Outcomes, patient acceptable symptom state, complications, and predictors after surgical correction of adult spinal deformity – a retrospective observational study

Outcomes, patient acceptable symptom state, complications, and predictors after surgical correction of adult spinal deformity – a retrospective observational study | 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 Research Article Outcomes, patient acceptable symptom state, complications, and predictors after surgical correction of adult spinal deformity – a retrospective observational study Vinjar Brenna Hansen, Thomas Johan Kibsgård, Christian Hellum, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7054892/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Adult spinal deformity surgery (ADS) has been associated with moderate results and a high risk of complications. Patient-acceptable symptom state (PASS), complications, and predictors of outcome may not be sufficiently documented. Purpose: To reassess PASS by the Oswestry Disability Index (ODI), describe reoperations, and study predictors for outcomes after ADS for the target population. Methods: This retrospective and cross-sectional observational survey assessed surgically corrected adult patients with degenerative and posttraumatic spinal deformities. Patients responded to PROM surveys at a median of 51 months (Q1: 30, Q3: 74). Treatment success was assessed using the Global Perceived Effect (GPE), and we employed ROC analysis to determine the corresponding PASS ODI cut-off. Reoperations were documented in electronic patient records (EPRs) with a minimum follow-up of 60 months (median; 80.5, Q1; 65.8, Q3; 107.3). Potential predictors for ODI were examined by linear regression. Results: We identified 82 adult patients with surgically treated deformities at two Norwegian hospitals. PASS was below 32 ODI points (AUC = 0.838, 95% CI: 0.727–0.950), and 24 of 59 (41%) patients achieved PASS. Regression analysis revealed that female gender (B = 12.6, 95% CI = 2.1–23.0, p = 0.019) and smoking (B = 14.4, 95% CI = 1.0-27.9, p = 0.036) predicted worse postoperative ODI. Conclusion: In this retrospective and cross-sectional observational study of adult spinal deformity patients, about 2 of 5 achieved a PASS ODI value below 32 ODI points. Over half of the patients required revision surgery within five years following the index surgery. Female gender and smoking predicted worse postoperative ODI. Adult deformity surgery (ADS) adult spinal deformity (ASD) post-fracture deformity patient acceptable symptom state (PASS) reoperation predictors Figures Figure 1 Introduction Adult spinal deformity (ASD) has a substantial impact on the health-related quality of life [ 1 ]. However, surgical correction of deformity has been associated with suboptimal patient-reported outcomes (PROMs) and a high risk of revision surgery [ 2 , 3 ]. Furthermore, any previous spinal surgeries may influence the acceptance of residual pain and dysfunction following the subsequent spinal surgery [ 4 ]. Patients who have undergone multiple previous spinal surgeries have lower expectations compared to those undergoing their first surgery [ 5 ]. As a result, the patient acceptable symptom state (PASS), as defined by an absolute postoperative Oswestry Disability Index (ODI) threshold value, may vary with the number of previous spinal surgeries [ 6 ]. To our knowledge, only one study has calculated a postoperative ODI PASS-value for an ASD population [ 7 ]. ASD patients frequently undergo subsequent spinal surgeries; a systematic review estimated that subsequent surgeries range from 17–40% at 90 days and 11 years, respectively, after the index deformity surgery [ 8 , 9 ]. Subsequent reoperations for degenerative spine conditions have been associated with a decreasing chance of treatment success [ 4 ]. Finally, age, gender, American Society of Anesthesiologists (ASA) physical status classification, smoking, obesity, prior spine surgery, surgeon experience, and osteoporosis may affect outcomes and the risk of complications following adult deformity surgery [ 10 – 13 ]. We aimed to study: Middle-term outcomes after ADS and determine a postoperative PASS ODI cut-off value corresponding to treatment success, as defined by the combined Global Perceived Effect categories" completely recover and much better". Frequency of and reasons for reoperations Predictors for patient-reported outcome measure (PROM) by Oswestry Disability Index. Materials and Methods Patients We retrospectively identified adult patients who underwent spinal deformity surgery from 2011 to 2019 by searching electronic patient records (EPRs) at Oslo and Haukeland University Hospitals. The search criteria were: 1) At least 20 years of age, 2) At least 20 degrees of deformity (scoliosis or kyphosis). We excluded patients with idiopathic scoliosis that progressed in adulthood, neuromuscular causes of deformity, acute fractures, active infections, or malignancies. Baseline data, including gender, BMI, smoking status, ASA, comorbidities, prior surgery, type of index surgery, and preoperative radiographs, were extracted from EPRs with a follow-up (FU) time of at least 60 months after index surgery (median; 81, Q1; 66, Q3; 107). We used the Schwab classification to categorise and describe the deformity based on preoperative standing radiographs of the total spine [ 14 ]. Patients who provided written consent received postoperative patient-reported outcome measures (PROM) questionnaires by mail. Patients who did not respond received up to three reminders by mail or phone. Since recording preoperative PROMs was not part of clinical practice, and for ethical reasons, we could not analyse the nonrespondents. PROMs Obtaining preoperative ODI was not established as clinical practice, nor was it systematically recorded in EPRs. We, therefore, obtained cross-sectional postoperative PROMs by mail. After index deformity surgery, the median response time was 51 months (Q1: 30, Q3: 74). Patients reported the following PROMs: Oswestry Disability Index (ODI), ten items, each scored 0–5 and presented as a percentage score (0-100%, no disability-severe disability) [ 15 ]. Numeric pain rating scales (NRS, 0–10, no pain to worst imaginable) for back and leg pain and satisfaction with treatment. Treatment satisfaction was assessed by Global Perceived Effect, a 7-category Likert scale with the following response options: 1 – completely recovered, 2 – much better, 3 – slightly improved, 4 – unchanged, 5 – slightly worse, 6 – much worse, 7 – worse than ever. The categories "completely recovered" and "much better" defined treatment success. Statistical analyses Continuous data are presented as means (SD or 95% CI) or medians (IQR), and categorical data as frequencies (%). The reported differences are between the baseline and the FU. The association between two categorical variables was analysed using the Pearson chi-squared test. Poisson regression methods were employed for three or more variables. Differences between the means of two unpaired groups were analysed using the Student's t-test for two independent samples. A one-sample t-test was used to investigate the average change from baseline to the last FU. The receiver operating characteristics curve (ROC) was used to establish the most accurate postoperative ODI cut-off corresponding to treatment success, as anchored by GPE categories "completely recovered" and "much better". The hypothetical perfect classifier is located at the upper left corner of the ROC, representing 100% sensitivity and 100% specificity. We used the ROC point closest to the perfect classifier to define the PASS ODI value with the highest combination of sensitivity and specificity. Finally, we calculated the area under the ROC curve [ 16 ]. AUC values are interpreted by the following categories: 0.9 = excellent accuracy [ 17 ]. Linear regression was applied to assess variables associated with the ODI, the primary outcome variable. ODI was checked for normal distribution. Seven possible covariates were selected based on previous literature, clinical experience, and results from the univariate analysis (p < 0.2) (Fig. 1 ). Variables with a p-value of less than 0.2 were analysed further with multivariate analysis. Multivariate analyses were done with and without imputation to handle missing ODI data. The R-square (0–1) was also reported for the goodness of fit. An R-squared value close to 1 indicates a perfect fit, implying that the predictor is highly relevant. The significance level was set to 0.05. We conducted the analyses using SPSS (version 29; IBM Corp., Armonk, NY, USA). The reported results adhere to the STROBE guidelines ( www.strobe-statement.org ). Patients signed an informed consent. The National Ethical Board (Regional Ethical Committee north) approved this study (REK 2017/1378). Additional permission is required for third-party use of data. Results Patient baseline characteristics We identified 82 patients, and their baseline characteristics are presented in Table 1 . The typical patient in our cohort was a female in her 60s with some comorbidities (ASA 2), who had received at least one spinal surgery previously. Preoperative radiographs were available in 80 out of 82 (98%) patients and showed degenerative deformities in 56 (68%) of the patients, while 26 (32%) had deformities resulting from previous spinal fractures. Most patients had significant spinal deformities, as shown by the Schwab classification parameters listed in Table 1 . Preoperative radiographs varied; therefore, sagittal vertical axis (SVA) and pelvic parameters (pelvic incidence and pelvic tilt) were available for 65 of 80 (81%) and 71 of 80 (89%), respectively (Table 1 ). Table 1 Baseline data with radiological characteristics for 82 surgically treated adult spinal deformity patients Variable n Mean or Number SD 1 or Percentage Age 82 60.0 13.3 Females 82 50 61% ASA 2 82 1 82 9 11% 2 82 52 63% 3 82 21 26% BMI 3 82 26.1 4.2 BMI > 30 82 14 17% Smoking 82 18 22% Diabetes 82 7 9% Coronary vascular disease 82 33 40% Prior spine surgery 82 42 51% Type of spinal deformity Degenerative 82 56 68% Post-fracture 82 26 32% Schwab classification No coronal curves 80 61 76% Lumbar coronal curve > 30° 80 18 23% Double curve thoracolumbar > 30° 80 1 1% 0 + ++ PI-LL 4 Mismatch 20 ° 71 11 (16%) 10 (14%) 50 (70%) Sagittal Vertical Axis 9.5cm 65 14 (22%) 21 (32%) 30 (46%) Pelvic Tilt 30° 71 13 (18%) 24 (34%) 34 (48%) Abbreviations: 1 SD = Standard deviation 2 ASA = American Society of Anesthesiologists classification 3 BMI = Body mass index 4 PI-LL = Pelvic incidence-lumbar lordosis Surgical details Surgeons addressed spinal deformities using various types of osteotomies, and a detailed account of the index surgeries is provided in Table 2 . Table 2 Baseline surgical data at the time of adult deformity surgery Number of patients Frequency (%) Type of surgery Pedicle subtraction osteotomy (PSO) 82 39 (47) Degenerative (PSO level) 39 19 (48) L1 19 1 (5) L2 19 6 (3) L3 19 10 (5) L4 19 2 (10) Post fracture (PSO level) 39 20 (51) Th12 20 5 (25) L1 20 8 (40) Th6, Th11, L2, L3 20 7 (35) Ponte Osteotomy 82 24 (29) Posterolateral fusion (PLF) 1 82 14 (17) Corpectomy/vertebral column resection (VCR) 82 5 (6) Surgical variables Fused levels, mean (SD) 82 6 (2) Rods 2 rods 82 79 (96) 3 rods 82 1 (1) 4 rods 82 2 (2) Augmented screws 82 12 (15) Neurological monitoring 82 15 (18.) Bone morphogenetic protein (BMP) 82 5 (6) Blood loss (ml), mean (SD) 82 1627.9 (877.0) Duration of surgery (hours), mean (SD) 82 5 (1) Hospital stay (days), mean (SD) 82 14 (11) 1 Posterolateral fusion = screw fixation, partial facet joint removal to increase flexibility and correction of deformity with dual rods. Mostly in cases of degenerative lumbar scoliosis. PROMs and PASS Fifty-nine of 82 (72%) responded to postoperative PROM surveys. The mean ODI was 39 (SD = 21), as shown in Table 3 . Table 3 Outcome among 82 patients operated for adult spinal deformity (2011–2019) N Mean (SD) Oswestry disability index 59 39.0 (21.0) Numeric rating scale back pain 59 4.2 (2.5) Numeric rating scale leg pain 59 2.9 (2.8) The most accurate ODI cut-off value corresponding to treatment success (GPE = 1: completely recovered or 2: much better) was below 32 ODI points (AUC = 0.838, 95% CI = 0.727–0.950) (Fig. 1 ), and was achieved by 24 of 59 (41%) patients. Mean pain scores were: NRS back pain 4.2 (SD = 2.5) and leg pain 2.9 (SD = 2.8). We did not find any difference in the proportions of postoperative complications among responders and nonresponders: 9 of 23 (39%) vs. 45 of 82 (55%); p = 0.074. A difference in the proportions of postoperative mortality among responders and nonresponders was detected: 2 of 82 (2.4%) vs. 5 of 82 (6.1%); p = 0.002. Reoperations At least one revision surgery was required in 45 of 82 (55%) patients during the first five years after the index surgery, and a total of 73 reoperations were performed in these 45 patients. Revision surgeries are detailed in Table 3 . Table 4 Revision surgeries among 82 adult deformity surgery patients, 0–5 years 1 reoperation 2 reoperations 3–5 reoperations In total, at least one reoperation n (%) 28 (34) 11 (14) 6 (7) 45 (55) Time (months), median (IQR) 9 (20) 35 (51) 44 (16) Indication first revision 1 Year 2 Years 3 Years 4 Years 5 Years Total (%) Distal junctional kyphosis 8 4 3 1 16 (20) Proximal junctional kyphosis 3 1 2 6 (7) Proximal- and distal junctional kyphosis 2 2 (3) Infection 5 1 6 (7) Neurological complication 1 6 6 (7) Pain 1 2 3 (4) Misplaced screw, pain 2 1 3 (4) Hardware failure 1 1 (1) Pseudarthrosis of osteotomy 1 1 (1) Wrong level surgery 1 1 (1) Total 28 9 6 1 1 45 (55) 1 Nerve root palsy in four patients, one medulla compression case, and one cauda equine syndrome. The most common reasons for revision surgeries were mechanical failure 28 of 82 (34%), infection 6 of 82 (7%), and neurological complications 6 of 82 (7%). Additionally, 14 of 82 patients (17%) experienced a complication that was not revised; the majority were proximal and distal junctional failures (PJK and DJK in 9 and 2 cases, respectively). Lower limb palsy occurred in 6 of 82 (7%), and 2 of the 6 (33%) patients suffered persistent paralysis of the lower limbs with bladder and bowel dysfunction (total risk paralysis: 2 of 82 (2%)). Predictors Lastly, we examined potential predictors of ODI (Table 5 ). Table 5 Predictors of Oswestry Disability Index reported by 59 of 82 adult patients who underwent spinal deformity surgery. Multivariate linear regression with raw data before imputation ODI post-surgery B 95% CI P-value R-Suare BMI 1.1 -0.05-2.2 0.061 Gender, female 12.6 2.1–23.0 0.019 Smoking 14.4 1.0-27.9 0.036 Multivariate R-Square 0.202 Female gender (B = 12.6, 95% CI = 2.1–23.0, p = 0.019) and smoking predicted worse ODI scores (B = 14.4, 95% CI = 1.0-27.9, p = 0.036). BMI was a confounder for the effect of gender and smoking on ODI and was relevant for the negative predictive impact of smoking on ODI after imputation (appendix 1.0). Discussion Summary of findings In this retrospective and cross-sectional observational study of surgically treated adult spinal deformity patients, the postoperative PASS value that most accurately corresponded with "completely recovered" or "much better" after surgery was below 32 ODI points, and two of five reached PASS. More than half needed revision surgery within five years after index surgery, primarily due to mechanical failure (34%), infection (7%), and neurological complications (7%). Female gender and smoking predicted a worse postoperative ODI at follow-up. In line with previously published PASS values, we expected PASS after complex surgical treatment of adult spinal deformity to differ from PASS following degenerative spinal surgery in general [ 7 , 18 ]. The PASS, defined by an absolute postoperative ODI value threshold, may vary based on the specific spinal diagnosis, number of previous spinal surgeries, and patient expectations [ 6 ] [ 7 ]. In our cohort, we found that a PASS value of less than 32 ODI points most accurately corresponded to "completely recovered" and "much better" (Fig. 2), and 24 of 59 (41%) participants achieved this value. Our study's ODI threshold and proportion that reached PASS align with previously published results [ 7 ]. However, the study above used a core outcome measure index (COMI) subscore as the anchor for treatment success [ 7 ], whereas we used GPE. Despite high rates of subsequent surgery in ASD cases, a relevant proportion of patients may still be satisfied with treatment. In a retrospective cohort study by Kyrölä et al., the mean preoperative ODI score of 51 improved to 34 (33% reduction) after surgery; however, 49 of 79 (62%) patients were satisfied with the treatment [ 19 ]. Additionally, 46.3% of patients with lumbar spinal stenosis who have undergone three or more surgeries reported success after surgery, with an ODI final score of 32.7 or less (ODI change of -25% or more) in less complex procedures [ 6 ]. The discrepancy between our PASS value of 32 ODI points and 23 by van Hooff et al. indicates that the ADS population tolerates more residual symptoms than degenerative spine patients in general [ 4 , 7 , 18 ]. The most frequent reason for revision surgery in our cohort was mechanical failure – a finding in line with previous publications [ 19 – 21 ]. A Finnish retrospective ADS cohort study reported a 5-year frequency of first reoperations due to mechanical failure of 30% (24 of 79) [ 19 ]. A Danish study described a 42% 2-year mechanical failure revision frequency (97 of 233) [ 20 ]. Junctional failures occur frequently after ADS [ 19 – 21 ]. A systematic review of ADS estimated the incidence of PJK to be 20–40% [ 22 ], while another systematic review estimated that DJKs occur in 4–23% [ 21 ]. In our study, the 5-year frequency of mechanical failures requiring revision surgery was 28 of 82 (34%). We studied an older population with significant sagittal imbalance (Table 1 ), which is similar to the populations described in two Scandinavian studies [ 19 , 20 ]. We could anticipate a high occurrence of mechanical complications in older populations with reduced bone density. Although less frequent than mechanical failure, the most severe ADS complications are neurological deficits and infections. Several factors can influence the frequency of surgical site infections (SSI). The frequency of postoperative infection in similar spine studies was just above 5% [ 23 – 25 ]. Kyrölä et al. reported SSI in 7 of 79 patients (8.9%) in a retrospective study of ADS patients with a 1 to 9-year follow-up [ 19 ]. It appears that obese patients have an increased risk of infection [ 25 , 26 ]. Factors associated with infection in deformity surgery may also include patient comorbidities [ 27 ]. Also, the amount of blood lost and staged procedures have been associated with an increased risk of postoperative SSI [ 23 ]. Vancomycin, administered locally during surgery, may decrease the risk of SSI. Still, a systematic