Return to Golf After Corrective Surgery in Adult Spinal Deformity Patients with Long Fusion Constructs: A Retrospective Case Series

Return to Golf After Corrective Surgery in Adult Spinal Deformity Patients with Long Fusion Constructs: A Retrospective Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Return to Golf After Corrective Surgery in Adult Spinal Deformity Patients with Long Fusion Constructs: A Retrospective Case Series Kurt Holuba, Justin Reyes, Brendan Schwartz, Roy Miller, Alexandra Dionne, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6699534/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Oct, 2025 Read the published version in European Spine Journal → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: Golf is a popular sport that requires truncal strength and spinal flexibility. Spinal fusion surgery limits range of motion with pelvic fixation may impact a golfer’s ability to return to golf (RTG). The purpose of this study is to report clinical outcomes and return to golf following long-construct spinal fusion surgery. Methods: Patients fused from the pelvis from T10 or higher were screened for golfing participation during November 2023 – April 2024. Inclusion criteria included: ≥18 years old, >2 year minimum follow-up, active golfers. Visual analogue scale (VAS) pain level, self-perceived golf ability, golf handicap score, average days golfing per year, pain while golfing, preoperative and postoperative physical rehabilitation information, and associated regret of undergoing surgery was collected. Predictive factors for ability to RTG were evaluated. Results: 12 golfers from 2015-2023 were included (age 61.1±10.0 years, BMI 23.4±4.0 kg/m², female composition 66.7%, follow-up 5.8±1.9 years). 75.0% (n=9) patients RTG at an average of 1.4±0.6 years after surgery. Patients who RTG maintained or improved their performance in the following metrics: 88.9% (n=8) in self-assessed golf ability, 40.0% (n=2) in golf handicap score, 66.7% (n=6) in average number of days golfing per year, and 100.0% (n=9) in pain while golfing. Pain scores improved from baseline to FFU: VAS (7.8±2.2 vs 1.3±1.4; p <0.01), SRS-22r (68.0±12.8 vs 92.0±15.0; p <0.01), ODI (35.3±18.1 vs 8.0±7.9; p <0.01). Conclusion: This was the largest and most in-depth series pertaining to return to golf following corrective spinal deformity surgery. 75% of golfers returned to golf after long-construct fusion to pelvis, and the majority reported similar or improved performance. Mean pain and quality of life scores improved significantly for the whole group. Adult spinal deformity patients that play golf can expect equal or improved performance following corrective spine surgery. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Golf is popular amongst millions of individuals. Although it may seem slow-paced, golf requires substantial physical ability. To generate sufficient power when striking the ball, one is required to rotate their torso, maintain stability, and shift their weight throughout the swing of the club. Therefore, the spine must be able to effectively twist, bend, and extend to generate maximal force production throughout the golf swing. Surgery for adult spinal deformity (ASD), particularly long-construct fusions with pelvic fixation, can significantly decrease a patient’s range of motion and potentially impact their ability to return to golf (RTG). Long fusions can also alter spinal alignment, posture, and center of gravity, all of which affect swing biomechanics and golf performance. However, there is currently insufficient data for surgeons to adequately address questions about if, when, and at what ability level their patients might RTG. There is no consensus for returning to sport after spinal fusion. Current guidelines are heterogeneous and largely based on surveys of clinicians’ protocols. 1–4 Most surgeons allow patients that undergo thoracic and lumbar fusions to return to contact sport after 6 to 12 months but disagree about returning to collision sports. 5–7 Recommendations tend to be more conservative for fusions extending past T12/L1. 8–9 There is general agreement that patients should be pain-free, neurologically intact, and have evidence of bone fusion before returning to play. Few primary studies have reported whether spine patients RTG following their operation, with minimal evaluation of effect on performance. Zuckerman et al. reported on 3 degenerative and 3 deformity patients that play golf. 10 The authors reported that all patients returned to play the same or more rounds of golf after undergoing various spinal surgical interventions ranging from cervical laminoplasty to corrective deformity surgery. 10 Other studies on RTG post spine-surgery have found that 35–100% of patients report similar or improved postoperative play and nearly 30% are limited by persistent back or leg pain. 11–15 This case series aims to contribute to this growing body of evidence, as golf remains a popular sport amongst patients suffering from spinal ailments. Using similar methodology from a previous study 10 , we analyzed a cohort of patients who were previously active in golf, that underwent long spinal fusion with instrumentation to the pelvis with a particular interest in clinical outcomes and ability to RTG. METHODS Patient Data Institutional Review Board approval was obtained for this retrospective study (IRB #AAAU6316) and informed consent was obtained from each patient enrolled. Consecutive patients from 2015–2023, who underwent primary or revision spinal fusion of consecutive levels, from pelvis to T10 or higher, at a single center, were considered for eligibility. Patients were screened over the phone for participation from November 2023 – April 2024. Patients who were ≥ 18 years of age, active golfers before surgery, and who had minimum of 2-year follow-up were asked to complete a questionnaire about their preoperative and postoperative ability (Appendix A). Active golfers were defined as having golfed ≥ 5 times in their life and ≥ 1 time in the 5 years prior to their surgery. The postoperative RTG time was obtained, as well as the following metrics: visual analogue scale (VAS) pain level, self-perceived golf ability, golf handicap score, average days golfing per year, associated pain while golfing, preoperative and postoperative physical therapy (PT) information, and associated regret of undergoing surgery. Patient-reported outcome measures such as the Scoliosis Research Society-22r (SRS-22r) 16 and Oswestry Disability Index (ODI) 17 scores were collected at baseline, one year postoperatively, and at final follow-up. Demographics, clinical presentation, and operative data were also collected. A total of 396 patients were available in the database. Patients who could not be contacted were excluded. 