by Elizabeth Hofheinz, M.P.H., M.Ed.
Patients facing spinal deformity surgery have many visions in their heads about their lives might change postoperatively. And they bring their visions into your office.
A new analysis from the International Spine Study Group adult spinal deformity (ASD) database, has delved into what is involved in thoroughly assessing postoperative improvements in pain, self-image, physical and social function, and mental health with the ultimate goal of properly advising patients upon expected outcomes from ASD surgery. 
The study, “Counseling Guidelines for Anticipated Postsurgical Improvements in Pain, Function, Mental Health, and Self-image for Different Types of Adult Spinal Deformity,” was published in the August 15, 2020 edition of Spine.
From random to research
Co-author Shay Bess, M.D., from the International Spine Study Group and an orthopedic spine surgeon at the Denver International Spine Center, told OSN, “One of the questions every patient asks prior to any surgery is, ‘What is this going to do for me?’ They want to know what exactly will change (function, pain, etc.) and how much it will change. Our goal was to provide guidelines, especially for patients undergoing large spine deformity surgery, in order to be able to give patients some honest parameters. Patients may often be told uneducated answers including, ‘You will be 100% improved following the surgery and will be back to normal again.’ We believe this sets up the surgeon and the patient for disappointment. Surgeons and patients need honest and educated parameters in order to generate a truly informed consent.’
The data used in this research paper was derived from a prospective cohort of ASD patients that nears level II prognostic evidence. “The primary thing that we all need to get our heads around is that adult spine deformity is very heterogenous with very different types of deformities that can occur throughout the spine. Scoliosis can occur in all parts of the spine. Some patients have a pure sagittal plane malalignment, while others demonstrate a mixture of scoliosis and sagittal plane malalignment, etc. Consequently, it is erroneous to box all ASD patients into just one type of spine deformity.”
Drilling down on spine deformity
Dr. Bess and the International Spine Study group previously published work in 2016 that showed that the amount of health deficit corresponds to the type and severity of the spine deformity. “Thus, in order for us to counsel patients accurately we need to measure the severity of the deformity as well as be cognizant of what type of deformity we are dealing with, including its exact location along the spinal column. We are discovering that there are different health deficits related to different types of deformity, and, therefore, there are variable amounts of improvements in different health domains following treatment that correspond to the type of spine deformity the ASD patient has.”
“Health deficits can include pain, poor physical function, and poor self-image. If a patient indicates that his or her main problem (health deficit) is lack of physical function and hopes to improve physical function after surgery, then as a surgeon I want to be able to tell my patient how much improvement he or she could expect in physical function following surgery (as well has how much improvement to expect in all other health domain categories). Ideally, we would be asking patients, ‘What do you want to improve?’ and then be able to provide honest and educated answers to help patients make treatment decisions.”
“Based on this research we do have the capacity,” says Dr. Bess, “to tell an ASD patient, ‘Surgery will probably reduce your pain by about 50% and improve your self-image by about 60-70%.’ If someone wants to have spine deformity corrective surgery solely for an improvement in mental health, we can let them know that their mental health will only improve about 25%.”
Teasing out the variables
Pointing out an issue with the Oswestry Disability Index (ODI), Dr. Bess notes, “We need to have comprehensive tools that evaluate the spectrum of health deficits. The problem with the ODI as a sole measure is that it’s a pain driven instrument—how pain impacts function, work, sex life—however it doesn’t have non-pain delineated metrics within it, such as self-image. Consequently, the ODI is an effective instrument to evaluate pathologies that are driven by pain. However, if you take ASD patients that have isolated thoracic scoliosis deformities, it is uncommonly a pain driven condition. These patients will improve their self-image following surgery by over 60% and roughly 70% of these patients will return to a self-image status that emulates a patient without scoliosis (these patients truly return to ‘normal’). However, for the majority of these patients, function and pain values don’t improve after surgery. Clearly, we are helping these patients, however, if the ODI is the only measure used to evaluate these patients, we would erroneously conclude that surgery did not help.”
“At baseline, the most impacted domain across all adult spinal deformities is self-image, followed by pain, then physical function, then social function, and then mental health. My colleagues and I have found that self-image is largely independent of mental health but correlates strongly with function and pain.”
Pointing to the cancer literature, Dr. Bess states, “For cancer patients, self-image is shown to be less tied to cachexia and hair loss and more tied to nausea. That tells us that if you feel good then you tend to think you look good. Self-image is critically important for ASD, and while there are numerous metrics used to evaluate spinal deformity, self-image isn’t consistently one of them.”
How they proceeded
The methodology for the paper included evaluation of surgically treated ASD patients (≥4 levels fused) prospectively enrolled into a multicenter database, minimum 2-year follow-up, were categorized into ASD types according to Scoliosis Research Society-Schwab ASD classification (THORACIC, LUMBAR, DOUBLE, SAGITTAL, MIXED). Demographic, radiographic, operative, and patient reported outcome measures (NRS back and leg pain, SRS-22r, SF-36) data were evaluated. Preoperative and last postoperative values for pain, physical and social function, mental health, and self-image were evaluated, improvements in each domain were quantified, and domain scores compared to generational normative values. Postoperative improvements were also calculated for three age cohorts (<45 yr, 45-65 yr, and >65 yr) within each deformity type.
Dr. Bess: “We found that 90% of adult spinal deformity patients across all deformities were two standard deviations worse than the normal population for self-image, pain, and physical function, which is not only statistically significant, but clinically vital as well as it shows the dramatic impact that ASD can have upon afflicted patients.”
“Domain improvements for the entire ASD population were 45.1% for back pain, 41.3% for leg pain, 27.1% for physical function, 35.9% for social function, 62.0% for self-image, and 22.6% for mental health,” wrote the authors. “LUMBAR, SAGITTAL, and MIXED had greatest improvements in pain and function, while THORACIC and DOUBLE had greatest improvements in self-image. Self-image was the most impacted preoperative domain and demonstrated the greatest postoperative improvement for all ASD types.”
Dr. Bess: “We believe this study provides spine surgeons valuable information…and provides an opportunity for education and honesty when it comes to counseling patients.”