Factors influencing patient satisfaction after adult scoliosis and spinal deformity surgery

Kazunori Hayashi Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;
Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan;

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Louis Boissière Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;
ELSAN, Polyclinique Jean Villar, Bruges, France;

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Fernando Guevara-Villazón Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;

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Daniel Larrieu Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;

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Susana Núñez-Pereira Spine Surgery Unit, Vall d’Hebron Hospital, Barcelona, Spain;

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Anouar Bourghli Orthopedic and Spinal Surgery Department, Kingdom Hospital, Riyadh, Saudi Arabia;

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Olivier Gille Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;

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Jean-Marc Vital Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;

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Ferran Pellisé Spine Surgery Unit, Vall d’Hebron Hospital, Barcelona, Spain;

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Francisco Javier Sánchez Pérez-Grueso Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain;

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Frank Kleinstück Spine Center, Schulthess Klinik, Zurich, Switzerland;

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Emre Acaroğlu Ankara Spine Center, Ankara, Turkey; and

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Ahmet Alanay Comprehensive Spine Center, Acibadem Maslak Hospital, Istanbul, Turkey

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Ibrahim Obeid Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France;
ELSAN, Polyclinique Jean Villar, Bruges, France;

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OBJECTIVE

Achieving high patient satisfaction with management is often one of the goals after adult spinal deformity (ASD) surgery. However, literature on associated factors and their correlations with patient satisfaction is limited. The aim of this study was to determine the clinical and radiographic factors independently correlated with patient satisfaction in terms of management at 2 years after surgery.

METHODS

A multicenter prospective database of ASD surgery was retrospectively reviewed. The demographics, complications, health-related quality of life (HRQOL) subdomains, and radiographic parameters were examined to determine their correlation coefficients with the Scoliosis Research Society-22 questionnaire (SRS-22R) satisfaction scores at 2 years (Sat-2y score). Subsequently, factors determined to be independently associated with low satisfaction (Sat-2y score ≤ 4.0) were used to construct 2 types of multivariate models: one with 2-year data and the other with improvement (score at 2 years − score at baseline) data.

RESULTS

A total of 422 patients who underwent ASD surgery (mean age 53.1 years) were enrolled. All HRQOL subdomains and several coronal and sagittal radiographic parameters had significantly improved 2 years after surgery. The Sat-2y score was strongly correlated with the SRS-22R self-image (SI)/appearance subdomain (r = 0.64), followed by moderate correlation with subdomains related to standing (r = 0.53), body pain (r = 0.49–0.55), and function (r = 0.41–0.55) at 2 years. Conversely, the correlation between radiographic or demographic parameters with Sat-2y score was weak (r < 0.4). Multivariate analysis to eliminate confounding factors revealed that a worse Oswestry Disability Index (ODI) score for standing (≥ 2 points; OR 4.48) and pain intensity (≥ 2 points; OR 2.07), SRS-22R SI/appearance subdomain (< 3 points; OR 2.70) at 2 years, and a greater sagittal vertical axis (SVA) (> 5 cm; OR 2.68) at 2 years were independent related factors for low satisfaction. According to the other model, a lower improvement in ODI for standing (< 30%; OR 2.68), SRS-22R pain (< 50%; OR 3.25) and SI/appearance (< 50%; OR 2.18) subdomains, and an inadequate restoration of the SVA from baseline (< 2 cm; OR 3.16) were associated with low satisfaction.

CONCLUSIONS

Self-image, pain, standing difficulty, and sagittal alignment restoration may be useful goals in improving patient satisfaction with management at 2 years after ASD surgery. Surgeons and other medical providers have to take care of these factors to prevent low satisfaction.

ABBREVIATIONS

ASA-PS = American Society of Anesthesiologists Physical Status; ASD = adult spinal deformity; CA = clavicle angle; GT = global tilt; HRQOL = health-related quality of life; LIV = lower instrumented vertebra; LL = lumbar lordosis; LLI = LL index; MCS = Mental Component Summary; NRS = numeric rating scale; ODI = Oswestry Disability Index; PCS = Physical Component Summary; PI = pelvic incidence; PI-LL = PI − LL; PT = pelvic tilt; Sat-2y = satisfaction at 2 years; SI = self-image; SRS-22R = Scoliosis Research Society-22; SVA = sagittal vertical axis; TK = thoracic kyphosis.

OBJECTIVE

Achieving high patient satisfaction with management is often one of the goals after adult spinal deformity (ASD) surgery. However, literature on associated factors and their correlations with patient satisfaction is limited. The aim of this study was to determine the clinical and radiographic factors independently correlated with patient satisfaction in terms of management at 2 years after surgery.

METHODS

A multicenter prospective database of ASD surgery was retrospectively reviewed. The demographics, complications, health-related quality of life (HRQOL) subdomains, and radiographic parameters were examined to determine their correlation coefficients with the Scoliosis Research Society-22 questionnaire (SRS-22R) satisfaction scores at 2 years (Sat-2y score). Subsequently, factors determined to be independently associated with low satisfaction (Sat-2y score ≤ 4.0) were used to construct 2 types of multivariate models: one with 2-year data and the other with improvement (score at 2 years − score at baseline) data.

RESULTS

A total of 422 patients who underwent ASD surgery (mean age 53.1 years) were enrolled. All HRQOL subdomains and several coronal and sagittal radiographic parameters had significantly improved 2 years after surgery. The Sat-2y score was strongly correlated with the SRS-22R self-image (SI)/appearance subdomain (r = 0.64), followed by moderate correlation with subdomains related to standing (r = 0.53), body pain (r = 0.49–0.55), and function (r = 0.41–0.55) at 2 years. Conversely, the correlation between radiographic or demographic parameters with Sat-2y score was weak (r < 0.4). Multivariate analysis to eliminate confounding factors revealed that a worse Oswestry Disability Index (ODI) score for standing (≥ 2 points; OR 4.48) and pain intensity (≥ 2 points; OR 2.07), SRS-22R SI/appearance subdomain (< 3 points; OR 2.70) at 2 years, and a greater sagittal vertical axis (SVA) (> 5 cm; OR 2.68) at 2 years were independent related factors for low satisfaction. According to the other model, a lower improvement in ODI for standing (< 30%; OR 2.68), SRS-22R pain (< 50%; OR 3.25) and SI/appearance (< 50%; OR 2.18) subdomains, and an inadequate restoration of the SVA from baseline (< 2 cm; OR 3.16) were associated with low satisfaction.