161 patients were contacted via phone call: 128 had never played golf, 19 had not played golf within 5 years before their surgery, and 2 were non-English speaking. 12 patients met inclusion criteria, and all agreed to participate in the study (Fig. 1 ). Statistical Analysis Statistical analyses were performed using SPSS Statistics Version 28 (IBM Corporation, Armonk, NY). All continuous variables were described with mean ± standard deviation, and nominal variables were described with frequencies (%). Due to limited sample size of this case series, inferential statistics was not possible. RESULTS Patient Characteristics A total of 12 golfers were included with a mean follow-up (FU) of 5.8 ± 1.9 years. Mean age was 61.1 ± 10.0 years, mean BMI was 23.4 ± 4.0 kg/m², and 66.7% (n = 8) patients were female. 33.0% (n = 4) patients underwent ≥ 1 previous spine procedure(s) prior to their long construct, and 16.7% (n = 2) underwent ≥ 2 previous spine procedures ( Table 1 ). Return to Golf : 75.0% (n = 9) patients RTG at a mean of 1.4 ± 0.6 years after surgery. Of those that did not RTG, 66.7% (n = 2) reported being physically unable to golf, and 33.3% (n = 1) did not provide an answer. Of those that RTG, patients maintained or improved their performance in the following metrics: 88.9% (n = 8) in self-assessed golf ability, 40.0% (n = 2) in golf handicap score, 66.7% (n = 6) in average number of days golfing per year, and 100.0% (n = 9) in pain while golfing ( Table 2 ). Pain Levels Patients improved in the VAS pain score from baseline (7.8 ± 2.2) to latest FU (1.3 ± 1.4; p < 0.01), in the SRS-22r score from baseline (68.0 ± 12.8) to 1 year postoperatively (95.3 ± 8.1; p < 0.01) and latest FU (92.0 ± 15.0; p < 0.01), and in the ODI score from baseline (35.3 ± 18.1) to 1 year postoperatively (10.7 ± 11.6; p < 0.01) and latest FU (8.0 ± 7.9; p < 0.01). All of these improvements met minimally clinically important difference (MCID) standards ( Table 3 ). 18–20 Predictive Factors There were no significant differences between those who RTG and those who did not, including age, number of spinal levels fused, sex, BMI, previous spine surgery, participation in preoperative PT, participation in postoperative PT, baseline VAS, baseline SRS-22 score, baseline ODI, baseline golf handicap, baseline average days golfing per year, and baseline golf ability. Representative Cases Three cases representative of deformity patients who returned to golf at 1) the same level, 2) at a slightly decreased level, or 3) did not RTG are presented in Figs. 2 – 4 . DISCUSSION Spinal injuries, particularly in the lumbar spine, are commonly reported in avid golf players. 21–24 Lumbar spinal injuries and low back pain have been attributed to biomechanical factors and increased torsional stresses related to the x-factor and crunch factor of the modern golf swing. 24–26 However, some recent studies have disputed this notion. 27–29 Given the epidemiology of low back pain and spinal-related injuries in golf, it is important to understand how spinal surgery affects return to play and post-operative sport performance. Few studies have evaluated return to play outcomes in golfers after corrective surgery for ASD. Zuckerman et al. reported RTG outcomes in 6 patients that underwent surgery for both deformity and degenerative pathologies. 10 All 3 ASD patients in the study underwent corrective surgery. Two ASD patients had fusion constructs extending from the pelvis to the upper thoracic spine (T2 & T3 Upper Instrumented Vertebrae, UIV; 16 & 15 Total Instrumented Levels, TIL). One patient underwent non-continuous fusion and instrumentation with one construct extending from the pelvis to L1 and the other being circumferential arthrodesis from C2-T1 (11 TIL). These patients RTG at 10, 18, and 42 months, respectively. 10 A recent study by Maayan et al., examined return to various sporting activities in ASD patients that underwent a minimum of 3 levels of posterior spinal fusion with pelvic fixation. 30 A total of 11 recreational golfers were included, of which 6 (54.5%) successfully RTG. One patient RTG between 3–6 months post-op, four RTG between 6–12 months, and one returned after 2 years of surgery. 30 Interestingly, 45.5% of ASD patients did not RTG after surgery. 30 In our cohort, patients had a mean TIL of 12.8 ± 4.0 and 75% RTG at mean 1.4 ± 0.6 yrs. In degenerative spine patients various RTG rates have been reported. 10–13 Zuckerman et al. reported that 3 patients with cervical and lumbar pathologies successfully RTG after surgery. The degenerative patients returned to play at a quicker rate compared to deformity patients (degenerative RTG time: 2–18 months vs. deformity RTG time: 10–42 months). 10 Shifflett et al. studied RTG in 34 patients that underwent single or two level primary lumbar fusion surgery. 11 At one year follow-up, half of the patients successfully RTG. 11 Richards et al. studied 35 patients that underwent anterior or posterior cervical spine surgery and reported that 81.6% of patients successfully RTG at one year follow-up. 12 Jain et al. reported a 100% RTG rate in 13 recreational golfers within 3–9 months after lumbar fusion. 13 As expected, degenerative spinal fusions with shorter constructs have higher rates of RTG than multi-level fusion surgery as commonly observed in ASD patients. Although RTG is important for active patients, post-operative performance is also an important factor to consider. Zuckerman et al. stated that 4 out of 6 had sustained or increased performance after surgery and only one patient had a slight decrease in handicap. 10 Maayan reported that 27.3% of subjects RTG at the same level or had increased performance while 27.3% of patients had decreased performance. 30 Physical limitation, fear, and pain were the most commonly cited reasons for decreased performance. 30 Shifflett et al. reported that 80% of golfers had sustained or improved handicap after return. 11 In one study, golfers returned to play at the same (41.4%) or improved (24.1%) level of performance after cervical spine surgery. 