Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review : Journal of Neurosurgical Anesthesiology

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Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review

Mohamed, Basma MBChB*,†; Ramachandran, Ramani MBBS, MD*,†; Rabai, Ferenc MD*,†,‡; Price, Catherine C. PhD*,‡,§; Polifka, Adam MD†,∥; Hoh, Daniel MD†,∥; Seubert, Christoph N. MD, PhD, DABMN*,†,‡

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Journal of Neurosurgical Anesthesiology 35(1):p 19-30, January 2023. | DOI: 10.1097/ANA.0000000000000787


Degenerative spine disease affects nearly 270 million people worldwide, with an estimated prevalence of nearly 3.6%.1 This disabling condition is disproportionately represented in older adults. Complex spine surgery may offer relief but is more frequently complex and associated with higher perioperative risks in older adults compared with those in younger age groups.2,3 Though the definition of complex spine surgery varies in the literature, it typically exceeds a simple laminectomy, discectomy, or 1 to 2 levels of fusion and comprises multilevel spine fusion, correction of spine deformity, >4 hours of operative time, and spine surgery in a medically complex patient.4,5

Older individuals not only carry a higher burden of well-defined disease states, but they also are more likely to have accrued significant declines in functional capacity and resilience. Such declines manifest as frailty, which is defined as the constellation of generalized organ and tissue atrophy, reduced physiological, physical, and cognitive reserves, deconditioning, and malnutrition. There is broad consensus that frailty decreases tolerance for stressors and confers added perioperative risks.6,7 In a retrospective study of 52,671 patients undergoing surgery for degenerative spine diseases between 2006 and 2012, 4% overall and 8% of those over 65 years of age were frail.7 The extent of frailty independently predicted postoperative complications such as reoperation for infection and 30-day mortality, as well as elements of social cost including hospital length of stay and discharge to an advanced care facility.7 These findings are echoed in systematic reviews of the impact of frailty on spine surgery outcomes.8–10 Frailty is usually associated with multiple comorbidities that are captured in the conventional preoperative assessment. However, the conventional preoperative assessment may fail to synthesize this information in a way that accounts for frailty. Even a frailty assessment may not fully capture cognitive and psychosocial dimensions of age-related decline as they affect perioperative risk or outcomes of patients considering complex spine surgery.

Systematic approaches to mitigate the physiological impact of surgery, based on ideas generated in colorectal and joint replacement surgery, are being developed for complex spine surgery patients. These include minimally invasive surgical techniques and enhanced recovery after surgery (ERAS) programs. The latter optimizes a limited range of preoperative factors such as smoking, alcohol use, and anemia, and decrease the stress response to surgery through effective pain control, behavioral interventions, perioperative nutrition therapy, early mobilization, and surgery-specific interventions.11 Some ERAS protocols for spine surgery include patients requiring complex spine surgeries.12–15 Routine assessment of frailty and interventions to ameliorate frailty by providing preoperative habilitation—or prehabilitation—are not yet consistently incorporated into such protocols.

The purpose of this narrative review is to provide an overview of frailty assessment in general, as well as the utility and limitations of common frailty assessment tools for spine surgery patients specifically. We assess the impact of frailty on perioperative outcomes in patients undergoing complex spine surgery for degenerative spine disease and adult spine deformity. We present components of multimodal prehabilitation as well as a summary of trials that addressed prehabilitation before spine surgery and its impact on perioperative outcomes.


The literature search included the PubMed, EMBASE, and Cochrane databases between 2000 and 2021. Included articles were focused on frailty and spine surgery, sarcopenia and spine surgery, frailty and prehabilitation in spine surgery, cognitive frailty, nutrition prehabilitation in spine surgery, and ERAS for spine surgery that addressed prehabilitation. Included articles were randomized controlled trials, observational case-control studies, prospective and retrospective cohort studies, systematic reviews, review articles, and case series. Results were limited to articles that addressed spine surgery for adult degenerative spine disease and spine deformity. The following articles were excluded: animal studies, editorials, commentary, letters, book chapters, conference proceedings, articles involving spine surgery for tumors, infections, or trauma, and non-English language articles.

