Abstract
Study design
Retrospective study.
Objective
This study aimed to investigate the impact of symptom duration on patient-reported outcomes (PROs), satisfaction, and expectation fulfillment in elderly patients undergoing multi-level thoracolumbar fusion for adult spinal deformity (ASD).
Methods
A retrospective cohort study was conducted on 237 ASD patients treated at our institution between July 2019 and July 2022. Patients were stratified based on symptom duration into three groups: Group A (6 months to ≤1 year), Group B (1 year to <2 years), and Group C (≥2 years). The study evaluated perioperative outcomes, PROs, achievement of minimal clinically important difference (MCID) for PROs—including the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol-5D-5 L (EQ-5D-5 L)—as well as satisfaction and expectation fulfillment at 6-month, 1-year, and 2-year follow-ups. Multivariable regression analyses were performed to identify predictors of poor outcomes.
Results
A cohort of 237 patients met the inclusion criteria and were stratified into three groups based on symptom duration: 66 patients with ≤1 year of symptoms, 73 patients with 1 to <2 years, and 98 patients with ≥2 years. Comparative analyses revealed that patients with symptoms lasting ≥2 years had significantly longer hospital stays and higher complication rates compared to those with ≤1 year of symptoms. Additionally, this group was more likely to fail to achieve the MCID across multiple measures—including the ODI, EQ-5D-5 L, VAS-Leg, and VAS-Back—at the 2-years follow-up. Similar patterns were observed in satisfaction scores and expectation fulfillment rates. Multivariable regression, using the ≤1-year group as a reference, showed that patients in both the 1 to <2 years and ≥2 years groups had significantly higher odds of failing to achieve MCID for VAS-Leg, VAS-Back, ODI, and EQ-5D (P < 0.05). Furthermore, both longer-duration groups were significantly less likely to report satisfaction and fulfilled expectations at all follow-up points (6-month, 1-year, and 2-years) (P < 0.05).
Conclusions
A symptom duration of ≥2 years was robustly associated with inferior PROs, reduced postoperative satisfaction, and lower fulfillment of expectations. These findings imply that prompt referral and surgical intervention for adult spinal deformity may play a pivotal role in optimizing patient outcomes.
Keywords: sagittal alignment, thoracolumbar, adult spinal deformity
Introduction
Over the past years, significant progress has been achieved in enhancing surgical outcomes for adult spinal deformity (ASD) correction. These advancements primarily stem from the development of comprehensive classification systems for spinal deformities and the implementation of effective strategies to mitigate perioperative complications.1-3 For ASD patients who have exhausted conservative treatment options and exhibit symptoms such as chronic back pain and impaired gait, surgical intervention becomes imperative.4,5 Nevertheless, despite the widespread adoption of orthopedic surgical procedures, a considerable number of patients experience substantial delays in receiving clinically indicated surgical treatment. 6 These delays are often attributable to various factors, including insurance-related constraints, diagnostic inaccuracies, inefficiencies in referral systems, histories of multiple unsuccessful conservative treatments, and surgical backlogs. 7 As a result, many elderly ASD patients endure prolonged symptom durations, which not only intensify their disease burden but also negatively affect their clinical outcomes.
For ASD patients, surgical intervention has been demonstrated to accelerate pain relief and improve both functional and clinical outcomes. 8 However, the relationship between symptom duration and postoperative outcomes following lumbar surgery remains a topic of ongoing debate. Numerous studies have investigated the impact of symptom duration on lumbar surgery outcomes, 9 with some indicating that prolonged symptom duration may correlate with less favorable treatment results. In contrast, other studies have failed to establish a significant association between symptom duration and surgical outcomes.10,11 Despite these findings, the body of evidence specifically examining this relationship in the context of ASD patients undergoing multi-level fusion remains limited, with conflicting conclusions on the impact of prolonged symptoms.
Therefore, this study aimed to investigate the impact of preoperative symptom duration on clinical outcomes in ASD patients. The findings from this research are expected to provide critical insights for spinal surgeons and patients regarding the optimal timing of surgical intervention for ASD. Additionally, the results will offer valuable guidance for preoperative patient consultations and support more informed decision-making processes regarding surgical treatment.
Materials and methods
Study Design
The study protocol received approval from our institutional review board (IRB#2024-010-002), and written informed consent was obtained from all participating patients. This research employed a retrospective design to analyze data gathered from our hospital between July 2019 and July 2022, focusing on perioperative outcomes, 2-years follow-up patient-reported outcomes (PROs), patient satisfaction, and the fulfillment of expectations at 6 months, 1 year, and 2 years post-surgery for elderly patients (aged 65 years and older) who underwent multi-level posterior thoracolumbar fusion surgery for ASD. All patients underwent posterior long-segment fusion using pedicle screw fixation. Interbody fusion procedures were selectively performed according to intraoperative assessment of segmental stability and disc degeneration. Presenting symptoms included lumbar back pain, lumbar radiculopathy, neuro genic claudication, scoliosis, and duration of symptoms. The patients were stratified into three groups based on their self-reported duration of symptoms prior to surgical intervention: Group A (6 months to ≤ 1 year), Group B (1 year to < 2 years), and Group C (≥2 years). The duration of symptoms was determined based on patient self-report during preoperative clinical evaluations. For this study, the ‘onset of symptoms’ was operationally defined as the time when the patient first experienced persistent and clinically significant pain or disability related to their spinal deformity that prompted them to seek medical consultation. The duration of preoperative symptoms was determined based on patient self-reports documented in the electronic medical record (EMR) at the time of initial consultation, a method commonly used in retrospective studies assessing chronic spinal conditions. 12 Although serial PROM data at 6-, 12-, and 24-month intervals prior to surgery were unavailable due to the retrospective nature of the study, the recorded symptom duration reliably reflected the chronicity and severity of each patient’s condition.
Inclusion and Exclusion Criteria
Inclusion Criteria
The study cohort was selected based on the following eligibility criteria: (1) All eligible patients with a definite diagnosis of ASD and requiring procedure intervention satisfied at least one following radiographic inclusion criteria: (1) Pelvic incidence-lumbar lordosis (PI-LL) ≥ 10°, (2) Pelvic tilt ≥ 25°, (3) Sagittal Vertical Axis (SVA) ≥ 5 cm, (4) Thoracic kyphosis ≥ 60°, and (5) coronal Cobb angle ≥ 20°; (2) age ≥65 years; (3) posterior thoracolumbar fusion surgery involving a minimum of 5 vertebral levels; (4) complete postoperative follow-up data for ≥2 years; and (5) patients who have failed to conservative treatment, including physical therapy, bracing, and medication, prior to surgical consideration. However, detailed information on the specific duration, type, and efficacy of these conservative treatments, as well as quantitative data on preoperative narcotic use, were unavailable due to incomplete documentation in retrospective records. Although all patients met diagnostic criteria for adult spinal deformity, not all demonstrated clinically significant fractional lumbosacral pathology. The decision to extend fusion to the sacrum and/or pelvis was individualized and based on radiographic evidence of lumbosacral degeneration or instability, foraminal stenosis, and spinopelvic alignment, rather than age or symptom severity alone.