12 Jain et al. reported a decrease in performance with a mean in handicap (preoperative: 13 ± 8 strokes, postoperative: 17 ± 11 strokes, p = 0.02 ) and a decrease in driving distance (preoperative: 223 ± 43 yards; postoperative: 212 ± 44 yards, p = 0.04 ). 13 In our study, 40% of golfers self-reported sustained or improved RTG handicap with 60% of golfers noting lower post-operative handicaps. Four patients did not keep track of their RTG handicap. However, 88.9% (n = 8) of golfers reported an improvement in self-assessed golf ability. With respect to pain, Zuckerman et al. reported decreased leg and back Numerical Rating Scale (NRS) scores in all patients. 10 Maayan et al. noted post-operative improvements in physical function according to the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) score. 30 In Shifflett’s study, 50% of patients saw an improvement in pain after surgery while 50% did not. 11 Jain et al. observed a significant reduction in VAS pain scores in their golf cohort (preoperative: 6.3 ± 3.7; postoperative: 1.8 ± 2.4, p = 0.01 ). In our cohort, we observed improvements in mean SRS-22r, and ODI scores at 1 year and final follow-up (Table 3). Moreover, all patients reported significant improvement in VAS scores (Table 2). We found no significant differences in prehabilitation, postoperative rehabilitation, and self-perceived ability between golfers that did and did not RTG. To our knowledge, this is the largest case series to evaluate RTG in patients that underwent spinal fusion surgery with long fusion constructs and pelvic fixation. Overall, 75% (n = 9) of patients RTG at a mean of 1.4 ± 0.6 years after surgery. No significant differences were observed between those who RTG and those who did not. Patients who RTG had improved PROMs according to SRS-22r, ODI, and VAS scores. The primary limitations of this study are its retrospective design and cohort size. Additionally, surveying patients about their recovery and time to RTG is susceptible to recall bias. Moreover, the low rate of response may have contributed to selection bias, which is worth consideration when interpreting the results of the study. Despite these limitations, this study provides a realistic outline of expectations regarding spinal deformity surgery. It also serves as a baseline for future studies to build on to further develop an understanding of this field of research. CONCLUSION In conclusion, it is possible for adult patients with complex spinal deformities to safely RTG after corrective surgery with long constructs. Additionally, despite possible restrictions in motion, sustained or improved performance is attainable in this unique population of patients. Further research is needed to further understand how spinal fusion affects RTG and post-operative performance longitudinally in recreational, collegiate, and elite golf athletes. Continued research and new knowledge will enable spinal surgeons to make evidence-based RTG recommendations in patients undergoing multi-level spinal fusion surgery. Abbreviations ASD - adult spinal deformity VAS - visual analogue scale SRS-22r - Scoliosis Research Society-22 ODI - Oswestry Disability Index FFU - final follow-up FU - follow-up RTG - return to golf MCID - minimally clinically important difference PT - physical therapy UIV - Upper Instrumented Vertebrae TIL - Total Instrumented Levels NRS - Numerical Rating Scale PROMIS-PF - Patient-Reported Outcomes Measurement Information System Physical Function Declarations Author Contribution Roles1 Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work2 Drafted the work or revised it critically for important intellectual content3 Approved the version to be published4 Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolvedContributions by AuthorKH: 1,2,3,4JR: 1,2,3,4BS: 1,2,3,4RM: 1,2,3,4AD: 1,2,3,4GG: 1,2,3,4JC: 1,2,3,4VA: 1,2,3,4RL: 1,2,3,4ZM: 1,2,3,4LL: 1,2,3,4JL: 1,2,3,4 References Li Y, Hresko MT. 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Risk Factors Associated With Low Back Pain in Golfers: A Systematic Review and Meta-analysis. Sports Health . 2018;10(6):538-546. Maayan, O., Zhang, B., Fourman, M. S., Clohisy, J., Pajak, A., Nakarai, H., Kazarian, G. S., Du, J., Merrill, R., Kaidi, A., Knopp, R., Akosman, I., Samuel, J., Andrews, L., Shahi, P., Lovecchio, F. C., & Kim, H. J. (2024). Return to Sporting Activities Following Long Fusions to the Pelvis in Adult Spinal Deformity. The spine journal : official journal of the North American Spine Society , S1529-9430(24)00268-7. Advance online publication Tables Tables 1 to 5 are available in the Supplementary Files section. Appendix Appendix is not available with this version. Additional Declarations No competing interests reported. Supplementary Files RTGTable1ESJ.jpg RTGTable2ESJ.jpg RTGTable3ESJ.jpg RTGTable4ESJ.jpg RTGTable5ESJ.jpg Cite Share Download PDF Status: Published Journal Publication published 02 Oct, 2025 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Revision requested 16 Jul, 2025 Reviews received at journal 08 Jul, 2025 Reviews received at journal 30 Jun, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers invited by journal 17 Jun, 2025 Editor assigned by journal 21 May, 2025 Submission checks completed at journal 21 May, 2025 First submitted to journal 19 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Center","correspondingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"","lastName":"Lehman","suffix":""},{"id":472533552,"identity":"ebc3eb8f-96ab-465c-b8c3-1879c19d9b6d","order_by":9,"name":"Zeeshan Sardar","email":"","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Zeeshan","middleName":"","lastName":"Sardar","suffix":""},{"id":472533553,"identity":"ccf414bc-1502-4cda-be55-c068b6785eb0","order_by":10,"name":"Lawrence Lenke","email":"","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Lawrence","middleName":"","lastName":"Lenke","suffix":""},{"id":472533554,"identity":"49c7fc85-4e75-42a8-95ab-798e83a58b36","order_by":11,"name":"Joseph Lombardi","email":"","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Lombardi","suffix":""}],"badges":[],"createdAt":"2025-05-19 13:38:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6699534/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6699534/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00586-025-09370-2","type":"published","date":"2025-10-02T15:57:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85178965,"identity":"33768eaa-211b-493e-bda9-7afe07003cba","added_by":"auto","created_at":"2025-06-23 