsp;=\u0026thinsp;0.001), and a higher CCI value (p\u0026thinsp;=\u0026thinsp;0.001) compared to the healthy group. Patients in the frail group had increased postoperative complication rates and CCI values compared to the pre-frail group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there was no similar effect in the pre-frail group compared to the healthy group. Therefore, we should pay attention and prevent the occurrence of frailty in the elderly population.\u003c/p\u003e \u003cp\u003eIn the present study, frailty (score\u0026thinsp;\u0026ge;\u0026thinsp;3) was significantly associated with the incidence of postoperative complications and adverse postoperative course; however, this was not the case for pre-frailty (scores of 1 or 2). Notably, frailty is a dynamic process that is potentially reversible, and it would make sense to implement individualized interventions in the early stages of frailty. However, as frailty progresses, the decline in reserve capacity due to massive stress injury makes it difficult for the organism to return to its initial state. Therefore, new perspectives suggest that early identification and active intervention can delay or even prevent the progression of frailty in both healthy and pre-frail patients \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. In our findings, pre-frailty was not an independent risk factor for postoperative adverse events, but raising awareness of this stage in the elderly population is crucial.\u003c/p\u003e \u003cp\u003eBesides postoperative complications, we also evaluated postoperative regression using the Composite Complication Index (CCI). Postoperative complications are a good indicator for evaluating surgical outcomes, but there is heterogeneity in most current studies on postoperative complications. Taking infection as an example, there are different levels of severity of postoperative infections; mild infections may only require anti-inflammatory drugs, while extremely severe infections may result in the requirement of intensive care or even death of the patient, which is unfair if all the different levels of infections are defined as just the occurrence of an infection. The CDC classification system evaluates the postoperative outcome according to the magnitude of the degree of intervention to correct a particular complication. However, in clinical studies, CDC usually reports only the highest grade. CCI was based on the CDC, which focuses not only on all postoperative outcomes but also on the number and severity of each complication \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Frailty and ASA grade\u0026thinsp;\u0026ge;\u0026thinsp;3 were found to be independent risk factors for the adverse postoperative course. Some studies have found that frailty is significantly associated with prolonged hospitalization \u003csup\u003e[\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. However, in our findings, frailty did not predict prolonged hospital stay. Although the decision to discharge a patient is made through a joint assessment between the surgeon and anesthetist, it may still be confounded by multiple factors. The role of frailty in predicting length of stay remains to be further explored.\u003c/p\u003e \u003cp\u003eThere are some shortcomings in this study. Firstly, this is a prospective cohort study in elderly patients undergoing elective spinal surgery, revealing that preoperative frailty identified by the Frail Scale assessment was significantly associated with the occurrence of postoperative adverse events, but it may not be sufficient to accurately estimate the OR due to the limited sample size. Second, whether the results of this study can be generalized to other types of surgery remains to be explored. Third, we used multifactorial logistic regression analyses to correct for possible confounders, but failure to thoroughly and adequately adjust for some variables cannot be ruled out.\u003c/p\u003e"},{"header":"5. Conclusion and perspectives","content":"\u003cp\u003eThe primary outcome of this study was that frailty was an independent risk factor for the occurrence of postoperative complications and adverse postoperative course. A simple preoperative frailty screening tool was found to identify those at high risk for adverse postoperative outcomes. Advocating for preoperative frailty assessment does not make \"frailty\" a contraindication to surgery, but rather anticipates that early identification of frailty and timely intervention may be particularly valuable in reducing the incidence of postoperative adverse events in elective surgery. Moreover, with the aim of promoting health and longevity in elderly patients, preoperative frailty assessment may support decision-making about whether surgery is truly beneficial to the patient.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"399\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull name\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eAlb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eAmerican society of anesthesiologists\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eBADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eBasic Activities of Daily Living\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eCCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eComprehensive Complication Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eCDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eClavien-Dindo classification\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eInterquartile range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.08771929824562%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.91228070175438%\" valign=\"top\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Shengjing Hospital of China Medical University, and elderly patients who agreed to participate were enrolled in the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Nature Science Foundation of China (No.81870838 to Ping Zhao; No. 82001154 to Ziyi Wu).