Exclusion Criteria
Patients were excluded if they met any of the following conditions: (1) age < 65 years; (2) concurrent cervical or coccygeal spinal interventions; (3) non-contiguous spinal segment interventions; (4) presence of active spinal infections, neoplastic spinal lesions, congenital spinal deformities, or acute vertebral fractures; (5) patient with the percentage of missing data exceeds 10%.
Variables, Data Sources, and Measurements
The dataset for this investigation comprised comprehensive patient information, including demographic characteristics, medical histories, clinical presentations, surgical procedures, hospitalization details, Radiology information, Short Form 36 Health Survey (SF-36) and postoperative adverse events occurring within the 90-day postoperative period. The study also evaluated the achievement of the Minimally Clinically Important Difference (MCID) thresholds for multiple assessment tools: Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol-5D-5 L (EQ-5D-5 L) assessments, with a 2-years follow-up period. Patient satisfaction and expectation fulfillment were systematically assessed at three time points: 6 months, 1 year, and 2 years postoperatively. To ensure data reliability and accuracy, trained medical professionals extracted symptom duration variables from medical records during annual data audits. Radiographic parameters such as SVA, PT, and PI-LL were measured and used to classify the severity of spinal deformity in each patient according to the SRS-Schwab classification. 13 Postoperative complications were quantified using the Comprehensive Complication Index (CCI), the CCI quantifies the cumulative burden of postoperative complications by weighting and summing all complications experienced by a patient. Scores range from 0 (no complications) to 100 (death) and categorized into three severity levels: mild complications (CCI 0-20), and severe complications (CCI >20). 14 The established MCID thresholds were as follows: a minimum improvement of 1.2 points from baseline for back pain VAS, 1.6 points for leg pain VAS, 12.8 points for ODI scores, and 0.15 points for EQ-5D scores. 15
The study employed the comprehensive 20-item Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey to quantify patient expectations.16-18 Preoperatively, patients were instructed to evaluate their anticipated level of improvement for each survey item using a standardized scoring system. This system ranged from “back to normal or complete improvement” (scored as 4 points) to “I do not have this expectation or this expectation does not apply to me” (scored as 0 points). The cumulative expectation score, derived from the summation of all item scores, ranged from 0 to 80, with higher scores reflecting more optimistic and elevated preoperative expectations. During postoperative follow-up assessments, patients were systematically evaluated for expectation fulfillment. They were required to indicate their actual improvement level for each corresponding item from their preoperative Expectations Survey. The response scale mirrored the preoperative format, ranging from “back to normal or complete improvement” (4 points) to “no improvement at all” (0 points), with intermediate gradations of significant, moderate, and minor improvements. The expectation fulfillment analysis involved calculating a proportional score by dividing the postoperative improvement score (sum of actual improvement points) by the preoperative expectation score (sum of expected improvement points). A score of 1.0 indicated complete fulfillment of preoperative expectations, while scores exceeding 1.0 represented outcomes that surpassed initial expectations.16,19-21 Additionally, patient satisfaction was measured using the North American Spinal Society (NASS) Patient Satisfaction scale, where satisfied patients were categorized as level 1 on the 4-point scale, the “satisfied patients” were defined as a score of 1 or 2, as previously described. 22
Statistical Analysis
Histograms and the Shapiro-Wilk test were used to evaluate the distribution of numerical variables. The mean and standard deviation of continuous variables were used to describe demographic, clinical, and surgical characteristics, and one-way ANOVA and Kruskal-Wallis tests were used to compare the differences between Group A, Group B, and Group C. At the same time, a post hoc test (Tukey’s HSD) was conducted for outcome indicators. Categorical variables are reported in frequency and percentage and compared using Fisher precision tests or chi-square tests. Multivariable models were fitted using ordered logistic regression, with the proportion of expectations fulfilled, satisfaction, and not-achieved MCID for the VAS-leg, VAS-back, ODI, and EQ-5D as the dependent variable, and variables found to be significant differences in bivariate analysis included as independent variables. Complications were included as a covariate in the multivariate logistic regression models to control for their potential confounding effect on postoperative outcomes. All the statistical analysis was performed based on SPSS Statistics 26 (SPSS, version 22.0, Inc. Chicago, IL, USA) with statistical significance set at Bonferroni adjusted-p < 0.017 in post hoc analysis.
Results
Population Preoperative and Surgery Characteristics
The study of all patients who underwent multi-level thoracolumbar fusion surgery with a 2-years follow-up duration yielded 237 patients who were eligible and included in the study with the appropriate follow-up period (Figure 1). Patient demographics are summarized in Table 1. The patients were divided into three cohorts: Group A (n = 66, 28%), Group B (n = 73, 31%), and Group C (n = 98, 41%). Statistical analysis of the demographic data presented in the table revealed no significant differences among the groups.
Figure 1.
Flowchart for patient inclusion and screening
Table 1.
