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Fig.7.6a–e(a,b)A64-year-oldwoman with degenerative lumbar scoliosiswas treated with Luqueinstrumentation 9
yearsagoin another hospital.PosteriorinstrumentationfromT5 toS1withanL1PSO wasperformedintherevision
surgery. (c) However,immediate postoperative coronalimbalance toward the convex side was noted. (d) Twoyears
later,therodfractured at therightsideof L2. (e)A second revision surgerywas performedwithsatellite rods. Both
coronalandsagittalbalancewasrestoredat6months’follow-up.
Anovelclassificationsystemhasbeendevisedforthecoronalbalancepatterninadult
scoliosis: type A, balanced; type B, imbalanced on the concave side; and type C,
imbalanced on the convex side. For a preoperative coronal pattern of type A or B, the
three-columnosteotomyshouldbeperformedrightattheapexfromtheconvexside.For
typeC,theoptimalstrategyofosteotomybeginsfromtheconcavesideofthemaincurve,
atamoredistallevel,usuallyattheL4vertebraorL4/5disk,followedbycorrectionofthe
apical region. For instrumentationfailure due to postoperative coronal decompensation,
revision surgery focuses on reinforcing the local construction, using in-line rod
connectors,cross-links,orsatelliterods.
Pearls
Consulttheclassificationsystemthathasbeendevisedforpreoperativecoronalbalancepatterninadultscoliosis.
Identifythefactorsthatdifferentiatedegenerativeandidiopathicadultscoliosis.
Keepinmindthatdiskdegenerationmaycontributetospinalimbalanceandcurveseverity.
Evaluatetheriskfactorsofpostoperativecoronaldecompensation.
Beawareofrevisionoptionsforinstrumentationfailureduetopostoperativecoronalimbalance.
Pitfalls
Postoperativecoronaldecompensationcanoccurafterosteotomyattheapex.
Postoperativecoronaldecompensationmayresultininstrumentationfailureandlossofcorrection.
References
FiveMust-ReadReferences
1.AebiM.Theadultscoliosis.EurSpineJ2005;14:925–948PubMed
2. Schwab F,Dubey A, GamezL, et al. Adultscoliosis: prevalence, SF-36,andnutritional parameters inan elderly
volunteerpopulation.Spine2005;30:1082–1085PubMed
3.XuL,SunX,HuangS,etal.DegenerativelumbarscoliosisinChineseHanpopulation:prevalenceandrelationship
toage,gender,bonemineraldensity,andbodymassindex.EurSpineJ2013;22:1326–1331PubMed
4. Glassman SD, Schwab FJ, Bridwell KH, Ondra SL, Berven S, Lenke LG. The selection of operative versus
nonoperativetreatmentinpatientswithadultscoliosis.Spine2007;32:93–97PubMed
5.SmithJS, ShaffreyCI,BervenS, etal;SpinalDeformityStudy Group.Operativeversusnonoperativetreatment of
legpaininadultswithscoliosis:aretrospectivereview ofaprospectivemulticenterdatabasewithtwo-year follow-
up.Spine2009;34:1693–1698PubMed
6. Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010; 28:E1
PubMed
7.BessS,Boachie-AdjeiO,BurtonD,etal;InternationalSpineStudyGroup.Painanddisabilitydeterminetreatment
modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine
2009;34:2186–2190PubMed
8.BridwellKH,EdwardsCCII,LenkeLG.TheprosandconstosavingtheL5-S1motionsegmentinalongscoliosis
fusionconstruct.Spine2003;28(20,Suppl):S234–S242PubMed
9.PollyDWJr,HamillCL,BridwellKH.Debate:tofuseornottofusetothesacrum,thefateoftheL5-S1disc.Spine
2006;31(19,Suppl):S179–S184PubMed
surgicaloutcomesreviewofadultidiopathicscoliosis.Minimum5yearsoffollow-up.Spine2012;37:1479–1489
PubMed
patients?JSpinalDisordTech2014;27:E176–E180PubMed
oflifeinadultscoliosis?Spine2009;34:E519–E527PubMed
discdegeneration.Spine2001;26:1873–1878PubMed
outcomesofadultpatientswithdeformity?Spine2013;38:476–483PubMed
symptomsinadultscoliosis.Spine2005;30:682–688PubMed
measurementsinadultdegenerativescoliosis.Spine2009;34:1581–1584PubMed