07:05:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39801,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection\u003c/p\u003e","description":"","filename":"RTGFigure1ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/fcadbf71d84d80123e918a53.jpg"},{"id":85180266,"identity":"e3b14a76-080f-4a0f-a9f4-fc4ecbb5a080","added_by":"auto","created_at":"2025-06-23 07:13:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":72430,"visible":true,"origin":"","legend":"\u003cp\u003ePatient #1 was a 36-year-old female with adult idiopathic scoliosis. She had a 16-degree proximal thoracic curve, a 65-degree main thoracic curve, a 60-degree lumbar curve, and a 22-degree fractional curve (A, B). She underwent a fusion from T3 to sacrum, with posterior column osteotomies from T5 to sacrum and L2-S1, and anterior cages at L4-S1 (C, D). At 4 years postop she had no complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRTT\u003c/strong\u003e: yes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRTT time\u003c/strong\u003e: 0.8yr\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVAS: 10\u003c/p\u003e\n\u003cp\u003eAbility: Intermediate\u003c/p\u003e\n\u003cp\u003eMax games: 0-3\u003c/p\u003e\n\u003cp\u003eDays per week: 3\u003c/p\u003e\n\u003cp\u003ePain limiting? Yes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVAS: 0\u003c/p\u003e\n\u003cp\u003eAbility: Intermediate\u003c/p\u003e\n\u003cp\u003eMax games: 4-6\u003c/p\u003e\n\u003cp\u003eDays per week: 5\u003c/p\u003e\n\u003cp\u003ePain limiting? No\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e: None\u003c/p\u003e","description":"","filename":"RTGFigure2ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/7d9177ca4748a37b9e5122b7.jpg"},{"id":85180267,"identity":"67470cd8-aeaf-4288-ae2d-88a7e8e324ae","added_by":"auto","created_at":"2025-06-23 07:13:31","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":78506,"visible":true,"origin":"","legend":"\u003cp\u003ePatient #7 was a 67-year-old female with adult idiopathic scoliosis, who had prior fusion and instrumentation with Harrington rod from T5-T8, T9-T11, and L2-L3. Pre-operatively, he had 74 degree thoracic curve, 63 lumbar curve, and 16 degree lumbosacral fractional curve, 36 degrees of thoracic kyphosis, 53 degrees of lumbar lordosis, and pelvic incidence of 58 degrees. (A, B). She underwent posterior fusion from T2 to sacrum with anterior cages at L5-S1 (C, D). At over 7 years postoperatively, she reported no complications or complaints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRTG\u003c/strong\u003e: Yes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRTG time\u003c/strong\u003e: 2.0 years\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVAS: 4\u003c/p\u003e\n\u003cp\u003eAbility: Beginner\u003c/p\u003e\n\u003cp\u003eHandicap: N/A\u003c/p\u003e\n\u003cp\u003eDays per year: 11-20\u003c/p\u003e\n\u003cp\u003ePain limiting? Yes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVAS: 1\u003c/p\u003e\n\u003cp\u003eAbility: Beginner\u003c/p\u003e\n\u003cp\u003eHandicap: N/A\u003c/p\u003e\n\u003cp\u003eDays per year: 0-10\u003c/p\u003e\n\u003cp\u003ePain limiting? No\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e: None at 7 years.\u003c/p\u003e","description":"","filename":"RTGFigure3ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/f55a16c5d9889e6652eddc16.jpg"},{"id":85178975,"identity":"06b43704-7dd7-477f-9c68-9f77cc51f959","added_by":"auto","created_at":"2025-06-23 07:05:31","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":73800,"visible":true,"origin":"","legend":"\u003cp\u003ePatient #6 was a 60-year-old male with thoracic hyperkyphosis. He had 90-degree thoracic kyphosis, 57-degree lumbar lordosis, and a pelvic incidence of 36 degrees (A, B). He underwent a fusion from T1 to sacrum, with posterior column osteotomy at T4-T8 and T10-S1, and anterior cages at L4-S1 and T8-T10 (C, D). At over 2 years postoperatively, he had no complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRTG\u003c/strong\u003e: no\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRTG time\u003c/strong\u003e: N/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVAS: 9\u003c/p\u003e\n\u003cp\u003eAbility: Intermediate\u003c/p\u003e\n\u003cp\u003eHandicap: 20.0\u003c/p\u003e\n\u003cp\u003eDays per year: 0-10\u003c/p\u003e\n\u003cp\u003ePain limiting? Yes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e: None\u003c/p\u003e","description":"","filename":"RTGFigure4ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/1fa57bb0eac3707cf030bd84.jpg"},{"id":92884001,"identity":"5bd20c4e-048d-4226-b456-1fe7abe5cfdd","added_by":"auto","created_at":"2025-10-06 16:11:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":842101,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/a0f15027-effc-4d83-8aed-a39fc98420ef.pdf"},{"id":85178967,"identity":"1461f1e2-a5d0-4782-8cd5-17eddf230272","added_by":"auto","created_at":"2025-06-23 07:05:31","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":91554,"visible":true,"origin":"","legend":"","description":"","filename":"RTGTable1ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/5de626204f1f3cbea97b99ba.jpg"},{"id":85180264,"identity":"7e66645a-274d-4301-9a4f-aa48a06ede22","added_by":"auto","created_at":"2025-06-23 07:13:31","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":35359,"visible":true,"origin":"","legend":"","description":"","filename":"RTGTable2ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/e160b134e08bb889594ad27b.jpg"},{"id":85178973,"identity":"0cdd0b21-cd70-4134-a184-425129c51215","added_by":"auto","created_at":"2025-06-23 07:05:31","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":50778,"visible":true,"origin":"","legend":"","description":"","filename":"RTGTable3ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/4702aef9509e1c087ddfdb3f.jpg"},{"id":85178981,"identity":"985ec77e-40e0-402f-9b34-a3de4962b7b8","added_by":"auto","created_at":"2025-06-23 07:05:31","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":74266,"visible":true,"origin":"","legend":"","description":"","filename":"RTGTable4ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/29f8e9e2e076b06f7359a1b3.jpg"},{"id":85178977,"identity":"352f6dc2-2b3e-4030-82fb-93a83e86e48e","added_by":"auto","created_at":"2025-06-23 07:05:31","extension":"jpg","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":51513,"visible":true,"origin":"","legend":"","description":"","filename":"RTGTable5ESJ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6699534/v1/962941ac8c223f220ac7424a.