Comparison of Population Characteristics in the A, B and C Groups
| Group A | Group B | Group C | P value | |
|---|---|---|---|---|
| Sample | 66 | 73 | 98 | |
| Age (mean ± SD) | 70.39 ± 9.00 | 70.67 ± 7.93 | 70.58 ± 7.44 | 0.979 |
| Sex | 0.815 | |||
| Male | 18 (27.3%) | 23 (31.5%) | 27 (27.6%) | |
| Female | 48 (72.7%) | 50 (68.5%) | 71 (72.4%) | |
| BMI (kg/m2) | 21.72 ± 2.00 | 21.69 ± 1.94 | 22.09 ± 3.85 | 0.853 |
| ASA | 0.413 | |||
| 1-2 | 51 (77.3%) | 49 (67.1%) | 70 (71.4%) | |
| 3-4 | 15 (22.7%) | 24 (32.9%) | 28 (28.6%) | |
| ACCI | 0.869 | |||
| ≤4 | 19 (28.8%) | 22 (30.1%) | 26 (26.5%) | |
| >4 | 47 (71.2%) | 51 (69.9%) | 72 (73.5%) | |
| Educational level | 0.531 | |||
| Less than high school | 15 (22.7%) | 26 (35.6%) | 32 (32.7%) | |
| High school | 35 (53.0%) | 31 (42.5%) | 46 (46.9%) | |
| College | 16 (24.2%) | 16 (21.9%) | 20 (20.4%) | |
| Living alone | 21 (31.8%) | 23 (31.5%) | 24 (24%) | 0.486 |
| Employment status | 0.426 | |||
| Full-time | 4 (6.1%) | 6 (8.2%) | 17 (17.3%) | |
| Part-time | 12 (18.2%) | 15 (20.5%) | 21 (21.4%) | |
| Retired | 38 (57.6%) | 37 (50.7%) | 41 (41.8%) | |
| Disability due to spine | 5 (7.6%) | 8 (11.0%) | 9 (9.2%) | |
| Other | 7 (10.6%) | 7 (9.6%) | 10 (10.2%) | |
| Marital status | 0.623 | |||
| Married | 61 (92.4%) | 64 (87.7%) | 89 (90.8%) | |
| Never married | 5 (7.6%) | 9 (12.3%) | 9 (9.21%) | |
| Smoking status | 0.794 | |||
| Never smoked | 46 (69.7%) | 50 (68.5%) | 61 (62.2%) | |
| Current smoker | 15 (22.7%) | 19 (26.0%) | 28 (28.6%) | |
| Quit smoking | 5 (7.6%) | 4 (5.5%) | 9 (9.2%) | |
| Drinking | 0.384 | |||
| Never drinking | 16 (24.2%) | 24 (32.9%) | 32 (32.7%) | |
| Current drinking | 30 (45.5%) | 35 (47.9%) | 48 (49.0%) | |
| Quit drinking | 20 (30.3%) | 14 (19.2%) | 18 (18.4%) |
Table 2 summarizes the characteristics of preoperative and operative the study population. The results of our analysis disclosed no statistically significant variations in comorbidity profiles or mental health status and surgical characteristics among the three patient cohorts (P > .05). The distribution of symptom duration in 237 patients classified according to the SRS Schwab system is summarized in Table 3. We can observe no statistically significant differences in symptom duration among patients with different spinal deformity severity.
Table 2.
Comparison of Patient Preoperative and Operative Characteristics in the A, B and C Groups
| Group A | Group B | Group C | P value | |
|---|---|---|---|---|
| Comorbidities | ||||
| Hypertension | 41 (62.1%) | 51 (69.9%) | 71 (72.4%) | 0.365 |
| Diabetes disease | 22 (33.3%) | 27 (27.0%) | 29 (29.6%) | 0.594 |
| Osteoporosis | 51 (77.3%) | 61 (83.6%) | 69 (70.4%) | 0.132 |
| Mental | ||||
| Depression, n (%) | 22 (33.3%) | 21 (28.8%) | 26 (26.5%) | 0.641 |
| Anxiety, n (%) | 19 (28.8%) | 22 (30.1%) | 23 (23.5%) | 0.579 |
| Preoperative expectation | 64.41 ± 7.34 | 67.07 ± 7.23 | 70.09 ± 8.01 | 0.379 |
| Physically active, n (%) | 34 (51.5%) | 45 (61.6%) | 51 (52.0%) | 0.374 |
| Predominant pain symptom | 0.899 | |||
| Predominant back pain | 25 (37.9%) | 31 (37.3%) | 32 (32.7%) | |
| Predominant leg pain | 20 (30.3%) | 29 (34.9%) | 35 (35.7%) | |
| Equal back and leg pain | 21 (31.8%) | 23 (27.7%) | 31 (31.6%) | |
| Previous spine surgery, n (%) | 10 (15.2%) | 12 (16.4%) | 13 (13.3%) | 0.841 |
| Procedure, n(%) | 0.762 | |||
| PLIF | 35 (53.0%) | 42 (57.5%) | 51 (52.0%) | |
| TLIF | 31 (47.0%) | 31 (42.5%) | 47 (48.0%) | |
| Number of levels fused | 7.74 ± 1.45 | 7.64 ± 1.95 | 7.56 ± 2.15 | 0.838 |
| Spinal osteotomy | 0.695 | |||
| ≤2 | 48 (72.7%) | 53 (72.6%) | 76 (77.6%) | |
| >2 | 18 (27.3%) | 20 (27.4%) | 22 (22.4%) | |
| Fusion to the sacrum, n (%) | 37 (56.2%) | 43 (58.9%) | 55 (56.1%) | 0.922 |
| Mean OT in minutes (mean ± SD) | 359.45 ± 74.24 | 366.90 ± 94.97 | 350.51 ± 116.57 | 0.564 |
| Mean EBL in mL (mean ± SD) | 913.03 ± 396.53 | 970.99 ± 574.04 | 849.94 ± 428.70 | 0.249 |
Table 3.
