What if You Could Treat the Same Patient Again,Would You do the Exact Same Spine Surgery? A Multi-Surgeon Survey of Their Own Revisions

Abstract

Study Design

Case-based survey.

Objectives

This study aims to investigate what a group of surgeons learned from their own revisions, and what they would do differently today.

Methods

A multi-center database of ASD surgical patients was queried to identify those with at least 2 surgical procedures performed by the same surgeon between 2009 and 2019. A clinical vignette was created for each case including demographics, a timeline of events, radiographs/measurements, patient-reported outcomes, complications, and surgical strategies used for the index and revision surgeries. The operative surgeon was then asked to fill out a five-question survey aimed at determining factors that contribute to operative decision-making and planning.

Results

86 patients were operated on by 6 participating surgeons for both index and revision ASD surgery. The revised patients had similar follow-up compared to the non-revised group (P = 0.73), with the most common complications indicating a need for revision surgery being proximal junctional failure (42%) and pseudoarthrosis (28%). Surgeons reported that they would not change their surgical strategy in 52.3% of the cases. The leading cause for revision was hardware/instrumentation issues (24.4%). Learning points included rod-related choice (23.3%), level selection (19.8), PJF prophylactic strategy (15.1%), and sagittal alignment objective (11.6%).

Conclusions

Surgeons saw opportunity in nearly half of the cases to improve outcomes by changing something in the original surgery. While 40% of the failures remained unexplained from the surgeons’ perspective, this study highlights the capacity for adopting changes in adult spinal deformity surgery and illuminates the reasoning behind certain surgical decisions.

Keywords

revision adult spinal deformity pseudoarthrosis proximal junctional failure

Introduction

Adult spinal deformity (ASD) is a spectrum of local, regional, and global three-dimensional abnormalities in the thoracic and lumbar spine that can result from degenerative changes, idiopathic scoliosis, trauma, or iatrogenic causes such as flatback syndrome.^1–4 ASD can exist across multiple age groups, however, it is closely linked with increased age and has a prevalence as high as 68% in subjects older than 60 years of age as determined by imaging studies, with a large proportion of those patients never seeking treatment.^4,5 Surgical treatment strategies for ASD vary based on the extent of deformity and are associated with substantial clinical benefit with regards to pain and disability in all health-related quality of life measures (HRQoL) compared with patients undergoing nonoperative treatment.^6,7 Despite these significant clinical benefits, ASD surgery is associated with high complication rates and rates of revision surgery at approximately 20% within 2 years.^8–10

According to the literature, revision surgery following adult spinal deformity surgery is often due to complications such as proximal junction failure, pseudoarthrosis, implant breakage, malalignment, and infection. With the recent expansion of ASD literature - 279 publications before 2015 compared to 1757 publications before 2022 (as per PubMed results for “Adult Spinal Deformity”) - and the use of a multidisciplinary team approach, there have been significant advancements in the treatment of these patients. The recent focus on optimizing preoperative modifiable risk factors has been shown to reduce postoperative complications and improve ASD surgery outcomes.¹¹ Additionally, reliable preoperative planning strategies, including patient-specific alignment targets and precise level selection, have been associated with fewer functional complications and better outcomes following ASD surgery.¹² However, there is still a discrepancy between research and clinical practice, possibly due to factors such as resistance to change, limited access to educational resources, the challenge of establishing new techniques, and the capacity and motivation for change.¹³

Tactics for productive conversations around changes rely on reception to constructive feedback, which is more readily accepted by surgeons in the setting of a discussion concerning problems encountered during surgery, while holding a follow-up discussion of specific errors is a necessary exercise that may be interpreted in a more threatening manner.^14,15 Moreover, studies have shown that people tend to exaggerate the subjective magnitude of their personal contributions when those actions are being observed,¹⁶ which may be insightful when surgeons are asked to comment on their own performance during an initially unsuccessful procedure. There has been research in general and colorectal surgery showing that surgeon self-review protocols led to constructive discussion, practice improvement, and a potential for large cost savings.^17,18 This process of self-review is important to discerning perception vs reality, with a prior investigation among gynecologic surgeons revealing an association between individuals that underestimated their own complication rate actually having a higher true complication rate as compared to their peers.¹⁹ To better understand the relationship between new practice guidelines, clinical outcomes, and surgeon feedback, a survey was generated to evaluate possible opportunities in the primary surgical treatment of ASD after surgeons were asked to analyze their own operations that required subsequent revision procedures.

Methods

The study population was selected from a prospective multi-center adult spinal deformity registry treated between 2009 and 2019. The database included data on baseline demographics, scoliosis films, and complications (ClinicalTrials.gov identifier: NCT00738439). IRB approvals were obtained from all collaborating institutions prior to subject enrollment, and informed consent was sought from all recruited patients for long-term follow-up. Inclusion criteria for the registry consisted of patients aged 18 or greater at the time of enrollment with a diagnosis of adult degenerative or idiopathic scoliosis meeting at least 1 of the following radiographic criteria of spinal deformity: coronal curvature of the spine greater than 20°, Sagittal Vertical Axis (SVA) > 5 cm, Pelvic Tilt >25°, and/or Thoracic kyphosis >60°. The current investigation only retained surgeons who contributed at least 50 cases and patients who sustained at least 2 consecutive spinal procedures while captured by the registry. For each of these patients, a detailed vignette was created and shared with the operating surgeons. These vignettes included patient demographics, all the relevant dates (inclusion, index surgery, revision surgery, and follow-up visits), dates and descriptions of all complications, detailed description of surgical procedures for the index and revision surgery, as well as coronal/sagittal scoliosis films, radiographic measurements, and PROMs for all visits from pre-op to post-revision surgery (Figures 1 and 2).

