BACKGROUND: Previous research has identified a specific subtype known as failure of pelvic compensation (FPC) in patients with adult spinal deformity (ASD). However, the criteria for assessing FPC remain inconsistent, and its impacts on spinal sagittal alignment and health-related quality-of-life (HRQoL) scores remain unclear.
OBJECTIVE: To propose a novel criterion for identifying FPC based on variations in spinopelvic alignment during the transition from the supine to upright position and to evaluate the effects of FPC on patients\' spinal sagittal alignment and HRQoL scores.
METHODS: Retrospective cross-sectional study.
METHODS: Patients with ASD from a monocenter database.
METHODS: Radiographic measures, including thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt, pelvic incidence (PI), and sagittal vertical axis (SVA), were measured on lateral whole-spine radiographs. LL and SS were also measured on reconstructed lumbar computed tomography images in the sagittal view taken in the supine position. The relative functional cross-sectional area (rFCSA) of paraspinal muscles was evaluated via lumbar magnetic resonance imaging. HRQoL measures, encompassing visual analog scale for back pain (VAS-BP), Oswestry Disability Index (ODI), and Scoliosis Research Society-22R (SRS-22R), were collected.
METHODS: A total of 154 patients were enrolled. Based on the calculated minimum detectable change of SS, FPC was defined as the change in SS of less than 3.4° between supine and upright positions. Patients were divided into 3 groups: sagittal balance with pelvic compensation (SI-PC), sagittal imbalance with pelvic compensation (SI-PC), and sagittal imbalance with failure of pelvic compensation (SI-FPC). Radiographic parameters and HRQoL scores were compared among the groups.
RESULTS: Thirty-six patients were categorized into the SB-PC group, 87 into the SI-PC group, and 31 into the SI-FPC group. Patients with low PI and small paraspinal muscles rFCSA were more prone to experiencing FPC accompanied by severe sagittal imbalance. The SI-FPC group exhibited less TK and a larger SS than the SI-PC group exhibited and had a similar SVA as that of the SI-PC group. Additionally, they displayed worse VAS-BP, ODI, SRS-function, and SRS-22 total scores than the SB-PC group displayed.
CONCLUSIONS: In patients with ASD, an inherently low pelvic compensatory reserve and a high fatty infiltration in paraspinal muscles are pivotal factors contributing to FPC. Compared with SI-PC patients, SI-FPC patients demonstrate a thoracic-dominant compensatory pattern for sagittal malalignment. In addition, these patients experienced more severe pain and functional decline than the SB-PC patients experienced.

OBJECTIVE: To review the current literature surrounding the assessment of self-image in pediatric and adult spinal deformity.
METHODS: The literature were reviewed for studies examining patient-reported outcome measurements (PROM) and self-image in pediatric and adult spinal deformity. PROM performance metrics were collected and described. The relationships between self-image PROM and patient outcomes, including satisfaction, were described.
RESULTS: Several self-image PROM exist, including the Scoliosis Research Society-22r (SRS-22r) self-image domain, the Body Image Disturbance Questionnaire (BIDQ), and the Spinal Appearance Questionnaire (SAQ). The most commonly used is the self-image domain of the SRS-22r. It is validated in adult and pediatric spinal deformity and is correlated with patient desire for surgery and satisfaction after surgery. This domain is limited by floor and ceiling effects.
CONCLUSIONS: Self-image assessment is critical to both pediatric and adult spinal deformity surgeries. The SRS-22r self-image domain is the most frequently reported PROM for this health domain. While valid in both surgical cohorts, this PROM is affected by floor and ceiling effects which limits the ability to discriminate between health states. Given the overall importance of this domain to patients with spinal deformity further efforts are needed to improve discrimination without gross increases in PROM question burden, which may limit broad acceptance and use.