CONCLUSIONS

Self-image, pain, standing difficulty, and sagittal alignment restoration may be useful goals in improving patient satisfaction with management at 2 years after ASD surgery. Surgeons and other medical providers have to take care of these factors to prevent low satisfaction.

In Brief

The authors examined the factors influencing patient satisfaction following corrective surgery for adult spinal deformity. They identify the factors that are moderately to strongly associated with patient satisfaction to prevent low satisfaction after surgery.

Adult spinal deformity (ASD) severely affects a patient’s quality of life, causing symptoms such as negative self-image, body pain, standing or gait disturbance, difficulty in social life, and mental problems.22 Surgical management was developed as the representative treatment method for severe cases of ASD, and it has been reported to improve all clinical parameters measured by the subdomains of the health-related quality of life (HRQOL) questionnaires, with the exception of lifting ability.13,15,23,31,32 Patient satisfaction with management is an important factor in patient-centered measures of healthcare for evaluating surgical success. Achieving adequate satisfaction is often regarded as one of the goals of ASD management. (Throughout this article, “satisfaction” refers to patient satisfaction with the results of management.) However, there is a lack of discussion on the specific demographic, radiographic, and health status factors associated with satisfaction. Spine surgeons should avoid targeting only the postoperative radiographic spinal alignment without considering the goal of the surgery. Furthermore, the preoperative factors and those improvements that affect patient satisfaction with the results after ASD surgery have not yet been well identified.1 These factors provide us information to predict the clinical results after surgery, resulting in patients being given an adequate explanation to help them avoid ineffective surgeries. Thus, the aim of the present study was to determine the clinical and radiographic factors that are independently correlated with patient satisfaction and the strength of the correlation at 2 years after ASD surgery using an international multicenter database.

Methods

Patient Inclusion

The present study was a retrospective analysis using prospectively collected data from a database on the treatment of ASD patients. The database included demographic, surgical, clinical, and radiographic data of all consecutive patients who underwent ASD treatments at 6 international institutions. The participating institutions followed the appropriate protocol and obtained approval for participation from their local institutional review board. The inclusion criteria of the database were age 18 years or older, with at least one of the following: a coronal Cobb angle of the major curve ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, pelvic tilt (PT) ≥ 25°, and thoracic kyphosis (TK) ≥ 60°. Data of 690 patients who received surgical treatment for ASD from October 2009 to August 2016 were available. Of those, patients with “neuromuscular” and “syndromic” etiologies of ASD and those who underwent spinal fusion of fewer than 4 levels were excluded. We included 590 patients in this study. Finally, 422 patients, who completed a follow-up and completely answered question numbers 21 and 22 (corresponding to the satisfaction with management subdomain) on the Scoliosis Research Society-22 questionnaire (SRS-22R) at 2 years after ASD treatment, were enrolled in the statistical analysis.

Patient Demographics and Clinical Outcome Evaluations

Data on patient demographics (age, sex, BMI, American Society of Anesthesiologists Physical Status [ASA-PS], and history of prior spine surgery) and surgical factors (surgical institution, surgical time, total blood loss, transfusion, number of fusion levels, lower instrumented vertebra [LIV], and 3-column osteotomy) were recorded. Data on surgery-related and potentially relevant complications and any reasons for revision surgery until 2 years after surgery were collected on the basis of the previous literature.14

The SRS-22R, Oswestry Disability Index (ODI), SF-36 items, and numeric rating scale (NRS) were used to evaluate HRQOL at baseline and 2 years after surgery.2,6,10,22 The SRS-22R is divided into 5 subdomains accounting for function/activity, pain, self-image (SI)/appearance, mental health, and satisfaction with management; each domain is rated from 1 to 5. The ODI comprises 10 subdomains: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling. The ODI score is calculated as a total. The SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were obtained using reported algorithms from their questionnaire.19 The NRS score ranges from 0 (no pain) to 10 (worst pain) for back and leg pain.

In the present study, the “satisfaction with management” subdomain of the SRS-22R questionnaire at 2 years (Sat-2y score) was used to evaluate satisfaction after ASD surgery. This subdomain is calculated using the following formula: (score of question number 21 + score of question 22)/2.

Radiographic Measurements

Full-length standing anteroposterior and lateral radiographs were obtained in all patients in the standardized upright position at baseline and at 2 years after surgery. For coronal and sagittal parameters, coronal Cobb angle, clavicle angle (CA), the coronal distance from the C7 plumb line to the top vertebra (coronal balance), SVA, T5–12 TK, T12–L1 lumbar lordosis (LL), pelvic incidence (PI), PI − LL (PI-LL), lumbar lordosis index (LLI), PT, and global tilt (GT) were measured.4,20