spinaldeformity:clinicalandradiographicriskfactors:clinicalarticle.JNeurosurgSpine2013;19:445–453PubMed
withlongspinal fusions:aminimum2–5year follow-upstudy.JSpinalDisordTech2013 Sep27.[Epubaheadof
print]PubMed
King/MoeandLenkeclassificationsystems.Spine2006;31(19,Suppl):S119–S125PubMed
resectionforspinaldeformity.Spine2006;31(19,Suppl):S171–S178PubMed
kyphoscoliosis.Spine2012;37:1847–1852PubMed
subtractionosteotomy.Neurosurgery2011;69:164–172,discussion172PubMed
8
Measuring Outcome and Value in Adult
DeformitySurgery
RobertWaldropandSigurdBerven
Introduction
Thedefinition ofahealth-related outcomevaries inthe literatureand mayencompass a
spectrum of measures. Clinical outcome is the end result of health care delivered to
patients or populations, and entails such considerations as quality, patient-based
assessment, and value of care. Measuring outcomes is complex, and there is no single
measure that summarizes the patient’s experience, the hospital perspective, the payer
perspective, and the treating physician’s perspective. Therefore, outcomes must be
consideredbroadlyandencompassaspectrumofperspectivesandmeasures.Thischapter
discussesmeasuresofhealth-relatedqualityoflife(HRQOL),andtheapplicationofthese
measurementsinassessingoutcomesofspinaldeformitysurgery.
Outcomemeasurementisanimportantaspect ofsurgeonaccountabilityandisvitalin
determining the quality and value of health care. Quality may be evaluated based on
process measures, objective health outcomes, patient-reported outcome measurements,
andcostofcare.Valueisabroadermeasurethatincorporatesananalysisofbothquality
andcost.Thischapterprovidesanoverviewofvariousoutcomemeasuresusedforspinal
deformity,andfindingsfromtheliteratureonoutcomesinadultspinaldeformitysurgery.
ProcessMeasures
Processmeasuresareareflectionofhowcareisdelivered.Examplesincludecompliance
withantibioticorthromboembolicprophylaxisguidelines,theuseofsurgical“time-outs”
beforesurgery,preoperativeriskassessmentsofpatients,andimplementingpostoperative
careprotocols forthe preventionof commonpostoperative complications.The utilityof
process measures depends on how reliably they are linked to clinical outcomes. For
example,measuringcompliancewithpreoperativeantibioticguidelinesisusefulinthatit
maypredictareductionintheincidenceofsurgicalsiteinfections.Althoughtheyarean
indirectmeasure ofquality,theimplementation andmeasurement ofsuchguidelinesare
importantinstandardizingcareandimprovingquality.
PhysiologicalOutcomeMeasures
Physiological outcomes represent clinical health metrics that may be measured
objectively.Inadultspinaldeformity,these mayincluderadiographic outcomes,implant
survival, and fusion rates. Cobb angle, sagittal vertical axis (SVA), and spinopelvic
parametersincludingpelvicincidence(PI),pelvictilt(PT),sacralslope(SS),andlumbar
lordosis(LL)areallimportantradiographicmeasurementsinspinal deformity.Although
these outcomes are easy to measure and interpret, it is important to evaluate clinical
measurements in relation to their correlation with quality measurements (e.g., do
radiographicoutcomespredictreoperationrates?).
QualityMeasures
Traditionalmeasurementsofqualityincludeoutcomes suchasoperativetime andlength
of hospitalstay,as wellas rates ofcomplications, reoperations, andreadmissions. Such
measuresprovideimportantinformationthatmaybeusedtocomparetheperformanceof
individualprovidersandhospitalsandtoestablishmetricsfor performanceand goalsfor
qualityimprovement.However,overallqualityofcareencompassesmuchmorethanthese
traditionallyreportedqualitymetrics.
