Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets

Ferran PelliséSpine Research Unit, Vall d’Hebron Research Institute, Barcelona;
Spine Surgery Unit, Vall d’Hebron University Hospital, Barcelona, Spain;

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Miquel Serra-BurrielEpidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland;

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Alba Vila-CasademuntSpine Research Unit, Vall d’Hebron Research Institute, Barcelona;

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Jeffrey L. GumNorton Leatherman Spine Center, Louisville, Kentucky;

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Ibrahim ObeidSpine Surgery Unit, Bordeaux University Hospital, Bordeaux, France;

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Justin S. SmithDepartment of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;

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Frank S. KleinstückSpine Center Division, Schulthess Klinik, Zurich, Switzerland;

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Shay BessDenver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado;

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Javier PizonesSpine Surgery Unit, La Paz University Hospital, Madrid, Spain;

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Virginie LafageDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;

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Francisco Javier S. Pérez-GruesoSpine Surgery Unit, La Paz University Hospital, Madrid, Spain;

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Frank J. SchwabDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;

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Douglas C. BurtonDepartment of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

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Eric O. KlinebergDepartment of Orthopedic Surgery, University of California, Davis, Sacramento, California;

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Christopher I. ShaffreyDuke University Medical Center, Durham, North Carolina;

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Ahmet AlanayDepartment of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey; and

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Christopher P. AmesDepartment of Neurosurgery, University of California, San Francisco, California

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on behalf of the International Spine Study Group (ISSG) and European Spine Study Group (ESSG)
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OBJECTIVE

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010.

METHODS

This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR).

RESULTS

Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010–2011 vs 2015–2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence–lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01).

CONCLUSIONS

The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; EBL = estimated blood loss; GAM = generalized additive model; HRQOL = health-related quality of life; ODI = Oswestry Disability Index; PI–LL = pelvic incidence–lumbar lordosis mismatch; SRS-22r = Scoliosis Research Society-22r; SVA = sagittal vertical axis; 3CO = 3-column osteotomy.

OBJECTIVE

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010.

METHODS

This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR).

RESULTS

Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010–2011 vs 2015–2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence–lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01).

CONCLUSIONS

The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

In Brief

This international (5 countries) longitudinal conjoined effort, based on > 2 years of follow-up of prospective multicenter high-quality (follow-up > 75%) data, shows a progressive and robust improvement in quality-of-care indicators associated with adult spinal deformity surgery. Over the last decade, postoperative complications and reinterventions have been progressively reduced by 50%, patient enrollment has increased, and postoperative improvement in disability has augmented, although baseline patient characteristics have remained the same. Quality metrics trends show that surgeons are facing the adult spinal deformity epidemic more efficiently.

Global demographic shifts have substantially affected the prevalence and burden of musculoskeletal diseases.1 The incidence of adult spinal deformity (ASD) in populations older than 65 years can reach up to 68%.2 Given that the proportion of the global population more than 65 years old will soon exceed the proportion of those younger than 5 years of age, and that by 2050 the rate of the world’s population reaching more than 60 years of age will nearly double, ASD is increasingly being recognized as a disease that could reach epidemic dimensions, becoming a primary concern for healthcare systems.1 ASD causes primarily pain and disability, reducing physical function; however, body self-image and mental health are frequently affected as well.3,4 Different studies have shown that in patients seeking medical attention, the impact of ASD on health-related quality of life (HRQOL) scores is substantial, and is larger than in other common chronic conditions.3,5

The effectiveness of nonsurgical treatment is very limited6,7 and not as extensively studied, whereas surgical treatment in carefully selected patients shows satisfactory results and is associated with sustained improvements in HRQOL scores.8,9 The aging of the population, the high prevalence of ASD, and an increasing demand to remain independent without significant disability in older age have together resulted in a marked increase in ASD surgery in recent decades. According to the Nationwide Inpatient Sample, in the US the surgical treatment of ASD increased by more than 50% over the years 2000–2010, compared with an increase of just 20% for other types of spine surgery over the same period of time.10

The primary concern regarding this rapid increase in ASD surgery is its very high rate of perioperative complications.11–16 The reported incidence varies between different studies, but can be greater than 70%,12 with an 18.8% risk of reoperation12 and a 0.3% risk of death.15 The cost of ASD surgery is high and varies substantially, due at least in part to the high rates of complications.17 The estimated direct cost per surgery in Europe ranges between €30,000 and €60,000. However, a recent US study shows that the catastrophic cost threshold (> US$100,000) is exceeded by 11.9%, 14.8%, and 19.1% of patients at index surgery, 90-day follow-up, and 2-year follow-up, respectively. The current trajectory of healthcare costs in many countries is unsustainable.

The direct cost of spine care is a growing proportion of this expenditure due to a rapid increase in the volume of spine procedures and their associated high costs, coupled with an aging population. During the last decade great efforts have been made on preoperative risk stratification, patient optimization, and personalized surgical planning to mitigate the occurrence of adverse events and improve overall ASD quality metrics.1 The goal of our study was to conjointly analyze the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and HRQOL outcomes) since 2010, using real-world observational, noninterventional data.