Statistical Analysis

Spearman’s rank correlation coefficient was used to assess the correlation between Sat-2y scores and patients’ demographic, surgical, and clinical data; complications; and radiographic measurements. The scores of each subdomain of the HRQOL and the radiographic parameters mentioned above were obtained at baseline and 2 years after surgery. Improvements in HRQOL were calculated as follows according to the method in a previous study: for SRS-22R and SF-36: (score at 2 years − score at baseline)/at baseline × 100. For the NRS and ODI: (score at baseline − score at 2 years)/at baseline × 100. The differences in radiographic parameters were calculated as the measurement at baseline − the measurement at 2 years.32 The strength of the correlation of each factor was considered as follows: correlation coefficient from 0.8 to 1 (very strong), 0.6 to 0.8 (strong), 0.4 to 0.6 (moderate), 0.2 to 0.4 (weak), and under 0.2 (very weak).17 Subsequently, we divided patients into 2 groups according to Sat-2y scores: those with ≥ 4.5 points (high-satisfaction group) and those with ≤ 4 points (low-satisfaction group). Welch’s modification of the paired t-test was used for continuous variables and the chi-square test for categorical variables. Finally, multiple logistic regression analysis was used to determine the factors associated with low satisfaction, after adjusting for potential confounders, and the odds ratios with 95% confidence intervals were calculated. The factors with higher correlation coefficients with the Sat-2y score, p < 0.05 in the univariate analysis, and those reported in previous papers as factors potentially related to satisfaction were included by the forced-entry method into the multivariate models.1 Two types of multivariate models were considered: the first model was structured with patient demographics, surgical factors, complications, revision surgeries, HRQOL subdomains, and radiographic parameters at 2 years to provide potential explanation variables. The second model included improvements in HRQOL domains, subdomains, and radiographic parameters, in addition to the patient demographics, surgical factors, and complications that were included in the first model. Nagelkerke’s R2 was calculated in the 2 models to check the coefficients of determination. All analyses were conducted using IBM SPSS (version 25.0, IBM Corp.).

Results

Overall Patient Data

A total of 422 patients (340 women and 82 men) were enrolled in this study. Overall, the mean age at initial surgery was 53.1 years, and the mean number of fused levels was 10.3. The LIV was the sacral or iliac vertebra in 218 patients (52%) and the lower lumbar vertebra (L4 or L5) in 104 patients (25%). Until the 2-year follow-up, complications were noted in 218 patients (52%): major complications were observed in 123 patients (29%), and at least one revision surgery was performed in 94 patients (22%). The mean Sat-2y score was 4.19, and the median Sat-2y was 4.5. For the coronal and sagittal radiographic parameters, all had improved significantly at 2 years after surgery, except CA, coronal balance, and PI.

Correlation of Demographic and Baseline Data With the Sat-2y Score

Of the patients’ demographic and surgical data, age, BMI, ASA-PS, number of prior surgeries, number of fused levels, and LIV affected the Sat-2y score; however, the correlations were very weak. Although the ODI score revealed the highest correlation coefficient (r = 0.3) in HRQOL measurements, no factor at baseline was determined to have a moderate correlation. For radiographic parameters, coronal Cobb angle, SVA, PI, and PT showed very weak correlations.

Correlation of Data at 2 Years, Improvements, and Complications With the Sat-2y Score

Only the SRS-22R SI/appearance subdomain at 2 years after surgery showed strong correlation with the Sat-2y score (r = 0.64). Among the HRQOL subdomains that showed moderate correlations with the Sat-2y score, the correlation coefficients of SRS-22R pain and ODI social life, standing, and sex life subdomains were over 0.5 (Table 1). Among radiographic parameters, SVA and GT at 2 years showed weak correlations. The results of the analysis of the improvement in the HRQOL ratio revealed that SRS-22R SI/appearance and ODI social life and standing subdomain improvements had moderate correlations, followed by pain-related subdomains of ODI and NRS (Table 2). Complications and revision surgery were determined to have weak correlations.

TABLE 1.

Spearman correlation between Sat-2y scores and the clinical and radiographic data at 2 years

Data at 2 YrsCorrelation Coefficient (r)P Value
HRQOL dataSRS-22R
 Function/activity0.47<0.001
 Pain0.55<0.001
 SI/appearance0.64<0.001
 Mental health0.43<0.001
 Subtotal score0.62<0.001
ODI
 Pain intensity−0.49<0.001
 Personal care−0.41<0.001
 Lifting−0.34<0.001
 Walking−0.38<0.001
 Sitting−0.36<0.001
 Standing−0.53<0.001
 Sleeping−0.35<0.001
 Social life−0.55<0.001
 Sex life−0.51<0.001
 Traveling−0.44<0.001
 Score−0.57<0.001
SF-36
 PCS0.49<0.001
 MCS0.40<0.001
NRS
 Back pain−0.40<0.001
 Leg pain−0.27<0.001
Radiographic  measurementsCoronal Cobb angle0.080.14
CA−0.020.73
Coronal balance−0.050.39
SVA−0.23<0.001
TK−0.030.62
LL−0.060.31
PI−0.170.002
PI-LL−0.150.006
LLI0.170.003
PT−0.150.006
GT−0.21<0.001

Values in boldface type represent strong correlations (> 0.5).

TABLE 2.

Spearman correlation between Sat-2y scores and the improvement in clinical and radiographic data

ImprovementCorrelation Coefficient (r)P Value
HRQOL dataSRS-22R
 Function/activity0.20<0.001
 Pain0.25<0.001
 SI/appearance0.45<0.001
 Mental health0.23<0.001
 Subtotal score0.41<0.001
ODI
 Pain intensity−0.40<0.001
 Personal care−0.38<0.001
 Lifting−0.29<0.001
 Walking−0.38<0.001
 Sitting−0.33<0.001
 Standing−0.44<0.001
 Sleeping−0.27<0.001
 Social life−0.45<0.001
 Sex life−0.37<0.001
 Traveling−0.34<0.001
 Score−0.44<0.001
SF-36
 PCS0.31<0.001
 MCS0.21<0.001
NRS
 Back pain−0.39<0.001
 Leg pain−0.27<0.001
Radiographic measurementsCoronal Cobb angle−0.150.008
CA0.000.98
Coronal balance−0.030.66
SVA−0.150.014
TK0.000.96
LL−0.090.12
PI0.020.67
PI-LL−0.090.11
LLI0.110.05
PT−0.070.23
GT−0.150.010
ComplicationComplication−0.26<0.001
Revision surgery−0.30<0.001

Values in boldface type indicate moderate correlation.