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYanhong Song conducted the experimental design, data collection and collation, statistical analysis, and drafted the first draft of the paper. Ziyi Wu, Anqi Zhao, and Jiayu Zhou made significant contributions to the experimental implementation and data collection. In addition, they also provided significant assistance in experimental design, data analysis, first draft writing, and revision. The whole process of designing, implementing, analyzing, writing, and revising the paper was completed under the supervision and guidance of Ping Zhao. The five of them agreed on the final submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely appreciate the staff of the Department of Anesthesiology and the Department of Spine and Joint Surgery at Shengjing Hospital for their support and assistance in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Bureau of Statistics. Seventh National Population Census Bulletin (No. 5) [EB/OL](2021-05-11)[2020-12-25]. http://www.stats.gov.cn/tjsj/tjgb/rkpcgb/qgrkpcgb/202106/t20210628_1818827.html .\u003c/li\u003e\n\u003cli\u003eHe W, Goodkind D, Kowal P. An Aging World: 2015. 2016. \u003c/li\u003e\n\u003cli\u003eKobayashi K, Imagama S, Ando K, et al. Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study. Global Spine J. 2017. 7(6): 560-566.\u003c/li\u003e\n\u003cli\u003eHuang Q, Liu S, Liang G. Research progress on risk factors, clinical prevention and treatment of postoperative delirium in patients undergoing spinal surgery. Zhonghua Wai Ke Za Zhi. 2019. 57(6).\u003c/li\u003e\n\u003cli\u003eZeng X, Wang L, Bao R. Nursing procedure intervention on falls and bed-drops in elderly patients. CHINA MODERN DOCTOR. 2019. 57(02): 142-144+148.\u003c/li\u003e\n\u003cli\u003eZhao Y, Atun R, Oldenburg B, et al. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data. Lancet Glob Health. 2020. 8(6): e840-e849.\u003c/li\u003e\n\u003cli\u003eGottesman D, McIsaac DI. Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults. Anaesthesia. 2022. 77(12): 1430-1438.\u003c/li\u003e\n\u003cli\u003ePanayi AC, Orkaby AR, Sakthivel D, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019. 218(2): 393-400.\u003c/li\u003e\n\u003cli\u003eSong Y, Wu Z, Huo H, Zhao P. The Impact of Frailty on Adverse Outcomes in Geriatric Hip Fracture Patients: A Systematic Review and Meta-Analysis. Front Public Health. 2022. 10: 890652.\u003c/li\u003e\n\u003cli\u003eHewitt J, Long S, Carter B, Bach S, McCarthy K, Clegg A. The prevalence of frailty and its association with clinical outcomes in general surgery: a systematic review and meta-analysis. Age Ageing. 2018. 47(6): 793-800.\u003c/li\u003e\n\u003cli\u003eChow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012. 215(4): 453-66.\u003c/li\u003e\n\u003cli\u003eRockwood K, Fox RA, Stolee P, Robertson D, Beattie BL. Frailty in elderly people: an evolving concept. CMAJ. 1994. 150(4): 489-95.\u003c/li\u003e\n\u003cli\u003eStrandberg TE, Pitk\u0026auml;l\u0026auml; KH. Frailty in elderly people. Lancet. 2007. 369(9570): 1328-1329.\u003c/li\u003e\n\u003cli\u003eFriedman SM, Shah K, Hall WJ. Failing to Focus on Healthy Aging: A Frailty of Our Discipline. J Am Geriatr Soc. 2015. 63(7): 1459-62.\u003c/li\u003e\n\u003cli\u003eMorley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012. 16(7): 601-8.\u003c/li\u003e\n\u003cli\u003eDent E, Morley JE, Cruz-Jentoft AJ, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging. 2019. 23(9): 771-787.\u003c/li\u003e\n\u003cli\u003eStaiger RD, Cimino M, Javed A, et al. The Comprehensive Complication Index (CCI\u0026reg;) is a Novel Cost Assessment Tool for Surgical Procedures. Ann Surg. 2018. 268(5): 784-791.\u003c/li\u003e\n\u003cli\u003eSlankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013. 258(1): 1-7.\u003c/li\u003e\n\u003cli\u003eSusano MJ, Grasfield RH, Friese M, et al. Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery. Anesthesiology. 2020. 133(6): 1184-1191.\u003c/li\u003e\n\u003cli\u003eCollard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012. 60(8): 1487-92.\u003c/li\u003e\n\u003cli\u003eHammami S, Zarrouk A, Piron C, Almas I, Sakly N, Latteur V. Prevalence and factors associated with frailty in hospitalized older patients. BMC Geriatr. 2020. 20(1): 144.\u003c/li\u003e\n\u003cli\u003eGong S, Qian D, Riazi S, et al. Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis. Anesth Analg. 2023. 136(2): 251-261.\u003c/li\u003e\n\u003cli\u003eKunz V, Wichmann G, Wald T, et al. Frailty Assessed with FRAIL Scale and G8 Questionnaire Predicts Severe Postoperative Complications in Patients Receiving Major Head and Neck Surgery. J Clin Med. 2022. 11(16).\u003c/li\u003e\n\u003cli\u003eGeriatrics CSo, Geriatrics EBoCJo. Chinese expert consensus on prevention of frailty in the elderly(2022). Chinese Journal of Geriatrics. 2022. 41(05): 503-511.\u003c/li\u003e\n\u003cli\u003eSchopmeyer L, El Moumni M, Nieuwenhuijs-Moeke GJ, Berger SP, Bakker S, Pol RA. Frailty has a significant influence on postoperative complications after kidney transplantation-a prospective study on short-term outcomes. Transpl Int. 2019. 32(1): 66-74.