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Return to Golf After Corrective Surgery in Adult Spinal Deformity Patients with Long Fusion Constructs: A Retrospective Case Series","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGolf is popular amongst millions of individuals. Although it may seem slow-paced, golf requires substantial physical ability. To generate sufficient power when striking the ball, one is required to rotate their torso, maintain stability, and shift their weight throughout the swing of the club. Therefore, the spine must be able to effectively twist, bend, and extend to generate maximal force production throughout the golf swing. Surgery for adult spinal deformity (ASD), particularly long-construct fusions with pelvic fixation, can significantly decrease a patient\u0026rsquo;s range of motion and potentially impact their ability to return to golf (RTG). Long fusions can also alter spinal alignment, posture, and center of gravity, all of which affect swing biomechanics and golf performance. However, there is currently insufficient data for surgeons to adequately address questions about if, when, and at what ability level their patients might RTG.\u003c/p\u003e \u003cp\u003eThere is no consensus for returning to sport after spinal fusion. Current guidelines are heterogeneous and largely based on surveys of clinicians\u0026rsquo; protocols.\u003csup\u003e1\u0026ndash;4\u003c/sup\u003e Most surgeons allow patients that undergo thoracic and lumbar fusions to return to contact sport after 6 to 12 months but disagree about returning to collision sports.\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e Recommendations tend to be more conservative for fusions extending past T12/L1.\u003csup\u003e8\u0026ndash;9\u003c/sup\u003e There is general agreement that patients should be pain-free, neurologically intact, and have evidence of bone fusion before returning to play.\u003c/p\u003e \u003cp\u003eFew primary studies have reported whether spine patients RTG following their operation, with minimal evaluation of effect on performance. Zuckerman et al. reported on 3 degenerative and 3 deformity patients that play golf.\u003csup\u003e10\u003c/sup\u003e The authors reported that all patients returned to play the same or more rounds of golf after undergoing various spinal surgical interventions ranging from cervical laminoplasty to corrective deformity surgery.\u003csup\u003e10\u003c/sup\u003e Other studies on RTG post spine-surgery have found that 35\u0026ndash;100% of patients report similar or improved postoperative play and nearly 30% are limited by persistent back or leg pain.\u003csup\u003e11\u0026ndash;15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis case series aims to contribute to this growing body of evidence, as golf remains a popular sport amongst patients suffering from spinal ailments. Using similar methodology from a previous study\u003csup\u003e10\u003c/sup\u003e, we analyzed a cohort of patients who were previously active in golf, that underwent long spinal fusion with instrumentation to the pelvis with a particular interest in clinical outcomes and ability to RTG.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Data\u003c/h2\u003e \u003cp\u003eInstitutional Review Board approval was obtained for this retrospective study (IRB #AAAU6316) and informed consent was obtained from each patient enrolled. Consecutive patients from 2015\u0026ndash;2023, who underwent primary or revision spinal fusion of consecutive levels, from pelvis to T10 or higher, at a single center, were considered for eligibility. Patients were screened over the phone for participation from November 2023 \u0026ndash; April 2024. Patients who were \u0026ge;\u0026thinsp;18 years of age, active golfers before surgery, and who had minimum of 2-year follow-up were asked to complete a questionnaire about their preoperative and postoperative ability (Appendix A). Active golfers were defined as having golfed\u0026thinsp;\u0026ge;\u0026thinsp;5 times in their life and \u0026ge;\u0026thinsp;1 time in the 5 years prior to their surgery. The postoperative RTG time was obtained, as well as the following metrics: visual analogue scale (VAS) pain level, self-perceived golf ability, golf handicap score, average days golfing per year, associated pain while golfing, preoperative and postoperative physical therapy (PT) information, and associated regret of undergoing surgery. Patient-reported outcome measures such as the Scoliosis Research Society-22r (SRS-22r)\u003csup\u003e16\u003c/sup\u003e and Oswestry Disability Index (ODI)\u003csup\u003e17\u003c/sup\u003e scores were collected at baseline, one year postoperatively, and at final follow-up. Demographics, clinical presentation, and operative data were also collected.\u003c/p\u003e \u003cp\u003eA total of 396 patients were available in the database. Patients who could not be contacted were excluded. 161 patients were contacted via phone call: 128 had never played golf, 19 had not played golf within 5 years before their surgery, and 2 were non-English speaking. 12 patients met inclusion criteria, and all agreed to participate in the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS Statistics Version 28 (IBM Corporation, Armonk, NY). All continuous variables were described with mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and nominal variables were described with frequencies (%). Due to limited sample size of this case series, inferential statistics was not possible.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 12 golfers were included with a mean follow-up (FU) of 5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 years. Mean age was 61.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0 years, mean BMI was 23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 kg/m\u0026sup2;, and 66.7% (n\u0026thinsp;=\u0026thinsp;8) patients were female. 