Group Division According to Sat-2y Score

The high-satisfaction group included 240 patients whose mean Sat-2y score was 4.82 (median 5.0). The low-satisfaction group included 182 patients whose mean Sat-2y score was 3.35 (median 3.5). Several demographic and surgical factors were significantly different between the 2 groups (Table 3). In addition, the low-satisfaction group had a significantly larger number of patients who encountered complications or underwent revision surgeries.

TABLE 3.

Comparison of patient demographics, surgical factors, and complications between the high-satisfaction and low-satisfaction groups

FactorHigh-Satisfaction Group (n = 240)Low-Satisfaction Group (n = 182)P Value
Mean age (yrs)50.456.70.001
Sex0.80
 Male4834
 Female192148
Mean BMI (kg/m2)24.725.90.012
Mean ASA-PS class1.721.890.008
Prior surgery0.06
 Yes6566
 No175116
Mean no. of fusion levels10.69.90.039
LIV0.034
 Upper L36832
 L4–55747
 S1–iliac115103
3-column osteotomy0.90
 Yes4737
 No193145
Mean surgical time (mins)3322870.006
Mean total blood loss (ml)155415100.72
Mean transfusion (ml)9089250.88
Complication<0.001
 Yes103115
 No13767
Revision surgery<0.001
 Yes3262
 No208120

ASA-PS = American Society of Anesthesiologists Physical Status; LIV = lower instrumented vertebra.

Values are presented as the number of patients unless stated otherwise.

Differences in HRQOL and Radiographic Measurements at 2 Years

In the high-satisfaction group, all HRQOL domains and subdomains of the SRS-22R and SF-36 were significantly higher, and those of the ODI and NRS were lower than those of the low-satisfaction group at 2 years after surgery (Table 4). There was no significant difference in radiographic coronal parameters, but in the sagittal parameters, SVA, LL, PI-LL, LLI, PT, and GT were significantly different between the 2 groups.

TABLE 4.

Comparison of the HRQOL and radiographic parameters at 2 years between the high-satisfaction and low-satisfaction groups

2-Yr DataHigh-Satisfaction Group (n = 240)*Low-Satisfaction Group (n = 182)*p Value
HRQOL dataSRS-22R
 Function/activity3.803.08<0.001
 Pain3.992.98<0.001
 SI/appearance3.952.98<0.001
 Mental health3.833.12<0.001
 Satisfaction4.823.35<0.001
ODI
 Pain intensity1.042.14<0.001
 Personal care0.571.38<0.001
 Lifting2.033.18<0.001
 Walking0.931.92<0.001
 Sitting0.831.56<0.001
 Standing1.142.65<0.001
 Sleeping0.471.12<0.001
 Sex life0.792.10<0.001
 Social life1.072.56<0.001
 Traveling0.981.87<0.001
ODI score18.439.5<0.001
SF-36
 PCS46.337.7<0.001
 MCS50.241.8<0.001
NRS
 Back pain3.15.0<0.001
 Leg pain2.13.5<0.001
Radiographic  measurementsCoronal Cobb angle (°)22.019.70.17
CA (°)0.450.870.27
Coronal balance (mm)−1.280.890.43
SVA (mm)17.040.9<0.001
TK (°)36.037.30.49
LL (°)−51.5−47.60.040
PI (°)54.056.70.06
PI-LL (°)1.68.00.001
LLI0.980.86<0.001
PT (°)19.822.30.026
GT (°)20.326.7<0.001

Values are mean scores.

Differences in HRQOL and Radiographic Improvements From Baseline

The high-satisfaction group showed better improvements in all HRQOL domains and subdomains compared with the low-satisfaction group (Table 5). In the low-satisfaction group, the improvements in ODI score, SF-36 PCS, NRS for leg pain domain, and function/activity and mental health subdomains of the SRS-22R did not reach the previously reported minimum clinically important difference after ASD surgery.8,9 Although coronal Cobb angle, SVA, TK, LL, PI-LL, LLI, PT, and GT improved significantly at 2 years compared with before surgery in both groups (data not shown), the high-satisfaction group showed higher improvements than the low-satisfaction group in the coronal Cobb angle, SVA, LL, LLI, and GT.

TABLE 5.

Comparison of improvement in HRQOL and radiographic parameters between high-satisfaction and low-satisfaction groups

Improvement DataHigh-Satisfaction Group (n = 240*)Low-Satisfaction Group (n = 182*)P Value
HRQOL dataSRS-22R
 Function/activity19.712.20.011
 Pain53.830.7<0.001
 SI/appearance74.936.0<0.001
 Mental health22.310.40.001
ODI
 Pain intensity52.819.9<0.001
 Personal care43.9−1.1<0.001
 Lifting15.5−22.9<0.001
 Walking50.04.5<0.001
 Sitting51.715.5<0.001
 Standing48.83.4<0.001
 Sleeping59.433.40.003
 Sex life46.819.00.044
 Social life42.7−6.9<0.001
 Traveling38.90.9<0.001
 ODI score39.42.3<0.001
SF-36
 PCS28.013.6<0.001
 MCS20.89.40.004
NRS
 Back pain52.221.8<0.001
 Leg pain53.422.00.002
Radiographic  measurementsCoronal Cobb angle (°)20.213.80.001
CA (°)−0.3−0.90.33
Coronal balance (mm)1.9−0.20.57
SVA (mm)28.411.30.009
TK (°)−5.7−6.50.74
LL (°)12.38.00.046
PI (°)0.5−0.20.09
PI-LL (°)13.49.40.08
LLI0.250.160.047
PT (°)2.01.40.44
GT (°)6.52.50.006

Values are mean scores.

Logistic Regression Model With the Data at 2 Years

A worse score for the ODI standing (≥ 2 points; OR 4.48) and pain intensity (≥ 2 points; OR 2.07) and SRS-22R SI/appearance (< 3 points; OR 2.70) subdomains and a higher SVA (> 5 cm; OR 2.68) at 2 years were independent predictors for low satisfaction in the multiple logistic regression model at 2 years (Table 6). Age, sex, BMI, ASA-PS, prior surgeries, surgical institutions, LIV, complications, revision surgeries, SF-36 MCS domain at baseline, SRS-22R pain subdomains at 2 years, and PT and LLI at 2 years were not detected as a predictor. Nagelkerke’s R2 for this model was 0.424.