Methods

Study Design and Patient Population

Two independent and compatible prospective multicenter ASD databases sharing the same inclusion criteria, one from the US and the other from Europe, were queried and merged. Patients were included in both databases if they were older than 18 years and had at least one of the following: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, pelvic tilt ≥ 25°, or thoracic kyphosis (TK) ≥ 60°. Patients were enrolled through an institutional review board–approved protocol at 23 sites (17 in the US, 2 in Spain, 2 in Turkey, 1 in France, and 1 in Switzerland). Prospectively collected data were obtained preoperatively and at 3, 6, 12, and 24 months after surgery. All patients who were treated surgically between January 2010 and December 2016, with 2-year follow-up data available by January 2019, were included in the analysis.

Patient Parameters

Patient characteristics included objective measurements (demographic data and radiographic parameters) and HRQOL scores. Demographic data included patient age, sex, height, weight, and number of previous spine surgeries. Full-length freestanding anteroposterior and lateral spine radiographs were analyzed using validated software for assessment of radiographic parameters. HRQOL scores included the Oswestry Disability Index (ODI),18 Scoliosis Research Society-22r (SRS-22r),19 and Optum SF-36v2 Health Survey (SF-36).20

Surgical Parameters

Surgical parameters included the following: number of prior spine surgeries, surgical approach, number of fused vertebral levels, use of pelvic fixation, operative time, and estimated blood loss (EBL). In addition, information on the use of interbody fusion was collected as well as whether it was performed as a transforaminal lumbar interbody fusion or anterior/lateral lumbar interbody fusion. Data on osteotomies were collected, including Smith-Petersen osteotomies, pedicle subtraction osteotomies, and vertebral column resections. Complications, from intraoperative incidents through the time of most recent follow-up, were assessed and classified as recommended by McDonnell et al.21

Quality Metrics Indicators

To assess trends in ASD surgical treatment we evaluated 5 dimensions: 1) baseline patient demographics and spinal deformity; 2) surgical invasiveness; 3) deformity correction; 4) postoperative surgical complications; and 5) change in normalized HRQOL scores ([Preoperative − Postoperative] %) at 2-year follow-up. A complication was defined as major if it substantially prolonged hospitalization, involved an invasive intervention, had prolonged or permanent morbidity, or resulted in death during the first 2 years of follow-up. Composite outcomes were used to define complications because the low prevalence of any particular complication made accurate modeling difficult.

Statistical Analysis

Trends and changes in indicators were presented graphically using local regression and were analyzed by adjusted ORs estimated through multivariable logistic regression models. More specifically, results were plotted with generalized additive model (GAM) outcome trends with 95% CIs.

Results

At the time of the analysis 2286 patients (76.8% female) were included in the 2 registries, and 1520 underwent surgery between 2010 and 2016. A total of 1256 (82.6%) had 1-year follow-up data, and 1151 (75.7%) had 2-year follow-up data and were included in the study. Of these, 594 were from the US and 557 were from Europe—surgeries were performed at 23 sites in 5 countries.

Patients who had 2-year follow-up data (included in the study) and those who did not have 2-year follow-up data (not included in the study) had very similar 1-year HRQOL gain: ODI change was −14.15 versus −14.94 (p = 0.67); SRS-22r change was 0.85 versus 0.85 (p = 0.92); SF-36 physical component summary score change was 7.55 versus 7.34 (p = 0.43); and SF-36 mental component summary score change was 5.09 versus 5.11 (p = 0.87), respectively.

The mean age at the time of enrollment of the 1151 patients included in the study was 56.3 years (SD 17.4 years); 40.5% had undergone a previous surgery; 52.1% were American Society of Anesthesiologists (ASA) grade 2; and 28.8% were ASA grade 3. A total of 84.6% were treated using a posterior-only approach and 14.9% had anterior-posterior surgery. The mean surgical time was 366 minutes (SD 187 minutes), the mean total EBL was 1654 ml (SD 1417 ml), 21.5% received a 3-column osteotomy (3CO), and in 54.6% the spine was fused down to the pelvis. The mean number of fused levels was 10.3 (SD 4.45) (Table 1). The baseline mean ODI score was 42.5 (SD 19.2), SRS-22r subtotal was 2.79 (SD 0.67), and the mean baseline SF-36 physical component summary score was 33.5 (SD 10.2).

TABLE 1.

Surgical characteristics in 1151 patients with ASD

CharacteristicValue
Invasiveness
 EBL, ml1654.9 (SD 1417.0)
 Surgical time, mins365.7 (SD 187.1)
Approach
 Posterior only974 (84.6%)
 Anterior only6 (0.5%)
 Combined anterior-posterior171 (14.9%)
Pts w/ posterior instrumented fusion1119 (97.2%)
 Mean no. of posterior levels fused10.3 (range 0–19)
 Use of pelvic fixation628 (54.6%)
 Use of double rods149 (12.9%)
Pts w/ anterior instrumented fusion4 (0.3%)
 Mean no. of anterior levels fused0.02 (range 0–11)
Pts w/ interbody fusions577 (50.1%)
 Mean no. of interbody fusions1.02 (range 0–9)
  Posterior-only interbody fusions400 (69.3%)
  Anterior-only interbody fusions156 (27.0%)
 Combined anterior & posterior interbody fusions21 (3.7%)
Pts w/ decompressions510 (44.3%)
 Mean no. of levels decompressed1.16 (range 0–9)
 Patients w/ decompressions w/o fusion9 (0.8%)
Pts w/ osteotomies717 (62.3%)
 Pts w/ 3COs247 (21.5%)
  Cervical osteotomies2 (0.2%)
  Thoracic osteotomies107 (9.3%)
  Thoracolumbar osteotomies195 (16.9%)
  Lumbar osteotomies413 (35.9%)

Pts = patients.