review suggests inconclusive results regarding the effect of Vancomycin powder in reducing SSI in major orthopedic surgeries [ 28 , 29 ]. However, in our cohort, we did not routinely use intra-wound vancomycin. Still, all patients received standard antibiotic prophylaxis with Cefazoline IV 2 grams x 4 (Clindamycin 600 mg x 3 was used for patients allergic to penicillin). The infection rate in our cohort at 7% (6 of 82) was somewhat higher compared to previously published data [ 23 – 25 ]. To further reduce the risk of infections, it may be relevant to consider prolonged perioperative antibiotic treatment (greater than 48 hours) and intra-wound application of vancomycin [ 27 , 28 ]. Selecting patients with fewer comorbidities, non-smokers, and a lower BMI, along with implementing measures to reduce surgical time and bleeding, may also decrease the risk of SSI. Previous studies reported neurological complication rates following ADS of 11–19% [ 19 , 30 – 32 ]. In two different retrospective ADS cohorts, neurological deficit occurred in 15 of 79 (19%) and 17 of 103 (17%) [ 19 , 30 ]. Two studies, one retrospective multicenter and one prospective, investigated patients who underwent pedicle subtraction osteotomy. The studies above reported neurological complications in 72 of 423 (16.7%) and 12 of 108 (11%) patients, respectively [ 31 , 32 ]. In our study, EPRs documented neurological deficits in 6 of 82 (7%) patients. However, less severe neurological deficits might have been underreported in EPRs. Pedicle subtraction osteotomies, 39 of 82 (48%), resulted in the most severe neurological complications- two patients suffered total paralysis. Finally, we aimed to identify predictors of outcome after surgery, as assessed by the ODI, and to compare our findings with previous publications on ADS patients [ 10 – 13 ]. We found that female gender and smoking were associated with higher levels of back-related disability, as assessed by the final ODI. Smoking has previously been described as a risk factor for the development of postoperative medical complications in a retrospective study of 448 patients [ 10 ]. Smoking affects the tissue microenvironment and the functions of inflammatory and reparative cells, leading to delayed wound healing. Additionally, two systematic reviews found that smoking was associated with pseudarthrosis, disc degeneration, lower return to work rates, and worse outcomes after surgery [ 12 , 13 ]. Female gender is known to be correlated with osteoporosis, a condition associated with increased risk of nonunion and reoperation [ 11 ]. Limitations and Strengths The main limitations of this cohort study are the lack of preoperative PROMs and the variation in follow-up times, as PROMs were collected cross-sectionally (i.e., at different time points after surgery). Additionally, there is a possibility that responders could differ systematically from nonresponders. However, there were no differences in reoperations or mortality between nonresponders and responders. To address the absence of preoperative PROMs, we calculated an absolute postoperative patient acceptable symptom state (PASS) value for our cohort; however, the ODI percentage change may be more accurate [ 6 ]. Furthermore, using patients as their own reference, i.e., ODI and GPE recorded by the same individual, may be a methodological limitation. Then again, previous studies have used patients as their own references [ 7 , 18 ]; however, these studies used a non-validated subscore of COMI as the reference for patient-reported satisfaction. Complications and reoperations may be underreported in retrospective designs; however, complications are more reliably documented in electronic patient records (EPRs) than in spine registries [ 33 ]. Furthermore, in Norway, patients are typically referred back to the centre where the initial surgery was performed. We also acknowledge the diversity of indications for surgery (degenerative and posttraumatic deformity), reasons for revision, and surgical techniques. The data in this study reflect the initial implementation phase of the ADS in Norway, suggesting the potential influence of a learning curve on the outcomes observed. Due to the limited sample size, we had to limit the number of variables chosen for the predictor analysis; however, other variables may still be relevant to consider. To address the methodological limitations of the present study, we have initiated the INTRAKS study, an international prospective study of patients with ASD treated surgically and conservatively (ClinicalTrials identifier: NCT04536909). Conclusion In this dual-centre retrospective observational study of 82 adult spinal deformity patients, the postoperative patient acceptable symptom state (PASS) was less than 32 ODI points. Using this PASS criterion, two of five were satisfied at a median FU time of 51 months. More than half needed at least one revision surgery during the first five years after index surgery, primarily due to mechanical failure, infection, and neurological complications. Female gender and smoking predicted poorer postoperative outcomes (ODI). Abbreviations Adult spinal deformity surgery (ADS), Patient-acceptable symptom state (PASS), Oswestry Disability Index (ODI), Global Perceived Effect (GPE), electronic patient records (EPRs), adult spinal deformity (ASD), patient-reported outcomes (PROMs), American Society of Anaesthesiologists (ASA), Numeric pain rating scales (NRS), receiver operating characteristics curve (ROC), area under the ROC curve (AUC), standard deviation (SD), body mass index (BMI), pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), pedicle subtraction osteotomy (PSO), posterolateral fusion (PLF), vertebral column resection (VCR), bone morphogenetic protein (BMP), core outcome measure index (COMI), surgical site infection (SSI), follow up (FU). Declarations Conflict of interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in this study were conducted following the ethical standards of the national ethical board (Regional Ethical Committee North) and the 1964 Helsinki Declaration and its subsequent amendments. The National Ethical Board (Regional Ethical Committee north) approved this study (REK 2017/1378). Additional permission is required for third-party use of data. Consent to participate Patients signed an informed consent. Consent to publish Not applicable. Competing interests All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria, educational grants, participation in speakers bureaus; membership, employment, consultancies, stock ownership, or other equity interests, and expert testimony or patent-licensing arrangements), or non-financial interests (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Authors` contributions Hansen V (Corresponding author): wrote the manuscript, created figures and tables, investigation and formal analysis. Kibsgård T: reviewed the manuscript. Hellum C: reviewed the manuscript. Röhrl S: Main supervisor, reviewed the manuscript, investigation, methodology. Lien M: Formal analysis, reviewed the manuscript. Dolatowski F: reviewed the manuscript, edited figures and tables, formal analysis, methodology. Founding The corresponding author receives founding from Helse Vest, University of Bergen, Norway. The remaining authors received no founding for the research in this paper. The corresponding author receives founding from Helse Vest, University of Bergen, Norway. Availability of data and materials The data in this paper is stored in “Service for secure data”/TSD at Oslo University and contains sensitive patient data. References Bess S, Line B, Fu KM, McCarthy I, Lafage V, Schwab F et al (2016) The Health Impact of Symptomatic Adult Spinal Deformity: Comparison of Deformity Types to United States Population Norms and Chronic Diseases. Spine (Phila Pa 1976) 41(3):224–233 La Maida GA, Luceri F, Gallozzi F, Ferraro M, Bernardo M (2015) Complication rate in adult deformity surgical treatment: safety of the posterior osteotomies. 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Spine (Phila Pa 1976) 36(17):1397–1401 Bianco K, Norton R, Schwab F, Smith JS, Klineberg E, Obeid I et al (2014) Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36(5):E18 Buchowski JM, Bridwell KH, Lenke LG, Kuhns CA, Lehman RA Jr., Kim YJ et al (2007) Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment. Spine (Phila Pa 1976) 32(20):2245–2252 Alhaug OK, Kaur S, Dolatowski F, Smastuen MC, Solberg TK, Lonne G (2022) Accuracy and agreement of national spine register data for 474 patients compared to corresponding electronic patient records. Eur Spine J 31(3):801–811 Additional Declarations No competing interests reported. Supplementary Files Appendix1.0Primaryoutcomepredictors150625VBH.docx Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7054892","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491865663,"identity":"2db862fe-7a56-426c-9141-cbdbe8d522b4","order_by":0,"name":"Vinjar Brenna Hansen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDACZgYGAwaGA3IMDDwkajEmQQsEHEhsIFqLwXHeAwU/99xJ33D87MEHHxjuyBHWcpgvwbDn2bPcDWfykg1nMDwzJqhFspnHwIDnwOHcDQdyzKR5GA4DXUiEFsM/Bw6nG5x/Q6QWfmYeA2OgLQkGN4i1BaxF5sBhw5k33hgbzjA4TNgvbPxnzAzfHDgsz3c+x/DBh4rDhEMMpMsARCocAJEGxGgAxv8DECnfQJzqUTAKRsEoGIEAAC0DPjC16ESyAAAAAElFTkSuQmCC","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Vinjar","middleName":"Brenna","lastName":"Hansen","suffix":""},{"id":491865664,"identity":"99441285-e5b8-4627-9160-e6a9d85c395d","order_by":1,"name":"Thomas Johan