TABLE 6.

Results of multiple regression models for Sat-2y score

ModelCategory of FactorsFactorThresholdOR95% CINagelkerke’s R2
Data at 2 yrsHRQOLODI standing≥2 points4.482.12–9.480.424
ODI pain intensity≥2 points2.071.0–4.23
SRS-22R appearance<3 points2.701.20–7.02
RadiographicSVA>5 cm2.681.20–6.02
Improvements at 2 yrs from  baselineHRQOL (baseline)SF-36 MCS<352.481.16–5.320.414
HRQOL (improvement)ODI standing<30%2.681.37–5.26
SRS-22R pain<50%3.251.54–6.87
SRS-22R appearance<50%2.181.09–4.39
RadiographicSVA<2 cm3.161.32–7.57

Logistic Regression Model With Data on Improvements

A lower improvement in the scores of the ODI standing (< 30%; OR 2.68), SRS-22R pain (< 50%; OR 3.25), and SI/appearance (< 50%; OR 2.18) subdomains; inadequate restoration of the SVA (< 2 cm; OR 3.16); and SF-36 MCS at baseline (< 35; OR 2.48) were independently related factors for low satisfaction in the multiple logistic regression model with the data of variance at 2 years from baseline (Table 6). Age, sex, BMI, ASA-PS, prior surgeries, surgical institutions, LIV, complications, revision surgeries, improvement of PT, PI-LL, and LLI were not detected as explanatory factors. Nagelkerke’s R2 of this model was 0.414.

Discussion

Study Background

In the present study, we demonstrated the components that correlated with patient satisfaction with the results at 2 years after ASD surgery. Among the SRS-22R, ODI, SF-36, and NRS at 2 years after surgery, the SRS-22R SI/appearance subdomain demonstrated the strongest correlation with patient satisfaction with management. The correlation coefficients for radiographic parameters such as SVA were weak or very weak and less than that for each HRQOL subdomain. Subsequently, we divided the patients into high-satisfaction and low-satisfaction groups. There were significant differences between the groups in several patient demographic characteristics, surgical factors, clinical results, radiographic parameters at 2 years, and clinical improvements from baseline. To eliminate confounding factors, 2 types of multiple logistic regression models were constructed. According to the first model, using clinical and radiographic data at 2 years, a low score for ODI standing, ODI pain intensity, and SRS-22R SI/appearance subdomains and higher SVA at 2 years were significant predictors for a lower satisfaction. In addition, according to the other model using the improvements from baseline, a lower improvement ratio of ODI standing, SRS-22R pain, and SRS-22R SI/appearance subdomains, and inadequate restoration of SVA were independently related factors.

Although some authors have pointed out that patient satisfaction after spine surgery is not an objective measurement, “satisfaction with management” in the SRS-22R subdomain has been used as a representative method for briefly determining patient subjective satisfaction after ASD surgery; previous reports have described the elements related to this subdomain.1,16–18,21,25 HRQOL domains at 2 years, including ODI and SF-36 PCS scores, are reported to have a moderate correlation with patient satisfaction.18 The SRS-22R SI/appearance might be one of the most relevant subdomains that is correlated with satisfaction.17 Another factor that has been shown to be important in terms of patient satisfaction is relief from back pain from that at baseline; this has been reported as being more important than relief from leg pain.18,25 Moreover, revision surgeries and SF-36 MCS score at baseline also affect satisfaction.1,17,21 However, the correlation with each subdomain of HRQOL has not yet been understood. In addition, previously reported factors have not been shown to be independent from each other, so the existence of potential confounding effects should be considered. Numerous papers have discussed the effects of patient demographics, preoperative or postoperative HRQOL, and radiographic parameters on postoperative clinical outcomes or complication rates.3,7,24,26–28 Moreover, revision surgeries also influence postoperative HRQOL domains, and SF-36 MCS scores at baseline are related to back pain improvements.1 Thus, elimination of confounding factors is needed to determine the “true” components related to patient satisfaction to evaluate their impact. To the best of our knowledge, few studies have been conducted using correlation coefficients and multivariate analysis models to evaluate this topic. Yoshida et al.32 demonstrated that fusion to the sacrum or ilium affects improvement in the subdomains of ODI personal care and lifting. Meanwhile, the effects of LIV on satisfaction are unknown. Thus, we also evaluated LIV as a potential risk factor.