Values are presented as mean (SD), number (%), or mean (range).

The mean baseline pelvic incidence–lumbar lordosis mismatch (PI–LL) was 14.1° (SD 23.4°), global tilt was 28.6° (SD 17.0°), and major Cobb angle was 37.0° (SD 23.1°). The mean rate of major complications at 90 days was 17%, at 1 year it was 24%, and at 2 years it was 30%. The mean rate of reoperation at 2 years was 20% (Table 2).

TABLE 2.

Baseline demographic, HRQOL, and radiological data together with surgical data and rate of postoperative complications and reintervention

VariableMean Value (SD)
Age, yrs56.3 (17.4)
BMI26.5 (5.55)
ODI score42.5 (19.2)
SRS-22 function2.94 (0.89)
SRS-22 pain2.50 (0.92)
SRS-22 self-image2.40 (0.74)
SRS-22 mental3.28 (0.89)
SRS-22 subtotal2.79 (0.67)
SF-36 PCS33.5 (10.2)
SF-36 MCS44.1 (13.0)
SVA, mm57.6 (69.2)
Pelvic tilt, °23.2 (11.1)
Sacral slope, °31.8 (13.7)
Global tilt, °28.6 (17.0)
PI–LL, °14.1 (23.4)
Major Cobb coronal angle, °37 (23.1)
90-day rate of major complications17%
1-yr rate of major complications24%
2-yr rate of major complications30%
2-yr rate of reop20%

MCS = mental component summary; PCS = physical component summary.

Patient enrollment increased progressively over the study period: 269 patients were operated on between 2010 and 2011 and 329 between 2015 and 2016 (OR 1.64, p < 0.01) (Fig. 1). On the contrary, baseline clinical characteristics such as age (p > 0.32), ASA grade distribution (p > 0.25), and HRQOL scores ODI, SRS-22r, and SF-36 (p > 0.05), as well as sagittal deformity (SVA, pelvic tilt, sacral slope, global tilt, PI–LL) (p > 0.3) and percent of cases with prior surgery, did not change over the study period (Fig. 2).

FIG. 1.
FIG. 1.

Patient enrollment histogram (N = 1151).

FIG. 2.
FIG. 2.

Baseline demographic characteristics evolution. Black line represents GAM smoothed regression; gray area represents 95% CI.

Since 2010 there has been a sustained reduction in major and minor complications observed at 90 days (major: OR 0.59, 95% CI 0.39–0.90; minor: OR 0.65, 95% CI 0.44–0.95; p < 0.01); at 1 year (major: OR 0.52, 95% CI 0.35–0.75; minor: OR 0.75, 95% CI 0.53–1.07; p < 0.01); and at 2 years of follow-up (major: OR 0.4, 95% CI 0.28–0.57; minor: OR 0.80, 95% CI 0.57–1.13; p < 0.01). There has also been a reduction in the 2-year reintervention rate (OR 0.41, 95% CI 0.27–0.61, p < 0.01) (Table 3 and Fig. 3). Simultaneously, there is a nonsignificant improvement in the correction of sagittal deformity (PI–LL) (OR 1.11, p = 0.19) associated with a progressive reduction of surgical aggressiveness:22 mean number of fused segments 11.2 (SD 4.47) in 2010 versus 9.14 (SD 4.42) in 2016 (OR 0.81, p < 0.01); percent pelvic fixation 60.6% in 2010 versus 46.1% in 2016 (OR 0.66, p < 0.01); and percent 3CO 26.8% in 2010 versus 17.4% in 2016 (OR 0.63, p < 0.01) (Fig. 4). Blood loss 1986 ml (SD 1790 ml) in 2010 versus 1320 ml (SD 1220 ml) in 2016 (p < 0.001) and total surgical time 403 minutes (SD 193 minutes) in 2010 versus 328 minutes (SD 206 minutes) in 2016 (p = 0.001) showed a significant progressive reduction over the study period too. No significant changes were observed regarding surgical approach over the study period. The percentage of cases treated with anterior-posterior surgery, anterior-only surgery, or posterior-only surgery remains stable.

TABLE 3.

Rate of major complications and reinterventions over the study period

Variable2010–20112012–2013201420152016p Value
No. of pts269306247214115
Major complication, 90 days22%15%16%15%12%0.126
Major complication, 1 yr32%22%23%20%19%0.006
Major complication, 2 yrs42%30%26%22%23%<0.001
Reinterventions, 2 yrs30%20%16%15%16%<0.001
FIG. 3.
FIG. 3.

Complication rate evolution. Black line represents GAM smoothed regression; gray area represents 95% CI.