Reciprocal sagittal alignment changes after adolescent idiopathic scoliosis (AIS) posterior corrective surgery have been reported in the cervical spine, but the evidence is not yet sufficient. Furthermore, much remains unknown about the effects of cervical kyphosis on clinical outcomes in AIS. Forty-five consecutive patients (4 males and 41 females) with AIS and Lenke type 1 or 2 curves underwent a posterior spinal fusion, and a minimum of 24-month follow-up was collected from our prospective database. We investigated radiographic parameters and SRS-22r. Before surgery, cervical kyphosis (cervical lordosis < 0°) was present in 89% and cervical hyperkyphosis (cervical lordosis < -10°) in 60%. There were no significant differences in age, sex, or Lenke type between the hyperkyphosis and the non-hyperkyphosis groups. Although cervical lordosis increased significantly after surgery, cervical kyphosis was observed in 73% of patients 2 years after surgery. We found a significant correlation between Δthoracic kyphosis (TK) and Δcervical lordosis. Preoperative cervical kyphosis, ΔT1 slope, and ΔTK were independently associated factors for postoperative cervical hyperkyphosis. The cervical hyperkyphosis group had significantly lower SRS-22r domains. In AIS corrective surgery, restoring TK leading to a gain of T1 slope may lead to an improvement of cervical sagittal alignment. Remaining cervical hyperkyphosis after AIS surgery may affect clinical outcomes.

To determine if preoperative Health Related Quality of Life (HRQoL) has declined in the past two decades for patients with Adolescent Idiopathic Scoliosis (AIS), as measured by the Scoliosis Research Society (SRS) questionnaire.
A retrospective review was conducted on AIS patients that underwent surgery at a single institution between 2002 and 2022. Patients were included if they completed an SRS questionnaire preoperatively. A multivariate linear regression was performed with the SRS domains as the dependent variables. The independent variables were surgery year, gender, race/ethnicity, BMI, Lenke type, and major Cobb angle. A second regression was performed where the SRS scores for AIS patients were dichotomized as being above or below normal based on a threshold set at two standard deviations below the mean SRS scores of a healthy adolescent population. The binary SRS scores were used as the outcome of interest in a second regression.
A total of 1380 patients (79.2% female, mean age 14.9 ± 2.0 years old) were included for analysis. Surgery year had a negative association with Pain (coefficient = - 0.03, p < 0.0001), Activity (coefficient = - 0.02, p < 0.0001), Mental Health (coefficient = - 0.01, p < 0.0001), and Total score (coefficient = - 0.01, p < 0.0001), indicating declining HRQoL over time. Similarly, AIS patients became more likely to fall below 2SD of the healthy adolescent means in Pain (OR: 1.061, p < 0.0001), Appearance (OR: 1.023, p = 0.0301), Activity (OR: 1.044, p = 0.0197), and Total score (OR: 1.06, p < 0.0001).
Over the past two decades, patients with surgical AIS have experienced a significant decline in various HRQoL domains preoperatively.

The Scoliosis Research Society 22r Questionnaire(SRS-22r) is the standard for assessing health-related quality of life(HRQoL) in patients with adolescent idiopathic scoliosis. Here we investigate whether patients\' perceptions of their HRQoL are influenced by knowledge of scoliosis and counseling by an orthopedic surgeon.
Patients ages 10-18 years referred for their first visit with an orthopaedic surgeon for scoliosis were enrolled from 9/30/19 to 10/22/20. Patients completed the SRS-22r pre- and post-visit. A Wilcoxon signed-rank test was used to analyze the SRS-22r scores.
52 patients participated in the study at a mean age of 14.3 years (95% CI 13.8-14.8 years) with an average major curve magnitude of 23.2 degrees (95% CI 19.4-27.0 degrees). SRS-22r scores were not correlated to curve magnitude pre- or post-visit. The SRS-22r Satisfaction with care domain exhibited a small increase from pre- to post-visit (pre: 3.3, post: 3.6). All other SRS-22r domains and total scores did not exhibit clinically significant differences.
Among new adolescent referrals for scoliosis, it is unlikely that counseling by a surgeon influences perceptions of HRQoL as measured by the SRS-22r.
III.