Kibsgård","email":"","orcid":"","institution":"Oslo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Johan","lastName":"Kibsgård","suffix":""},{"id":491865665,"identity":"a7894ca9-a2b0-4637-a179-d4769d4181eb","order_by":2,"name":"Christian Hellum","email":"","orcid":"","institution":"Oslo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Hellum","suffix":""},{"id":491865672,"identity":"2dd961f4-d8a1-4ded-a30b-cd3dad0d4b7d","order_by":3,"name":"Stephan M. Röhrl","email":"","orcid":"","institution":"Oslo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Stephan","middleName":"M.","lastName":"Röhrl","suffix":""},{"id":491865673,"identity":"f0187506-5600-4cc2-b35e-0238bec25e9f","order_by":4,"name":"Lien My Diep","email":"","orcid":"","institution":"Oslo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lien","middleName":"My","lastName":"Diep","suffix":""},{"id":491865674,"identity":"842b78d9-af46-4711-a413-1bc8b8024636","order_by":5,"name":"Filip Celestyn Dolatowski","email":"","orcid":"","institution":"Oslo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Filip","middleName":"Celestyn","lastName":"Dolatowski","suffix":""}],"badges":[],"createdAt":"2025-07-05 20:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7054892/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7054892/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88001642,"identity":"977b7585-fa3b-4669-9771-d353ba0c7921","added_by":"auto","created_at":"2025-07-31 10:24:09","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107881,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver Operator Curve: Final postoperative ODI score and accuracy to discriminate between successful \"completely recovered\" or \"much better\" by GPE and non-successful outcome after ADS. The blue arrow indicates the most accurate postoperative ODI cut-off value corresponding to treatment success (SPSS)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7054892/v1/bb99b6d226c6413781fbbac2.jpeg"},{"id":89024300,"identity":"1ced0fe6-0d95-4c8e-bc5e-0f67e01a4c75","added_by":"auto","created_at":"2025-08-13 22:01:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1034516,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7054892/v1/20cb65e9-3e02-425d-ab5e-e04ab40a5fb7.pdf"},{"id":88001660,"identity":"1d4aa552-3e9d-42db-afff-9b01a01c87e1","added_by":"auto","created_at":"2025-07-31 10:24:11","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27208,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.0Primaryoutcomepredictors150625VBH.docx","url":"https://assets-eu.researchsquare.com/files/rs-7054892/v1/98b83e613b8bf5260d1d8509.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes, patient acceptable symptom state, complications, and predictors after surgical correction of adult spinal deformity – a retrospective observational study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdult spinal deformity (ASD) has a substantial impact on the health-related quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, surgical correction of deformity has been associated with suboptimal patient-reported outcomes (PROMs) and a high risk of revision surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, any previous spinal surgeries may influence the acceptance of residual pain and dysfunction following the subsequent spinal surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Patients who have undergone multiple previous spinal surgeries have lower expectations compared to those undergoing their first surgery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As a result, the patient acceptable symptom state (PASS), as defined by an absolute postoperative Oswestry Disability Index (ODI) threshold value, may vary with the number of previous spinal surgeries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To our knowledge, only one study has calculated a postoperative ODI PASS-value for an ASD population [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. ASD patients frequently undergo subsequent spinal surgeries; a systematic review estimated that subsequent surgeries range from 17\u0026ndash;40% at 90 days and 11 years, respectively, after the index deformity surgery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Subsequent reoperations for degenerative spine conditions have been associated with a decreasing chance of treatment success [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Finally, age, gender, American Society of Anesthesiologists (ASA) physical status classification, smoking, obesity, prior spine surgery, surgeon experience, and osteoporosis may affect outcomes and the risk of complications following adult deformity surgery [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe aimed to study:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMiddle-term outcomes after ADS and determine a postoperative PASS ODI cut-off value corresponding to treatment success, as defined by the combined Global Perceived Effect categories\" completely recover and much better\".\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFrequency of and reasons for reoperations\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePredictors for patient-reported outcome measure (PROM) by Oswestry Disability Index.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003ePatients\u003c/p\u003e\u003cp\u003eWe retrospectively identified adult patients who underwent spinal deformity surgery from 2011 to 2019 by searching electronic patient records (EPRs) at Oslo and Haukeland University Hospitals. The search criteria were: 1) At least 20 years of age, 2) At least 20 degrees of deformity (scoliosis or kyphosis). We excluded patients with idiopathic scoliosis that progressed in adulthood, neuromuscular causes of deformity, acute fractures, active infections, or malignancies.\u003c/p\u003e\u003cp\u003eBaseline data, including gender, BMI, smoking status, ASA, comorbidities, prior surgery, type of index surgery, and preoperative radiographs, were extracted from EPRs with a follow-up (FU) time of at least 60 months after index surgery (median; 81, Q1; 66, Q3; 107).\u003c/p\u003e\u003cp\u003eWe used the Schwab classification to categorise and describe the deformity based on preoperative standing radiographs of the total spine [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Patients who provided written consent received postoperative patient-reported outcome measures (PROM) questionnaires by mail. Patients who did not respond received up to three reminders by mail or phone. Since recording preoperative PROMs was not part of clinical practice, and for ethical reasons, we could not analyse the nonrespondents.\u003c/p\u003e\u003cp\u003ePROMs\u003c/p\u003e\u003cp\u003eObtaining preoperative ODI was not established as clinical practice, nor was it systematically recorded in EPRs. We, therefore, obtained cross-sectional postoperative PROMs by mail. After index deformity surgery, the median response time was 51 months (Q1: 30, Q3: 74). Patients reported the following PROMs: Oswestry Disability Index (ODI), ten items, each scored 0\u0026ndash;5 and presented as a percentage score (0-100%, no disability-severe disability) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Numeric pain rating scales (NRS, 0\u0026ndash;10, no pain to worst imaginable) for back and leg pain and satisfaction with treatment. Treatment satisfaction was assessed by Global Perceived Effect, a 7-category Likert scale with the following response options: 1 \u0026ndash; completely recovered, 2 \u0026ndash; much better, 3 \u0026ndash; slightly improved, 4 \u0026ndash; unchanged, 5 \u0026ndash; slightly worse, 6 \u0026ndash; much worse, 7 \u0026ndash; worse than ever. The categories \"completely recovered\" and \"much better\" defined treatment success.\u003c/p\u003e\u003cp\u003eStatistical analyses\u003c/p\u003e\u003cp\u003eContinuous data are presented as means (SD or 95% CI) or medians (IQR), and categorical data as frequencies (%). The reported differences are between the baseline and the FU. The association between two categorical variables was analysed using the Pearson chi-squared test. Poisson regression methods were employed for three or more variables. Differences between the means of two unpaired groups were analysed using the Student's t-test for two independent samples. A one-sample t-test was used to investigate the average change from baseline to the last FU.\u003c/p\u003e\u003cp\u003eThe receiver operating characteristics curve (ROC) was used to establish the most accurate postoperative ODI cut-off corresponding to treatment success, as anchored by GPE categories \"completely recovered\" and \"much better\". The hypothetical perfect classifier is located at the upper left corner of the ROC, representing 100% sensitivity and 100% specificity. We used the ROC point closest to the perfect classifier to define the PASS ODI value with the highest combination of sensitivity and specificity. Finally, we calculated the area under the ROC curve [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. AUC values are interpreted by the following categories: \u0026lt;0.7\u0026thinsp;=\u0026thinsp;poor, 0.7\u0026ndash;0.8\u0026thinsp;=\u0026thinsp;fair, 0.8\u0026ndash;0.9\u0026thinsp;=\u0026thinsp;good, and \u0026gt;\u0026thinsp;0.9\u0026thinsp;=\u0026thinsp;excellent accuracy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLinear regression was applied to assess variables associated with the ODI, the primary outcome variable. ODI was checked for normal distribution. Seven possible covariates were selected based on previous literature, clinical experience, and results from the univariate analysis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.2) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Variables with a p-value of less than 0.2 were analysed further with multivariate analysis. Multivariate analyses were done with and without imputation to handle missing ODI data. The R-square (0\u0026ndash;1) was also reported for the goodness of fit. An R-squared value close to 1 indicates a perfect fit, implying that the predictor is highly relevant. The significance level was set to 0.05.