FIG. 4
FIG. 4

Deformity correction and Invasiveness evolution. Black line represents GAM smoothed regression; gray area represents 95% CI.

The change in normalized HRQOL scores at 2 years postoperatively showed a greater gain in ODI score (26% in 2010 vs 40% in 2016, p = 0.02) over the study period, whereas SRS-22r self-image and mental domains (OR 1.16, p = 0.13) showed a nonsignificantly greater gain. SRS-22r function, pain, and satisfaction domains as well as SF-36 normalized change remained stable over the study period. None of the HRQOL measures showed a normalized change reduction from 2010 to 2016 (Fig. 5).

FIG. 5
FIG. 5

HRQOL normalized change ([Preoperative − Postoperative] %) evolution.

When comparing characteristics between US and EU cohorts, some differences could be identified. At baseline, US patients were slightly older, had a higher BMI, more sagittal deformity, and a worse ODI score. The percentage of patients having pelvic fixation was higher in the US cohort, whereas the percentage of patients receiving 3CO was similar in both continents. SVA and PI–LL correction were slightly higher in US centers, whereas postoperative complications tended to be lower in Europe. Overall, HRQOL normalized change was greater in US patients, but a trend toward greater HRQOL score change over the study period was more evident in Europe.

Discussion

The reported rate of complications and cost of ASD surgery, combined with an increase in the number of surgeries, call for alarm among healthcare payers and providers worldwide.1,23 This international (5 countries, 2 continents) longitudinal conjoined effort, based on a minimum 2-year follow-up of prospective multicenter (23 sites), high-quality (follow-up > 75%) data, represents the best available real-world evidence and shows a progressive and robust improvement in quality-of-care indicators associated with ASD surgery. Over the last decade, ASD postoperative complications and reinterventions have been progressively reduced by 50%, patient enrollment has increased, postoperative improvement in disability has augmented, and baseline patient characteristics have remained the same.

The rate of postoperative complications depends fundamentally on 2 factors: patient characteristics and surgical invasiveness.22,24 Our study shows that efforts toward optimizing ASD surgical plans and metrics over the last decade have made the undertaking of cases with similar baseline characteristics more feasible. ASD quality metrics have not improved by operating on healthier and less deformed patients or by decreasing the surgical correction rate. On the contrary, we have been able to achieve the same or better deformity correction, progressively reducing blood loss, surgical time, and use of 3CO or pelvic fixation. Our data and evidence generated over the last decade show that the robust reduction of postoperative complications following ASD surgery is multifactorial and includes surgeons’ learning curve, improved intra- and postoperative patient management, better understanding of the spinal deformity, and refinement of surgical techniques, among others.

The estimated annual incidence in surgically treated ASD cases increased steadily after the year 2000, as shown by Passias et al. in their analysis of US data collected between 2003 and 2010.25 Our data show the same trend, with a maintained increment in the number of cases enrolled in the combined US-EU data set from 2010 to 2016. ASD correction requires complex surgical techniques,22 which became widely used in the new millennium. Different studies show that for surgeons treating ASD, years of experience is a significant factor in mitigating complications and improving quality measures, including a continuous decrease in operative time as the surgeon’s experience increases.26,27 The surgeon’s learning curve has also been associated with a decrease in EBL, although the magnitude of correction may not change with increasing surgeon experience.27 Factors other than surgeons’ learning curve may have contributed to the reduction of EBL over the last decade. A recent meta-analysis including articles published through December 2018 shows that the use of tranexamic acid is associated with lower intraoperative blood loss and lower total transfusion volumes in ASD surgery.28 Both surgical time and EBL were significantly reduced over our study period, and both have been identified as important predictors of complications following ASD surgery.22

Simultaneously, multiple efforts have been made worldwide to better understand sagittal alignment and ASD surgical correction. The improved definition of individualized postoperative alignment goals has been repeatedly associated with fewer postoperative mechanical complications.29–32 Refinement of anterior and posterior surgical techniques restoring segmental lordosis has reduced the use of 3CO, a procedure that is technically challenging and that carries high morbidity rates.33,34 Although still needed in a substantial proportion of patients with ASD (pelvic fixation 50%; 3CO 20%), our data may suggest some overuse of pelvic fixation and 3CO in earlier times. The more strict and adjusted use of these techniques has probably contributed to improvements in ASD surgical outcomes in the later cohorts. The use of multirod constructs, effective to provide increased stability to potentially prevent or at least delay implant failure and symptomatic pseudarthrosis, is nowadays common practice in ASD surgeries.35 The larger postoperative improvement in disability observed over the study period can be explained by the very relevant reduction in the complication and reoperation rate. Núñez-Pereira et al. showed that even when properly managed and resolved, surgical complications still have a relevant impact on surgical outcomes, being associated with worse HRQOL scores at mid- and long-term follow-up.36

Our study has the limitations of observational longitudinal studies, not allowing us to establish causal relationships. However, the combined International Spine Study Group (ISSG) and European Spine Study Group (ESSG) data set represents the largest and most comprehensive ASD-specific, prospective, longitudinal source of information. With a 2-year follow-up rate of > 75%, the data included in this study, coming from 17 centers, 2 continents, and 5 countries, represent the best available evidence of real-world ASD surgical practice and provide the medical community with an outstanding source of information on trends associated with treatment. The large number of centers and surgeons involved advocate for the generalizability of the reported results to a wide range of patients. The latest developments are centered on personalized risk stratification,37 ASD cluster analysis,38 and personalized prediction of midterm surgical outcomes.39,40 Together with a sophisticated refinement of the surgical technique and preoperative patient optimization, these advancements forecast a maintained improvement in ASD quality metrics allowing patients, providers, and payers to face the ASD epidemic more efficiently.