Quality metrics are valuable in identifying outliers, and in improving care processes
and pathways. However, overall quality measures are distinct from patient-centered
clinicaloutcomemeasures.Oneimportantconcernregardingrelianceonqualitymeasures
isthepossibilitythatmeasuringqualityalonemayleadtoafocusonoutcomesthatarenot
patient-centered. If the target for outcome were only length of stay or avoidance of
readmission,thenthatgoalmayincentivizesignificantundertreatmentofcomplex spinal
disorders.Fig.8.1provides anexampleofacaseinwhichapatientunderwentalimited
decompression and posterior-based tethering procedure for a complex spinal deformity.
Measured by only length of stay or complications of care, the limited decompression
surgery would be rated as a high-quality outcome. However, the patient had no
improvementin herhealthstatus orinher deformitymeasures.The patientunderwenta
revision surgery3 years after the indexprocedureand was treated with athree-column
osteotomy for multiplanar realignment of the spine. The revision surgery resulted in a
longer stay, higher cost, and more risk and potential for complication than the index
surgery.However,thepatientreportedadramaticimprovementinhealthstatusthatisnot
captured by the qualitymetrics alone. It is important to avoid myopic focuson quality
metricswithoutgivingprioritytopatient-centeredmeasuresofclinicaloutcomesinspinal
deformity.
Patient-ReportedOutcomes
Although process measures, physiological outcomes, and traditional quality metrics are
important toolsfor assessing health care quality,they do not reflectthe patient’shealth
careexperienceortheimpactofcareonHRQOL.Therehasbeenanincreasingemphasis
on patient-based health assessments in recent years. Patient-reportedoutcomemeasures
(PROMs)mayincludeaspectrumofdomainstoassessHRQOL.Frequentlyuseddomains
include disability/functional status, pain and other symptoms, emotional/psychological
well-being,generalhealthstatus,andsatisfactionwithhealthcareexperience.TheVisual
AnalogueScale(VAS)forpainassessmentisanothercommonlyusedoutcomemeasure.
Measurement tools for patient-reported outcomes include both disease-specific and
general health status measures. Disease-specific measures focus on domains associated
with a particular condition or patient population, and have the advantage of increased
responsiveness to change (there is a more reliable change in outcome score as the
underlyingconditionchanges)comparedwithgeneralhealthstatusmeasures.Examplesof
specificoutcometoolsincludetheScoliosisResearchSociety(SRS-22)questionnaire,the
OswestryDisabilityIndex(ODI),andtheNeckDisabilityIndex(NDI).
Generalhealthstatusoutcomestoolsareadvantageousinthattheymaybeusedinany
patient population and allow for broad comparisons across a spectrum of medical and
surgical conditions. However, they are often less responsive to changes in particular
conditionsordiseasestates.ExamplesofgenericprofilesincludetheShortForm36(SF-
36), ShortForm 6Domains (SF-6D), theEuroQOLfive dimensions questionnaire(EQ-
5D),andtheHealthUtilitiesIndex(HUI).
Fig.8.1a,b(a) A73-year-oldwomanpresentedwith sagittal and coronalplanedeformity, back pain, andneurogenic
claudication. She was unable to live independently. The patient was treated with a limited decompression and a
posterior-basedtetheringdevice.Althoughthelengthofstaywas3days,andtherewasnocomplicationorreadmission
within90days, there was also noimprovementinradiographicorpatient-centered clinical outcomes, and thepatient
remained disabled. (b)Postoperative X-rays 2 years aftera revision surgeryin which thepatient wastreated with a
three-columnosteotomyforrealignmentofthespine.Thepatientstayedinthehospitalfor6daysandherperioperative
course was complicated by a supraventriculartachycardia thatrequired cardioversion.At 2-yearfollow-up, she was
livingindependentlyandwalkingwithoutlimits.
Bothgeneralhealthstatusmeasuresandcertaindisease-specificoutcometoolsmaybe
used as indirect measures to calculate utility scores. A utility score reflects societal
preferencesforahealthstate.Differenthealthstatesareratedonacontinuousscalefrom0
to1,withthevaluereflectingameasureofwellyearsoflife.Utilityscoresderivedfrom
patient-reportedoutcome questionnairesusingvalidated instrumentsprovide information
on a patient’s health status and the value that society places on that health state.
Consideration of a utility score over time yields a quality-adjusted life year (QALY),
calculated as the utility score multiplied by the number of years that health state is
maintained.Thus,thedurabilityof anoutcomeresultsinincreasedQALYsovertime.A
QALY isan outcomemeasure that representsa standardizedunit for comparisonacross
fieldsandcanbeassignedvaluebysociety.