Summary of SRS-Schwab Adult Spinal Deformity Classification Modifier Grades and Radiological Parameters for 237 Patients
| ALL (n = 237) | Group A | Group B | Group C | P value | |
|---|---|---|---|---|---|
| PT, no. (%) | |||||
| 0 | 138 (58.2%) | 41 (62.1%) | 44 (60.3%) | 53 (54.1%) | 0.783 |
| + | 63 (26.6%) | 15 (22.7%) | 20 (27.4%) | 28 (28.6%) | |
| ++ | 36 (15.2%) | 10 (15.2%) | 9 (12.3%) | 17 (17.3%) | |
| SVA, no. (%) | |||||
| 0 | 144 (60.8%) | 46 (69.7%) | 43 (58.9%) | 55 (56.1%) | 0.523 |
| + | 50 (21.1%) | 11 (21.9%) | 16 (21.9%) | 23 (23.5%) | |
| ++ | 43 (18.1%) | 9 (13.6%) | 14 (19.2%) | 20 (20.4%) | |
| PI-LL, no. (%) | |||||
| 0 | 129 (54.4%) | 38 (57.6%) | 42 (57.5%) | 49 (50.0%) | 0.704 |
| + | 58 (24.5%) | 17 (25.8%) | 15 (20.5%) | 26 (26.5%) | |
| + | 50 (21.1%) | 11 (16.7%) | 16 (21.9%) | 23 (23.5%) | |
| Radiological parameters | |||||
| Preoperative | |||||
| TK (°) | 26.21 ± 17.76 | 27.03 ± 15.19 | 29.06 ± 16.88 | 0.647 | |
| LL (°) | 16.24 ± 15.01 | 20.34 ± 13.22 | 24.63 ± 15.01 | 0.421 | |
| PT (°) | 23.01 ± 9.05 | 23.87 ± 8.59 | 25.46 ± 8.87 | 0.632 | |
| PI (°) | 55.72 ± 10.21 | 56.42 ± 11.13 | 58.30 ± 10.85 | 0.744 | |
| SVA (cm) | 7.53 ± 5.01 | 9.01 ± 5.91 | 11.06 ± 6.07 | 0.711 | |
| PI-LL (°) | 31.75 ± 11.34 | 29.59 ± 10.23 | 27.61 ± 10.02 | 0.598 | |
| TL/L curve Cobb angle (°) | 32.07 ± 2.11 | 33.27 ± 1.91 | 33.42 ± 2.09 | 0.814 | |
| Postoperative | |||||
| TK (°) | 30.17 ± 15.49 | 30.94 ± 16.01 | 31.35 ± 16.47 | 0.842 | |
| LL (°) | 24.35 ± 13.89 | 25.29 ± 13.47 | 27.79 ± 14.38 | 0.726 | |
| PT (°) | 24.24 ± 10.51 | 28.05 ± 8.34 | 32.19 ± 8.79 | 0.421 | |
| PI (°) | 47.99 ± 9.99 | 49.93 ± 11.08 | 52.24 ± 11.28 | 0.541 | |
| SVA (cm) | 5.26 ± 3.72 | 6.53 ± 4.03 | 7.06 ± 4.10 | 0.506 | |
| PI-LL (°) | 23.64 ± 9.16 | 24.64 ± 8.89 | 24.45 ± 9.42 | 0.876 | |
| TL/L curve Cobb angle (°) | 21.11 ± 4.23 | 22.47 ± 4.21 | 26.18 ± 5.08 | 0.387 | |
Perioperative Outcome Data in the Three Groups
Table 4 shows the comparison of each perioperative outcome between the three groups. The mean length of stay (LOS) was 10.88 (standard deviation 3.06), 12.63 (4.32), and 13.99 (3.50) in the A, B, and C groups (P < .001). Pairwise comparisons indicated a positive correlation between increased symptom duration and prolonged postoperative LOS. Similarly, the mean drainage volume shows the same trend. In terms of postoperative physiological function recovery, the groups also differed significantly in terms of Foley discontinuation postoperative day (POD) and 1st ambulation on POD (P < .001); however, 1st bowel movement on POD was not significant between the groups. Pairwise comparisons revealed that both Foley catheter discontinuation and first ambulation were delayed as symptom duration increased (only the 1st bowel movement on POD was not significant between the groups; P > .05). For postoperative complications, we can see that all groups have significant statistical significance in severe complications, and minor complications (P < .05). Pairwise comparisons between groups revealed that the complications for severe complications, and minor complications were significantly greater as symptom duration was significantly greater (all complications were not significant between the B and C groups; P > .05). For postoperative 90-day readmission, we can see that all groups have significant statistical significance (P < .05). Pairwise comparisons between groups revealed that the 90-day readmission was significantly greater as symptom duration was significantly greater (only significant between the A and C groups; P < .05).
Table 4.
Comparison of Perioperative Outcomes in the A, B and C Groups
| Group A | Group B | Group C | P value | P value | |||
|---|---|---|---|---|---|---|---|
| A vs B | A vs C | B vs C | |||||
| Length of stay, days, mean ± SD | 10.88 ± 3.06 | 12.63 ± 4.32 | 13.99 ± 3.50 | <0.001 | 0.005 | <0.001 | 0.017 |
| Drainage volume(ml) | 949.95 ± 303.91 | 1147.33 ± 474.05 | 1292.93 ± 480.70 | <0.001 | 0.008 | <0.001 | 0.032 |
| Physiological function recovery | |||||||
| Foley discontinuation POD | 3.07 ± 2.09 | 3.74 ± 2.11 | 4.49 ± 2.18 | <0.001 | 0.006 | <0.001 | 0.004 |
| 1st ambulation on POD | 2.18 ± 1.66 | 3.03 ± 2.02 | 4.24 ± 2.09 | <0.001 | 0.002 | <0.001 | 0.001 |
| 1st bowel movement on POD | 3.53 ± 1.72 | 3.72 ± 1.98 | 3.76 ± 1.48 | 0.234 | 0.365 | 0.144 | 0.742 |
| Complications | |||||||
| Severe complications | 9 (13.6%) | 21 (28.8%) | 34 (34.7%) | 0.011 | 0.030 | 0.003 | 0.412 |
| Mild complications | 17 (25.8%) | 39 (53.4%) | 57 (58.2%) | 0.039 | 0.028 | 0.016 | 0.913 |
| Non-home discharge, n (%) | 7 (10.6%) | 6 (8.2%) | 10 (10.2%) | 0.872 | 0.629 | 0.937 | 0.659 |
| 90-days readmission rates, n (%) | 1 (1.5%) | 6 (8.2%) | 12 (12.2%) | 0.016 | 0.013 | 0.007 | 0.396 |
| 90-days reoperation, n (%) | 2 (3.0%) | 5 (6.8%) | 8 (8.2%) | 0.406 | 0.304 | 0.178 | 0.748 |
Clinical Outcomes in all Groups
Table 5 shows the comparison of each clinical outcome between the three groups. There was no significant difference in the preoperative VAS scores for preoperative back pain and leg pain between these three groups (P > 0.05). The results were consistent in post hoc analyses. Postoperative and 2-years follow-up VAS scores differed significantly in terms of back pain (P < 0.001) and leg pain (P < .001). Pairwise comparisons between groups demonstrated that postoperative and 2-years follow-up back pain and leg pain in group C were significantly worse than in group A (P < .001, respectively). There were significant differences in postoperative and 2-years follow-up ODI, EQ-5D, and SF-36 scores between groups (P < .05). Pairwise comparison between groups showed that postoperative and 2-years follow-up ODI and SF-36 PCS in group A were significantly better than in group B or C (P < .05 for all comparisons, respectively), but those in group B were not significantly worse than those in group C (P > .05, respectively). Pairwise comparison between groups showed that postoperative and 2-years follow-up EQ-5D and SF-36 MCS in group A were significantly better than in group C (P < .05 for all comparisons, respectively), but those in group B were not significantly worse than those in groups A or C (P > .05, respectively).
Table 5.