Findings and Clinical Implications of the Study

First, demographic and baseline data were revealed not to have notable correlation with Sat-2y score. Subsequently, however, we found that the SRS-22R SI/appearance at 2 years had strong correlation with the Sat-2y score. This is similar to the findings of previous studies.17 Scatterplot analysis found no cases that showed high appearance and low satisfaction scores (Fig. 1). It is noteworthy that SRS-22R pain and ODI social life and standing had correlation coefficients of over 0.5 with the Sat-2y score. Similar results were determined through analysis of their improvement ratio. According to these results, body pain and standing were also important elements associated with satisfaction, following appearance. For radiographic parameters, SVA and other sagittal parameters at 2 years after surgery demonstrated weak correlations with the satisfaction score. Interestingly, their correlation coefficients were less than those of HRQOL subdomains. The scatterplot reveals several cases that showed low (ideal) SVA but a low satisfaction score (Fig. 2). This result suggests that the quality of life after surgery more precisely reflected satisfaction with management than any radiographic findings. Boissière et al.5 reported that GT and other sagittal parameters did not exhibit high impact on ODI variance. Conversely, inadequate sagittal balance restoration was previously reported as the factor related to postoperative poor HRQOL outcomes.24,26,30 Thus, we elucidated the independently related factors for Sat-2y score to confirm the importance of the radiographic findings. The threshold of the low-satisfaction group was set as Sat-2y score ≤ 4.0 because the median Sat-2y score was 4.5. We found that several demographic and surgical factors, complication and revision surgery rates, all HRQOL domains and subdomains at 2 years, and improvement from baseline differed between the 2 groups in the univariate analyses. It is noteworthy that the differences in the HRQOL subdomains between groups were most apparent in SRS-22R pain, SI/appearance, ODI standing, and ODI social life subdomains. In the low-satisfaction group, there were no improvements, or the improvements seemed insufficient in several HRQOL subdomains. Differences were also noted in several radiographic sagittal parameters at 2 years and with improvement. These results indicate that patient satisfaction is affected by multiple factors, and medical care providers have to consider various aspects of patient demographics, complications, and clinical and radiographic findings as potential explanatory factors for the Sat-2y score. Subsequently, we established a logistic regression model to elucidate the risk factors for low Sat-2y score. The model indicates that a low score in the ODI standing, ODI pain intensity, and SRS-22R appearance subdomains and a higher SVA at 2 years are independent related factors for low satisfaction. Similarly, we established a second logistic regression model to determine whether clinical outcomes and radiographic parameters from the baseline might also be affecting Sat-2y scores. The model determined that a lower improvement in SRS-22R pain, SRS-22R appearance, and ODI standing subdomains and insufficient correction of the SVA and low SF-36 MCS score at baseline were independent associated factors for low patient satisfaction at 2 years. The result on the importance of HRQOL is consistent with that of the first analysis of correlation coefficients. ASD patients who required operative management showed lower scores for the appearance and pain subdomains than did patients who did not require operative management.11,12 The SRS-22R appearance subdomain was the most relevant driving factor for surgical decision-making. Our results indicate that postoperative score and improvement from the baseline in this subdomain were independent factors related to Sat-2y scores; thus, the curative treatment for poor self-image and pain, which might be an important indication for surgery, can lead to high satisfaction. On the other hand, in addition to HRQOL, our findings confirmed that inadequate sagittal balance restoration was one of the factors responsible for low patient satisfaction at 2 years, which seems to contradict the results of the correlation coefficients. However, the results of the regression analysis suggested that surgeons cannot ignore sagittal alignment despite the fact that an ideal SVA does not always coexist with substantial satisfaction. According to entire analysis, a patient’s self-image, standing ability, relief from pain, and sagittal alignment may be useful goals for surgeons and physicians managing ASD in improving patient satisfaction.

FIG. 1.
FIG. 1.

Distribution of the subdomains of the satisfaction score and SRS-22R SI/appearance at 2 years after surgery.

FIG. 2.
FIG. 2.

Distribution of the subdomains of the satisfaction score and SVA at 2 years after surgery.

Limitations and Future Prospects

This study has several limitations. First, the study had a retrospective design using a database. The database could not capture all the variables that potentially affect satisfaction such as the relationship between each patient and physician or patient trait. These factors were not evaluated with the existing HRQOL questionnaire; thus, they were not included in the analysis. However, a large number of variables in the database related to demographics and physical and mental status were analyzed to address this concern. Second, the median Sat-2y score was 4.5. The low-satisfaction group was defined and included patients whose rate of Sat-2y was lower than the median value. Therefore, patients who answered “satisfied with management” in question 21 and “would probably have the same management” in question 22 were categorized into the low-satisfaction group. The potential ceiling effect was considered as one of the disadvantages of SRS-22R satisfaction with management subdomain.2,18,29 In this study, approximately one-third of patients answered with highest score of 5. Furthermore, nonparametric statistical methods were adopted for the correlation coefficient analysis. Third, we were unable to determine an adequate logistic regression model with clinical and radiographic data at baseline. Although we achieved a statistically significant model, the coefficient of determination represented by Nagelkerke’s R2 of the model was not high; thus, we could not demonstrate the independent predictors of high or low Sat-2y scores. From other viewpoints, this could mean that improving a patient’s appearance-related self-image and standing ability, relieving pain, and achieving adequate SVA had greater impact on preventing low Sat-2y scores in ASD surgery candidates than any clinical or radiographic measurements at baseline. Finally, satisfaction over longer follow-up periods after surgery could not be assessed in this retrospective analysis. On the basis of the results of this study, further investigation will be planned using propensity-matched cohorts to determine whether or not these factors are causatively related to patient satisfaction and those effects at longer follow-up periods.

Conclusions

Patient self-image, pain, and standing are the factors that are moderately to strongly associated with satisfaction at 2 years after ASD surgery. The multivariate analysis indicated that a patient’s self-image, freedom from pain, ability to stand, and SVA after ASD surgery might be factors independently related to satisfaction at 2 years postoperatively. Additionally, the improvement ratios of patient self-image, the standing ability, patient-reported body pain, and correction of SVA were also shown to have an independent correlation with patient satisfaction at 2 years. Surgeons and other medical providers should take these results into consideration and focus on improving patient self-image, standing ability, and pain relief with adequate restoration of sagittal imbalance at surgery and during the postoperative period.

Disclosures

The ESSG is supported by grants from DePuy Synthes and Medtronic. Dr. Hayashi: grant from Konishi Foundation for International Exchange. Dr. Boissière: consultant for Spineart and Medicrea, and support from DePuy for the current study. Dr. Pellisé and Dr. Acaroğlu: support from DePuy and Medtronic for the study described; and consultant for AOSpine. Dr. Sánchez Pérez-Grueso: support from DePuy for the study described, and consultant for K2M. Dr. Kleinstück: support from DePuy for the study described. Dr. Alanay: support from DePuy Synthes and Medtronic for the study described. Dr. Obeid: consultant for DePuy Synthes and Medtronic; support from DePuy Synthes for the study described; and royalties from Alphatec, Clariance, and Spineart.