\u003c/p\u003e\u003cp\u003eWe conducted the analyses using SPSS (version 29; IBM Corp., Armonk, NY, USA). The reported results adhere to the STROBE guidelines (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.strobe-statement.org\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.strobe-statement.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Patients signed an informed consent. The National Ethical Board (Regional Ethical Committee north) approved this study (REK 2017/1378). Additional permission is required for third-party use of data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient baseline characteristics\u003c/p\u003e\u003cp\u003eWe identified 82 patients, and their baseline characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The typical patient in our cohort was a female in her 60s with some comorbidities (ASA 2), who had received at least one spinal surgery previously. Preoperative radiographs were available in 80 out of 82 (98%) patients and showed degenerative deformities in 56 (68%) of the patients, while 26 (32%) had deformities resulting from previous spinal fractures. Most patients had significant spinal deformities, as shown by the Schwab classification parameters listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Preoperative radiographs varied; therefore, sagittal vertical axis (SVA) and pelvic parameters (pelvic incidence and pelvic tilt) were available for 65 of 80 (81%) and 71 of 80 (89%), respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline data with radiological characteristics for 82 surgically treated adult spinal deformity patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean or Number\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSD\u003csub\u003e1\u003c/sub\u003e or Percentage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003csub\u003e3\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026gt;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoronary vascular disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior spine surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eType of spinal deformity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDegenerative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-fracture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSchwab classification\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo coronal curves\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLumbar coronal curve\u0026thinsp;\u0026gt;\u0026thinsp;30\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDouble curve thoracolumbar\u0026thinsp;\u0026gt;\u0026thinsp;30\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e+\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e++\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePI-LL\u003c/b\u003e\u003csub\u003e\u003cb\u003e4\u003c/b\u003e\u003c/sub\u003e \u003cb\u003eMismatch\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e10\u0026ndash;20\u003c/b\u003e\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;20\u003c/b\u003e\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e(16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e(14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50\u003c/p\u003e\u003cp\u003e(70%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSagittal Vertical Axis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;4cm\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4-9.5cm\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;9.5cm\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003cp\u003e(22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003cp\u003e(32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30\u003c/p\u003e\u003cp\u003e(46%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePelvic Tilt\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;20\u0026deg;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e20\u0026ndash;30\u0026deg;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;30\u0026deg;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003cp\u003e(18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003cp\u003e(34%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e34\u003c/p\u003e\u003cp\u003e(48%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: \u003csub\u003e1\u003c/sub\u003eSD = Standard deviation \u003csub\u003e2\u003c/sub\u003eASA = American Society of Anesthesiologists classification \u003csub\u003e3\u003c/sub\u003eBMI = Body mass index \u003csub\u003e4\u003c/sub\u003ePI-LL\u0026thinsp;=\u0026thinsp;Pelvic incidence-lumbar lordosis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSurgical details\u003c/p\u003e\u003cp\u003eSurgeons addressed spinal deformities using various types of osteotomies, and a detailed account of the index surgeries is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline surgical data at the time of adult deformity surgery\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePedicle subtraction osteotomy (PSO)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (47)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDegenerative (PSO level)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eL1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eL2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eL3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eL4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost fracture (PSO level)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (51)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTh12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eL1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTh6, Th11, L2, L3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePonte Osteotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (29)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePosterolateral fusion (PLF)\u003csub\u003e1\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorpectomy/vertebral column resection (VCR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical variables\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFused levels, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 rods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79 (96)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 rods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4 rods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAugmented screws\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurological monitoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (18.)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBone morphogenetic protein (BMP)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss (ml), mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1627.9 (877.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of surgery (hours), mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay (days), mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003csub\u003e1\u003c/sub\u003ePosterolateral fusion\u0026thinsp;=\u0026thinsp;screw fixation, partial facet joint removal to increase flexibility and correction of deformity with dual rods. Mostly in cases of degenerative lumbar scoliosis.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePROMs and PASS\u003c/p\u003e\u003cp\u003eFifty-nine of 82 (72%) responded to postoperative PROM surveys. The mean ODI was 39 (SD\u0026thinsp;=\u0026thinsp;21), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutcome among 82 patients operated for adult spinal deformity (2011\u0026ndash;2019)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOswestry disability index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.0 (21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eNumeric rating scale back pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.2 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eNumeric rating scale leg pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.9 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe most accurate ODI cut-off value corresponding to treatment success (GPE\u0026thinsp;=\u0026thinsp;1: completely recovered or 2: much better) was below 32 ODI points (AUC\u0026thinsp;=\u0026thinsp;0.838, 95% CI\u0026thinsp;=\u0026thinsp;0.727\u0026ndash;0.950) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and was achieved by 24 of 59 (41%) patients. Mean pain scores were: NRS back pain 4.2 (SD\u0026thinsp;=\u0026thinsp;2.5) and leg pain 2.9 (SD\u0026thinsp;=\u0026thinsp;2.8). We did not find any difference in the proportions of postoperative complications among responders and nonresponders: 9 of 23 (39%) vs. 45 of 82 (55%); p\u0026thinsp;=\u0026thinsp;0.074. A difference in the proportions of postoperative mortality among responders and nonresponders was detected: 2 of 82 (2.4%) vs. 5 of 82 (6.1%); p\u0026thinsp;=\u0026thinsp;0.002.