Conclusions

Our analysis shows a robust global improvement in ASD surgery quality metrics over the last decade within our large combined database. Surgical complications and reoperations have been reduced by half, improvement in disability has been increased, and correction rates have been maintained in patients with similar baseline characteristics.

Disclosures

The ISSG Foundation receives funding support from DePuy Synthes, K2M, NuVasive, Orthofix, and Zimmer Biomet. The ESSG receives funding support from DePuy Synthes and Medtronic. Dr. Pellisé is a consultant for Medtronic and DePuy Spine, and he also received clinical or research support for the study described (includes equipment or material) from those companies. He is a board member of the Scoliosis Research Society and an associate board member of the AO Spine Deformity Knowledge Forum. Dr. Gum is an employee of Norton Healthcare and a consultant for Medtronic, Acuity, K2M/Stryker, NuVasive, and Mazor. He is in the speaker’s bureau for DePuy, and receives royalties from Acuity and NuVasive. He has received honoraria from Picira Pharmaceuticals, Baxter, Broadwater, and NASS. He has received clinical or research support for the study described (includes equipment or material) from Integra, Intellirod Spine Inc., Pfizer, ISSG, NuVasive, Norton Healthcare, Texas Scottish Rite Hospital, Alan L. and Jacqueline B. Stuart Research, Cerepedics Inc., SRS, and Medtronic. He reports direct stock ownership in Cingulate Therapeutics, and holds a patent with Medtronic. He is on the advisory/editorial boards of K2M/Stryker, Medtronic, and National Spine Health. Dr. Obeid is a consultant for DePuy Synthes and Medtronic. He has received clinical or research support for the study described (includes equipment or material) from DePuy Synthes. He receives royalties from Alphatec, Spineart, and Clariance. Dr. Smith is a consultant for Zimmer Biomet, NuVasive, Stryker, DePuy, Cerapedics, and Carlsmed. He reports direct stock ownership in NuVasive and Alphatec, and he receives royalties from Zimmer Biomet, NuVasive, and Thieme. He receives support of a non–study-related clinical or research effort that he oversees from DePuy Synthes, NuVasive, and AO Spine. He receives clinical or research support for the study described (includes equipment or material) from DePuy Synthes. AO Spine has provided him with fellowship support. Dr. Kleinstück is in the speaker’s bureau for DePuy Synthes. Dr. Bess is a consultant for K2M Stryker, and is a patent holder with K2M Stryker and NuVasive. He receives clinical or research support for the study described (includes equipment or material) from DePuy Synthes, ISSGF, K2M Stryker, and NuVasive. He receives support of a non–study-related clinical or research effort that he oversees from Medtronic, Globus, and SI Bone. He receives royalties from K2M Stryker. Dr. Pizones is a consultant for Medtronic. Dr. Lafage is a consultant for Globus Medical. She receives royalties from NuVasive and honoraria from DePuy Synthes and J&J. Dr. Schwab is a consultant for Zimmer Biomet, MSD, and Globus Medical. He receives royalties from MDS and Zimmer Biomet. He is on the executive committee of the ISSG. Dr. Burton is a patent holder with DePuy, and has direct stock ownership in Progenerative Medica. He receives clinical or research support for the study described (includes equipment or material) from the ISSG Foundation. Dr. Klineberg is a consultant for DePuy Synthes, Stryker, and Medicrea/Medtronic. He receives honoraria and a fellowship grant from AO Spine. Dr. Shaffrey is a consultant for Medtronic, NuVasive, and SI Bone. He has direct stock ownership in NuVasive, and is a patent holder with Medtronic, NuVasive, and Zimmer Biomet. He receives royalties from Medtronic, NuVasive, and SI Bone. Dr. Ames is an employee of UCSF. He receives royalties from Stryker, DePuy Synthes, Biomet Zimmer Spine, NuVasive, Next Orthosurgical, K2M, and Medicrea. He is a consultant for DePuy Synthes, Medtronic, Medicrea, and K2M. He conducts research for Titan Spine, DePuy Synthes, and ISSG; is on the editorial board of Operative Neurosurgery; receives grant funding from SRS; is on the executive committee for ISSG; and is a director for Global Spinal Analytics.

Author Contributions

Conception and design: Pellisé, Serra-Burriel. Acquisition of data: Pellisé, Gum, Obeid, Smith, Kleinstück, Bess, Pizones, Pérez-Grueso, Schwab, Burton, Klineberg, Shaffrey, Alanay, Ames. Analysis and interpretation of data: Pellisé, Serra-Burriel, Vila-Casademunt. Drafting the article: Pellisé, Serra-Burriel. Critically revising the article: Vila-Casademunt, Gum, Obeid, Smith, Kleinstück, Bess, Pizones, Lafage, Pérez-Grueso, Schwab, Burton, Klineberg, Shaffrey, Alanay, Ames. Reviewed submitted version of manuscript: Pellisé, Serra-Burriel. Approved the final version of the manuscript on behalf of all authors: Pellisé. Statistical analysis: Serra-Burriel. Administrative/technical/material support: Vila-Casademunt. Study supervision: Pellisé, Ames.