Author Contributions

Conception and design: Hayashi, Boissière, Obeid. Acquisition of data: Boissière, Bourghli, Pellisé, Sánchez Pérez-Grueso, Kleinstück, Acaroğlu, Alanay, Obeid. Analysis and interpretation of data: Hayashi. Drafting the article: Hayashi, Guevara-Villazón. Critically revising the article: Hayashi, Boissière, Núñez-Pereira, Obeid. Reviewed submitted version of manuscript: Boissière, Larrieu, Núñez-Pereira, Bourghli, Gille, Vital, Pellisé, Obeid. Statistical analysis: Hayashi, Larrieu. Study supervision: Boissière, Obeid.

References

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    Bhagat S, Vozar V, Lutchman L, Crawford RJ, Rai AS: Morbidity and mortality in adult spinal deformity surgery: Norwich Spinal Unit experience. Eur Spine J 22 (Suppl 1):S42S46, 2013

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    Boissière L, Bourghli A, Vital JM, Gille O, Obeid I: The lumbar lordosis index: a new ratio to detect spinal malalignment with a therapeutic impact for sagittal balance correction decisions in adult scoliosis surgery. Eur Spine J 22:13391345, 2013

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    • PubMed
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    Boissière L, Takemoto M, Bourghli A, Vital JM, Pellisé F, Alanay A, et al.: Global tilt and lumbar lordosis index: two parameters correlating with health-related quality of life scores—but how do they truly impact disability? Spine J 17:480488, 2017

    • Crossref
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    • Search Google Scholar
    • Export Citation
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    Bridwell KH, Berven S, Glassman S, Hamill C, Horton WC III, Lenke LG, et al.: Is the SRS-22 instrument responsive to change in adult scoliosis patients having primary spinal deformity surgery? Spine (Phila Pa 1976) 32:22202225, 2007

    • Crossref
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    Carreon LY, Glassman SD, Shaffrey CI, Fehlings MG, Dahl B, Ames CP, et al.: Predictors of health-related quality-of-life after complex adult spinal deformity surgery: a Scoli-RISK-1 secondary analysis. Spine Deform 5:139144, 2017

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    • PubMed
    • Search Google Scholar
    • Export Citation
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    Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY: Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 8:968974, 2008

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    • Search Google Scholar
    • Export Citation
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    Crawford CH III, Glassman SD, Bridwell KH, Berven SH, Carreon LY: The minimum clinically important difference in SRS-22R total score, appearance, activity and pain domains after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976) 40:377381, 2015

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    Fairbank JC, Couper J, Davies JB, O’Brien JP: The Oswestry low back pain disability questionnaire. Physiotherapy 66:271273, 1980

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    Fu KM, Bess S, Shaffrey CI, Smith JS, Lafage V, Schwab F, et al.: Patients with adult spinal deformity treated operatively report greater baseline pain and disability than patients treated nonoperatively; however, deformities differ between age groups. Spine (Phila Pa 1976) 39:14011407, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
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    Fujishiro T, Boissière L, Cawley DT, Larrieu D, Gille O, Vital JM, et al.: Decision-making factors in the treatment of adult spinal deformity. Eur Spine J 27:23122321, 2018

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    • PubMed
    • Search Google Scholar
    • Export Citation
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    Glassman SD, Berven S, Kostuik J, Dimar JR, Horton WC, Bridwell K: Nonsurgical resource utilization in adult spinal deformity. Spine (Phila Pa 1976) 31:941947, 2006

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    • PubMed
    • Search Google Scholar
    • Export Citation
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    Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG: The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976) 32:27642770, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Glassman SD, Schwab FJ, Bridwell KH, Ondra SL, Berven S, Lenke LG: The selection of operative versus nonoperative treatment in patients with adult scoliosis. Spine (Phila Pa 1976) 32:9397, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Godil SS, Parker SL, Zuckerman SL, Mendenhall SK, Devin CJ, Asher AL, et al.: Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy. Spine J 13:10061012, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Gum JL, Bridwell KH, Lenke LG, Bumpass DB, Sugrue PA, Karikari IO, et al.: SRS22R appearance domain correlates most with patient satisfaction after adult deformity surgery to the sacrum at 5-year follow-up. Spine (Phila Pa 1976) 40:12971302, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Hamilton DK, Kong C, Hiratzka J, Contag AG, Ailon T, Line B, et al.: Patient satisfaction after adult spinal deformity surgery does not strongly correlate with health-related quality of life scores, radiographic parameters, or occurrence of complications. Spine (Phila Pa 1976) 42:764769, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Jenkinson C, Layte R, Lawrence K: Development and testing of the Medical Outcomes Study 36-Item Short Form Health Survey summary scale scores in the United Kingdom. Results from a large-scale survey and a clinical trial. Med Care 35:410416, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Obeid I, Boissière L, Yilgor C, Larrieu D, Pellisé F, Alanay A, et al.: Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning. Eur Spine J 25:36443649, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Passias PG, Soroceanu A, Yang S, Schwab F, Ames C, Boniello A, et al.: Predictors of revision surgical procedure excluding wound complications in adult spinal deformity and impact on patient-reported outcomes and satisfaction: a two-year follow-up. J Bone Joint Surg Am 98:536543, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Pellisé F, Vila-Casademunt A, Ferrer M, Domingo-Sàbat M, Bagó J, Pérez-Grueso FJ, et al.: Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J 24:311, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Scheer JK, Hostin R, Robinson C, Schwab F, Lafage V, Burton DC, et al.: Operative management of adult spinal deformity results in significant increases in QALYs gained compared to nonoperative management: analysis of 479 patients with minimum 2-year follow-up. Spine (Phila Pa 1976) 43:339347, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Scheer JK, Lafage R, Schwab FJ, Liabaud B, Smith JS, Mundis GM, et al.: Under correction of sagittal deformities based on age-adjusted alignment thresholds leads to worse health-related quality of life whereas over correction provides no additional benefit. Spine (Phila Pa 1976) 43:388393, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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    Takemoto M, Boissière L, Vital JM, Pellisé F, Perez-Grueso FJS, Kleinstück F, et al.: Are sagittal spinopelvic radiographic parameters significantly associated with quality of life of adult spinal deformity patients? Multivariate linear regression analyses for pre-operative and short-term post-operative health-related quality of life. Eur Spine J 26:21762186, 2017

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    Yoshida G, Boissiere L, Larrieu D, Bourghli A, Vital JM, Gille O, et al.: Advantages and disadvantages of adult spinal deformity surgery and its impact on health-related quality of life. Spine (Phila Pa 1976) 42:411419, 2017

    • Crossref
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  • Collapse
  • Expand
  • FIG. 1.