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eReoperations\u003c/p\u003e\u003cp\u003eAt least one revision surgery was required in 45 of 82 (55%) patients during the first five years after the index surgery, and a total of 73 reoperations were performed in these 45 patients. Revision surgeries are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRevision surgeries among 82 adult deformity surgery patients, 0\u0026ndash;5 years\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 reoperation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 reoperations\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u0026ndash;5 reoperations\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eIn total, at least one reoperation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e45 (55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime (months), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndication first revision\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1 Year\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e3 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e4 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e5 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eTotal (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistal junctional kyphosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e16 (20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProximal junctional kyphosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 (7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProximal- and distal junctional kyphosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2 (3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 (7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurological complication\u003csub\u003e1\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 (7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMisplaced screw, pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHardware failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePseudarthrosis of osteotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWrong level surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e45 (55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e1 Nerve root palsy in four patients, one medulla compression case, and one cauda equine syndrome.\u003c/p\u003e\u003cp\u003eThe most common reasons for revision surgeries were mechanical failure 28 of 82 (34%), infection 6 of 82 (7%), and neurological complications 6 of 82 (7%). Additionally, 14 of 82 patients (17%) experienced a complication that was not revised; the majority were proximal and distal junctional failures (PJK and DJK in 9 and 2 cases, respectively). Lower limb palsy occurred in 6 of 82 (7%), and 2 of the 6 (33%) patients suffered persistent paralysis of the lower limbs with bladder and bowel dysfunction (total risk paralysis: 2 of 82 (2%)).\u003c/p\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003cp\u003eLastly, we examined potential predictors of ODI (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePredictors of Oswestry Disability Index reported by 59 of 82 adult patients who underwent spinal deformity surgery. Multivariate linear regression with raw data before imputation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eODI post-surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eR-Suare\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.05-2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender, female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u0026ndash;23.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0-27.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultivariate R-Square\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.202\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFemale gender (B\u0026thinsp;=\u0026thinsp;12.6, 95% CI\u0026thinsp;=\u0026thinsp;2.1\u0026ndash;23.0, p\u0026thinsp;=\u0026thinsp;0.019) and smoking predicted worse ODI scores (B\u0026thinsp;=\u0026thinsp;14.4, 95% CI\u0026thinsp;=\u0026thinsp;1.0-27.9, p\u0026thinsp;=\u0026thinsp;0.036). BMI was a confounder for the effect of gender and smoking on ODI and was relevant for the negative predictive impact of smoking on ODI after imputation (appendix 1.0).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSummary of findings\u003c/p\u003e\u003cp\u003eIn this retrospective and cross-sectional observational study of surgically treated adult spinal deformity patients, the postoperative PASS value that most accurately corresponded with \"completely recovered\" or \"much better\" after surgery was below 32 ODI points, and two of five reached PASS. More than half needed revision surgery within five years after index surgery, primarily due to mechanical failure (34%), infection (7%), and neurological complications (7%). Female gender and smoking predicted a worse postoperative ODI at follow-up.\u003c/p\u003e\u003cp\u003eIn line with previously published PASS values, we expected PASS after complex surgical treatment of adult spinal deformity to differ from PASS following degenerative spinal surgery in general [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The PASS, defined by an absolute postoperative ODI value threshold, may vary based on the specific spinal diagnosis, number of previous spinal surgeries, and patient expectations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our cohort, we found that a PASS value of less than 32 ODI points most accurately corresponded to \"completely recovered\" and \"much better\" (Fig.\u0026nbsp;2), and 24 of 59 (41%) participants achieved this value. Our study's ODI threshold and proportion that reached PASS align with previously published results [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, the study above used a core outcome measure index (COMI) subscore as the anchor for treatment success [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], whereas we used GPE.\u003c/p\u003e\u003cp\u003eDespite high rates of subsequent surgery in ASD cases, a relevant proportion of patients may still be satisfied with treatment. In a retrospective cohort study by Kyr\u0026ouml;l\u0026auml; et al., the mean preoperative ODI score of 51 improved to 34 (33% reduction) after surgery; however, 49 of 79 (62%) patients were satisfied with the treatment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, 46.3% of patients with lumbar spinal stenosis who have undergone three or more surgeries reported success after surgery, with an ODI final score of 32.7 or less (ODI change of -25% or more) in less complex procedures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The discrepancy between our PASS value of 32 ODI points and 23 by van Hooff et al. indicates that the ADS population tolerates more residual symptoms than degenerative spine patients in general [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe most frequent reason for revision surgery in our cohort was mechanical failure \u0026ndash; a finding in line with previous publications [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A Finnish retrospective ADS cohort study reported a 5-year frequency of first reoperations due to mechanical failure of 30% (24 of 79) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A Danish study described a 42% 2-year mechanical failure revision frequency (97 of 233) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Junctional failures occur frequently after ADS [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A systematic review of ADS estimated the incidence of PJK to be 20\u0026ndash;40% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], while another systematic review estimated that DJKs occur in 4\u0026ndash;23% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study, the 5-year frequency of mechanical failures requiring revision surgery was 28 of 82 (34%).\u003c/p\u003e\u003cp\u003eWe studied an older population with significant sagittal imbalance (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), which is similar to the populations described in two Scandinavian studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We could anticipate a high occurrence of mechanical complications in older populations with reduced bone density.\u003c/p\u003e\u003cp\u003eAlthough less frequent than mechanical failure, the most severe ADS complications are neurological deficits and infections. Several factors can influence the frequency of surgical site infections (SSI). The frequency of postoperative infection in similar spine studies was just above 5% [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Kyr\u0026ouml;l\u0026auml; et al. reported SSI in 7 of 79 patients (8.9%) in a retrospective study of ADS patients with a 1 to 9-year follow-up [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It appears that obese patients have an increased risk of infection [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Factors associated with infection in deformity surgery may also include patient comorbidities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Also, the amount of blood lost and staged procedures have been associated with an increased risk of postoperative SSI [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Vancomycin, administered locally during surgery, may decrease the risk of SSI. Still, a systematic review suggests inconclusive results regarding the effect of Vancomycin powder in reducing SSI in major orthopedic surgeries [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, in our cohort, we did not routinely use intra-wound vancomycin. Still, all patients received standard antibiotic prophylaxis with Cefazoline IV 2 grams x 4 (Clindamycin 600 mg x 3 was used for patients allergic to penicillin). The infection rate in our cohort at 7% (6 of 82) was somewhat higher compared to previously published data [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To further reduce the risk of infections, it may be relevant to consider prolonged perioperative antibiotic treatment (greater than 48 hours) and intra-wound application of vancomycin [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Selecting patients with fewer comorbidities, non-smokers, and a lower BMI, along with implementing measures to reduce surgical time and bleeding, may also decrease the risk of SSI.