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STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the outcomes of patients with adult spinal deformity (ASD) following spinal fusion with the lowest instrumented vertebra (LIV) at L4/L5 versus S1/ilium. METHODS: A multicenter ASD database was evaluated. Patients were categorized into 2 groups based on LIV levels-groups L (fusion to L4/L5) and S (fusion to S1/ilium). Both groups were propensity matched by age and preoperative radiographic alignments. Patient demographics, operative details, radiographic parameters, revision rates, and health-related quality of life (HRQOL) scores were compared. RESULTS: Overall, 349 patients had complete data, with a mean follow-up of 46 months. Patients in group S (n = 311) were older and had larger sagittal and coronal plane deformities than those in group L (n = 38). After matching, 28 patients were allocated to each group with similar demographic, radiographic, and clinical parameters. Sagittal alignment restoration at postoperative week 6 was significantly better in group S than in group L, but it was similar in both groups at the 2-year follow-up. Fusion to S1/ilium involved a longer operating time, higher PJK rates, and greater PJK angles than that to L4/L5. There were no significant differences in the complication and revision rates between the groups. Both groups showed significant improvements in HRQOL scores. CONCLUSIONS: Fusion to S1/ilium had better sagittal alignment restoration at postoperative week 6 and involved higher PJK rates and greater PJK angles than that to L4/L5. The clinical outcomes and rates of revision surgery and complications were similar between the groups.

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STUDY DESIGN: Comparative cohort study. OBJECTIVE: Factors that influence the lower instrumented vertebra (LIV) selection in adult cervical deformity (ACD) are less reported, and outcomes in the cervicothoracic junction (CTJ) and proximal thoracic (PT) spine are unclear. METHODS: A prospective ACD database was analyzed using the following inclusion criteria: LIV between C7 and T5, upper instrumented vertebra at C2, and at least a 1-year follow-up. Patients were divided into CTJ (LIV C7-T2) and PT groups (LIV T3-T5) based on LIV levels. Demographics, operative details, radiographic parameters, and the health-related quality of life (HRQOL) scores were compared. RESULTS: Forty-six patients were included (mean age, 62 years), with 22 and 24 patients in the CTJ and PT groups, respectively. Demographics and surgical parameters were comparable between the groups. The PT group had a significantly higher preoperative C2-C7 sagittal vertical axis (cSVA) (46.9 mm vs 32.6 mm, P = 0.002) and T1 slope minus cervical lordosis (45.9° vs 36.0°, P = 0.042) than the CTJ group and was more likely treated with pedicle-subtraction osteotomy (33.3% vs 0%, P = 0.004). The PT group had a larger correction of cSVA (-7.7 vs 0.7 mm, P = 0.037) and reciprocal change of increased T4-T12 kyphosis (8.6° vs 0.0°, P = 0.001). Complications and reoperations were comparable. The HRQOL scores were not different preoperatively and at 1-year follow-up. CONCLUSIONS: The selection of PT LIV in cervical deformities was more common in patients with larger baseline deformities, who were more likely to undergo pedicle-subtraction osteotomy. Despite this, the complications and HRQOL outcomes were comparable at 1-year follow-up.

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BACKGROUND: To analyze the impact of spino cranial angle (SCA) on alteration of cervical alignment after multi-level anterior cervical discectomy fusion (ACDF) and explore the relationship between SCA and health-related quality of life (HRQOL) scores. MATERIAL AND METHODS: In total, 49 patients following multi-level ACDF for multi-level cervical spondylotic myelopathy (MCSM) with more than 2 years follow-up period were enrolled. Radiographic data including SCA were measured. Receiver operating characteristics (ROC) curve analysis was applied to confirm the optimal cut-off values of SCA for predicting sagittal balance. Patients were divided into two groups on the basis of the cut-off value of preoperative SCA. Correlation coefficients were analyzed between SCA and HRQOL scores. RESULTS: Optimal cut-off values for predicting sagittal balance was SCA of 88.6°. Patients with higher SCA, no matter preoperatively, postoperatively and at follow-up, got lower T1-Slope (T1s), C2-C7 lordosis angle (CA) and higher △SCA (pre vs post: p = 0.036, pre vs F/U: p = 0.022). Simultaneously, pre-SCA, post-SCA, and F/U-SCA in the high SCA group were positively correlated with the pre-NDI, post-NDI, and F/U-NDI scores respectively (pre: p < 0.001, post: p = 0.015, F/U: p = 0.003). However, no correlation was performed in the low SCA group. CONCLUSION: An excessive SCA can be considered to cause poorer clinical outcomes at preoperative and better correction after surgery. The SCA could be used as a new reference value to determine sagittal balance parameters of the cervical spine and to assess the quality of life.