33.0% (n\u0026thinsp;=\u0026thinsp;4) patients underwent\u0026thinsp;\u0026ge;\u0026thinsp;1 previous spine procedure(s) prior to their long construct, and 16.7% (n\u0026thinsp;=\u0026thinsp;2) underwent\u0026thinsp;\u0026ge;\u0026thinsp;2 previous spine procedures (\u003cstrong\u003eTable\u0026nbsp;1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReturn to Golf\u003c/em\u003e: 75.0% (n\u0026thinsp;=\u0026thinsp;9) patients RTG at a mean of 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 years after surgery. Of those that did not RTG, 66.7% (n\u0026thinsp;=\u0026thinsp;2) reported being physically unable to golf, and 33.3% (n\u0026thinsp;=\u0026thinsp;1) did not provide an answer. Of those that RTG, patients maintained or improved their performance in the following metrics: 88.9% (n\u0026thinsp;=\u0026thinsp;8) in self-assessed golf ability, 40.0% (n\u0026thinsp;=\u0026thinsp;2) in golf handicap score, 66.7% (n\u0026thinsp;=\u0026thinsp;6) in average number of days golfing per year, and 100.0% (n\u0026thinsp;=\u0026thinsp;9) in pain while golfing (\u003cstrong\u003eTable\u0026nbsp;2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePain Levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients improved in the VAS pain score from baseline (7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2) to latest FU (1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), in the SRS-22r score from baseline (68.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8) to 1 year postoperatively (95.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and latest FU (92.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and in the ODI score from baseline (35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;18.1) to 1 year postoperatively (10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and latest FU (8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). All of these improvements met minimally clinically important difference (MCID) standards (\u003cstrong\u003eTable\u0026nbsp;3\u003c/strong\u003e).\u003csup\u003e18\u0026ndash;20\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictive Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between those who RTG and those who did not, including age, number of spinal levels fused, sex, BMI, previous spine surgery, participation in preoperative PT, participation in postoperative PT, baseline VAS, baseline SRS-22 score, baseline ODI, baseline golf handicap, baseline average days golfing per year, and baseline golf ability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRepresentative Cases\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree cases representative of deformity patients who returned to golf at 1) the same level, 2) at a slightly decreased level, or 3) did not RTG are presented in Figs. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSpinal injuries, particularly in the lumbar spine, are commonly reported in avid golf players.\u003csup\u003e21\u0026ndash;24\u003c/sup\u003e Lumbar spinal injuries and low back pain have been attributed to biomechanical factors and increased torsional stresses related to the x-factor and crunch factor of the modern golf swing.\u003csup\u003e24\u0026ndash;26\u003c/sup\u003e However, some recent studies have disputed this notion.\u003csup\u003e27\u0026ndash;29\u003c/sup\u003e Given the epidemiology of low back pain and spinal-related injuries in golf, it is important to understand how spinal surgery affects return to play and post-operative sport performance.\u003c/p\u003e \u003cp\u003eFew studies have evaluated return to play outcomes in golfers after corrective surgery for ASD. Zuckerman et al. reported RTG outcomes in 6 patients that underwent surgery for both deformity and degenerative pathologies.\u003csup\u003e10\u003c/sup\u003e All 3 ASD patients in the study underwent corrective surgery. Two ASD patients had fusion constructs extending from the pelvis to the upper thoracic spine (T2 \u0026amp; T3 Upper Instrumented Vertebrae, UIV; 16 \u0026amp; 15 Total Instrumented Levels, TIL). One patient underwent non-continuous fusion and instrumentation with one construct extending from the pelvis to L1 and the other being circumferential arthrodesis from C2-T1 (11 TIL). These patients RTG at 10, 18, and 42 months, respectively.\u003csup\u003e10\u003c/sup\u003e A recent study by Maayan et al., examined return to various sporting activities in ASD patients that underwent a minimum of 3 levels of posterior spinal fusion with pelvic fixation.\u003csup\u003e30\u003c/sup\u003e A total of 11 recreational golfers were included, of which 6 (54.5%) successfully RTG. One patient RTG between 3\u0026ndash;6 months post-op, four RTG between 6\u0026ndash;12 months, and one returned after 2 years of surgery.\u003csup\u003e30\u003c/sup\u003e Interestingly, 45.5% of ASD patients did not RTG after surgery.\u003csup\u003e30\u003c/sup\u003e In our cohort, patients had a mean TIL of 12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 and 75% RTG at mean 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 yrs.\u003c/p\u003e \u003cp\u003eIn degenerative spine patients various RTG rates have been reported.\u003csup\u003e10\u0026ndash;13\u003c/sup\u003e Zuckerman et al. reported that 3 patients with cervical and lumbar pathologies successfully RTG after surgery. The degenerative patients returned to play at a quicker rate compared to deformity patients (degenerative RTG time: 2\u0026ndash;18 months vs. deformity RTG time: 10\u0026ndash;42 months).\u003csup\u003e10\u003c/sup\u003e Shifflett et al. studied RTG in 34 patients that underwent single or two level primary lumbar fusion surgery.\u003csup\u003e11\u003c/sup\u003e At one year follow-up, half of the patients successfully RTG.\u003csup\u003e11\u003c/sup\u003e Richards et al. studied 35 patients that underwent anterior or posterior cervical spine surgery and reported that 81.6% of patients successfully RTG at one year follow-up.\u003csup\u003e12\u003c/sup\u003e Jain et al. reported a 100% RTG rate in 13 recreational golfers within 3\u0026ndash;9 months after lumbar fusion.\u003csup\u003e13\u003c/sup\u003e As expected, degenerative spinal fusions with shorter constructs have higher rates of RTG than multi-level fusion surgery as commonly observed in ASD patients.\u003c/p\u003e \u003cp\u003eAlthough RTG is important for active patients, post-operative performance is also an important factor to consider. Zuckerman et al. stated that 4 out of 6 had sustained or increased performance after surgery and only one patient had a slight decrease in handicap.\u003csup\u003e10\u003c/sup\u003e Maayan reported that 27.3% of subjects RTG at the same level or had increased performance while 27.3% of patients had decreased performance.