Comparison of VAS, EQ-5D, SF-36 and ODI in the A, B and C Groups
| Group A | Group B | Group C | P value | P value | ||||
|---|---|---|---|---|---|---|---|---|
| A vs B | A vs C | B vs C | ||||||
| VAS, mean ± SD | ||||||||
| Pain (low back) | Pre | 6.41 ± 0.74 | 6.47 ± 0.63 | 6.44 ± 0.64 | 0.880 | 0.614 | 0.778 | 0.792 |
| Post | 1.95 ± 0.85 | 2.21 ± 0.90 | 2.45 ± 0.75 | <0.001 | 0.074 | <0.001 | 0.047 | |
| Post-Pre | −4.45 ± 1.23 | −4.26 ± 1.17 | −3.99 ± 1.14 | 0.011 | 0.013 | 0.007 | 0.137 | |
| 2 years follow-up | 1.68 ± 0.55 | 1.98 ± 0.71 | 2.15 ± 0.59 | <0.001 | 0.051 | <0.001 | 0.039 | |
| Pain (leg) | Pre | 6.07 ± 0.73 | 6.28 ± 0.75 | 6.22 ± 0.73 | 0.108 | 0.053 | 0.103 | 0.584 |
| Post | 1.50 ± 0.71 | 1.86 ± 0.87 | 2.23 ± 0.81 | <0.001 | 0.008 | <0.001 | 0.003 | |
| Post-Pre | −4.57 ± 1.07 | −4.42 ± 1.09 | −3.99 ± 1.09 | <0.001 | 0.108 | <0.001 | 0.022 | |
| 2 years follow-up | 1.32 ± 0.56 | 1.67 ± 0.71 | 2.01 ± 0.74 | <0.001 | 0.006 | <0.001 | 0.007 | |
| ODI %, mean ± SD | Pre | 55.75 ± 5.59 | 55.01 ± 4.12 | 54.78 ± 3.04 | 0.541 | 0.875 | 0.586 | 0.601 |
| Post | 11.79 ± 4.83 | 19.72 ± 4.03 | 25.24 ± 3.21 | <0.001 | 0.023 | <0.001 | 0.106 | |
| Post-Pre | −43.96 ± 5.03 | −35.29 ± 4.11 | −29.54 ± 3.37 | 0.001 | 0.011 | 0.001 | 0.087 | |
| 2 years follow-up | 10.71 ± 4.24 | 17.72 ± 4.13 | 22.23 ± 4.01 | 0.001 | 0.043 | <0.001 | 0.213 | |
| EQ-5D, mean ± SD | Pre | 0.52 ± 0.19 | 0.51 ± 0.21 | 0.49 ± 0.22 | 0.346 | 0.284 | 0.146 | 0.542 |
| Post | 0.86 ± 0.17 | 0.81 ± 0.18 | 0.78 ± 0.19 | 0.003 | 0.112 | 0.001 | 0.346 | |
| Post-Pre | 0.34 ± 0.21 | 0.30 ± 0.23 | 0.29 ± 0.22 | 0.011 | 0.242 | 0.008 | 0.754 | |
| 2 years follow-up | 0.89 ± 0.16 | 0.82 ± 0.15 | 0.80 ± 0.18 | 0.002 | 0.092 | 0.001 | 0.271 | |
| SF-36 PCS, mean ± SD | Pre | 30.04 ± 3.59 | 29.12 ± 3.78 | 27.31 ± 3.65 | 0.124 | 0.564 | 0.107 | 0.462 |
| Post | 58.76 ± 3.89 | 43.09 ± 4.78 | 37.30 ± 4.21 | <0.001 | 0.012 | <0.001 | 0.135 | |
| Post-Pre | 28.72 ± 3.66 | 13.97 ± 4.97 | 9.99 ± 4.06 | <0.001 | 0.005 | <0.001 | 0.342 | |
| 2 years follow-up | 59.89 ± 4.16 | 51.21 ± 3.95 | 42.83 ± 4.02 | <0.001 | 0.012 | <0.001 | 0.009 | |
| SF-36 MCS, mean ± SD | Pre | 29.42 ± 4.01 | 29.14 ± 3.89 | 28.01 ± 3.67 | 0.565 | 0.886 | 0.203 | 0.468 |
| Post | 48.15 ± 4.03 | 41.42 ± 3.76 | 37.21 ± 3.89 | <0.001 | 0.241 | <0.001 | 0.452 | |
| Post-Pre | 18.73 ± 4.21 | 12.28 ± 4.01 | 9.20 ± 3.97 | <0.001 | 0.294 | <0.001 | 0.541 | |
| 2 years follow-up | 50.08 ± 3.76 | 42.11 ± 3.87 | 36.12 ± 3.54 | <0.001 | 0.057 | <0.001 | 0.232 | |
| Achieved MCID, n (%) | ||||||||
| Achieved MCID for ODI | 54 (81.8%) | 49 (67.1%) | 52 (53.1%) | <0.001 | 0.048 | <0.001 | 0.064 | |
| Achieved MCID for VAS-low back | 56 (84.8%) | 53 (72.6%) | 61 (62.2%) | 0.007 | 0.080 | 0.002 | 0.155 | |
| Achieved MCID for VAS-leg | 55 (83.3%) | 52 (71.2%) | 63 (64.3%) | 0.009 | 0.051 | 0.003 | 0.338 | |
| Achieved MCID for EQ-5D | 56 (84.8%) | 51 (69.9%) | 60 (61.2%) | 0.004 | 0.010 | 0.002 | 0.143 | |
The proportion of patients who achieved MCID in the 2-years follow-up VAS, ODI, and EQ-5D scores differed significantly (P < .05). Pairwise comparison between groups showed that the greater the symptom duration, the significantly lower the proportion of achieved MCID (all groups were significant between group A and C, and only ODI and EQ-5D were significant between group A and B; P < .05). In addition, we included the possible influencing factors (P < .05) of unachieved MCID into the multivariate logistic regression analysis, and the results are shown in Table 6. Individuals with Age-Adjusted Charlson Comorbidity Index (ACCI) > 4, greater than 1 year but less than 2 years (ref greater than 6 months but less than 1 year), 2 years or more (ref greater than 6 months but less than 1 year), positive preoperative screen for depression, the number of levels fused ≥ 5 and mean EBL in mL were independent risk factors for unachieved MCID in the VAS-leg and VAS-back at the 2-years follow-up. Individuals with ACCI > 4, greater than 1 year but less than 2 years (ref greater than 6 months but less than 1 year), 2 years or more (ref greater than 6 months but less than 1 year), equal with back and leg pain, positive preoperative screen for depression, mean EBL in mL, and previous spine surgery were independent risk factors for unachieved MCID in the ODI and EQ-5D at 2 years follow-up.
Table 6.
