>> Thank you very much for having me.
It's really a pleasure to be here.
So I'll be presenting on frailty and spinal conditions.
Here are my disclosures, all related to research.
I'll give you a brief overview.
The spine is made up of concentric layers of bone,
all the way from the skull down to the tailbone,
thirty-one concentric layers,
you have seven cervical vertebrae that connects to
twelve thoracic, each with paired ribs all the way around,
and then five lumbar and a few sacrum.
The sacrum is like a keystone that sits
in the ring of the pelvis,
and in the middle of it you have here
the spinal cord roots that come out,
basically like a tree of a trunk and the
roots that come out that give your function
to your arms and your legs and so forth.
Tumors and traumatic condition mostly affect the
vertebral bodies here, and vertebral compression fractures,
when they occur, could press on the nerves
on the side or on the spinal cord.
When they press on a nerve, they can cause weakness
in what that nerve innervates over to the
hand or to the legs.
When it hits on the spine,
here lets say in the cervical spine,
it'll cause injury to whatever is lower,
so a tumor that eats away at the bone in the
cervical spine can cause progressive weakness
in the arms' and legs' function.
And then you have these jelly-like discs,
intervertebral discs in between each layer,
that are basically shock absorbers.
They degenerate over time and lose water.
So I'm gonna talk a little bit about primary tumors.
There's two types of tumors in the spine;
there's primary tumors and metastatic tumors.
Metastatic is somebody has breast cancer, prostate cancer,
a tumor of some other site, it jumps to the spine
through systemic disease and you have a spinal lesion,
often accompanied with lesions in the liver,
or visceral organs, femur.
That's different than primary tumors.
Primary tumors begin in the spine
and because of that, the indications for surgery
and really the goals of treatment are different,
and so for metastatic disease its purely palliative.
These are patients that will often come in with pain,
with weakness if there's cord compression
or nerve compression, and you wanna decompress that,
you want to stabilize them and give them
a better quality of life.
A primary lesion, if there's no systemic disease,
can be curative, and because of that,
you want to take the tumor out all in one piece,
and so the surgery's a bit different, too,
than metastatic disease.
So if this mic is a metastatic tumor,
you might cut it away little by little
and decompress the nerve or decompress the spinal cord.
If this is a primary tumor,
you're taking the whole podium.
And so you want an en bloc resection,
which means the tumor all in one piece
with a normal tissue capsule around it,
and just by the metaphors you can see that
that's really a much more involved surgery,
a much more significant surgery,
and that's really where frailty and
patient selection comes into consideration.
So, this is a paper that we published in
"World Neurosurgery" last year looking at
frailty in disease and sort of risk stratification
for patients with primary spinal tumors.
Here are some examples of primary spinal tumors.
A picture speaks a thousand words and I wanted to
give you an idea of what these surgeries
can kind of look like for primary spinal tumors.
Here are normal surgical windows for
cervical spine pathologies,
and this is a patient with a high cervical chordoma,
which is a primary spinal tumor that grows
from the embryological notochord.
It's too large, spanning from a C2 to C4.
This is the tongue here for orientation,
the brain stem right there, cerebellum,
the patient's facing that way to the left.
It's too large for any one of these approaches,
so really what needs to be done
is a transmandibular approach where the jaw is split,
and this is a fantastic illustration from our institution.
And so the jaw is split, the pharynx is breached in there,
moving the tongue to the side,
and you can see in the back there
with the nerves to the facial expression
and to the tongue preserved and then
corroded the jugular here, dissected the inner esophagus,
and trachea moved to the side.
You can see the high cervical segments up here,
and really that's the only approach
to get to that bony segment and to that tumor
and take it out en bloc,
and then what needs to be done
is you see the spinal cord back here
because all that bone that was basically connecting
the skull to the spine is removed,
all those neck segments are removed,
and so it needs a really significant reconstruction.
This is in the thoracic spine, in the high thoracic spine.
Often you need cardiothoracic surgeons to help
with the exposure and split the breast bone.
Lower down, you may have to cut the ribs out
and take this entire tumor in one piece,
leaving bone on top, bone below and then the spinal cord,
also requiring some significant reconstruction
in the front and in the back.
And then, this is the scoring system for sacral chordomas,
which was also pioneered at our institution.
This is a patient with a large sacral chordoma
pushing on the rectum.
These patients will often come in with these large lesions
because they're not, unlike the brainstem,
where you may lose function of chewing, swallowing,
in lower sacral segments, really people don't notice it
until they're becoming incontinent,
losing bowel/bladder function, so these grow quite large,
and the treatment for them is a complete sacral amputation,
so dissociating lumbar spine from the pelvis,
and then requiring significant reconstruction.
And so the reason I go into all of that is
you can see that these surgeries are really very involved,
and so what we wanted to do is develop
a preoperative frailty index and aid in
risk stratification for patients undergoing this surgery.
So we did a univariate and a multivariate analysis
of about fifty different factors and nine came up
that were each significantly associated with
in-hospital morbidity and length of hospital stay,
and these are outlined here.
We gave each of these one point
and if a patient had zero preoperatively,
they were not frail.
If they had one, mildly frail. Two, moderate.
Three, severely frail or more.
These were complications that were associated
in a retrospect of cohort of about fifteen-hundred patients
and what we found is that the overall complication rate
was about ten percent and the odds ratio
was significant between groups of frailty,
so between not frail, mildly frail,
moderately and severely frail,
they had an increased odds ratio of having
some kind of complication during their
postoperative hospital stay,
and the same was seen for hospital
postoperative length of stay,
so the more frail they were preoperatively,
the more their length of stay was.