Supplemental Information

Previous Presentations

This work was presented online at the 55th Scoliosis Research Society (SRS) Annual Meeting (September 9–13, 2020); at the 2020 Eurospine Annual Meeting (October 6–9, 2020); and at the 34th Spanish Spine Society (GEER) Annual Meeting (December 10–12, 2020).

References

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    Diebo BG, Shah NV, Boachie-Adjei O, et al. Adult spinal deformity. Lancet. 2019;394(10193):160172.

  • 2

    Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976).2005;30(9):10821085.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Bess S, Line B, Fu KM, et al. The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases. Spine (Phila Pa 1976).2016;41(3):224233.

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

    Diebo BG, Cherkalin D, Jalai CM, et al. Comparing psychological burden of orthopaedic diseases against medical conditions: Investigation on hospital course of hip, knee, and spine surgery patients. J Orthop. 2018;15(2):297301.

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

    Pellisé F, Vila-Casademunt A, Ferrer M, et al. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):311.

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

    Bridwell KH, Glassman S, Horton W, et al. Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976).2009;34(20):21712178.

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

    Glassman SD, Carreon LY, Shaffrey CI, et al. The costs and benefits of nonoperative management for adult scoliosis. Spine (Phila Pa 1976).2010;35(5):578582.

  • 8

    Mannion AF, Vila-Casademunt A, Domingo-Sàbat M, et al. The Core Outcome Measures Index (COMI) is a responsive instrument for assessing the outcome of treatment for adult spinal deformity. Eur Spine J. 2016;25(8):26382648.

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

    Kelly MP, Lurie JD, Yanik EL, et al. Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis. J Bone Joint Surg Am. 2019;101(4):338352.

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    HCUP databases. Healthcare Cost and Utilization Project (HCUP),. Agency for Healthcare Research and Quality. Accessed May 14, 2021. www.hcup-us.ahrq.gov/nisoverview.jsp

    • Search Google Scholar
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    Soroceanu A, Burton DC, Oren JH, et al. Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine (Phila Pa 1976).2016;41(22):17181723.

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

    Scheer JK, Tang JA, Smith JS, et al. Reoperation rates and impact on outcome in a large, prospective, multicenter, adult spinal deformity database: clinical article. J Neurosurg Spine. 2013;19(4):464470.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Smith JS, Saulle D, Chen CJ, et al. Rates and causes of mortality associated with spine surgery based on 108,419 procedures: a review of the Scoliosis Research Society Morbidity and Mortality Database. Spine (Phila Pa 1976).2012;37(23):19751982.

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

    Smith JS, Sansur CA, Donaldson WF III, et al. Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976).2011;36(12):958964.

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

    Sansur CA, Smith JS, Coe JD, et al. Scoliosis research society morbidity and mortality of adult scoliosis surgery. Spine (Phila Pa 1976).2011;36(9):E593E597.

  • 16

    Sciubba DM, Yurter A, Smith JS, et al. A comprehensive review of complication rates after surgery for adult deformity: a reference for informed consent. Spine Deform. 2015;3(6):575594.

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

    Ames CP, Smith JS, Gum JL, et al. Utilization of predictive modeling to determine episode of care costs and to accurately identify catastrophic cost nonwarranty outlier patients in adult spinal deformity surgery: a step toward bundled payments and risk sharing. Spine (Phila Pa 1976).2020;45(5):E252E265.

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

    Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976).2000;25(22):29402952.

  • 19

    Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the Scoliosis Research Society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976).2003;28(1):6369.

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

    Jenkinson C, Coulter A, Wright L. Short form 36 (SF36) health survey questionnaire: normative data for adults of working age. BMJ. 1993;306(6890):14371440.

  • 21

    McDonnell MF, Glassman SD, Dimar JR II, et al. Perioperative complications of anterior procedures on the spine. J Bone Joint Surg Am. 1996;78(6):839847.

  • 22

    Pellisé F, Vila-Casademunt A, Núñez-Pereira S, et al. The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications. Spine J. 2018;18(2):216225.

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

    O’Lynnger TM, Zuckerman SL, Morone PJ, et al. Trends for spine surgery for the elderly: implications for access to healthcare in North America. Neurosurgery. 2015;77(suppl 4):S136S141.

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

    Mirza SK, Deyo RA, Heagerty PJ, et al. Towards standardized measurement of adverse events in spine surgery: conceptual model and pilot evaluation. BMC Musculoskelet Disord.2006;7:53.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Passias PG, Jalai CM, Worley N, et al. Adult spinal deformity: national trends in the presentation, treatment, and perioperative outcomes from. 2003 to 2010.Spine Deform. 2017;5(5):342350.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Lau D, Deviren V, Ames CP. The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve. J Neurosurg Spine. 2019;32(2):207220.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Raad M, Puvanesarajah V, Harris A, et al. The learning curve for performing three-column osteotomies in adult spinal deformity patients: one surgeon’s experience with 197 cases. Spine J. 2019;19(12):19261933.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Hariharan D, Mammi M, Daniels K, et al. The safety and efficacy of tranexamic acid in adult spinal deformity surgery: a systematic review and meta-analysis. Drugs. 2019;79(15):16791688.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Yilgor C, Sogunmez N, Boissiere L, et al. Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am. 2017;99(19):16611672.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Lafage R, Schwab F, Glassman S, et al. Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976).2017;42(17):12751282.

