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Introduction Adult spinal deformity (ASD) is a major public health problem. There are pros and cons of the available treatment alternatives (surgical or non-surgical) and it had been difficult to identify the best treatment modality. Aim of this study is to construct a statistical decision analysis (DA) model to identify the optimum overall treatment in ASD.Material and Methods From an international multicentre database of ASD patients (968 pts), 535 who had completed 1 year follow-up (371 non-surgical –NS), 164 surgical –S), constitute the population of this study. DA was structured in two main steps of: 1) Baseline analysis (Assessing the probabilities of outcomes, Assessing the values of preference –utilities-, Combining information on probability and utility and assigning the quality adjusted life expectancy (QALE) for each treatment) and 2) Sensitivity analysis.Results 432 patients (309 NS, 123 S) had baseline and 1 year follow-up ODI measurements. Overall, 104 (24.1%) were found to be improved (a decrease in ODI > 8 points), 225 (52.1%) unchanged (−8 > ODI > 8) and 65 deteriorated. Surgery presented with a higher chance of improvement (54.2%) versus NS (9.7%) (Table 1a). The overall QALE ranged from 56 to 69 (of 100 years) and demonstrated better final outcomes in the NS group, although this group had also started with higher QALE. There were improvements in overall QALE in both groups but this was significant only in the surgical group (Table 1b). In addition, in the subgroup of patients with significant baseline disability (ODI > 25) surgery appeared to yield marginally better final QALE (Table 1c).Conclusion This study demonstrated that a single best treatment modality for ASD may not exist. Conservative treatment appears to yield higher (up to 6%) QALE compared with surgery, probably secondary to a higher baseline QALE; except in patients with significant disability at baseline. On the other hand, surgery provides a significantly higher increase in QALE and chances of improvement at 1st year are significantly lower with NS treatment.

Introduction Surgical goals and alignment objectives mostly depend on sagittal plane parameters. SVA, C7 tilt and T1 tilt account for spinal balance and PI, PT, SS, PI-LL account for pelvic compensatory mechanism, which are all affected by patient positioning. GT is the angle between the line drawn from the center of C7 to the center of the sacral endplate and a line drawn from the center of the sacral endplate to the center of the femoral head. GT is a single parameter that takes both balance and pelvic compensation into account as a single parameter. GT has been shown to be less affected by patient positioning compared with SVA and PT. Aim was to analyze the correlation of GT with HRQoL parameters and compare with other sagittal plane parameters.Material and Methods A retrospective analysis of a multicenter, prospective, consecutive patient series. 337 patients (285F,52M) with adult spinal deformity were included, (mean age: 58.2± 15.7). Pelvic parameters (PT, PI, SS), sagittal balance parameters (SVA, T1 tilt), GT and lordosis gap(LGap) were measured by using Surgimap. HRQoL instruments included: Oswestry Disability Index(ODI), Short Form-36, SRS-22. Correlation analysis between radiographic pelvic and sagittal balance parameters, GT and LGap was pursued. Kruskal-Wallis test was used to compare GT, SVA and PT for ODI < 20, 20–40 and > 40 disability groups.Results Global tilt significantly correlated with ODI, SRS-22 pain, function, self image, and subtotal scores and SF-36 PCS (p< 0.01) similar to SVA, PT and LGap. None of the radiographic parameters correlated with SRS-22 mental health or SF-36 MCS (Table 1). GT was more sensitive in detecting ODI disability groups when compared with SVA and PT (p< 0.01)Conclusion GT has a similar or better correlation with HRQoL domains compared with PT and SVA. This information adds another important feature of this parameter in addition to being a single parameter taking into account both the spinal balance and pelvic compensation and being less affected by patient positioning.

Introduction Elderly patients undergoing major surgery may experience cognitive deterioration due to lesser plasticity in their brain tissue. This so called postoperative cognitive dysfunction (POCD) syndrome is characterized with non-specific dysfunction in memory, concentration and analysis skills. It is not known whether adult spinal deformity (ASD) surgery is associated with POCD. Purpose of this study is to analyze the cognitive abilities of older patients undergoing spinal deformity surgery before and after the surgery so as to understand whether ASD surgery is associated with POCD.Material and Methods A prospective longitudinal study was performed on surgical patients older than 50 years enrolled in a prospective multi-centric database. Mini mental state examination (MMSE) was performed to assess cognitive functions in addition to the health related quality of life (HRQOL) tests (SF-36, ODI and SRS-22) at preoperative, post-operative 6th week and 6th month points. Demographics, preoperative health status, comorbidities, surgical characteristics were also analyzed. Descriptive statistics and repeated measures of variance analysis were performed.Results A total of 90 patients with a mean age of 67.4 ± 8.2 were enrolled in the study; all had 6th week and 58 had both 6th week and 6th month follow-up MMSE evaluations. Averages (standard deviation) of surgical time, estimated blood loss (EBL), number of screws used and hospital stay were 240.1 (111.9)min, 1621.2 (1058.7)ml, 11.2 (4.4) and 14.2 (11.45)days respectively. On analysis, it was seen that there was even a slight increase in mean MMSE score (p > 0.05) between time points (Table 1). There was a decrease of > 2 points (3 or 4 points) in 6 patients (6.7%) at both time points.Conclusion Although ASD surgery in older patients is recognized as challenging, this study suggests that it is not necessarily associated with a significant deterioration in the cognitive abilities of patients undergoing it. These results are different compared with those reported for other major surgical interventions. This may be due to the relatively minor influence of ASD itself on the cognitive abilities of the patients involved as well as to the relatively stable hemodynamic conditions obtainable during modern ASD surgery.