OBJECTIVE: Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL.
METHODS: We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves.
RESULTS: The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains.
CONCLUSIONS: In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis.Cite this article: Bone Joint J 2023;105-B(2):166-171.

BACKGROUND: Adult spinal deformity is a spectrum of degenerative spinal diseases with increasing prevalence and healthcare burden worldwide. Identification of patients who are more likely to improve through conservative management may reduce cost and potentially prevent surgery and its associated costs and complications. This study aims to identify predictive factors for MCID in improvement of ODI and SRS-22r questionnaires in patients with adult spinal deformity treated with conservative treatment.
METHODS: A prospective, observational cohort study of 46 patients was conducted at a spine specialist clinic. Inclusion criteria were 30-80 years of age, diagnosis of neglected adolescent idiopathic scoliosis, de-novo scoliosis, degenerative spondylolisthesis, and sagittal plane deformities (thoracic hypokyphosis, lumbar hypolordosis), presenting with mechanical back pain with or without radicular leg pain. All patients received conservative management including medication and physiotherapy. Radiological and clinical parameters were measured at baseline and at 1-year follow-up. Primary outcomes were ODI and SRS-22r scores. Secondary outcomes were EQ-5D-5L scores and requiring spine surgery during conservative treatment. Predictors for MCID improvement in ODI and SRS-22r were identified using multivariate regressions and receiver operating characteristic (ROC) analyses.
RESULTS: At baseline, patients who reached MCID in ODI and/or SRS-22r showed less comorbidities (diabetes mellitus, hypertension, ischemic heart disease, osteoarthritis, cancer), smaller range of lateral spinal flexion, larger trunk shift, larger pelvic incidence, a higher EQ-5D-5L anxiety/depression dimension score, a lower SRS-22r total score, and presence of spondylolisthesis. Lateral flexion range < 25 degrees, trunk shift > 14 mm, pelvic incidence > 50 degrees, EQ-5D-5L anxiety/depression dimension score > 1, and SRS-22r total score < 3.5 were the cut-off values generated by ROC analysis.
CONCLUSIONS: Both radiological and clinical predictive factors for MCID improvement in health-related quality of life were identified. Future research should identify subgroups of patients who are responsive to specific conservative treatment modalities, so as to provide information for personalized medicine.
METHODS: II.

OBJECTIVE: In recent years, it has become possible to predict postoperative correction and residual deformity in adolescent idiopathic scoliosis (AIS) surgery based on the technique used and extent of fixation. However, the recommended degree of correction has not yet been established. In this study, the authors aimed to clarify the extent to which a residual postoperative deformity would be acceptable according to Scoliosis Research Society (SRS)-22r and satisfaction scores after AIS surgery.
METHODS: Overall, 92 patients who underwent posterior spinal fusion for Lenke type 1 or 2 AIS were retrospectively included. The Patient Acceptable Symptom State (PASS) cutoff values for each SRS-22r domain were calculated using receiver operating characteristic (ROC) curves to obtain predictive values of treatment satisfaction 2 years after surgery. Multivariate logistic regression analysis was performed with deformity parameters and demographic data as explanatory variables, and achieving the PASS cutoff value of each SRS-22r domain and treatment satisfaction were objective variables. Cutoff values were calculated using ROC analysis.
RESULTS: The PASS cutoff values for SRS-22r domains were 3.69 (area under the ROC curve [AUC] 0.86) for self-image, 4.25 (AUC 0.82) for mental health, and 4.22 (AUC 0.82) for the subtotal. The residual main thoracic Cobb angle was not remarkably related to SRS-22r or treatment satisfaction. The residual thoracolumbar/lumbar (TL/L) Cobb angle was significantly associated with treatment satisfaction, with a cutoff value of 12.5° (AUC 0.75). The parameters of deformity that were significantly associated with achieving the PASS cutoff value for self-image were the TL/L Cobb angle and main thoracic apical vertebral translation, although their respective AUCs were < 0.7.
CONCLUSIONS: In patients with Lenke type 1 and 2 AIS, the residual postoperative TL/L Cobb angle was significantly associated with achieving the PASS cutoff values for self-image and treatment satisfaction. Satisfaction with treatment was more likely when the TL/L Cobb angle was ≤ 12.5°.