A total of 795 articles resulted from the search and 206 were found as duplicates; 598 titles and abstracts were reviewed, resulting in 128 articles that met inclusion criteria for full-text review (Supplemental Digital Content 1: Flow diagram of literature search methodology,


Within a common trajectory of aging, a frailty assessment systematically captures the difference between the chronological and the physiological age of an individual. There is broad consensus that frailty decreases tolerance for the stressors which are commonly encountered during the perioperative course6; therefore, frailty confers added perioperative risks. However, frailty assessment is challenging and there is a lack of consensus about the optimal method and clinical tools. This problem is highlighted by the number of proposed scoring systems and their modifications introduced over the past 2 decades (Table 1).9,25

TABLE 1 - Frailty Assessment Tools in Spine Surgery
Instrument Method of Assessment Advantages Disadvantages Used in Spine Scoring
Accumulating deficits mFI-117,16 11 comorbidities also captured in NSQIP: Functional health status, COPD, DM, CHF within 30 d, MI within 6 mo, PCI or previous cardiac surgery, HTN, impaired sensorium, TIA or CVA, CVA with residual neurological deficits, PVD Easily performed in the preoperative setting. Obtainable retrospectively from NSQIP database Consistent with comorbidity index Focused on comorbidity burden. Does not capture nutrition, cognition, or mental health Yes Number of items present divided by 11 to obtain a score of 0-1 Robust=0 Prefrail <0.27 Frail≥0.27
mFI-517 5 comorbidities also captured in NSQIP: CHF within 30 d, DM (insulin or non–insulin-dependent), COPD or pneumonia, partially dependent or totally dependent functional status, HTN on medications 87% agreement with mFI-11 Shorter than mFI-11; Obtainable retrospectively from NSQIP database 87% agreement with mFI-11 and equally effective in predicting adverse events after spine surgery Focused on comorbidity burden Does not capture nutrition, cognition, or mental health Yes Number of items present Robust=0 Prefrail=1 Frail=2-5
ASDFI18,19 42 variables including comorbidities and disabilities Tailored to adult spine deformity patients Includes disability and patient-reported outcomes resulting from spine disease Cumbersome to perform in a preoperative setting Only specific to adult spine deformity Yes Number of items present divided by 42 to obtain a score of 0-1 Not frail <0.3 Frail=0.3-0.5 Severely frail >0.5
CDFI 40 variables including comorbidities and patient-reported variables extracted from quality of life, neck disability index, and lumbar spine disability index questionnaires20 Validated in the spine surgery population Most variables are available in the patient’s records Patient-reported variables can be obtained through patient questionnaires such as ODI, NDI, or quality of life questionnaires Extensive number of variables that may not be readily available Might be complex for a busy preoperative clinic practice Only applicable to cervical spine deformity patients (not validated for other cervical spine surgery patients) Yes The mean score of all the health deficits is calculated (ratio of patient’s deficits to total number of deficits, ie, 40) CDFI score ranges from 0 to 1 <0.2 is not frail, 0.2-0.4 is frail >0.4 is considered severely frail
HFRS Uses ICD-10 diagnostic codes related to elective and nonelective hospital admissions within 2 y before the current encounter Uses the diagnostic data in an algorithm to identify the risk of frailty and outcome such as death and readmission21,22 Easily used to conduct large-scale frailty analysis on large data sets Diagnostic codes are easily captured in the electronic health records Only validated in admitted patients Cumbersome to use in the preoperative setting May miss frailty in patients with no or few past admissions Yes 0-5 ICD-10 diagnostic codes=low-risk frailty 5-15 ICD diagnostic codes=moderate-risk frailty >15 ICD diagnostic codes=high-risk frailty
Phenotype FRAIL Scale (Fried phenotype or Frailty Phenotype)6,23 5 indicators: Unintentional weight loss >10 lbs Grip strength, 20th percentile Self-reported exhaustion Slowness: 15 foot walking speed, low activity: males <383 kcal/wk, females <270 kcal/wk Its predictive accuracy is almost similar to mFI Incorporation of aging elements other than comorbidities may allow further optimization beyond medical diseases (prehabilitation, nutrition management)Relatively easy to use Special equipment required 3 of 5 items rely on self-report Cognition not assessed No Number of items present Not frail=0 Prefrail=1-2 Frail=3-5
Clinical Frailty Scale6 Global clinical assessment: (1) Very fit: robust, very active, and motivated. These people commonly exercise regularly. They are among the fittest of their age (2) Well: no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally (3) Managing well: medical problems are well controlled, but rarely active beyond walking (4) Vulnerable: not dependent on daily help but symptoms limit activities. “Slowed up” and/or tired during the day (5) Mildly frail: more evident slowing and need help in high-order activities such as shopping and walking outside alone, meal preparation, and housework (6) Moderately frail: need help with all outside activities and housekeeping. Problems with stairs, may need help with dressing and bathing (7) Severely frail: dependent for all personal care, but clinically stable and not high risk, they are at risk of dying within ∼6 mo (8) Very severely frail: completely dependent, reaching the end of life. At risk even from a minor illness (9) Terminally ill: life expectancy <6 mo, may not be evidently frail Can add significant predictive value when included in a risk prediction model with age, sex, ASA score, and procedural risk Easy to use Less time compared with FRAIL Scale No Assigned at assessment Very fit Well managing Well vulnerable Mildly frail Moderately frail Severely frail Very severely frail Terminally ill
Other Psoas Muscle Index (PMI) Total cross-sectional areas of bilateral psoas muscles at L3 vertebral body measured on preoperative MRI or CT divided by height2 (mm2/m2) Available for most lumbar surgeries A measure of sarcopenia associated with poor postoperative adverse events Not available for some surgeries No assessment of function, comorbidities, or cognition Yes PMI cutoff for predicting perioperative AEs were <500 mm2/m2 in males and <412 mm2/m2 in females24
ASA indicates American Society of Anesthesiology physical status; ASDFI, Adult Spine Deformity Frailty Index; CDFI, Adult Cervical Deformity Frailty Index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CT, computed tomography; CVA, cerebrovascular accident; DM, diabetes mellitus; HFRS, Hospital Frailty Risk Score; HTN, hypertension; ICD-10, International Classification of Diseases, 10th Revision; mFI, Modified Frailty Index; MI, myocardial Infarction; MRI, magnetic resonance imaging; NDI, Neck Disability Index; NSQIP, National Surgical Quality Improvement Program; ODI, Oswestry Disability Index; PCI, percutaneous coronary intervention; PVD, peripheral vascular disease.

