Highlights
In a multicenter randomized trial of adults aged 75 years or older undergoing elective spinal fusion, a 4-week multimodal prehabilitation program added to Enhanced Recovery After Surgery (PREERAS) was associated with fewer 90-day postoperative complications than ERAS alone.
The absolute complication burden remained high in both groups, underscoring how physiologic vulnerability persists in very old adults despite optimized perioperative pathways.
The intervention combined supervised exercise, nutrition optimization, and psychological support, suggesting that a multicomponent approach may be more effective than single-domain preoperative interventions.
Because participants and clinicians were not blinded and the study was conducted in tertiary hospitals in China, implementation in other systems will require careful assessment of local resources, patient selection, and feasibility.
Clinical Background and Unmet Need
Elective spinal fusion can improve pain, stability, and function in selected patients, but it is also a major physiologic stressor. Older adults often enter surgery with reduced cardiopulmonary reserve, sarcopenia, frailty, malnutrition risk, impaired mobility, and higher baseline comorbidity burden. These factors increase the likelihood of postoperative complications such as infection, delirium, pulmonary events, prolonged immobility, and delayed recovery.
Enhanced Recovery After Surgery, or ERAS, has improved perioperative outcomes across many surgical fields by standardizing evidence-based practices around analgesia, early mobilization, fluid management, and nutrition. However, ERAS is primarily a perioperative system of care, not a program designed to improve preoperative physiologic reserve. That gap has driven interest in prehabilitation: structured interventions delivered before surgery to strengthen physical, nutritional, and psychological resilience.
For older adults, the appeal of prehabilitation is straightforward. If a patient can enter surgery stronger, better nourished, and better prepared mentally, postoperative recovery may be smoother and complication risk may fall. The challenge has been proving that these gains are real, clinically meaningful, and scalable in routine practice.
Study Design and Interventions
This multicenter, open-label, assessor-blinded, 1:1 randomized clinical trial evaluated whether multimodal prehabilitation plus ERAS, termed PREERAS, reduced 90-day postoperative complications compared with ERAS alone. The study enrolled adults aged 75 years or older undergoing elective spinal fusion surgery across 3 tertiary hospitals in China between May 2024 and May 2025. The trial was registered on ClinicalTrials.gov as NCT06140797.
Of 312 patients assessed for eligibility, 164 were randomized. The final analysis included 159 patients with a mean age of 78.7 years, and 59% were women. The intervention was a 4-week prehabilitation program built around Vivifrail-based multimodal care. Vivifrail is a multicomponent exercise approach intended to match exercise intensity to functional capacity in older adults. In this trial, the program integrated supervised group sessions, multicomponent exercise, nutritional optimization, and psychological interventions.
The comparator was ERAS alone. The primary endpoint was any postoperative complication within 90 days of surgery, with events recorded and graded according to the Clavien-Dindo classification system, a widely used surgical complication grading framework that distinguishes minor from more severe adverse events.
Key Findings
The main result was clinically important and directionally consistent with the trial hypothesis. Postoperative complications occurred in 59 patients in the PREERAS group, representing 74.7%, versus 73 patients in the ERAS group, representing 91.2%. The relative effect was a risk ratio of 0.80 with a 95% confidence interval of 0.67 to 0.95, and the absolute risk difference was -18.0% with a 95% confidence interval of -27.0% to -9.0%.
These numbers suggest that multimodal prehabilitation reduced the proportion of patients experiencing at least one complication by about one-fifth relative to ERAS alone, with a meaningful absolute reduction as well. In practical terms, the absolute difference implies that roughly 1 fewer patient experienced a complication for every 6 patients treated, although this should be interpreted cautiously because the full statistical context, including exact definitions and event distribution, is not provided in the abstract.
Several aspects make the result notable. First, the event rate in the control group was very high, which reflects the intrinsic risk of spinal fusion in older adults and the vulnerability of this population. Second, even with ERAS in place, complication rates remained substantial, indicating that perioperative optimization alone may not be sufficient for frail or physiologically limited patients. Third, the benefit emerged from a bundled intervention rather than a single modality, which is clinically relevant because older adults typically have overlapping deficits in mobility, nutrition, and psychological readiness.
Although the abstract does not provide the distribution of complication severity, the use of Clavien-Dindo grading is important. In surgical outcomes research, the distinction between minor self-limited events and major complications requiring invasive intervention or causing long-term harm matters at least as much as the total number of events. A reduction in mild events is useful, but a reduction in major events would be more compelling. Without the detailed breakdown, the clinical interpretation of the benefit remains incomplete.