CommonlyUsedOutcomeMeasurements
Thefollowinginstrumentsarecommonlyusedpatient-reportedoutcomemeasurementsin
adultspinaldeformitythathavevalidatedconversionstoutilityscores/QALYs.
ShortForm36(SF-36)andShortForm6Domains(SF-6D)
The SF-36 is a widely used generichealth survey consisting of 36 questions with four
physical health scales (physical functioning, physical role limitation, bodily pain, and
generalhealth) andfourmental healthscales (vitality,socialfunctioning, emotionalrole
limitation,andmentalhealth).TheSF-6DisanabbreviatedversionoftheSF-36thathas
beenestablishedasapreference-basedhealthstateclassificationthatmaybeconvertedto
autilityscore.
1
EuroQOLFiveDimensionsQuestionnaire(EQ-5D)
TheEQ-5Disanothervalidatedandwidelyusedgeneralhealthquestionnairethatisused
to establish a utility score.It includes five health dimensions: mobility, self-care, usual
activities,pain/discomfort,andanxiety/depression.
ScoliosisResearchSocietyQuestionnaire
The Scoliosis Research Society (SRS) questionnaire measures how spinal deformity
affects a patient’s HRQOL based on five domains: pain, function, self-image, mental
health,andsatisfaction.The22-itemquestionnaire(SRS-22)isthemostwidelyusedand
validatedversion,althoughseveralotherversionsexist(SRS-24,SRS-29,SRS-30).SRS-
22 has been validated as a reliable instrument with high internal consistency,
responsiveness, reproducibility, and discriminatory capacity for patients with adult
deformity.
2,3
AmodelhasbeenestablishedfortranslatingSRS-22scorestoSF-6Dscores
todetermineutilityscores.
4,5
OswestryDisabilityIndex(ODI)
TheODImeasuresHRQOLin patientswithlow backpain.It ratesapatient’sdisability
score based on 10 measures: pain, personal care, sitting, standing, walking, lifting,
sleeping,sexlife,sociallife, andtraveling.Higherscorescorrespondtoagreaterdegree
of disability. The ODI is a validated and widely used measure that can be reliably
translatedtoautilityscore.
6
CostandValue
In our current health care economy, cost has become an increasingly important
considerationintheassessmentofhealthcareinterventions.Economicanalysesofhealth
careinterventionsincludecost-minimizationstudies,cost-effectivenessanalyses,andcost-
utility analyses. An assessment of costs may include direct costs, charges, and
reimbursements. Indirect costs such as loss of productivity due to time off from work,
transportationtohealthcarefacilities,andthecostofcaregiversmayalsobeincludedin
costanalysesandincorporateawiderviewoftotalcostsfromasocietalperspective.
Although cost in itself is an important consideration, the value of care provides the
mostmeaningfulassessmentofahealthcareintervention.Valueofcareencompassesboth
outcomeandcostandisdefinedasthenetbenefitofcarerelativetothenetcostofcare,or
whatwegetforwhatwespend.Themeasurementofbenefitsandcostsinspinesurgeryis
notuniform andmayvary dependingonthe perspectiveofthe stakeholderinthe health
care economy. Hospitals and other health care facilities may emphasize outcomes and
coststhataffectasingleadmissionsuchaslengthofhospitalstay,implantutilization,and
complications. Third-partypayers often focuson outcomes andcosts in amedium-term
time-frameincludingreadmissionswithin90daysorthecostofoutpatientcare.Thevalue
of a health care intervention to the physician and patient is established over a longer
timeframe than a single admission; its impact is measured based on HRQOL over a
lifetime.
Cost-utilitystudiesprovidethemostusefulinformationaboutthevalueofahealthcare
interventionbecause autilityscore isable tocapture apatient’spreference fordifferent
health states over time. An outcome measure that directly reflects HRQOL and is
translatable across disease states, such as QALYs, is an important prerequisite for
estimating the value of orthopedic care. The length of follow-up is also an important
consideration when measuring value, as the cost of a single episode of care will be
significantlydiscountedbythedurationofthebenefit.
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