Logistic Regression Model for Predictive Factors of Non-achievement VAS, ODI and EQ-5D of MCID
| Non-Achievement VAS-Leg of MCID | Non-Achievement VAS-Back of MCID | Non-Achievement ODI of MCID | Non-Achievement EQ-5D of MCID | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Variable | OR | 95% Cl | P value | OR | 95% Cl | P value | OR | 95% Cl | P value | OR | 95% Cl | P value |
| ACCI>4 | 1.01 | 1.00-1.02 | 0.037 | 1.07 | 1.01-1.34 | 0.047 | 1.84 | 1.34-2.27 | 0.040 | 1.21 | 1.01-1.84 | 0.045 |
| Symptom duration (Ref: Greater than 6 months but less than 1 year) | ||||||||||||
| Greater than 1 year but less than 2 years | 1.03 | 1.01-1.06 | 0.047 | 1.32 | 1.00-1.51 | 0.034 | 1.35 | 1.11-1.67 | 0.029 | 1.09 | 1.04-1.13 | 0.018 |
| 2 years or more | 1.36 | 1.24-1.49 | 0.011 | 2.03 | 1.74-3.65 | 0.004 | 2.14 | 1.15-2.89 | 0.013 | 1.25 | 1.21-1.28 | 0.009 |
| Equal with back and leg pain | * | * | * | * | * | * | 1.02 | 1.01-1.05 | 0.039 | 1.30 | 1.02-1.46 | 0.024 |
| Positive preoperative screen for depression | 1.03 | 1.00-1.09 | 0.038 | 1.36 | 1.24-1.59 | 0.013 | 1.28 | 1.24-1.46 | 0.021 | 1.87 | 1.46-2.01 | 0.034 |
| Preoperative ODI | 1.21 | 0.98-1.38 | 0.476 | * | * | * | 1.33 | 0.87-1.47 | 0.289 | 1.03 | 0.92-1.21 | 0.421 |
| Preoperative EQ-5D | * | * | * | 1.45 | 0.67-1.68 | 0.721 | 1.11 | 0.99-1.28 | 0.134 | * | * | * |
| Preoperative SF-36 | ||||||||||||
| PCS | 1.04 | 0.79-1.14 | 0.341 | * | * | * | 1.05 | 0.86-1.22 | 0.345 | 1.23 | 0.95-1.36 | 0.462 |
| MCS | 1.32 | 0.92-1.45 | 0.264 | 1.42 | 0.85-1.64 | 0.624 | 1.25 | 0.75-1.68 | 0.416 | 1.40 | 0.88-1.42 | 0.451 |
| Number of levels fused ≥ 5 | 1.48 | 1.09-2.64 | 0.007 | 2.01 | 1.87-3.21 | 0.008 | 1.23 | 1.11-1.48 | 0.011 | 1.03 | 0.45-1.32 | 0.316 |
| Spinal osteotomy ≥ 2 | 1.36 | 0.98-2.01 | 0.754 | 1.34 | 1.21-1.52 | 0.031 | 1.48 | 0.79-2.01 | 0.491 | 1.13 | 0.87-1.35 | 0.267 |
| Mean EBL in mL | 1.03 | 1.00-1.07 | 0.024 | 1.32 | 1.07-1.84 | 0.032 | 1.68 | 1.23-2.34 | 0.046 | 1.48 | 1.23-1.79 | 0.035 |
| Previous spine surgery | 1.02 | 0.57-1.36 | 0.457 | 1.24 | 0.57-1.87 | 0.624 | 1.65 | 1.04-1.89 | 0.034 | 1.74 | 1.67-1.98 | 0.032 |
Patient Satisfaction Rate and Fulfilled Expectation Rate
At the 6-month follow-up, 92.7% of patients were satisfied, and 74.3% of patients were fulfilled expectations with their surgery; at the 1-year follow-up, 86.1% of patients were satisfied, and 69.4% of patients were fulfilled expectations with their surgery; at the 2-years follow-up, 82.0% of patients were satisfied, and 67.5% of patients were fulfilled expectations with their surgery; there was a positive statistically significant association (P = .03) between 1-year and 2-years satisfaction rates and fulfilled expectation rates (Table 7).
Table 7.
Percentage of Satisfaction and Fulfilled Expectation at 6-Month, 1 and 2-Year Stratified by Duration of Symptoms
| Satisfaction 6-months (%) | Satisfaction 1-year (%) | Satisfaction 2-years (%) | Fulfilled expectation 6-months (%) | Fulfilled expectation 1-year (%) | Fulfilled expectation 2-years (%) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Group A | 97.9 | X2 = 1.912, df = 2, P = 0.384 | 92.4 | X2 = 6.305, df = 2, P = 0.013 | 91.9 | X2 = 7.911, df = 2, P = 0.009 | 81.8 | X2 = 3.193, df = 2, P = 0.203 | 81.3 | X2 = 6.618, df = 2, P = 0.037 | 80.3 | X2 = 9.911, df = 2, P = 0.007 |
| Group B | 92.2 | 86.7 | 82.9 | 74 | 68.5 | 69.9 | ||||||
| Group C | 89.6 | 79.4 | 71.2 | 69.4 | 62.2 | 57.1 | ||||||
| 92.7 | 86.1 | 82.0 | 74.3 | 69.4 | 67.5 | |||||||
There was a positive significant association between 1-year and 2-years change symptom duration and satisfaction and fulfilled expectation rates as shown in Table 7 (P < .05). In addition, possible influencing variables (P < .05) were included in the logistic regression model, and the results are shown in Table 8. Individuals with Greater than 1 year but less than 2 years (Ref Greater than 6 months but less than 1 year), 2 years or more (Ref Greater than 6 months but less than 1 year), Unachieved MCID for VAS-back, ODI, and achieved EQ-5D, and Δ SF-36 PCS were independent risk factor for satisfaction at 6-months, 1-year and 2-years follow-up. Individuals with Greater than 1 year but less than 2 years (Ref Greater than 6 months but less than 1 year), 2 years or more (Ref Greater than 6 months but less than 1 year), Unachieved MCID for Vas-leg, ODI, and achieved EQ-5D, ΔSF-36 MCS were independent risk factor for fulfilled expectation at 6-months, 1-year and 2-years follow-up. The positive preoperative screen for depression was independent risk factor for fulfilled expectation at 1-year and 2-years follow-up.
Table 8.