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OBJECTIVE: Preoperative pain assessment is often used to gauge the amount of disability in patients with lumbar disc herniation. How high preoperative pain scores impact the clinical course and outcomes of patients after lumbar microdiscectomy is not always clear. Here, the authors aimed to determine whether patients reporting higher preoperative pain scores have worse outcomes after lumbar microdiscectomy than those reporting lower preoperative scores. METHODS: The authors performed a retrospective review of patients with symptomatic lumbar disc herniations that had failed to improve with nonsurgical methods and who had undergone tubular lumbar microdiscectomy. Health-related quality of life (HRQOL) scores had been collected in the preoperative and postoperative period. The anatomical severity of disease was graded based on lumbar disc health (Pfirrmann classification), facet degeneration, thecal sac cross-sectional area, and disc herniation grade. Data on each patient's narcotic consumption and length of stay were collected. A Student t-test and chi-square test were used to compare patients with high preoperative pain scores (HP cohort) and those with lower preoperative scores (non-HP cohort). RESULTS: One hundred thirty-eight patients were included in this analysis. The 47 patients in the HP cohort had taken more preoperative opioids (12.0 ± 21.2 vs 3.6 ± 11.1 morphine equivalent doses, p = 0.01). However, there was no statistically significant difference in Pfirrmann classification (p > 0.15), facet grade (p > 0.11), thecal sac cross-sectional area (p = 0.45), or disc herniation grade (p = 0.39) between the HP and non-HP cohorts. The latter cohort had statistically significant higher preoperative PROMIS scores (36.5 ± 7.0 vs 29.9 ± 6.4, p < 0.001), SF-12 mental component summary scores (48.7 ± 11.5 vs 38.9 ± 16.1, p < 0.001), and SF-12 physical component summary scores (PCS; 32.4 ± 8.6 vs 27.5 ± 10.0, p = 0.005), but a lower Oswestry Disability Index (56.4 ± 22.1 vs 35.4 ± 15.5, p < 0.001). There were only two time points after microdiscectomy when the HP cohort had worse HRQOL scores: at the 2-week follow-up for SF-12 PCS scores (32.4 ± 8.6 vs 29.3 ± 7.1, p = 0.03) and the 12-week follow-up for PROMIS scores (45.2 ± 9.5 vs 39.5 ± 7.1, p = 0.01). All other postoperative HRQOL measurements were similar between the two cohorts (p > 0.05). CONCLUSIONS: A patient's perceived severity of disease often does not correlate with the actual clinical pathology on imaging. Although patients who report high pain and have a symptomatic lumbar disc herniation may describe their pain as more extreme, they should be counseled that the outcomes of microdiscectomy are positive.