Frailty assessments are based on 2 different models. One model counts accumulated deficits across organ systems, while the other assesses the frailty phenotype based on the age-associated decline in activity, lean body mass, and strength.26 The Frailty index is an accumulated deficits tool which includes >40 binary variables and focuses on comorbidities, activities of daily living, and physical signs and symptoms of the disease.27 Currently, 2 shortened frailty indices, the 11-item modified frailty index-11, and 5-item modified frailty index-5, use comorbidities captured in the National Surgical Quality Improvement Program and have been validated in the spine surgery population as predictive of adverse events.8,9,16,17,28 Similarly, the adult spinal deformity frailty index counts accumulated deficits and has been validated in spine surgery patients.18,29 In accumulated deficit models of frailty, deficits are simply counted and then divided by the total number of possible deficits, resulting in scores between 0 and 1. Frailty is scored according to an arbitrary cutoff (eg, >0.21 for the frailty index) or as a continuous variable. Examples of phenotypic assessments are the Fried frailty phenotype,30 the Hopkins frailty score,31 and the clinical frailty scale.27 Fried frailty phenotype assesses weight loss, weakness, exhaustion, slowness of movement, and low levels of physical activity; a score of 0 indicates the absence of frailty, 1 through 2 is a prefrail state, and 3 to 5 is overt frailty.32 Fried frailty phenotype has not been used or validated in the spine surgery population. The clinical frailty scale was developed from and validated against the frailty index.27 It uses phenotypic criteria combining measures of physical fitness and comorbidities, as well as cognitive impairment, to classify individuals from level 1 (fit) to level 9 (terminally ill). In a recent meta-analysis of frailty scales in surgical patients, the clinical frailty scale was clinically most feasible and most accurately predicted mortality and discharge to a destination other than home.33 Despite its clinical utility, the clinical frailty scale has not been validated in the spine surgery population.