Logistic Regression Model for Predictive Factors of Satisfaction and Fulfilled Expectation at 6 Months, 1 year and 2 years Follow-Up
| Satisfaction 6-months | Satisfaction 1-year | Satisfaction 2-years | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Variable | OR | 95% Cl | P value | OR | 95% Cl | P value | OR | 95% Cl | P value |
| Symptom duration (Ref: Greater than 6 months but less than 1 year) | |||||||||
| Greater than 1 year but less than 2 years | 0.78 | 0.26-0.98 | 0.023 | 0.71 | 0.24-0.88 | 0.034 | 0.59 | 0.31-0.72 | 0.019 |
| 2 years or more | 0.58 | 0.24-0.69 | 0.011 | 0.67 | 0.36-0.89 | 0.008 | 0.79 | 0.21-0.98 | 0.004 |
| Previous surgery | 0.17 | 0.04-0.68 | 0.028 | * | * | * | 0.68 | 0.47-0.79 | 0.037 |
| Unachieved MCID for VAS-Back | 0.35 | 0.13-0.66 | 0.018 | 0.75 | 0.67-0.89 | 0.034 | 0.67 | 0.42-0.92 | 0.016 |
| Unachieved MCID for ODI | 0.46 | 0.23-0.71 | 0.042 | 0.49 | 0.18-0.67 | 0.019 | 0.75 | 0.34-0.95 | 0.017 |
| Achieved MCID for EQ-5D | 2.59 | 1.87-3.06 | 0.025 | 3.58 | 1.47-5.31 | 0.020 | 4.98 | 2.72-5.04 | 0.017 |
| Δ SF-36 PCS | 1.23 | 1.21-1.26 | 0.021 | 1.89 | 1.54-2.03 | 0.016 | 1.62 | 1.34-1.79 | 0.009 |
| Fulfilled expectation | 1.68 | 1.21-1.49 | 0.034 | 1.59 | 1.57-1.62 | 0.021 | 1.74 | 1.43-1.89 | 0.011 |
Discussion
This single-center retrospective study investigated the association between symptom duration and postoperative outcomes in elderly patients with adult spinal deformity undergoing thoracolumbar fusion surgery. Our analysis demonstrated significant correlations between prolonged symptom duration (≥2 years) and unfavorable postoperative outcomes. Specifically, patients with symptom durations of 1-2 years and ≥2 years showed comparatively poorer PROs, lower achievement rates of the MCID for VAS, ODI, and EQ-5D assessments, along with reduced satisfaction levels and diminished expectation fulfillment compared to those with ≤1 year of symptoms. These findings collectively establish a clear dose-response relationship between symptom chronicity and clinical outcomes, particularly evident through PROs, patient satisfaction metrics, and expectation fulfillment at follow-up evaluations. Patients with symptom duration ≥2 years show particularly significant performance deficits in multiple outcome domains. Early intervention based on the patient’s symptom presentation and diagnosis may lead to better postoperative outcomes.
Our findings show that expeditious surgical intervention may benefit patients in achieving favorable outcomes. However, our evidence does not suggest a causal relationship between symptom duration and outcomes, as there were no formal nonoperative groups for the intervals investigated Adult spinal deformity, as a dynamic condition characterized by evolving symptomatology, often allows adult patients to endure symptoms for prolonged periods. In elderly patients with adult spinal deformity, diminished pain sensitivity associated with age-related physiological decline frequently results in delayed diagnosis and treatment compared to younger populations. 23 Current understanding remains unclear regarding the impact of symptom duration on surgical outcomes and the critical time threshold for intervention. Existing research presents conflicting conclusions: Sayari et al found no correlation between symptom duration and clinical/radiographic outcomes, advocating for extended conservative management to avoid surgery, 24 while Kristen E. Radcliff et al identified significantly worse clinical outcomes when symptoms persisted beyond one year. 25 This study investigated perioperative outcomes in elderly adult spinal deformity patients stratified by symptom duration. Specifically, our study builds upon this by demonstrating a clear relationship in ASD, preoperative symptom duration significantly influenced multiple surgical parameters including hospital length of stay, complication rates, and functional recovery. 25 Our analysis revealed that patients with ≥2 years of symptom duration experienced notably prolonged length of stay (P < .05), higher complication incidence, and delayed physiological recovery compared to those with ≤1 year of symptoms. The observed differences in perioperative outcomes among groups with varying symptom durations—including longer hospital stay, increased blood loss, delayed Foley catheter removal, and higher 90-day readmission rates—likely arise from a combination of pathophysiological, functional, and systemic mechanisms. Patients with chronic symptoms (≥2 years) often demonstrate advanced degenerative changes, greater neuromuscular deconditioning, and more complex compensatory spinal alignment, which may increase operative difficulty and physiological stress despite comparable surgical extent. These biological factors may contribute to delayed mobilization and slower recovery of autonomic function, as reflected by postponed Foley catheter removal. Functionally, these patients also exhibited lower baseline SF-36 PCS and higher ODI scores, indicating diminished physical reserve, which has been consistently linked to slower rehabilitation and prolonged hospitalization. The lower proportion of patients achieving MCID further supports this interpretation. Finally, the elevated 90-day readmission rate in this cohort is likely multifactorial, reflecting both a greater complication burden and possible deficits in postoperative support or compliance. Collectively, these findings highlight that prolonged symptom duration negatively affects perioperative recovery and short-term outcomes, underscoring the potential benefit of early surgical intervention once conservative management fails. At the moment, these findings emphasize the importance of timely intervention in elderly spinal deformity management. Our findings should be interpreted within the context of the study population, which included only patients who had already failed conservative treatment and met the surgical indications for ASD correction. Therefore, the results do not suggest that every patient with early symptoms should proceed directly to surgery, but rather indicate that among candidates for surgical treatment, delaying surgery after the establishment of surgical indications may lead to inferior postoperative outcomes.
The study results reveal a noteworthy negative correlation between the duration of preoperative symptoms and postoperative clinical outcomes in adults with spinal deformity. This is similar to the results of the study by Devin CJ et al, in which the authors used the Quality Outcomes Database and used multivariate regression to determine the effect of preoperative symptom characteristics (location, severity, and duration) on postoperative outcomes. 26 Outcome-reported symptom duration and baseline numeric rating scale for leg pain were the most significant predictors of achieving MCID, which is consistent with our findings. Patients with symptoms lasting more than 2 years are less likely to achieve MCID than those with symptoms lasting less than 2 years. In addition, we performed a multivariate regression model analysis for patients who did not achieve MCID. The results showed that the duration of symptoms was >1 year but <2 years, and the duration of symptoms was ≥2 years, which were independent risk factors compared with the duration of symptoms ≤1 year. Furthermore, in a retrospective study by Travis Hamilton, MD et al, on the effect of symptom duration on outcomes after lumbar surgery, 27 the authors found that symptom duration ≥1 year was associated with worse outcomes on multiple outcome measures. In line with this finding, we also found that patients with symptoms lasting more than 2 years had worse outcomes than those with symptoms lasting less than 1 year in the study.