OBJECTIVE: To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires.
METHODS: A total of 1,000 participants with equal sex distribution were included and categorized in five age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years. Individuals with spinal pathologies were excluded. Participants completed the Scoliosis Research Society-22 (SRS-22r), visual analogue scale (VAS) for back/leg pain, and the EuroQol five-dimension index (EQ-5D/VAS) questionnaires, and disclosed their age, sex, and occupation. They were also categorized in five professional groups: doctors, nurses, allied health professionals, office workers, and manual workers.
RESULTS: The mean age of all participants was 43.8 years (20 to 69). There was no difference in the SRS-22r, EQ-5D, or VAS scores among male and female participants (p > 0.05). There was incremental decrease in SRS-22r total scores as the age increased. The mean EQ-5D index score (0.84) ranged little across the age groups (0.72 to 0.91) but reduced gradually with increasing age. There was difference between the SRS-22r total score (4.51), the individual domain scores, and the EQ-5D score (index: 0.94 and VAS: 89) for the doctors\' group compared to all other occupational categories (p < 0.001). Doctors had a younger mean age of participants, which may explain their improved spinal health. There was no difference in the total or sub-domain SRS-22r and EQ-5D scores between the other four occupational groups.
CONCLUSIONS: This study provides the first normative data for the SRS-22r, EQ-5D, and VAS for back/leg pain questionnaires among adults in the UK. We recorded an excellent correlation between the three assessment tools with individuals who reported less back and leg pain having better quality of life and greater function. The participants\' age, rather than their sex or profession, appears to be the major determinant for spinal health and quality of life. Cite this article: Bone Jt Open 2022;3(2):130-134.

OBJECTIVE: To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.
METHODS: AIS patients were systematically enrolled in an institutional registry. In all, 144 AIS patients aged ≤ 25 years undergoing primary surgery (median age 15 years (interquartile range 14 to 17) were included. Patient-reported (condition-specific and health-related quality of life (QoL); functional status; back and leg pain intensity) and clinician-reported outcomes (complications, revision surgery) were recorded. Changes in patient-reported outcome measures (PROMs) were analyzed using Friedman\'s analysis of variance. Clinical relevancy was determined using minimally important changes (Scoliosis Research Society (SRS)-22r), cut-off values for relevant effect on functioning (pain scores) and a patient-acceptable symptom state (PASS; Oswestry Disability Index).
RESULTS: At baseline, 65 out of 144 patients (45%) reported numerical rating scale (NRS) back pain scores > 5. All PROMs significantly improved at two-year follow-up. Mean improvements in SRS-22r function (+ 1.2 (SD 0.6)), pain (+ 0.6 (SD 0.8)), and self-image (+ 1.1 (SD 0.7)) domain scores, and the SRS-22r total score (+ 0.5 (SD 0.5)), were clinically relevant. At two-year follow-up, 14 out of 144 patients (10%) reported NRS back pain > 5. Surgical site infections did not occur. Only one patient (0.7%) underwent revision surgery.
CONCLUSIONS: Relevant improvement in functioning, condition-specific and health-related QoL, self-image, and a relevant decrease in pain is shown at two-year follow-up after fusion surgery for AIS, with few adverse events. Contrary to the general perception that AIS is a largely asymptomatic condition, nearly half of patients report significant preoperative back pain, which reduced to 10% at two-year follow-up. Cite this article: Bone Joint J 2022;104-B(2):265-273.