    Distribution of the subdomains of the satisfaction score and SRS-22R SI/appearance at 2 years after surgery.

  • FIG. 2.

    Distribution of the subdomains of the satisfaction score and SVA at 2 years after surgery.

  • 1

    Bakhsheshian J, Scheer JK, Gum JL, Hostin R, Lafage V, Bess S, et al.: Impact of poor mental health in adult spinal deformity patients with poor physical function: a retrospective analysis with a 2-year follow-up. J Neurosurg Spine 26:116124, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Berven S, Deviren V, Demir-Deviren S, Hu SS, Bradford DS: Studies in the modified Scoliosis Research Society Outcomes Instrument in adults: validation, reliability, and discriminatory capacity. Spine (Phila Pa 1976) 28:21642169, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bhagat S, Vozar V, Lutchman L, Crawford RJ, Rai AS: Morbidity and mortality in adult spinal deformity surgery: Norwich Spinal Unit experience. Eur Spine J 22 (Suppl 1):S42S46, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Boissière L, Bourghli A, Vital JM, Gille O, Obeid I: The lumbar lordosis index: a new ratio to detect spinal malalignment with a therapeutic impact for sagittal balance correction decisions in adult scoliosis surgery. Eur Spine J 22:13391345, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Boissière L, Takemoto M, Bourghli A, Vital JM, Pellisé F, Alanay A, et al.: Global tilt and lumbar lordosis index: two parameters correlating with health-related quality of life scores—but how do they truly impact disability? Spine J 17:480488, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bridwell KH, Berven S, Glassman S, Hamill C, Horton WC III, Lenke LG, et al.: Is the SRS-22 instrument responsive to change in adult scoliosis patients having primary spinal deformity surgery? Spine (Phila Pa 1976) 32:22202225, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Carreon LY, Glassman SD, Shaffrey CI, Fehlings MG, Dahl B, Ames CP, et al.: Predictors of health-related quality-of-life after complex adult spinal deformity surgery: a Scoli-RISK-1 secondary analysis. Spine Deform 5:139144, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY: Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 8:968974, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Crawford CH III, Glassman SD, Bridwell KH, Berven SH, Carreon LY: The minimum clinically important difference in SRS-22R total score, appearance, activity and pain domains after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976) 40:377381, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Fairbank JC, Couper J, Davies JB, O’Brien JP: The Oswestry low back pain disability questionnaire. Physiotherapy 66:271273, 1980

  • 11

    Fu KM, Bess S, Shaffrey CI, Smith JS, Lafage V, Schwab F, et al.: Patients with adult spinal deformity treated operatively report greater baseline pain and disability than patients treated nonoperatively; however, deformities differ between age groups. Spine (Phila Pa 1976) 39:14011407, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Fujishiro T, Boissière L, Cawley DT, Larrieu D, Gille O, Vital JM, et al.: Decision-making factors in the treatment of adult spinal deformity. Eur Spine J 27:23122321, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Glassman SD, Berven S, Kostuik J, Dimar JR, Horton WC, Bridwell K: Nonsurgical resource utilization in adult spinal deformity. Spine (Phila Pa 1976) 31:941947, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG: The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976) 32:27642770, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Glassman SD, Schwab FJ, Bridwell KH, Ondra SL, Berven S, Lenke LG: The selection of operative versus nonoperative treatment in patients with adult scoliosis. Spine (Phila Pa 1976) 32:9397, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Godil SS, Parker SL, Zuckerman SL, Mendenhall SK, Devin CJ, Asher AL, et al.: Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy. Spine J 13:10061012, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Gum JL, Bridwell KH, Lenke LG, Bumpass DB, Sugrue PA, Karikari IO, et al.: SRS22R appearance domain correlates most with patient satisfaction after adult deformity surgery to the sacrum at 5-year follow-up. Spine (Phila Pa 1976) 40:12971302, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Hamilton DK, Kong C, Hiratzka J, Contag AG, Ailon T, Line B, et al.: Patient satisfaction after adult spinal deformity surgery does not strongly correlate with health-related quality of life scores, radiographic parameters, or occurrence of complications. Spine (Phila Pa 1976) 42:764769, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Jenkinson C, Layte R, Lawrence K: Development and testing of the Medical Outcomes Study 36-Item Short Form Health Survey summary scale scores in the United Kingdom. Results from a large-scale survey and a clinical trial. Med Care 35:410416, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Obeid I, Boissière L, Yilgor C, Larrieu D, Pellisé F, Alanay A, et al.: Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning. Eur Spine J 25:36443649, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Passias PG, Soroceanu A, Yang S, Schwab F, Ames C, Boniello A, et al.: Predictors of revision surgical procedure excluding wound complications in adult spinal deformity and impact on patient-reported outcomes and satisfaction: a two-year follow-up. J Bone Joint Surg Am 98:536543, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Pellisé F, Vila-Casademunt A, Ferrer M, Domingo-Sàbat M, Bagó J, Pérez-Grueso FJ, et al.: Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J 24:311, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Scheer JK, Hostin R, Robinson C, Schwab F, Lafage V, Burton DC, et al.: Operative management of adult spinal deformity results in significant increases in QALYs gained compared to nonoperative management: analysis of 479 patients with minimum 2-year follow-up. Spine (Phila Pa 1976) 43:339347, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Scheer JK, Lafage R, Schwab FJ, Liabaud B, Smith JS, Mundis GM, et al.: Under correction of sagittal deformities based on age-adjusted alignment thresholds leads to worse health-related quality of life whereas over correction provides no additional benefit. Spine (Phila Pa 1976) 43:388393, 2018

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