\u003csup\u003e30\u003c/sup\u003e Physical limitation, fear, and pain were the most commonly cited reasons for decreased performance.\u003csup\u003e30\u003c/sup\u003e Shifflett et al. reported that 80% of golfers had sustained or improved handicap after return.\u003csup\u003e11\u003c/sup\u003e In one study, golfers returned to play at the same (41.4%) or improved (24.1%) level of performance after cervical spine surgery.\u003csup\u003e12\u003c/sup\u003e Jain et al. reported a decrease in performance with a mean in handicap (preoperative: 13\u0026thinsp;\u0026plusmn;\u0026thinsp;8 strokes, postoperative: 17\u0026thinsp;\u0026plusmn;\u0026thinsp;11 strokes, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/em\u003e) and a decrease in driving distance (preoperative: 223\u0026thinsp;\u0026plusmn;\u0026thinsp;43 yards; postoperative: 212\u0026thinsp;\u0026plusmn;\u0026thinsp;44 yards, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.04\u003c/em\u003e).\u003csup\u003e13\u003c/sup\u003e In our study, 40% of golfers self-reported sustained or improved RTG handicap with 60% of golfers noting lower post-operative handicaps. Four patients did not keep track of their RTG handicap. However, 88.9% (n\u0026thinsp;=\u0026thinsp;8) of golfers reported an improvement in self-assessed golf ability.\u003c/p\u003e \u003cp\u003eWith respect to pain, Zuckerman et al. reported decreased leg and back Numerical Rating Scale (NRS) scores in all patients.\u003csup\u003e10\u003c/sup\u003e Maayan et al. noted post-operative improvements in physical function according to the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) score.\u003csup\u003e30\u003c/sup\u003e In Shifflett\u0026rsquo;s study, 50% of patients saw an improvement in pain after surgery while 50% did not.\u003csup\u003e11\u003c/sup\u003e Jain et al. observed a significant reduction in VAS pain scores in their golf cohort (preoperative: 6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7; postoperative: 1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.01\u003c/em\u003e). In our cohort, we observed improvements in mean SRS-22r, and ODI scores at 1 year and final follow-up (Table\u0026nbsp;3). Moreover, all patients reported significant improvement in VAS scores (Table\u0026nbsp;2). We found no significant differences in prehabilitation, postoperative rehabilitation, and self-perceived ability between golfers that did and did not RTG.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the largest case series to evaluate RTG in patients that underwent spinal fusion surgery with long fusion constructs and pelvic fixation. Overall, 75% (n\u0026thinsp;=\u0026thinsp;9) of patients RTG at a mean of 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 years after surgery. No significant differences were observed between those who RTG and those who did not. Patients who RTG had improved PROMs according to SRS-22r, ODI, and VAS scores.\u003c/p\u003e \u003cp\u003eThe primary limitations of this study are its retrospective design and cohort size. Additionally, surveying patients about their recovery and time to RTG is susceptible to recall bias. Moreover, the low rate of response may have contributed to selection bias, which is worth consideration when interpreting the results of the study. Despite these limitations, this study provides a realistic outline of expectations regarding spinal deformity surgery. It also serves as a baseline for future studies to build on to further develop an understanding of this field of research.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, it is possible for adult patients with complex spinal deformities to safely RTG after corrective surgery with long constructs. Additionally, despite possible restrictions in motion, sustained or improved performance is attainable in this unique population of patients. Further research is needed to further understand how spinal fusion affects RTG and post-operative performance longitudinally in recreational, collegiate, and elite golf athletes. Continued research and new knowledge will enable spinal surgeons to make evidence-based RTG recommendations in patients undergoing multi-level spinal fusion surgery.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASD - adult spinal deformity\u003c/p\u003e\n\u003cp\u003eVAS - visual analogue scale\u003c/p\u003e\n\u003cp\u003eSRS-22r - Scoliosis Research Society-22\u003c/p\u003e\n\u003cp\u003eODI - Oswestry Disability Index\u003c/p\u003e\n\u003cp\u003eFFU - final follow-up\u003c/p\u003e\n\u003cp\u003eFU - follow-up\u003c/p\u003e\n\u003cp\u003eRTG - return to golf\u003c/p\u003e\n\u003cp\u003eMCID - minimally clinically important difference\u003c/p\u003e\n\u003cp\u003ePT - physical therapy\u003c/p\u003e\n\u003cp\u003eUIV - Upper Instrumented Vertebrae\u003c/p\u003e\n\u003cp\u003eTIL - Total Instrumented Levels\u003c/p\u003e\n\u003cp\u003eNRS - Numerical Rating Scale\u003c/p\u003e\n\u003cp\u003ePROMIS-PF - Patient-Reported Outcomes Measurement Information System Physical Function\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRoles1 Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work2 Drafted the work or revised it critically for important intellectual content3 Approved the version to be published4 Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolvedContributions by AuthorKH: 1,2,3,4JR: 1,2,3,4BS: 1,2,3,4RM: 1,2,3,4AD: 1,2,3,4GG: 1,2,3,4JC: 1,2,3,4VA: 1,2,3,4RL: 1,2,3,4ZM: 1,2,3,4LL: 1,2,3,4JL: 1,2,3,4\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLi Y, Hresko MT. 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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). 2015 Mar 15;40(6):377-81.\u003c/li\u003e\n\u003cli\u003eMacDowall A, Skeppholm M, Robinson Y, Olerud C. Validation of the visual analog scale in the cervical spine. J Neurosurg Spine. 2018 Mar;28(3):227-235.\u003c/li\u003e\n\u003cli\u003eHung M, Saltzman CL, Kendall R, Bounsanga J, Voss MW, Lawrence B, Spiker R, Brodke D. What Are the MCIDs for PROMIS, NDI, and ODI Instruments Among Patients With Spinal Conditions? Clin Orthop Relat Res. 2018 Oct;476(10):2027-2036.\u003c/li\u003e\n\u003cli\u003eWilliamson TR, Kay RS, Robinson PG, Murray AD, Clement ND. Epidemiology of musculoskeletal injury in professional and amateur golfers: a systematic review and meta-analysis. \u003cem\u003eBr J Sports Med\u003c/em\u003e. 2024;58(11):606-614. Published 2024 May 28.