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BACKGROUND CONTEXT: Patients with severe cervical deformity (CD) often have profound deficits in numerous activities of daily living. The association between health status and postoperative radiographic goals is difficult to quantify. PURPOSE: We aimed to investigate the radiographic characteristics of patients who achieved optimal health related quality of life scores following surgery for CD. STUDY DESIGN: We performed a retrospective review of a prospectively collected database of patients with spinal deformity. PATIENT SAMPLE: One hundred and fifty-three patients with cervical deformity OUTCOME MEASURES: Common health-related quality of life scores (HRQOLs) measurements were taken for patients treated operatively for cervical deformity including neck disability index (NDI), modified Japanese Orthopaedic Association scale (mJOA) for myelopathy and numeric rating scale for neck pain (NRS-neck), METHODS: Surgical patients with severe CD were isolated based upon a previously presented discriminant analysis which outlined a combination of preoperative cervical sagittal vertical axis (cSVA), T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. Those with available preoperative and 1-year postoperative HRQL data were included. Based on a previous study, patients were grouped into three distinct sagittal morphotypes of CD: focal deformity (FD), flat neck (FN = large TS-CL and lack of compensation), or cervicothoracic (CT). Postoperative outcomes were defined as "good" if a patient had ≥2 of the three following criteria (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Within each distinct deformity group, patients with good outcomes were compared to those with poor outcomes (ie, not meeting the criteria for good) for differences in demographics, HRQOL scores, and alignment, via Chi-squared or student's t tests. RESULTS: Overall, 83 of 153 patients met the criteria of severe CD and 40 patients had complete 1-year follow-up of clinical/radiographic data. Patient breakdown by deformity pattern was: CT (N=13), FN (N=17), and FD (N=17), with 7 patients meeting criteria for both FD and FN deformities. Within the FD cohort, maximal focal kyphosis (ie, kyphosis at one level) was better corrected in patients with a "good" outcome (p=.03). In the FN cohort, patients with "good" outcomes presented preoperatively with worse horizontal gaze (McGregor Slope 21° vs. 6°, p=.061) and cSVA (72 mm vs. 60 mm, p=.030). "Good" outcome FN patients showed significantly greater postop correction of horizontal gaze (-25° vs. -5°, p=.031). In the CT cohort, patients with "good" outcomes had superior global alignment both pre- (SVA: -17 mm vs. 108 mm, p<.001) and postoperatively (50 mm vs. 145 mm, p=.001). CT patients with "good" outcomes also had better postop cervical alignment (cSVA 35 mm vs. 49 mm, p=.030), and less kyphotic segments during extension (p=.011). In the FD cohort, there were no differences between "good" and "poor" outcomes patients in preoperative alignment; however, "good" outcome patients showed superior changes in postoperative focal kyphosis (-2° vs. 5°, p=.030). Within all three deformity pattern categories, there were no differences between "good" and "poor" outcome patients with respect to demographics or surgical parameters (levels fused, surgical approach, decompression, osteotomy, all p>.050). CONCLUSIONS: The results of this study show each CD patient's unique deformity must be carefully examined in order to determine the appropriate alignment goals to achieve optimal HRQOLs. In particular, the recognition of the sagittal morphotype can help assist surgeons to aim for specific alignment goals for CT, FN and FD. Distinct deformity specific intra-operative goals include obtaining proper sagittal global/cervical alignment for cervicothoracic patients, correcting maximal focal kyphosis in focal deformity patients, and correcting horizontal gaze for flatneck patients.

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PURPOSE: To assess pain, health-related quality of life (HRQOL) scores and sagittal parameters of adult spinal deformity (ASD)-operated patients in the context of their analgesic consumption especially opioids (narcotics) over the first year postoperative period. METHODS: In total, 372 patients from a multicenter database were stratified into 3 groups at baseline: 241 patients in the minimal group (no analgesic, or NSAIDs/narcotics weekly or less), 64 in the NSAIDs every day group and 67 in the narcotics every day group. HRQOL and back and leg pain scores were evaluated at 6 months and 1 year postoperatively. Also several sagittal alignment parameters were assessed. RESULTS: Significant improvements in pain and HRQOL scores were observed across all 3 groups by 1 year (P < 0.05) postoperatively. While the minimal group had the best pre- and postoperative HRQOL scores, the NSAID group demonstrated the best improvement in HRQOL. Only the minimal group displayed continued improvement from 6 months to 1 year. 90%, 65% and 40% of minimal, NSAID and narcotic groups of patients, respectively, no longer took any analgesics at 1 year postoperatively. Alternatively, 36% of patients in the narcotics group continued to take narcotics at 1 year. Residual malalignment increased NSAIDs consumption in different groups at 1 year. CONCLUSION: This study evaluated the analgesics use after ASD surgery in relation to the clinical and radiological outcomes. Despite important postoperative opioids consumption in the narcotics group, clinical outcome yet improved. Malalignment parameters demonstrated a predictive value in regard to NSAIDs' usage. These slides can be retrieved under Electronic Supplementary Material.