Interpretation and Clinical Relevance
This trial supports a growing body of evidence that older surgical patients may benefit from targeted preoperative conditioning. The biologic plausibility is strong. Exercise can improve muscle strength, cardiopulmonary efficiency, and balance; nutritional optimization can address protein-energy insufficiency and support healing; and psychological interventions may improve adherence, reduce perioperative anxiety, and improve engagement with postoperative rehabilitation.
Importantly, the study tested a realistic, multidisciplinary strategy rather than an isolated intervention. That is a strength because surgical patients rarely have a single modifiable risk factor. Frailty, sarcopenia, poor appetite, fear of surgery, and low activity levels often coexist. A bundled prehabilitation model is therefore more aligned with geriatric care than a one-size-fits-all approach.
From a clinical standpoint, the findings raise a practical question: should multimodal prehabilitation become routine before elective spinal fusion in adults aged 75 years and older? The answer is not yet universal, but this trial moves the field closer to that direction. For centers with available physiotherapy, dietetic, and behavioral health resources, a 4-week prehabilitation window may be a feasible strategy to lower postoperative morbidity. For systems with fewer resources, careful triage may be needed to target the intervention to the highest-risk patients, such as those with frailty, low functional reserve, or malnutrition.
Limitations and Caution in Interpretation
Despite the encouraging findings, several limitations should temper overinterpretation. The trial was open-label, so participants and clinicians knew group allocation. That design is often unavoidable in rehabilitation studies, but it can introduce performance bias, particularly for outcomes that depend partly on care intensity, reporting, or threshold for diagnosis. The assessors were blinded, which helps, but does not eliminate all bias.
Generalizability is another issue. The study was conducted in 3 tertiary hospitals in China, and the authors note that longer hospital stays in the Chinese health care system may limit applicability elsewhere. Prehabilitation programs are also resource-intensive. Their success depends on trained staff, patient adherence, coordination across disciplines, and enough time before surgery. Real-world implementation may be harder in settings with short waiting times or limited rehabilitation infrastructure.
The abstract does not describe secondary outcomes, quality of life, functional recovery, length of stay, readmission, or specific adverse events attributable to the prehabilitation program. Those data would be important for judging the full value proposition. A reduction in complications is valuable, but policy and adoption decisions also depend on patient burden, cost, and the effect on recovery trajectory.
Finally, the participants were all at least 75 years old, which is exactly the population of interest but also a very specific one. The findings should not automatically be extended to younger adults, less frail patients, or those undergoing other orthopedic procedures without supporting evidence.
Practice Implications
For clinicians, the key message is that preoperative optimization should not be limited to medication review and surgical planning. In older adults facing major spine surgery, a structured 4-week multimodal program may meaningfully reduce postoperative complications when layered onto ERAS care. The components used here—exercise, nutrition, and psychological preparation—are conceptually attractive because they address multiple dimensions of vulnerability at once.
For hospital leaders and health systems, the study suggests that investing in prehabilitation may improve surgical outcomes, but only if the program is delivered with enough fidelity and patient uptake. Local implementation should consider staffing models, referral pathways, patient education, and whether the expected reduction in complications justifies the upfront resource use. A cost-effectiveness analysis would be especially useful.
For researchers, the next steps are clear: confirm the effect in other health systems, identify which subgroups benefit most, determine whether the benefit is driven by fewer minor events, fewer major complications, or both, and evaluate cost, scalability, and patient-centered outcomes. It would also be helpful to determine which components of the bundle are essential and whether a shorter or more targeted prehabilitation program can achieve similar results.
Conclusion
This randomized clinical trial provides meaningful evidence that multimodal prehabilitation added to ERAS can reduce 90-day postoperative complications in older adults undergoing elective spinal fusion. The findings are clinically relevant because the target population is high risk, the intervention is feasible in principle, and the absolute reduction in complications is substantial. At the same time, implementation will depend on local resources, and the open-label design and geographic setting warrant caution. Overall, the study strengthens the case for prehabilitation as a serious perioperative strategy in geriatric spine surgery.
Funding and Trial Registration
Primary funding source: Capital’s Funds for Health Improvement and Research.
ClinicalTrials.gov: NCT06140797.
References
Wang S, Wang P, Li J, Han D, Zhao Y, Zhang Y, Li Z, Du Y, Briggs N, Wang Y, Wang W, Li X, Wang Q, Diwan AD, Zhang Z, Wang T, Yang Y, Li C, Chen X, Lu S. Multimodal Prehabilitation for Older Adults Undergoing Spinal Fusion: A Randomized Clinical Trial. Ann Intern Med. 2026-06-16. PMID: 42296500.
Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-196.
Gillis C, Carli F. Promoting perioperative metabolic and nutritional care. Anesthesiology. 2015;123(6):1455-1472.
Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth. 2015;115(3):313-324.