\u003c/li\u003e\n\u003cli\u003eMinghelli B, Soares ASP, Cabrita CD, Martins CC. Epidemiology of Musculoskeletal Injuries in Golf Athletes: A Championship in Portugal. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2024;21(5):542. Published 2024 Apr 25.\u003c/li\u003e\n\u003cli\u003eFradkin AJ, Cameron PA, Gabbe BJ. Golf injuries--common and potentially avoidable. \u003cem\u003eJ Sci Med Sport\u003c/em\u003e. 2005;8(2):163-170.\u003c/li\u003e\n\u003cli\u003eVad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews JR. Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits. Am J Sports Med. 2004;32(2):494-497.\u003c/li\u003e\n\u003cli\u003eWalker, C. T., Uribe, J. S., \u0026amp; Porter, R. W. (2019). Golf: a contact sport. Repetitive traumatic discopathy may be the driver of early lumbar degeneration in modern-era golfers\u003cem\u003e. Journal of Neurosurgery: Spine\u003c/em\u003e SPI, 31(6), 914-917.\u003c/li\u003e\n\u003cli\u003eJoyce C, Burnett A, Ball K. Methodological considerations for the 3D measurement of the X-factor and lower trunk movement in golf. \u003cem\u003eSports Biomech\u003c/em\u003e. 2010;9(3):206-221.\u003c/li\u003e\n\u003cli\u003eCole MH, Grimshaw PN. The crunch factor\u0026apos;s role in golf-related low back pain. Spine J. 2014;14(5):799-807.\u003c/li\u003e\n\u003cli\u003eWatson M, Coughlan D, Clement ND, Murray IR, Murray AD, Miller SC. Biomechanical parameters of the golf swing associated with lower back pain: A systematic review. J Sports Sci. 2023;41(24):2236-2250.\u003c/li\u003e\n\u003cli\u003eSmith JA, Hawkins A, Grant-Beuttler M, Beuttler R, Lee SP. Risk Factors Associated With Low Back Pain in Golfers: A Systematic Review and Meta-analysis. \u003cem\u003eSports Health\u003c/em\u003e. 2018;10(6):538-546.\u003c/li\u003e\n\u003cli\u003eMaayan, O., Zhang, B., Fourman, M. S., Clohisy, J., Pajak, A., Nakarai, H., Kazarian, G. S., Du, J., Merrill, R., Kaidi, A., Knopp, R., Akosman, I., Samuel, J., Andrews, L., Shahi, P., Lovecchio, F. C., \u0026amp; Kim, H. J. (2024). Return to Sporting Activities Following Long Fusions to the Pelvis in Adult Spinal Deformity. \u003cem\u003eThe spine journal : official journal of the North American Spine Society\u003c/em\u003e, S1529-9430(24)00268-7. Advance online publication\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"},{"header":"Appendix","content":"\u003cp\u003eAppendix is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6699534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6699534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eGolf is a popular sport that requires truncal strength and spinal flexibility. Spinal fusion surgery limits range of motion with pelvic fixation may impact a golfer’s ability to return to golf (RTG). The purpose of this study is to report clinical outcomes and return to golf following long-construct spinal fusion surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Patients fused from the pelvis from T10 or higher were screened for golfing participation during November 2023 – April 2024. Inclusion criteria included: \u0026nbsp;≥18 years old, \u0026gt;2 year minimum follow-up, active golfers. Visual analogue scale (VAS) pain level, self-perceived golf ability, golf handicap score, average days golfing per year, pain while golfing, preoperative and postoperative physical rehabilitation information, and associated regret of undergoing surgery was collected. Predictive factors for ability to RTG were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e12 golfers from 2015-2023 were included (age 61.1±10.0 years, BMI 23.4±4.0 kg/m², female composition 66.7%, follow-up 5.8±1.9 years). 75.0% (n=9) patients RTG at an average of 1.4±0.6 years after surgery. Patients who RTG maintained or improved their performance in the following metrics: 88.9% (n=8) in self-assessed golf ability, 40.0% (n=2) in golf handicap score, 66.7% (n=6) in average number of days golfing per year, and 100.0% (n=9) in pain while golfing. Pain scores improved from baseline to FFU: VAS (7.8±2.2 vs 1.3±1.4; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.01), SRS-22r (68.0±12.8 vs 92.0±15.0; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.01), ODI (35.3±18.1 vs 8.0±7.9; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis was the largest and most in-depth series pertaining to return to golf following corrective spinal deformity surgery. 75% of golfers returned to golf after long-construct fusion to pelvis, and the majority reported similar or improved performance. Mean pain and quality of life scores improved significantly for the whole group. Adult spinal deformity patients that play golf can expect equal or improved performance following corrective spine surgery.\u003c/p\u003e","manuscriptTitle":"Return to Golf After Corrective Surgery in Adult Spinal Deformity Patients with Long Fusion Constructs: A Retrospective Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 07:05:26","doi":"10.21203/rs.3.rs-6699534/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-16T08:36:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-08T19:26:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-30T18:32:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260358473473972700948621961547203422445","date":"2025-06-26T05:00:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298451353931318612951564530679201419489","date":"2025-06-17T11:38:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20183046931928047512801632465554467687","date":"2025-06-17T09:04:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T07:09:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-22T03:51:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-22T03:49:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-05-19T13:36:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5a92f60f-4f25-4a7b-8bbc-df000a28edf4","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:06:44+00:00","versionOfRecord":{"articleIdentity":"rs-6699534","link":"https://doi.org/10.1007/s00586-025-09370-2","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2025-10-02 15:57:47","publishedOnDateReadable":"October 2nd, 2025"},"versionCreatedAt":"2025-06-23 07:05:26","video":"","vorDoi":"10.1007/s00586-025-09370-2","vorDoiUrl":"https://doi.org/10.1007/s00586-025-09370-2","workflowStages":[]},"version":"v1","identity":"rs-6699534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6699534","identity":"rs-6699534","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}