Introduction To analyze the factors that may influence surgical vs non-surgical treatment for AdIS patients within gray zone (40–55°) main thoracic (MT) curves.Material and Methods A retrospective analysis of a multicenter, prospective, consecutive patient series. Inclusion criteria were: AdIS, ≥18 years of age, major curve to be MT, Cobb between 40 and 55°. Ninety-one patients (69 Non-surgical and 22 Surgical) were included. Non-surgery group had 57F and 12M; mean age: 28.3 (18–47), mean Cobb: 46.8° (40- 55). Surgery group had 19 F and 3M; mean age: 31.1 (18–71), mean Cobb: 49.2°(42–55). All patients completed SF-36, SRS-22 and ODI when they were first seen in the clinic. AP and lateral Cobb measurements and sagittal plane parameters were measured. Independent samples t-test was used to compare groups. Variable importance analysis was done using classification and regression tree algorithm to predict factors that influence surgical decision.Results ODI, SF-36 PCS and SRS-22 subtotal, function, pain, self-image scores were significantly different between the groups (p< 0.05). Age, MT curve Cobb, Lumbar curve Cobb, trunk shift, SVA, coronal balance, SF-36 MCS and SRS22 mental health were not statistically different (p > 0.05). Most important variable that created a tendency toward surgery was SRS-22 functional status followed by ODI, SRS-22 pain score, SF-36 PCS and SRS-22 self image score (Fig. 1).Conclusion AdIS patients having a curve magnitude in the gray zone (40–55°) with decreased SRS-22 function, pain, self-image and SF-36 PCS and increased ODI scores had a predilection toward surgery. Most important variable was SRS-22 function score.

Introduction As surgical decision-making and preoperative planning for adult spinal deformity (ASD) need strongly be interrelated to health related quality of life (HRQOL), there are multiple studies focusing on factors with an impact on it. Based on the general perception of association between the treatment results and the psychological condition of patients with ASD, analyzing the factors governing the baseline psychological status of this group may be worthwhile. Aim of study is to develop an understanding of which factors have a greater impact on the SF-36 mental component score (MCS) and to establish a hierarchy of these parameters through multiple regression analysis.Material and Methods Prospectively collected data from a multicentric adult deformity database was analyzed using multiple regression analysis with SF-36 MCS designated as the dependent variable and demographic, radiological and the HRQOL parameters as independent variables. The regression model was started with a correlation analysis between SF-36 MCS and all independent variables then conducted by introducing the variables with the highest correlation with SF-36 MCS, sequentially.Results A total of 229 patients (181♀, 47♂) with a mean age of 49.4 (18– 85) years, were analyzed. A strong correlation between SF-36 MCS and Scoliosis Research Society (SRS)-22, Oswestry Disability Index (ODI), gender, and diagnosis were found (p< 0.05). The distribution graph and results of regression analysis are summarized in Fig. 1. The overall R2 of this model was 0.254 (p< 0.001).Conclusion This study has demonstrated that, among the evaluated parameters, the overall HRQOL (SRS-22 and ODI) as well as thoracic kyphosis (TK) and gender are the most important parameters affecting the mental component summary of SF-36 in ASD population. Although the strong association with SRS-22 and/or ODI was to be expected, less strong associations with TK (as a token of appearance?) and gender (due to different mechanisms of coping with disability?) were less expected and may warrant further consideration in our understanding of the population of ASD.

Introduction There is little information about the effects of scoliotic curves on self image (SI) and mental health (MH) based on validated questionnaires. Aim was to analyze the effect of scoliosis on MH and SI in a non-disabled adult idiopathic scoliosis (AdIS) population having curves under surgical indication threshold (Main Thoracic (MT) Cobb (≤ 55°), and Thoracolumbar/Lumbar (TL) curve (≤ 45°).Material and Methods A retrospective analysis of a multicenter, prospective, consecutive patient series. Inclusion criteria were: non operated AdIS, ≥ 18 years of age, MT Cobb 20–55°, TL Cobb 20–45°, ODI <20, SRS 22 Pain score > 4. ODI and SRS22 pain score were used to distinguish patients that have pain and disability from the ones that do not. SRS- 22 and SF-36 normative data for different age groups were used for comparison. AP and lateral Cobb measurements, sagittal plane parameters and demographic data were analyzed in terms of correlations with SI and MH parameters.Results 76 patients (64F, 12M) met the inclusion criteria. Mean age was 25.9 (18–44), mean MT Cobb was 38.5° (21–55) and TL Cobb was 34.6° (25–44). SRS-22 MH, SI and other domains were similar with SRS normative data (p > 0.05). SF-36 MCS and PCS domains for age groups 18–24, 25–34 and 35–44 were not significantly different than normative data (p > 0.05). None of the demographic and radiographic parameters were correlated with changes in SRS-22 function, SI, MH and SF 36 MCS, PCS parameters.Conclusion AdIS does not affect mental health and self-image in non-disabled patients with curve magnitudes below the surgical threshold.