Tools that measure objective biomarkers of frailty, such as muscle mass or nutritional and inflammatory biochemical markers in the blood, are beginning to be incorporated into frailty assessments.34 Ideally, these tools should accurately identify frailty, reliably predict outcomes or response to therapies, and be grounded in a framework that causally links biological processes with frailty.25 Muscle mass and function are frequently decreased in the elderly in a syndrome typically described as sarcopenia. Sarcopenia is characterized by a general loss of muscle mass, strength, and performance. Disuse and poor nutrition contribute to sarcopenia, which in turn increases risks of physical disability, poor quality of life, and death.8,26 Psoas muscle area on axial computed tomography or magnetic resonance imaging of the lumbar spine has been used as a proxy for sarcopenia. Recent reviews found sarcopenia (assessed as psoas area) to be a useful assessment of frailty but insufficiently validated to predict outcomes of spine surgery.26,35 All objective biomarkers add time and expense to the preoperative assessment and should be regarded as research interventions until their value is better characterized.

The prevalence of frailty in a given population depends on the tool used to measure frailty. Accumulated deficit tools tend to estimate a lower prevalence of frailty overall, whereas phenotypic assessments typically estimate at least twice the prevalence.6,36 When stratified by age, however, phenotypic tools estimate greater prevalence in younger patients, whereas in patients aged 50 years and older, accumulation-of-deficit tools estimate greater prevalence.36

The choice and application of frailty assessment tools in individuals undergoing complex spine surgeries are complicated by the interaction and overlap of elements of spine pathology and frailty.26,37 Degenerative spine disease causes maladaptive processes such as chronic pain, reduced activity, inflammation, osteoporosis, and atrophy of paraspinal muscles. Such manifestations of spine disease mimic phenotypes of frailty and are potentially reversible.8,26 This creates challenges in applying traditional phenotypic frailty scales to this patient population. For example, weakness and slowness of movement may be manifestations of both frailty and neurological deficits. Likewise, low levels of physical activity may represent frailty or pain-induced fear of movement known as kinesophobia, a maladaptive coping with pain. Therefore, frailty assessment methods relying on the accumulation of deficits models as opposed to phenotypic models may be more appropriate for patients with degenerative spine disease. In a systematic review evaluating different frailty assessment tools in the spine surgery population, the modified frailty index-11 was proposed as the most appropriate tool for assessing frailty because it is externally validated, well reported in the spine population, and suitable for predicting outcome.9


Cognitive decline and psychosocial isolation are also features of advancing age. Though distinct from physical frailty, they may interact with frailty in important ways. Cognitive decline and psychosocial isolation may precede, accompany, or follow the onset of physical frailty but, when present, may independently influence surgical outcomes.38 Individuals with early Alzheimer disease, for example, are typically not frail, but face greater risks of postoperative delirium and may struggle to comply with a rehabilitation program.39 In Parkinson disease, frailty typically tracks with disease severity.40 Conversely, severe physical frailty limits an individual’s ability to participate in life, causing psychosocial isolation and potentially accelerating cognitive decline. Cognitive and psychosocial functioning are prevalent confounders that are frequently not well characterized in studies of the medical impact of frailty. Up to one fourth of community-dwelling individuals present to a preoperative setting with early signs of the mild neurocognitive disorder, but unaware of their cognitive impairments.41

Cognitive decline increases the risk for postoperative delirium, prolonged hospital stay, and mortality, beyond that conferred by advanced age and frailty.42 Other prevalent risk factors for delirium in the spine surgery population are pain and opioid use, previous delirium history, multiple comorbidities, polypharmacy, and hearing or vision loss.43


Regardless of the specific frailty assessment tool, the presence and degree of frailty impact outcomes of complex spine surgery for degenerative spine disease.8–10,37 Complications that increase in the presence of frailty are mortality, length of hospital stay, readmission, nonhome discharge, and various composites of adverse events.8–10,37 Importantly, frailty predicted perioperative and postoperative complications similarly in retrospective analyses of different prospective databases. Increasing frailty predicted increased complications not just for the extensively studied American College of Surgeons National Surgical Quality Improvement Project database,7,16,44,45 but also for the International Spine Study Group20,46 and the European Spine Study Group47 databases. The impact of frailty on outcomes appears to be more important for more invasive surgeries. Thus, frailty has been found to increase complication rates—typically in a dose-dependent manner—for more invasive surgeries such as adult deformity corrections,18,45 whereas frailty did not predict increased complication rates for less complex surgical procedures such as simple posterior fusions.47