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BACKGROUND: Lumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD. PURPOSE: To analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in health-related quality of life scores (HRQoL) after MLD. STUDY DESIGN/SETTING: Retrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a 2-year period. PATIENT SAMPLE: Eighty-eight patients receiving MLD treatment for HNP. OUTCOME MEASURES: Cephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, gray, or mixed); Baseline (BL); and 3-month (3M) postoperative HRQoL scores. METHODS: Patients >18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID-). The MCID for PROMIS pain intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi-squared tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID- groups. RESULTS: There were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% female). PROMIS pain interference and pain intensity were strongly correlated with ODI and VAS Back/Leg (R≥0.505), and physical function correlated with ODI and VAS Back/Leg (R=-0.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were gray disc appearance, HNP area (>116.6 mm2), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a gray HNP MRI signal than a mixed or black HNP MRI signal in five out of six HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID- patients had in five out of six HRQoL score comparisons (116.6 mm2±46.4 vs 90.0 mm2±43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID- patients had in four out of six HRQoL score comparisons (51.8%±14.7 vs 43.9%±14.9, p<.05). CONCLUSIONS: Patients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7× more likely to have a gray MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient-reported improvement after MLD.

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We developed a predictive model to describe risk factors for complications in cervical deformity surgeries. Cervical deformity (CD) surgical patients are growing in number, but remain under-studied in the literature. CD was defined as at least one of the following: C2-C7 Cobb >10°, CL >10°, cSVA >4 cm, CBVA >25°. Patient demographics and clinical data were assessed as risk factors for medical/surgical complications using multivariate regression models. 123 patients underwent CD surgery (60.6 yrs, 60.8% F). The most common complications were neurologic (24.4%), dysphagia (13.0%), cardiopulmonary (11.4%), infection (9.7%). 51 (41.5%) of patients experienced a medical complication and 73 (59.3%) had a surgical complication. An overall complication was predicted with high accuracy (AUC = 0.79) by the following combinations of factors: higher baseline EQ5D pain and lower baseline EQ5D anxiety/depression scores, and higher cervical and global SVA. A medical complication can be predicted by male gender, baseline mJOA score, and cervical SVA (AUC = 0.770). A surgical complication can be predicted by higher estimated blood loss, lower anxiety scores, and larger global SVA (AUC = 0.739). 64.2% of patients undergoing cervical deformity correction sustained any complication. While the most reliable predictor of the occurrence of a complication involved a cluster of risk factors, a radiographic baseline sagittal parameter of cervical SVA was the strongest isolated predictor for complications across categories. Although these findings are specific to a cervical population with moderate to severe deformities, collectively they can be utilized for pre-operative risk assessment and patient education.

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STUDY DESIGN: A single-center, retrospective cohort study. OBJECTIVE: To predict patient-reported outcomes (PROs) using preoperative health-related quality-of-life (HRQoL) scores by quantifying the correlation between them, so as to aid selection of surgical candidates and preoperative counselling. METHODS: All patients who underwent single-level elective lumbar spine surgery over a 2-year period were divided into 3 diagnosis groups: spondylolisthesis, spinal stenosis, and disc herniation. Patient characteristics and health scores (Oswestry Low Back Pain and Disability Index [ODI], EQ-5D, and Short Form-36 version 2 [SF-36v2]) were collected at 6 and 24 months and compared between the 3 diagnosis groups. Multivariate modelling was performed to investigate the predictive value of each parameter, particularly preoperative ODI and EQ-5D, on postoperative ODI and EQ-5D scores for all the patients. RESULTS: ODI and EQ-5D at 6 and 24 months improved significantly for all patients, especially in the disc herniation group, compared to the baseline. The magnitude of improvement in ODI and EQ-5D was predictable using preoperative ODI, EQ-5D, and SF-36v2 Mental Component Score. At 6 months, 1-point baseline ODI predicts for 0.7-point increase in changed ODI, and a 0.01-point increase in baseline EQ-5D predicts for 0.01-point decrease in changed EQ-5D score. At 24 months, 1-point baseline ODI predicts for 1-point increase in changed ODI, and a 0.01-point increase in baseline EQ-5D predicts for 0.009-point decrease in changed EQ-5D. A younger age is shown to be a positive predictor of ODI at 24 months. CONCLUSIONS: Poorer baseline health scores predict greater improvement in postoperative PROs at 6 and 24 months after the surgery. HRQoL scores can be used to decide on surgery and in preoperative counselling.