  • 31

    Kim HJ, Bridwell KH, Lenke LG, et al. Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections. Spine (Phila Pa 1976).2014;39(9):E576E580.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Pizones J, Moreno-Manzanaro L, Sánchez Pérez-Grueso FJ, et al. Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications. Eur Spine J. 2020;29(1):5462.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Saigal R, Mundis GM Jr, Eastlack R, et al. Anterior column realignment (ACR) in adult sagittal deformity correction: technique and review of the literature. Spine (Phila Pa 1976). 2016;41(suppl 8):S66–S73.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Lewis SJ, Keshen SG, Kato S, Gazendam AM. Posterior versus three-column osteotomy for late correction of residual coronal deformity in patients with previous fusions for idiopathic scoliosis. Spine Deform. 2017;5(3):189196.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Hyun SJ, Lenke LG, Kim YC, et al. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976).2014;39(22):18991904.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Núñez-Pereira S, Pellisé F, Vila-Casademunt A, et al. Impact of resolved early major complications on 2-year follow-up outcome following adult spinal deformity surgery. Eur Spine J. 2019;28(9):22082215.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Pellisé F, Serra-Burriel M, Smith JS, et al. Development and validation of risk stratification models for adult spinal deformity surgery. J Neurosurg Spine. 2019;31(4):587599.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38

    Ames CP, Smith JS, Pellisé F, et al. Artificial intelligence based hierarchical clustering of patient types and intervention categories in adult spinal deformity surgery: towards a new classification scheme that predicts quality and value. Spine (Phila Pa 1976).2019;44(13):915926.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Ames CP, Smith JS, Pellisé F, et al. Development of predictive models for all individual questions of SRS-22R after adult spinal deformity surgery: a step toward individualized medicine. Eur Spine J. 2019;28(9):19982011.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Ames CP, Smith JS, Pellisé F, et al. Development of deployable predictive models for minimal clinically important difference achievement across the commonly used health-related quality of life instruments in adult spinal deformity surgery. Spine (Phila Pa 1976).2019;44(16):11441153.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • View in gallery
    FIG. 1.

    Patient enrollment histogram (N = 1151).

  • View in gallery
    FIG. 2.

    Baseline demographic characteristics evolution. Black line represents GAM smoothed regression; gray area represents 95% CI.

  • View in gallery
    FIG. 3.

    Complication rate evolution. Black line represents GAM smoothed regression; gray area represents 95% CI.

  • View in gallery
    FIG. 4

    Deformity correction and Invasiveness evolution. Black line represents GAM smoothed regression; gray area represents 95% CI.

  • View in gallery
    FIG. 5

    HRQOL normalized change ([Preoperative − Postoperative] %) evolution.

  • 1

    Diebo BG, Shah NV, Boachie-Adjei O, et al. Adult spinal deformity. Lancet. 2019;394(10193):160172.

  • 2

    Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976).2005;30(9):10821085.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Bess S, Line B, Fu KM, et al. The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases. Spine (Phila Pa 1976).2016;41(3):224233.

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

    Diebo BG, Cherkalin D, Jalai CM, et al. Comparing psychological burden of orthopaedic diseases against medical conditions: Investigation on hospital course of hip, knee, and spine surgery patients. J Orthop. 2018;15(2):297301.

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

    Pellisé F, Vila-Casademunt A, Ferrer M, et al. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):311.

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

    Bridwell KH, Glassman S, Horton W, et al. Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976).2009;34(20):21712178.

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

    Glassman SD, Carreon LY, Shaffrey CI, et al. The costs and benefits of nonoperative management for adult scoliosis. Spine (Phila Pa 1976).2010;35(5):578582.

  • 8

    Mannion AF, Vila-Casademunt A, Domingo-Sàbat M, et al. The Core Outcome Measures Index (COMI) is a responsive instrument for assessing the outcome of treatment for adult spinal deformity. Eur Spine J. 2016;25(8):26382648.

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

    Kelly MP, Lurie JD, Yanik EL, et al. Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis. J Bone Joint Surg Am. 2019;101(4):338352.

  • 10

    HCUP databases. Healthcare Cost and Utilization Project (HCUP),. Agency for Healthcare Research and Quality. Accessed May 14, 2021. www.hcup-us.ahrq.gov/nisoverview.jsp

    • Search Google Scholar
    • Export Citation
  • 11

    Soroceanu A, Burton DC, Oren JH, et al. Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine (Phila Pa 1976).2016;41(22):17181723.