Minimizing complications, however, is not the only goal in the decision for spine surgery. Achieving clinically meaningful improvements for patients may justify accepting an increased risk of complications. Thus, Reid et al48 found that compared with nonfrail individuals, frail patients who underwent spinal fusions of >4 segments had greater improvements in pain, disability, and quality of life when assessed 2 years after surgery despite higher complication rates. The greater improvement in frail patients was in part driven by their more significant disability before surgery (Fig. 1), consistent with the notion that spine pathology and frailty overlap to some extent. Nonetheless, the independent impact of frailty on outcomes remained because severely frail patients were least likely to achieve substantial clinical benefit. For cervical deformity, a recent study suggests that successful surgery improves frailty itself by improving elements of the cervical deformity frailty index, namely constitutional symptoms of fatigue and exhaustion and means of engagement in life through driving and reading.49 More recently, the International Spine Study Group reported similar results for adult spinal deformity correction.50,51 Although patients with more advanced frailty assessed with the adult spinal deformity frailty index had more severe deformities, more invasive surgeries, and higher complication rates than nonfrail patients, they had greater improvements in back pain, disability, and quality of life. Taken together, these studies suggest that the simple presence of frailty should not preclude complex spine surgery. Conversely, a study of 3-year outcomes for adult spine deformity correction showed increased risks for complications and decreasing benefits for patients grouped by progressive frailty.52

Frailty’s impact on the benefits of complex spine surgery. Patients undergoing spine fusions of >4 levels were assessed for disability (Oswestry Disability Index), quality of life (Short Form 36 Physical Component Summary), and pain before and 2 years after surgery. Outcomes were scaled on a 10-point scale, with 0 representing the best and 10 representing the worst possible score for a given scale. Results are grouped by color for the degree of frailty. For the Oswestry Disability Index, Short Form 36 Physical Component Summary, and pain, the rate of improvement, represented by the downward slope of the lines connecting preoperative and 2-year assessments, was greatest for the patients in the frail group. Adapted from Reid et al.48 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.


The concept of prehabilitation originated in physical therapy to describe the focused physical exercise programs implemented before an injury—during training of army recruits—to minimize injury-induced disruption of physical performance.53 Though prehabilitation originated in the context of military injuries, it has since spread to sports injuries and lately to surgery as an injurious event (Fig. 2).

The potential impact of prehabilitation of frail/prefrail individuals undergoing spine surgery on complications, recovery of functional status, discharge disposition, and hospital length of stay. The diagram depicts hypothetical perioperative clinical timelines and physiologic recovery trajectories of fit individuals and frail or prefrail people either with prehabilitation or without prehabilitation. Risks of complications (vertical arrows to the left) are a function of preoperative baseline frailty score (horizontal dotted lines) and surgery-induced functional decline (vertical drop in the clinical trajectories). Fitness is associated with greater reserves, less physiologic decline, more rapid scheduling of surgery, fewer complications, and faster recovery to home discharge. In frailty, the lower preoperative functional status is usually coupled with a greater increase in physiologic exhaustion, more workup before surgery, and higher complication rates in response to surgery. In the absence of prehabilitation, a protracted recovery with lower recovery potential and nonhome discharge are more likely. Prehabilitation may improve baseline functional status and resistance to surgical stress in frail patients by shifting the recovery trajectory towards improved recovery (curved arrows). Thus, prehabilitation results in a shorter period below the line of dependence (horizontal dashed line) and a faster recovery and greater recovery potential after surgery. Although prehabilitation may typically delay surgery, reduced hospital length of stay and higher likelihood of home discharge after surgery are potential distinct advantages in frailty syndrome (horizontal arrows at the top).