\u003c/p\u003e\u003cp\u003ePrevious studies reported neurological complication rates following ADS of 11\u0026ndash;19% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In two different retrospective ADS cohorts, neurological deficit occurred in 15 of 79 (19%) and 17 of 103 (17%) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Two studies, one retrospective multicenter and one prospective, investigated patients who underwent pedicle subtraction osteotomy. The studies above reported neurological complications in 72 of 423 (16.7%) and 12 of 108 (11%) patients, respectively [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In our study, EPRs documented neurological deficits in 6 of 82 (7%) patients. However, less severe neurological deficits might have been underreported in EPRs. Pedicle subtraction osteotomies, 39 of 82 (48%), resulted in the most severe neurological complications- two patients suffered total paralysis.\u003c/p\u003e\u003cp\u003eFinally, we aimed to identify predictors of outcome after surgery, as assessed by the ODI, and to compare our findings with previous publications on ADS patients [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. We found that female gender and smoking were associated with higher levels of back-related disability, as assessed by the final ODI. Smoking has previously been described as a risk factor for the development of postoperative medical complications in a retrospective study of 448 patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Smoking affects the tissue microenvironment and the functions of inflammatory and reparative cells, leading to delayed wound healing. Additionally, two systematic reviews found that smoking was associated with pseudarthrosis, disc degeneration, lower return to work rates, and worse outcomes after surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Female gender is known to be correlated with osteoporosis, a condition associated with increased risk of nonunion and reoperation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLimitations and Strengths\u003c/p\u003e\u003cp\u003eThe main limitations of this cohort study are the lack of preoperative PROMs and the variation in follow-up times, as PROMs were collected cross-sectionally (i.e., at different time points after surgery). Additionally, there is a possibility that responders could differ systematically from nonresponders. However, there were no differences in reoperations or mortality between nonresponders and responders. To address the absence of preoperative PROMs, we calculated an absolute postoperative patient acceptable symptom state (PASS) value for our cohort; however, the ODI percentage change may be more accurate [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Furthermore, using patients as their own reference, i.e., ODI and GPE recorded by the same individual, may be a methodological limitation. Then again, previous studies have used patients as their own references [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]; however, these studies used a non-validated subscore of COMI as the reference for patient-reported satisfaction. Complications and reoperations may be underreported in retrospective designs; however, complications are more reliably documented in electronic patient records (EPRs) than in spine registries [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Furthermore, in Norway, patients are typically referred back to the centre where the initial surgery was performed. We also acknowledge the diversity of indications for surgery (degenerative and posttraumatic deformity), reasons for revision, and surgical techniques. The data in this study reflect the initial implementation phase of the ADS in Norway, suggesting the potential influence of a learning curve on the outcomes observed.\u003c/p\u003e\u003cp\u003eDue to the limited sample size, we had to limit the number of variables chosen for the predictor analysis; however, other variables may still be relevant to consider. To address the methodological limitations of the present study, we have initiated the INTRAKS study, an international prospective study of patients with ASD treated surgically and conservatively (ClinicalTrials identifier: NCT04536909).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this dual-centre retrospective observational study of 82 adult spinal deformity patients, the postoperative patient acceptable symptom state (PASS) was less than 32 ODI points. Using this PASS criterion, two of five were satisfied at a median FU time of 51 months. More than half needed at least one revision surgery during the first five years after index surgery, primarily due to mechanical failure, infection, and neurological complications. Female gender and smoking predicted poorer postoperative outcomes (ODI).\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAdult spinal deformity surgery (ADS), Patient-acceptable symptom state (PASS), Oswestry Disability Index (ODI), Global Perceived Effect (GPE), electronic patient records (EPRs), adult spinal deformity (ASD), patient-reported outcomes (PROMs), American Society of Anaesthesiologists (ASA), Numeric pain rating scales (NRS), receiver operating characteristics curve (ROC), area under the ROC curve (AUC), standard deviation (SD), body mass index (BMI), pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), pedicle subtraction osteotomy (PSO), posterolateral fusion (PLF), vertebral column resection (VCR), bone morphogenetic protein (BMP), core outcome measure index (COMI), surgical site infection (SSI), follow up (FU).\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eConflict of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eEthical approval\u003c/h3\u003e\n\u003cp\u003eAll procedures performed in this study were conducted following the ethical standards of the national ethical board (Regional Ethical Committee North) and the 1964 Helsinki Declaration and its subsequent amendments. The National Ethical Board (Regional Ethical Committee north) approved this study (REK 2017/1378). Additional permission is required for third-party use of data.\u003c/p\u003e\n\u003ch3\u003eConsent to participate\u003c/h3\u003e\n\u003cp\u003ePatients signed an informed consent.\u003c/p\u003e\n\u003ch3\u003eConsent to publish\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria, educational grants, participation in speakers bureaus; membership, employment, consultancies, stock ownership, or other equity interests, and expert testimony or patent-licensing arrangements), or non-financial interests (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAuthors` contributions\u003c/h3\u003e\n\u003cp\u003eHansen V (Corresponding author): wrote the manuscript, created figures and tables, investigation and formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKibsg\u0026aring;rd T: reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eHellum C: reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eR\u0026ouml;hrl S: Main supervisor, reviewed the manuscript, investigation, methodology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLien M: Formal analysis, reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eDolatowski F: reviewed the manuscript, edited figures and tables, formal analysis, methodology.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFounding\u003c/h3\u003e\n\u003cp\u003eThe corresponding author receives founding from Helse Vest, University of Bergen, Norway. The remaining authors received no founding for the research in this paper.\u003c/p\u003e\n\u003cp\u003eThe corresponding author receives founding from Helse Vest, University of Bergen, Norway.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe data in this paper is stored in \u0026ldquo;Service for secure data\u0026rdquo;/TSD at Oslo University and contains sensitive patient data.