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OBJECTIVE Frailty’s role in preoperative risk assessment in spine surgery has increased in association with the increasing size of the aging population. However, previous frailty assessment tools have significant limitations. The aim of this study was to compare the predictive ability of the Risk Analysis Index (RAI) with the 5-factor modified frailty index (mFI-5) for postoperative spine surgery morbidity and mortality. METHODS Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database for adults > 18 years who underwent spine surgery between 2015 and 2019. Multivariate modeling and receiver operating characteristic curve analysis, including area under the curve/C-statistic calculations, were performed to evaluate the comparative discriminative ability of RAI and mFI-5 on postoperative outcomes. RESULTS In a cohort of 292,225 spine surgery patients, multivariate modeling showed that increasing RAI scores, and not increasing mFI-5 scores, were independent predictors of increased postoperative mortality for the trauma, tumor, and infection subcohorts. In the overall spine cohort, both increasing RAI and increasing mFI-5 scores were associated with increased mortality, but C-statistics indicated that the RAI (C-statistic 0.802 [95% CI 0.800–0.803], p < 0.0001, DeLong test) had superior discrimination compared with the mFI-5 (C-statistic 0.677 [95% CI 0.675–0.679], p < 0.0001, DeLong test). In subgroup analyses, the RAI had superior discriminative ability to mFI-5 for mortality in the trauma and infection groups (p < 0.001 and p = 0.039, respectively). CONCLUSIONS The RAI demonstrates superior discrimination to the mFI-5 for predicting postoperative mortality and morbidity after spine surgery and the RAI maintains conceptual fidelity to the frailty phenotype. Patients with high RAI scores may benefit from knowing the possibility of increased surgical risk with potential spine surgery.

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BACKGROUND AND IMPORTANCE: Intraparenchymal hemorrhage (IPH) is a debilitating and highly morbid type of stroke with limited effective treatment modalities. Minimally invasive evacuation with tissue plasminogen activator (rt-PA) has demonstrated promise for mortality/functional improvements with adequate clot volume reduction. In this study, we report 2 cases of continuous rt-PA infusion using a closed circuit, dual lumen catheter, and irrigation system (IRRAflow) for IPH treatment. CLINICAL PRESENTATION: A 55-year-old man was admitted for acute onset left hemiparesis; he was found to have right basal ganglia IPH. He was treated with continuous rt-PA irrigation using the IRRAflow device, at a rate of 30 mL/h for 119 hours, with a total volume reduction of 87.8 mL and post-treatment volume of 1.2 mL. At 3-month follow-up, he exhibited a modified Rankin score of 4 and improved hemiparesis. A 39-year-old woman was admitted for acute onset left facial droop, left hemianopsia, and left hemiparesis; she was diagnosed with a right basal ganglia IPH. She was treated with drainage and continuous rt-PA irrigation at 30 mL/h for 24 hours, with a total hematoma volume reduction of 41 mL and with a final post-treatment volume of 9.1 mL. At 3-month followup, she exhibited a modified Rankin score of 3 with some improvement in left hemiparesis. CONCLUSION: Continuous rt-PA infusion using a minimally invasive catheter with saline irrigation was feasible and resulted in successful volume reduction in 2 patients with IPH. This technique is similar to the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE) approach but offers the potential advantages of less breaks in the sterile circuit, continuous intracranial pressure monitoring, and may provide more efficient clot lysis compared with intermittent bolusing.