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

    Scheer JK, Tang JA, Smith JS, et al. Reoperation rates and impact on outcome in a large, prospective, multicenter, adult spinal deformity database: clinical article. J Neurosurg Spine. 2013;19(4):464470.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Smith JS, Saulle D, Chen CJ, et al. Rates and causes of mortality associated with spine surgery based on 108,419 procedures: a review of the Scoliosis Research Society Morbidity and Mortality Database. Spine (Phila Pa 1976).2012;37(23):19751982.

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

    Smith JS, Sansur CA, Donaldson WF III, et al. Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976).2011;36(12):958964.

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

    Sansur CA, Smith JS, Coe JD, et al. Scoliosis research society morbidity and mortality of adult scoliosis surgery. Spine (Phila Pa 1976).2011;36(9):E593E597.

  • 16

    Sciubba DM, Yurter A, Smith JS, et al. A comprehensive review of complication rates after surgery for adult deformity: a reference for informed consent. Spine Deform. 2015;3(6):575594.

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

    Ames CP, Smith JS, Gum JL, et al. Utilization of predictive modeling to determine episode of care costs and to accurately identify catastrophic cost nonwarranty outlier patients in adult spinal deformity surgery: a step toward bundled payments and risk sharing. Spine (Phila Pa 1976).2020;45(5):E252E265.

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

    Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976).2000;25(22):29402952.

  • 19

    Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the Scoliosis Research Society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976).2003;28(1):6369.

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

    Jenkinson C, Coulter A, Wright L. Short form 36 (SF36) health survey questionnaire: normative data for adults of working age. BMJ. 1993;306(6890):14371440.

  • 21

    McDonnell MF, Glassman SD, Dimar JR II, et al. Perioperative complications of anterior procedures on the spine. J Bone Joint Surg Am. 1996;78(6):839847.

  • 22

    Pellisé F, Vila-Casademunt A, Núñez-Pereira S, et al. The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications. Spine J. 2018;18(2):216225.

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

    O’Lynnger TM, Zuckerman SL, Morone PJ, et al. Trends for spine surgery for the elderly: implications for access to healthcare in North America. Neurosurgery. 2015;77(suppl 4):S136S141.

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

    Mirza SK, Deyo RA, Heagerty PJ, et al. Towards standardized measurement of adverse events in spine surgery: conceptual model and pilot evaluation. BMC Musculoskelet Disord.2006;7:53.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Passias PG, Jalai CM, Worley N, et al. Adult spinal deformity: national trends in the presentation, treatment, and perioperative outcomes from. 2003 to 2010.Spine Deform. 2017;5(5):342350.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Lau D, Deviren V, Ames CP. The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve. J Neurosurg Spine. 2019;32(2):207220.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Raad M, Puvanesarajah V, Harris A, et al. The learning curve for performing three-column osteotomies in adult spinal deformity patients: one surgeon’s experience with 197 cases. Spine J. 2019;19(12):19261933.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Hariharan D, Mammi M, Daniels K, et al. The safety and efficacy of tranexamic acid in adult spinal deformity surgery: a systematic review and meta-analysis. Drugs. 2019;79(15):16791688.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Yilgor C, Sogunmez N, Boissiere L, et al. Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am. 2017;99(19):16611672.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Lafage R, Schwab F, Glassman S, et al. Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976).2017;42(17):12751282.

  • 31

    Kim HJ, Bridwell KH, Lenke LG, et al. Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections. Spine (Phila Pa 1976).2014;39(9):E576E580.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Pizones J, Moreno-Manzanaro L, Sánchez Pérez-Grueso FJ, et al. Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications. Eur Spine J. 2020;29(1):5462.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Saigal R, Mundis GM Jr, Eastlack R, et al. Anterior column realignment (ACR) in adult sagittal deformity correction: technique and review of the literature. Spine (Phila Pa 1976). 2016;41(suppl 8):S66–S73.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Lewis SJ, Keshen SG, Kato S, Gazendam AM. Posterior versus three-column osteotomy for late correction of residual coronal deformity in patients with previous fusions for idiopathic scoliosis. Spine Deform. 2017;5(3):189196.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Hyun SJ, Lenke LG, Kim YC, et al. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976).2014;39(22):18991904.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Núñez-Pereira S, Pellisé F, Vila-Casademunt A, et al. Impact of resolved early major complications on 2-year follow-up outcome following adult spinal deformity surgery. Eur Spine J. 2019;28(9):22082215.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Pellisé F, Serra-Burriel M, Smith JS, et al. Development and validation of risk stratification models for adult spinal deformity surgery. J Neurosurg Spine. 2019;31(4):587599.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38

    Ames CP, Smith JS, Pellisé F, et al. Artificial intelligence based hierarchical clustering of patient types and intervention categories in adult spinal deformity surgery: towards a new classification scheme that predicts quality and value. Spine (Phila Pa 1976).2019;44(13):915926.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Ames CP, Smith JS, Pellisé F, et al. Development of predictive models for all individual questions of SRS-22R after adult spinal deformity surgery: a step toward individualized medicine. Eur Spine J. 2019;28(9):19982011.

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    Ames CP, Smith JS, Pellisé F, et al. Development of deployable predictive models for minimal clinically important difference achievement across the commonly used health-related quality of life instruments in adult spinal deformity surgery. Spine (Phila Pa 1976).2019;44(16):11441153.

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