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBess S, Line B, Fu KM, McCarthy I, Lafage V, Schwab F et al (2016) The Health Impact of Symptomatic Adult Spinal Deformity: Comparison of Deformity Types to United States Population Norms and Chronic Diseases. Spine (Phila Pa 1976) 41(3):224\u0026ndash;233\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLa Maida GA, Luceri F, Gallozzi F, Ferraro M, Bernardo M (2015) Complication rate in adult deformity surgical treatment: safety of the posterior osteotomies. Eur Spine J 24(Suppl 7):879\u0026ndash;886\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNielsen CJ, Lewis SJ, Oitment C, Martin AR, Lenke LG, Qiu Y et al (2021) Stratifying outcome based on the Oswestry Disability Index for operative treatment of adult spinal deformity on patients 60 years of age or older: a multicenter, multi-continental study on Prospective Evaluation of Elderly Deformity Surgery (PEEDS). Spine J 21(11):1775\u0026ndash;1783\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRiksaasen AS, Kaur S, Solberg TK, Austevoll I, Brox JI, Dolatowski FC et al (2023) Impact of the number of previous lumbar operations on patient-reported outcomes after surgery for lumbar spinal stenosis or lumbar disc herniation. Bone Joint J 105\u0026ndash;B(4):422\u0026ndash;430\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrundnes IB, Alhaug OK, Reis J, Jakobsen RB (2024) Expectations in patients undergoing spine surgery are high and unmet. Spine J\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlhaug OK, Dolatowski FC (2024) Redefining Oswestry Disability Index success criteria to assess the effect of consecutive surgeries on lumbar spinal stenosis. Spine J\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMannion AF, Loibl M, Bago J, Vila-Casademunt A, Richner-Wunderlin S, Fekete TF et al (2020) What level of symptoms are patients with adult spinal deformity prepared to live with? A cross-sectional analysis of the 12-month follow-up data from 1043 patients. Eur Spine J 29(6):1340\u0026ndash;1352\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePitter FT, Lindberg-Larsen M, Pedersen AB, Dahl B, Gehrchen M, Readmissions (2019) Length of Stay, and Mortality After Primary Surgery for Adult Spinal Deformity: A 10-Year Danish Nationwide Cohort Study. Spine (Phila Pa 1976) 44(2):E107\u0026ndash;E16\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaraj SSA, Haanstra TM, Martijn H, de Kleuver M, van Royen BJ (2017) Functional outcome of non-surgical and surgical management for de novo degenerative lumbar scoliosis: a mean follow-up of 10 years. Scoliosis Spinal Disord 12:35\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoroceanu A, Burton DC, Oren JH, Smith JS, Hostin R, Shaffrey CI et al (2016) Medical Complications After Adult Spinal Deformity Surgery: Incidence, Risk Factors, and Clinical Impact. Spine (Phila Pa 1976) 41(22):1718\u0026ndash;1723\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupta A, Cha T, Schwab J, Fogel H, Tobert D, Razi AE et al (2021) Osteoporosis increases the likelihood of revision surgery following a long spinal fusion for adult spinal deformity. Spine J 21(1):134\u0026ndash;140\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJackson KL 2nd, Devine JG (2016) The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature. 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Physiotherapy 66(8):271\u0026ndash;273\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCosman F, Crittenden DB, Adachi JD, Binkley N, Czerwinski E, Ferrari S et al (2016) Romosozumab Treatment in Postmenopausal Women with Osteoporosis. N Engl J Med 375(16):1532\u0026ndash;1543\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlhaug OK, Dolatowski FC, Solberg TK, Lonne G (2021) Criteria for failure and worsening after surgery for lumbar spinal stenosis: a prospective national spine registry observational study. Spine J 21(9):1489\u0026ndash;1496\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Hooff ML, Mannion AF, Staub LP, Ostelo RW, Fairbank JC (2016) Determination of the Oswestry Disability Index score equivalent to a satisfactory symptom state in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry-based study. 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Clin Spine Surg 34(9):347\u0026ndash;354\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLau D, Clark AJ, Scheer JK, Daubs MD, Coe JD, Paonessa KJ et al (2014) Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976) 39(25):2093\u0026ndash;2102\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePull ter Gunne AF, van Laarhoven CJ, Cohen DB (2010) Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk. Eur Spine J 19(6):982\u0026ndash;988\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaddad S, Nunez-Pereira S, Pigrau C, Rodriguez-Pardo D, Vila-Casademunt A, Alanay A et al (2018) The impact of deep surgical site infection on surgical outcomes after posterior adult spinal deformity surgery: a matched control study. Eur Spine J 27(10):2518\u0026ndash;2528\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoroceanu A, Burton DC, Diebo BG, Smith JS, Hostin R, Shaffrey CI et al (2015) Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery. J Neurosurg Spine 23(5):656\u0026ndash;664\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeijs AP, Koek MBG, Vos MC, Geerlings SE, Vogely HC, de Greeff SC (2019) The effect of body mass index on the risk of surgical site infection. Infect Control Hosp Epidemiol 40(9):991\u0026ndash;996\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiebo BG, Shah NV, Boachie-Adjei O, Zhu F, Rothenfluh DA, Paulino CB et al (2019) Adult spinal deformity. Lancet 394(10193):160\u0026ndash;172\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTheologis AA, Demirkiran G, Callahan M, Pekmezci M, Ames C, Deviren V (2014) Local intrawound vancomycin powder decreases the risk of surgical site infections in complex adult deformity reconstruction: a cost analysis. Spine (Phila Pa 1976) 39(22):1875\u0026ndash;1880\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaka N, Yamada K, Ono K, Iwata E, Mihara T, Uchiyama K et al (2024) Effect of topical vancomycin powder on surgical site infection prevention in major orthopaedic surgery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. J Hosp Infect 150:105\u0026ndash;113\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHowe CR, Agel J, Lee MJ, Bransford RJ, Wagner TA, Bellabarba C et al (2011) The morbidity and mortality of fusions from the thoracic spine to the pelvis in the adult population. Spine (Phila Pa 1976) 36(17):1397\u0026ndash;1401\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBianco K, Norton R, Schwab F, Smith JS, Klineberg E, Obeid I et al (2014) Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36(5):E18\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuchowski JM, Bridwell KH, Lenke LG, Kuhns CA, Lehman RA Jr., Kim YJ et al (2007) Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment. Spine (Phila Pa 1976) 32(20):2245\u0026ndash;2252\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlhaug OK, Kaur S, Dolatowski F, Smastuen MC, Solberg TK, Lonne G (2022) Accuracy and agreement of national spine register data for 474 patients compared to corresponding electronic patient records. Eur Spine J 31(3):801\u0026ndash;811\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adult deformity surgery (ADS), adult spinal deformity (ASD), post-fracture deformity, patient acceptable symptom state (PASS), reoperation, predictors","lastPublishedDoi":"10.21203/rs.3.rs-7054892/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7054892/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAdult spinal deformity surgery (ADS) has been associated with moderate results and a high risk of complications. Patient-acceptable symptom state (PASS), complications, and predictors of outcome may not be sufficiently documented. Purpose: To reassess PASS by the Oswestry Disability Index (ODI), describe reoperations, and study predictors for outcomes after ADS for the target population.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis retrospective and cross-sectional observational survey assessed surgically corrected adult patients with degenerative and posttraumatic spinal deformities. Patients responded to PROM surveys at a median of 51 months (Q1: 30, Q3: 74). Treatment success was assessed using the Global Perceived Effect (GPE), and we employed ROC analysis to determine the corresponding PASS ODI cut-off. Reoperations were documented in electronic patient records (EPRs) with a minimum follow-up of 60 months (median; 80.5, Q1; 65.8, Q3; 107.3). Potential predictors for ODI were examined by linear regression.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe identified 82 adult patients with surgically treated deformities at two Norwegian hospitals. PASS was below 32 ODI points (AUC\u0026thinsp;=\u0026thinsp;0.838, 95% CI: 0.727\u0026ndash;0.950), and 24 of 59 (41%) patients achieved PASS. Regression analysis revealed that female gender (B\u0026thinsp;=\u0026thinsp;12.6, 95% CI\u0026thinsp;=\u0026thinsp;2.1\u0026ndash;23.0, p\u0026thinsp;=\u0026thinsp;0.019) and smoking (B\u0026thinsp;=\u0026thinsp;14.4, 95% CI\u0026thinsp;=\u0026thinsp;1.0-27.9, p\u0026thinsp;=\u0026thinsp;0.036) predicted worse postoperative ODI.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn this retrospective and cross-sectional observational study of adult spinal deformity patients, about 2 of 5 achieved a PASS ODI value below 32 ODI points. Over half of the patients required revision surgery within five years following the index surgery. Female gender and smoking predicted worse postoperative ODI.\u003c/p\u003e","manuscriptTitle":"Outcomes, patient acceptable symptom state, complications, and predictors after surgical correction of adult spinal deformity – a retrospective observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 10:23:57","doi":"10.21203/rs.3.rs-7054892/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"24ef5284-f0ee-4040-b37c-3eb01636dbf4","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T14:08:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 10:23:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7054892","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7054892","identity":"rs-7054892","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}