Prehabilitation programs have been shown to improve outcomes in colorectal and other cancer surgeries as well as in cardiothoracic surgery.54–56 The effort and delay of completing a prehabilitation program may be justified for all patients when dealing with a life-altering diagnosis such as coronary disease or when faced with obligatory preparations before surgery such as neoadjuvant therapy for cancer. All prehabilitation programs include exercise to improve functional capacity, and multimodal prehabilitation typically adds nutritional supplementation. Additional modalities are tailored to specific patient populations, such as coping skills or psychological and behavioral therapy to alleviate anxiety and depression in cancer patients or respiratory exercise programs for cardiac and thoracic surgery patients.56–61

Prehabilitation specifically focused on frail patients implicitly combines 2 distinct intentions: reversing frailty, which moves the patient to a more favorable risk category, and specifically targeting aspects of frailty that adversely affect surgical outcomes.62 Such studies used frailty as a screening tool and to design interventions before surgery, but frequently failed to assess frailty as an outcome. For adult spine deformity, Yagi et al63 compared a small cohort of frail and prefrail patients on whether the deficits of frailty were appropriately addressed based on comorbidity-specific guidelines, albeit in the absence of a prehabilitation program. While a frail/prefrail state increased complications and morbidity beyond those experienced by robust individuals, medical therapy of the comorbidities did not significantly improve outcomes.

Components of Multimodal Prehabilitation

Multimodal prehabilitation programs include interventions targeted to physical and nutritional prehabilitation, behavioral interventions targeting pain, and cognitive prehabilitation for brain health.

Physical Prehabilitation

Exercise effectively decreases frailty and boosts quality of life while also improving cognition and depression.64 The duration of physical prehabilitation varies among studies, with typical ranges of 2 to 12 weeks. The minimum duration of an exercise regimen to improve any postoperative outcomes appears to be 2 weeks, but longer durations may be needed depending on the patient population and outcome under study. In most studies, the bulk of the exercise training is done at home with good compliance, variably supported to sustain motivation. By engaging patients and improving physical functioning, exercise interventions frequently improve quality of life even while awaiting more definitive care. The physical exercise intensity is typically tailored to each patient’s capacity, and progressively modified to obtain increasing levels of difficulty.65–67 For example, a supine hip raise to strengthen the trunk and paraspinous muscles might start on the floor with bent knees, progress to straight legs with the heels on a physio ball, and end as straight leg raises in a reverse plank position on a physio ball.68

Nutritional Prehabilitation

Nutritional prehabilitation, typically provided as protein supplementation, targets malnutrition and sarcopenia. Studies in frail patients suggest that, although nutrition and physical performance can be enhanced, improving sarcopenia may be beyond the scope of the preoperative setting. A randomized double-blind placebo-controlled trial of protein supplements and resistance exercise in frail individuals reported very modest improvements in lean body mass of 1.3 kg over 24 weeks, but significant improvements in physical performance and strength.69 A separate study of protein supplementation only found comparable improvements in physical performance even in the absence of a formal exercise program.70

A perioperative focus on nutrition and protein intake appears beneficial in spine surgery patients. A daily supplement of 36 g of protein started 48 hours before spine fusion surgery and continued for 30 days increased the cross-sectional area of paraspinal muscles and reduced muscle atrophy, while decreasing pain and disability 30 days postoperatively.71 Similarly, protein and glucose supplementation started the night before surgery in patients undergoing 1-level to 2-level lumbar fusion was associated with shorter hospital length of stay and higher postoperative albumin level on postoperative day 3 compared with a control group.72 Evaluation of nutritional deficiency for lumbar spine fusion is recommended by the ERAS Society.73 Supplementation of iron, calcium, or vitamin D in the absence of documented deficiencies has not been sufficiently studied in the spine surgery population.

Behavioral Interventions Targeting Pain

Chronic pain, catastrophizing, and kinesophobia are prevalent in patients with degenerative spine disease.74 Behavioral interventions aim to disrupt the vicious cycle of fear and avoidance that mutually reinforces inactivity and promotes disability in patients with back pain. Such interventions are usually performed by trained physiotherapists who provide either pain neuroscience education or combine such education with behavioral therapy as formal cognitive behavioral therapy (CBT). Pain neuroscience education assures patients that chronic axial back pain does not portend progressive tissue damage, whereas inactivity promotes disability. It helps patients understand the pain through neurophysiological, social, and physical components of their individual pain experience.75 Pain neuroscience education is an effective educational strategy when combined with rehabilitation programs. In the absence of surgery, the addition of CBT to guideline-based active treatment for low back pain significantly reduced disability and pain.76 After lumbar spine surgery, the addition of CBT improved fear of movement, catastrophizing, and disability while improving quality of life in both the short and long terms.77