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Objective To investigate the health related quality of life score [primary biliary cholangitis (PBC)-40] in patients with PBC,and the relationship between PBC-40 and clinical presentations.Methods The PBC-40 score and clinical presentations in PBC patients (n=65) were adapted in this study.Patients were divided into the untreated group and the treated group,and the treated group was further divided into ursodesoxycholic acid (UDCA) response group and UDCA non-response group.PBC-40 scores of different groups were analyzed by t-test and the relationship between PBC-40 and clinical presentations were analyzed with Pearson's test.Results Dimensions of PBC-40 scores of this group of patients were as follows:symptoms were (15.8±4.1) points,itch was (4.9±2.8) points,atigue was (23.8±8.9) points,cognitive dysfunction score was (11.4±4.7) points,social activity score was (17.0±7.5) points,and the emotion score was (6.5±3.1) points.The untreated group had higher emotion scores than the treated group (t=2.024,P=0.045).Compared with the UDCA response group,UDCA non-response group had higher scores in cognitive,social and emotion dimension (t =2.126,2.309,2.062,respectively,P=0.039,0.025,0.045,respectively).Itch score was significantly correlated with total bilirubin (TBil),direct bilirubin (DBil),alkaline phosphatase (ALP) and total bile acid (TBA) (r=0.349,0.345,0.324,0.427,respectively,P＜0.01),while the social scores were correlated with TBil,DBil,aspartate aminotransferase (AST) and TBA (r=0.361,0.383,0.316,0.331,P＜0.01) and emotion scores were associated with ALT,TBil,GGT,ALP,AST and TBA (r=0.332,0.430,0.265,0.326,0.297,0.353,P＜0.05).ConclusionPBC-40 can be used as a health-related quality of life assessment for PBC patients inChinese population.Itch,social and emotion dimensions are correlated with clinical activity indicators.Hyperbilirubin,ALP and TBA can predict low health quality of life in PBC patients.Conclusion PBC-40 can be used as a health-related quality of life assessment for PBC patients in Chinese population.Itch,social and emotion dimensions are correlated with clinical activity indicators.Hyperbilirubin,ALP and TBA can predict low health related quality of life in PBC patients.

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PURPOSE: ASD is assessed radiologically with the spinopelvic parameters and clinically with HRQOL scores. The revision rate after ASD surgery is high and usually occurs during the first or second postoperative year. The aim of this study is to find clinical or radiological factors that could predict revision surgery in the second postoperative year. MATERIALS AND METHODS: Inclusion criterion: ASD patients operated on by instrumented posterior fusion with more than 2 years follow-up were enrolled prospectively. Additional criterion was no revision surgery during the first postoperative year. From a multicenter database of 560 operated ASD patients, 164 patients met these criteria. The patients were divided into two groups depending on the need of revision surgery during the second postoperative year. Preoperative, 6-month, 1-year and 2-year data were collected and compared for both groups. RESULTS: A total of 22 patients needed revision surgery and 142 did not. All revisions were for mechanical complications (non-fusion and implant related). Preoperatively, there was a significant difference between the groups (no revision vs. revision) for age (48 vs. 60 years), ODI (37 vs. 53), and SVA (29 vs. 76 mm), respectively. At 6 months, a significant difference in sagittal alignment was found, though HRQOL scores were similar. At 1 year, the no revision group scores improved, whereas the revision group scores remained stable or worsened. At 2 years, the no revision group scores remained stable. Comparing 6- and 12-month data, patients with improved, stable and worsened HRQOL scores had 8, 15 and 28% revision rates, respectively. CONCLUSION: The revision rate at the second-year post-surgery (13.4%) remains high and demonstrated that a 2-year follow-up is mandatory. In addition to usual risk factors for mechanical complications in ASD surgery, stabilization or worsening of the HRQOL scores between the 6th and 12th month postop was highly predictive of revision rate. This observation is beneficial for ASD patient follow-up as clinical symptoms clearly precede mechanical failure.