And so, in conclusion for that part,
the frail patients had a significant increased odds
of developing postoperative complications
and risk stratification really can help
patient selection, surgical indications
for patients that maybe are not able
to tolerate such a massive procedure.
So, we're gonna just switch gears for the second half.
We spoke a little bit about the spinal oncology.
Trauma is also a huge factor in these patients,
especially with an aging population with comorbidities,
and osteoporosis, and low bone density,
and that often affects the thoracic
and the thoracolumbar spine,
and so if we go back here, it's sort of a
biomechanical issue, if we go back to
where I showed the anatomy a bit.
So here you have the thoracic segment,
which is pretty rigid, held in place by ribs,
then you have a lumbar segment below
which is very mobile, which really accounts for
all of your flexion extension of the torso,
and in the middle of the 'S' you have an apex here
which is under a high stress and so
elder patients with frailty and low bone density
will often have fractures in that region,
that thoracolumbar apex region because of the high
axial and sheer force stresses present.
And so what we wanted to do was also look at the frailty
of patients in this geriatric population that have
thoracic and thoracolumbar spinal tumors,
and that's been demonstrated in other studies,
but really hasn't been done before for frail patients.
We published this in "Clinical Neurology and Neuroscience"
about a month ago.
We used the ACS, American College of Surgeons,
national database and we looked at patients
who underwent decompression, refusion,
or some kind of decompression and fixative procedure
for thoracic and thoracolumbar spinal fractures.
We used that database in a previously published
well-cited frailty and disease score
to stratify these patients and score them,
and we found that patients,
that 62% of the cohort underwent surgery,
as we expected, 38 had some kind of
cement augmentation, where a needle's injected
into the vertebral body to stabilize that segment,
and frail patients had a significantly larger
thirty-day mortality rate compared to the non-frail group,
that was 16.7 compared to 0.6 percent.
And so, in conclusion, frailty and surgical intervention
correlate with a higher 30-day complication rate
for patients with thoracic and thoracolumbar fractures,
and they also correlate with a higher 30-day mortality.
And so, both frailty is important in the decision making
for spinal oncology and for traumatic injury
for the aging population.
Thank you, and that's my email if
anybody has any questions afterwards.
(clapping)
>> Any question for Ali?
I have one.
If we've got a patient who's got a large primary
and shows up as a greater risk on the frailty index,
so what's the decision there?
>> Has a large primary spinal tumor or primary elsewhere?
>> Primary spinal tumor.
Primary tumor impinging on the spine
and also shows up at greatly elevated risk
because of frailty factors.
What's the decision tree there?
>> So it depends on how they present,
what the neurologic function is,
what the extent of surgery would be.
I mean, I think that these scores and sort of our work
is helping to helping to restratify patients
but it also depends on a patient-by-patient standpoint
and it depends on where the lesion is located,
what the adjacent structures are
and how much function you would need to take
from the patient and what the surgical morbidity would be.
If it was a small primary lesion
and the patient was not as frail,
they might tolerate it better.
If it was a large lesion and they were already
older population and their prognosis wasn't as good,
you might turn a curative procedure into
maybe a more palliative indication for that patient.
So it goes into the decision making.
If that answers that question.
>> It does. Thanks very much.
>> Thank you so much, appreciate it.
>> There we go.
>> Liz: Hi, Liz Szabo with Kaiser Health News.
I'm interested in how you communicate
these risks to patients, because in reporting on people
with metastatic cancer, often they or their families
will say, "We want to do everything possible."
Do you show them those illustrations?
That might talk me out of it.
(laughter)
I'm just wondering...
I've written about different ways to communicate
surgical risks to patients. How do you do that?
>> A lot of the time, as you would imagine,
the illustrations are published and they're available,
but they're not really shown as part of the
consent process usually, but it's more of function,
what the patient will be left with,
so with those large sacral lesions,
S2-4 is responsible for bowel/bladder
and if you want to give that patient a cure,
or a chance of a cure and the tumor
is wrapped around the whole thing,
you might discuss with them, oh, by the way,
you will take a longer time to get up,
you will be, you know, the massive reconstruction,
you may be in PT for a while and you'll lose
all bowel/bladder function and so,
it really depends again, what we were saying,
what the adjacent structures are,
what the indication for surgery, and then,
it's really a shared decision, and so
options are offered to patients and a lot of patients
will say, "I want to be completely cured of this.
I don't wanna worry about this.
I'm okay with having a little bit of a foot drop
or a bowel/bladder issue," and some patients will say,
"No, maybe if you could leave a little rim around that nerve
and preserve that nerve and I'm okay with taking
the radiation and the chance for local recurrence,"
and so, it's a shared decision making,
and really the options are offered in the sense of
what's the surgical morbidity and what's the function
and what's the chance of the cure
and so it's really a balance between the risk
and benefit that's shared between the
decision making and the best you can offer patients
is to be honest about what the morbidity
of both options are.
>> One last question.
>> Audience Member: How fixed is position
on your frailty index?
Is there rarely a chance for prehab, if you will,
to modify their risks from the surgery?
>> Yeah, and it's a really great question.
Because of the data that we did was from
national inpatient samples, a lot of it is limited
in looking at those kinds of variables.
They do collect the preoperative electrolyte
and preoperative prealbumin and different serum markers
which might be affected if patients have
a long course of prehab, but it wasn't one of the factors
that were in ours, but the point is well received.
>> Thanks very much.
>> Thanks, appreciate it.