Cognitive Prehabilitation for Brain Health

Three areas deserve consideration for addressing cognitive and psychosocial dimensions of frailty. First, optimization of a patient’s medications is suggested by the independent effect of opiates, benzodiazepines, and anticholinergic medications on postoperative delirium. Indeed, a geriatric medicine consultation proved an effective way to decrease postoperative delirium in a predominantly frail cohort of patients with hip fracture.78 A prehabilitation program offers the time to devise a less opioid-reliant pain management strategy. Such interventions have been implemented with the intent of reducing the risk of opioid addiction.79 Second, prehabilitation should minimize the risk of postoperative delirium. In a feasibility study of home-based cognitive prehabilitation in older surgical patients, barriers to cognitive training included feeling overwhelmed, technical issues with training, and the time commitment.80 The third area is maintenance of cognitive health throughout the perioperative period. Postoperative cognitive dysfunction, manifesting as delayed neurocognitive recovery or as persistent neurocognitive disorder, is moving from anecdote and research construct toward a clinical entity.81 Currently, there is a knowledge gap in regarding whether preoperative optimization protocols can improve cognitive outcomes.


There are still only a handful of prospective clinical studies investigating prehabilitation for spine surgery; our literature search revealed only 7 randomized studies (Table 2). Although most studies included physical conditioning and cognitive interventions, some focused on cognitive interventions alone. None of the studies specifically focused on frail patients or assessed frailty in their study cohort.

TABLE 2 - Randomized Controlled Trials of Prehabilitation in Spine Surgery
References Marchand et al68 Lindbäck et al65 Fors et al66 Nielsen et al67 Louw et al82 Rolving et al83 Lotzke et al84
Patients (n) 40 197 197 60 60 90 118
Age (mean±SD) 69±9 59±12 59±12 50 50 49 46±8
Diagnosis/procedure Lumbar stenosis Lumbar spondylosis Lumbar spondylosis Lumbar spondylosis Lumbar radiculopathy Lumbar fusion, 1-3 levels Lumbar fusion, 1-3 levels
 Physical therapy 30 min, 3×week for 6 wk 30-40 min, 2×week for 9 wk 30-40 min, 2×week for 9 wk 30 min, daily for 6-8 wk NA NA NA
 Cognitive Information about posture CBT for fear avoidance CBT for fear avoidance NA 30 min education on pain neuroscience 3-h CBT group; 4 preoperative, 2 postoperative 1-h CBT individual; 4 preoperative, 1 postoperative
 Nutrition NA NA NA Protein drink before/after surgery NA NA NA
Outcome measures Pain, disability, quality of life Pain, disability, anxiety Walking ability, speed, muscle strength Pain, disability, quality of life Disability, behavioral measures Disability, anxiety, fear, pain Disability, fear, pain, quality of life
 After prehabilitation Improved pain and disability Improved pain, disability, and coping Improved walking and strength Improved pain and disability NA NA Secondary outcomes improved, eg, quality of life
 Last follow-up No difference at 6 mo Only activity different at 12 mo Moderate association with activity level at 12 mo Disability and pain improved at 6 mo No difference in pain and disability at 6 mo No difference in pain and disability at 1 y No difference in disability or pain
Comments Feasibility/pilot only Relatively low dose of physical therapy; average completion of 11 of 18 sessions 12 or more sessions of physiotherapy is more effective Compliance with physical therapy 85% length of stay less and satisfaction improved Satisfaction improved and health care cost less Relatively young patients Relatively young patients
CBT indicates cognitive behavioral therapy; NA, not available.

Radiation and duration of pain are predisposing factors for poor outcome after back surgery.85 Lindbäck et al65 studied 197 patients undergoing surgery for degenerative lumbar spine disease in the PREPARE study; all patients had back pain and/or leg pain for >2 years. The treatment group in the PREPARE study underwent biweekly supervised physiotherapy and some behavioral conditioning to reduce anxiety/pain and increase functional activity. Three months postoperatively, the treatment group did better in all patient-reported outcomes compared with those who received standard presurgery information. One year later, only physical activity was better, whereas the primary outcome of disability was the same for both groups. Limitation in walking is one of the primary reasons patients seek care, and progressive reduction in walking distance due to pain is an indication for back surgery.86 Fors et al66 analyzed secondary outcomes of walking ability and speed, lower limb muscle strength, and disability and found that prehabilitation improved all measures of walking. Patients who had >12 sessions of physiotherapy improved in normal as well as fast gait speed, whereas those who attended 11 or fewer sessions improved in normal gait alone. Together, these 2 studies suggest that prehabilitation improves functional ability before surgery, but disability 1 year postoperatively remains unchanged with only some secondary outcomes favoring prehabilitation.