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INTRODUCTION: Surgical management for lumbar stenosis is generally safe and provides significant improvements in pain, disability, and function. Successful lumbar decompression hinges on removing an appropriate amount of lamina and other compressive pathology in the lateral recess. Too little bony decompression can result in persistent pain and disability, while over resection of the pars and/or facets may jeopardize spinal stability. CASE REPORT: In this unique report, we present for the first time an acute iatrogenic grade 4 L5-S1 spondylolisthesis distal to a L3-5 laminectomy and circumferential instrumented fusion due to bilateral iatrogenic L5 pars fractures and its management and clinical outcomes after revision operation. The patient presented with worsening pain, neurologic compromise, and severe sagittal imbalance. The iatrogenic, high-grade spondylolisthesis was urgently addressed with a L5-S1 anterior lumbar interbody fusion and extension of posterior instrumentation to the pelvis, which resulted in considerable pain relief, resolution of neurologic deficits, and reconstitution of acceptable sagittal imbalance. CONCLUSION: All attempts during a lumbar decompression should be made to prevent iatrogenic pars fractures, as they may result in severe sagittal imbalance, neurologic compromise, and persistent disability. Iatrogenic, high-grade L5-S1 spondylolisthesis can be successfully treated with reduction using circumferential fusion of the lumbosacral junction.

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BACKGROUND CONTEXT: Many radiological parameters have been reported to correlate with patient's disability including sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL). European literature reports other parameters such as lumbar lordosis index (LLI) and the global tilt (GT). If most parameters correlate with health-related quality of life scores (HRQLs), their impact on disability remains unclear. PURPOSE: This study aimed to validate these parameters by investigating their correlation with HRQLs. It also aimed to evaluate the relationship between each of these sagittal parameters and HRQLs to fully understand the impact in adult spinal deformity management. STUDY DESIGN: A retrospective review of a multicenter, prospective database was carried out. PATIENT SAMPLE: The database inclusion criteria were adults (>18 years old) presenting any of the following radiographic parameters: scoliosis (Cobb ≥20°), SVA ≥5 cm, thoracic kyphosis ≥60° or PT ≥25°. All patients with complete data at baseline were included. OUTCOME MEASURES: Health-related quality of life scores, demographic variables (DVs), and radiographic parameters were collected at baseline. METHODS: Differences in HRQLs among groups of each DV were assessed with analyses of variance. Correlations between radiographic variables and HRQLs were assessed using the Spearman rank correlation. Multivariate linear regression models were fitted for each of the HRQLs (Oswestry Disability Index [ODI], Scoliosis Research Society-22 subtotal score, or physical component summaries) with sagittal parameters and covariants as independent variables. A p<.05 value was considered statistically significant. RESULTS: Among a total of 755 included patients (mean age, 52.1 years), 431 were non-surgical candidates and 324 were surgical candidates. Global tilt and LLI significantly correlated with HRQLs (r=0.4 and -0.3, respectively) for univariate analysis. Demographic variables such as age, gender, body mass index, past surgery, and surgical or non-surgical candidate were significant predictors of ODI score. The likelihood ratio tests for the addition of the sagittal parameters showed that SVA, GT, T1 sagittal tilt, PI-LL, and LLI were statistically significant predictors for ODI score even adjusted for covariates. The differences of R2 values from Model 1 were 1.5% at maximum, indicating that the addition of sagittal parameters to the reference model increased only 1.5% of the variance of ODI explained by the models. CONCLUSION: GT and LLI appear to be independent radiographic parameters impacting ODI variance. If most of the parameters described in the literature are correlated with ODI, the impact of these radiographic parameters is less than 2% of ODI variance, whereas 40% are explained by DVs. The importance of radiographic parameters lies more on their purpose to describe and understand the malalignment mechanisms than their univariate correlation with HRQLs.

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