Patient satisfaction is a crucial metric in assessing value-based healthcare. By identifying the factors that drive satisfaction, healthcare providers can pinpoint patients who may be less likely to experience improvement following spinal surgery, thereby preemptively addressing potential dissatisfaction in cases of suboptimal surgical outcomes.28,29 Recognizing these satisfaction drivers offers the opportunity to enhance outcomes through targeted interventions. Patient satisfaction is affected by many factors, such as BMI and smoking habits. 30 In this study, we followed up on the satisfaction at 6 months, 1 year, and 2 years after surgery and explored its driving factors. We found that the longer the duration of symptoms, the worse the postoperative satisfaction, and the difference was statistically significant at 1 and 2 years of follow-up. The results of the multivariate regression model again showed that the duration of symptoms was an independent risk factor for satisfaction at different follow-up periods. At the same time, postoperative outcome indicators (unachieved MCID for VAS, ODI) were correlated with satisfaction. Satisfaction-related baseline variables such as fulfilled expectation: Patients with fulfilled expectations were more likely to be satisfied.
In the context of adult spinal deformity, a significant proportion of patients often hold high expectations for spinal surgery prior to undergoing the procedure. 31 Consequently, many opt for conservative treatments initially, leading to an extended duration of their condition. Mayilee Canizares et al observed in their study that as the duration of symptoms increases, patients’ preoperative expectations tend to rise, which paradoxically correlates with poorer postoperative pain management and physiological function recovery. 32 This suggests a potential positive relationship between the duration of symptoms and preoperative expectations, where heightened preoperative expectations may diminish the likelihood of expectation fulfillment. Consistent with these findings, our study analyzed the rate of expectation fulfillment across different follow-up periods and discovered that a longer duration of symptoms was associated with a decreased possibility of expectation fulfillment. This correlation was statistically significant at both 1-year and 2-years follow-ups. Furthermore, multivariate regression analysis of unfulfilled expectations across various follow-up periods revealed that the duration of preoperative symptoms served as an independent risk factor for unmet expectations. Specifically, a longer duration of symptoms was predictive of a lower probability of achieving postoperative expectations.
One of the key strengths of this study lies in its comprehensive retrospective analysis of 237 adult patients with spinal deformity, coupled with continuous patient follow-up, which enhances the study’s validity and mitigates potential unknown inherent biases. By employing a multivariate regression model, we were able to rigorously analyze postoperative MCID attainment, satisfaction, and expectation fulfillment, accurately identifying the relevant risk factors. However, it is important to acknowledge the limitations of this study. Firstly, specific to our study, there are no data on the reason for the length of time between onset of symptoms and eventual surgery. Whether there were delays in diagnosis, overuse of nonoperative treatment, delays in insurance approval, OR scheduling issues, or simply patient choice to delay surgery or consulting with a surgeon is largely unknown, and any of these would influence outcomes differently. Our results should be interpreted with this in mind given the potential heterogeneity within the symptom duration cohorts. Secondly, one of the limitations of this study is its relatively small sample size and single-center design, which may restrict the generalizability of the findings. Thirdly, this study included only patients who underwent surgery after failed conservative management; therefore, patients who remained on non-operative treatment were not evaluated. Consequently, our results reflect outcomes among surgical candidates rather than the broader symptomatic ASD population. At the moment, although radiographic alignment parameters were controlled for as covariates in our regression models, the potential impact of residual sagittal malalignment at the individual level remains a limitation of this study. Another limitation is this study did not account for pre-operative treatments and medications, such as chronic opioid use, which has been previously associated with poorer pain outcomes in ASD patients. The retrospective design and inconsistent medical record documentation precluded us from accurately quantifying the type and duration of conservative treatments or the extent of narcotic consumption before surgery. Given that preoperative narcotic use has been associated with poorer postoperative outcomes, future prospective studies should collect these data systematically to better understand their impact on surgical prognosis. Also, the onset and duration of symptoms were based on patient recall documented in the EMR, which may be subject to recall bias. However, this approach is consistent with prior retrospective studies and provides a clinically reasonable estimate of symptom chronicity in ASD patients. Lastly, this study did not distinguish the symptom characteristics, location and severity of symptoms in detail, which may have potential impact on the generalization of the present findings, the potential influence should be taken into account when interpreting our results. In the future, we propose prospective cohort studies incorporating mixed-methods approaches (e.g., patient interviews, healthcare system audits) to elucidate root causes of delays. Despite these limitations, we maintain that our study findings are broadly generalizable and contribute valuable insights into the relationship between symptom duration and postoperative outcomes in elderly patients with adult spinal deformity. At the moment, our findings provide foundational epidemiological evidence to prioritize high-risk subgroups for targeted interventions while more nuanced causal investigations are developed.
Conclusion
In summary, a symptom duration of ≥2 years was associated with poorer PROs, patient satisfaction, physical function recovery, and fulfilled expectations. Our analysis suggests a need for lumbar surgeries to be performed prior to 1 year of symptom duration in order to maximize patient outcomes. An emphasis on timely referrals after failure of conservative measures is of great import to provide the surgical care that these patients may need.
Acknowledgements
We thank the Department of Orthopedics, Xuanwu Hospital Capital Medical University staff and all the patients who participated in the study.
Appendix.
Abbreviations
- ASD
Adult spinal deformity
- LOS
length of stay
- BMI
body mass index
- ASA
American Society of Anesthesiologists
Footnotes
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Capital’s Funds for Health Improvement and Research (No.2024-1-2012), the Beijing Hospitals Authority’s Ascent Plan [No. DFL20190802], National Key Research and Development Program of China (No. 2020YFC2004900), and Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support [No. XMLX202116]. The funders played no role in the design of this study, the collection, analysis and interpretation of data or preparation of the manuscript.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
ORCID iDs
Qingyang Huang https://orcid.org/0009-0000-1320-2558
Peng Cui https://orcid.org/0000-0002-1636-4832
Xiaolong Chen https://orcid.org/0000-0002-8128-0969
Shibao Lu https://orcid.org/0000-0001-7052-7041
Ethical Considerations
The study protocol was validated by the institutional review board in Xuanwu Hospital Capital Medical University (2018086). A written informed consent was obtained from all the participants in this study.
Data Availability Statement
The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.*
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.*