\u003c/li\u003e\n\u003cli\u003eErne F, Wallmeier V, Ihle C, et al. The modified 5-item frailty index determines the length of hospital stay and accompanies with mortality rate in patients with bone and implant-associated infections after trauma and orthopedic surgery. Injury. 2023 .\u003c/li\u003e\n\u003cli\u003eLiu EX, Kuhataparuks P, Liow ML, et al. Clinical Frailty Scale is a better predictor for adverse post-operative complications and functional outcomes than Modified Frailty Index and Charlson Comorbidity Index after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2023 .\u003c/li\u003e\n\u003cli\u003eElsamadicy AA, Koo AB, Reeves BC, et al. Prevalence and Influence of Frailty on Hospital Outcomes after Surgical Resection of Spinal Meningiomas. World Neurosurg. 2023 .\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Frailty, Spinal surgery, Elderly people, Adverse postoperative outcomes","lastPublishedDoi":"10.21203/rs.3.rs-3886717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3886717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aims to investigate the relationship between a brief preoperative frailty assessment and the occurrence of adverse postoperative outcomes in elective spinal surgery in the elderly.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a prospective cohort study. The participants selected for the study were elderly patients undergoing elective spinal surgery at Shengjing Hospital of China Medical University. A total of 231 elderly patients aged 65 years or older were assessed for preoperative frailty using the FRAIL scale, a brief frailty screening scale that covers five main aspects: fatigue, resistance, mobility, disease status, and weight, within 1 week before surgery. Follow-up was conducted within 30 days after surgery to obtain information about postoperative recovery. The primary outcome indicator was the occurrence of postoperative complications. Complications of interest included postoperative infections (respiratory, urinary, and surgical site infections), cardiovascular complications, blood transfusions, electrolyte disturbances, and problems with postoperative feeding. Secondary outcome indicators were prolonged hospital stay and adverse postoperative course.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 207 patients were eventually analyzed in this study, of whom 101 (48.8%) were male and 106 (51.2%) were female. The median age of the cohort was 69 (67\u0026ndash;72) years. Preoperative frailty assessment resulted in 30 (14.5%) being healthy, 121 (58.5%) being prefrail and 56 (27.1%) being frail. A total of 65 (31.4%) of the 207 patients experienced postoperative complications. In a multifactorial analysis, frailty (score\u0026thinsp;\u0026ge;\u0026thinsp;3) (OR, 4.80; 95% CI, 1.1-20.96) and ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (OR, 2.53; 95% CI, 1.23\u0026ndash;5.21) were independent risk factors for the development of postoperative complications. ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (OR, 2.21; 95% CI, 1.046\u0026ndash;4.69) was significantly associated with a prolonged hospital stay. Patients with frailty (score\u0026thinsp;\u0026ge;\u0026thinsp;3) (OR, 6.426; 95%CI, 1.13\u0026ndash;36.69) or ASA classification\u0026thinsp;\u0026ge;\u0026thinsp;3 (OR, 4.10; 95% CI, 1.71\u0026ndash;9.83) were at increased risk of adverse postoperative course (CCI above the 75th percentile).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn geriatric elective spinal surgery, preoperative assessment with the brief frailty screening scale can help identify individuals at high potential risk of postoperative adverse events.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThis study was initially registered in the Chinese Clinical Trial Registry on 8/8/2021 under the registration number ChiCTR2100049677.\u003c/p\u003e","manuscriptTitle":"Association of preoperative frailty with adverse postoperative outcomes in elderly patients undergoing elective spinal surgery: A prospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-21 18:11:08","doi":"10.21203/rs.3.rs-3886717/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-01T11:27:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-27T15:45:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2025-02-27T11:43:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-29T14:41:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-29T14:41:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281523203024162192356873841896105074698","date":"2024-06-19T13:13:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-05T10:48:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-28T13:21:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-19T09:12:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-19T09:10:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-01-22T02:30:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d144d90-7e0e-4efa-9dda-15d7835cb976","owner":[],"postedDate":"February 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T15:58:39+00:00","versionOfRecord":{"articleIdentity":"rs-3886717","link":"https://doi.org/10.1186/s12877-025-06352-3","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-09-24 15:56:53","publishedOnDateReadable":"September 24th, 2025"},"versionCreatedAt":"2024-02-21 18:11:08","video":"","vorDoi":"10.1186/s12877-025-06352-3","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06352-3","workflowStages":[]},"version":"v1","identity":"rs-3886717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3886717","identity":"rs-3886717","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}