One early study evaluated the impact of adding prehabilitation to early rehabilitation in 60 patients with degenerative lumbar spine disease experiencing low back and leg pain.67 All patients received detailed information about the surgery and postoperative care from their team. Prehabilitation consisted of 30 minutes of physiotherapy each day for 8 weeks that was focused on improving back and leg muscle strength, and protein supplementation the day before and day after surgery. Prehabilitation improved disability preoperatively, and those receiving prehabilitation improved faster, had shorter length of hospital of stay, and improved satisfaction. The complication rate also was lower in those receiving prehabilitation, although this was not statistically significant. Most subjects in the study had high pain scores for a prolonged period of time, findings known to be associated with higher postoperative complication rates.87 Nonetheless, average age and excellent health preordained outstanding recovery potential for this relatively minor spine surgery.

Marchand et al68 performed a randomized pilot study of prehabilitation comprising 6 weeks of supervised progressive exercise focused on improving muscle strength, endurance, and spine stabilization in 40 patients scheduled for lumbar spine decompression surgery.68 Although prehabilitation improved preoperative pain and disability, postoperative outcomes did not differ between groups, suggesting that the immediate benefits of surgery outweighed the benefits of active prehabilitation.

Three trials evaluated preoperative CBT or preoperative pain and neuroscience education. Louw et al82 found that patients receiving one session of pain neuroscience education were better prepared for surgery and had more realistic expectations and a more positive outlook than those who received usual preoperative care. As a result, patients who received pain neuroscience education sought less health care in the year following surgery, at a savings of $2600. In contrast, Morris et al88 found that pain neuroscience education after surgery did not impact outcomes. Two trials of CBT found no impact on disability postoperatively although recovery appeared faster in patients who received CBT.83,84 The benefits of CBT are supported by studies of postoperative CBT in addition to rehabilitation, where combined therapy was superior to rehabilitation alone.89,90

In summary, data for prehabilitation in complex spine surgery remains sparse. Most studies focused on relatively young, healthy patients, and minor surgeries and did not assess frailty, length of stay, or discharge to a nonhome setting.


This review supports adding a frailty measure for all patients considering complex spine surgery. Frailty assessments synthesize the patient’s physiological and functional status, as well as comorbidities, in the context of their individual aging process, and add important information for risk assessment and planning. While lesser degrees of frailty should not simply preclude complex spine surgery because the surgery itself may improve pain, quality of life, and potentially even frailty itself for these patients, severe frailty may prevent a patient from realizing benefits from undergoing surgery. Among the general frailty measures, the modified frailty index appears most appropriate for spine surgery patients because it avoids some of the phenotypic overlaps between frailty and manifestations of degenerative spine disease. Frailty indices specifically developed for spine patients may provide additional useful information for specific patient groups. Biomarkers should currently be regarded as research tools.

Whether formal prehabilitation has a role to play for patients undergoing complex spine surgery for degenerative spine disease awaits further studies. Current evidence does not support broad implementation of prehabilitation before complex spine surgery. Two specific barriers to prehabilitation are apparent. Patients may resent postponing surgery because it delays the perceived benefit of their surgical “fix.” Likewise, surgeons may object to the added complexities of scheduling introduced by prehabilitation. A clear conception of the duration of a prehabilitation program may alleviate this concern. A second barrier to prehabilitation may be the resources required for its implementation. Resources are different for a daily supervised exercise regimen supported by CBT and nutritional education compared with a home-based program supported through an activity monitor, reminder phone calls, and limited in-person instruction. Because successful surgery reduces pain and disability, prehabilitation may have its greatest impact for a subset of patients who are no longer fully functional but still capable of realizing meaningful gains in the interval before surgery. How to best measure the success of prehabilitation remains to be determined. Successful measurements will likely need to go beyond improvements in frailty, especially if items on the frailty tool are scored as present or absent.


The authors thank Corey Astrom, ELS, and Leah Buletti for their editorial assistance with this manuscript.


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