Figure 1.

Example of patient demographics and surgical data for primary and revision surgery sent to each surgeon for review of their own case.

Figure 2.

Example of pre-operative, post-operative, and post-revision radiographic data sent to surgeon for review.

For each of their own cases, the operating surgeon was asked to review these vignettes and to fill out a five-item questionnaire (Table 1) designed by the participating surgeons and capturing their most common questions. Surgeons were asked to respond to the free text question in their own words, without any character limits or any predefined themes. After data collection, responses were manually reviewed and analyzed by the research team without input from the operating surgeons to identify recurring themes, patterns, or topics. These identified themes were then used to create distinct categories ensuring comprehensive coverage of the dataset. The research team independently categorized each answer according to these established categories, keeping in mind that a specific answer could cover multiple categories. To ensure consistency across all answers, the categorization process was performed twice, and any discrepancies or uncertainties were resolved through discussion and consensus. The percentage of answers by category was reported overall as well as by surgeon or by reason for revision.

Table 1.

5 Item Questionnaire Sent to the Participating Surgeons.

#	Question
1	Based on what you know today, would you do the exact same surgery
2	Why was a revision procedure required (ie, indication)?
3	What do you think is the underlying cause that led to a requirement for revision surgery?
4	Are there particular circumstances or patient factors that played a role in requiring a revision procedure?
5	What did you learn from this case that others should be aware of (for example related to patient, strategy, or operative execution)?

Results

Cohort Description

The registry query identified 6 surgeons with 437 patients enrolled in the database between 2009 and 2019. Of these, 90 patients (20.6%) sustained a revision surgery, 4 by a different surgeon, and 86 by the same surgeon. The total follow-up period between the no revision group (9.3 months to 9.8 years) and the revision group (9.1 months to 9.1 years) showed no significant difference (P = 0.73). On average, the revision procedure occurred 429 days after the index procedure, ranging from zero days to 5.4 years.

Why was a revision procedure required?

According to the operating surgeons, the most common indication for a revision procedure was proximal junctional failure (PJF), with 36 patients making up 8.2% of the cohort and 42% of the revision cases. The second most common indication was pseudoarthrosis (24 patients), making up 5.5% of the cohort and 28% of the revision cases. When comparing the different surgeons, most surgeons had similar reasons for revision (approximately 40% PJF, 25% pseudoarthrosis), with only 1 surgeon having a higher incidence of revision for PJF (75%) than the other (Table 2).

Table 2.

Most Common Indications for Revision Procedure as Reported by Operating Surgeons.

	Surgeon 1	Surgeon 2	Surgeon 3	Surgeon 4	Surgeon 5	Surgeon 6	Total
Fusion too short					1 (4.5%)	1 (5.3%)	2 (2.3%)
Infection	1 (12.5%)				1 (4.5%)	3 (15.8%)	5 (5.8%)
LIV failure		1 (10.0%)			1 (4.5%)		2 (2.3%)
Painful implant		2 (20.0%)	3 (23.1%)		1 (4.5%)		6 (7.0%)
PJF	6 (75.0%)	3 (30.0%)	5 (38.5%)	7 (50.0%)	9 (40.9%)	6 (31.6%)	36 (41.9%)
Pseudoarthrosis	1 (12.5%)	2 (20.0%)	4 (30.8%)	4 (28.6%)	6 (27.3%)	7 (36.8%)	24 (27.9%)
Radiculopathy		1 (10.0%)		2 (14.3%)			3 (3.5%)
Technical issue		1 (10.0%)	1 (7.7%)	1 (7.1%)	2 (9.1%)	2 (10.5%)	7 (8.1%)
Other					1 (4.5%)		1 (1.2%)
Total	8 (9.3%)	10 (11.6%)	13 (15.1%)	14 (16.3%)	22 (25.6%)	19 (22.1%)

Underlying Cause Leading to Revision

When the operative surgeons were asked what underlying cause led to a need for revision surgery the most common associated cause was instrumentation issues (24.4%: broken rod, improper screw, malpositioned instrumentation, lack of interbody fusion (IBF), etc.…), degenerative and/or progression of deformity (20.0%: adjacent stenosis, PJF, aggravation SI joint, degenerative cascade, etc.…), bone quality (18.6%: osteoporosis, osteopenia, poor bone quality etc.…), alignment correction (18.6%: thoracic deformity not addressed, lordosis overcorrection, sagittal plane under-correction, L4-S1 under correction, etc.…) and biologic (17.4%: failed fusion, no posterior arthrodesis, pseudo, etc.…). The frequency of the underlying causes by most common indication for revision and by surgeon are reported in Table 3.

Table 3.

Summary of the Most Common Categories of Underlying Causes Leading to Revision Surgery. For Report Purpose, Reasons Were Classified Into 8 Categories: Bone Quality [Bone], Alignment Correction [Correction], Patients’ Comorbidities [Comor.], Biologic, Hardware Issues [Hardware], Adjacent Degeneration And/Or Progression [Degen/Prog], Muscle Quality [Muscle] or Other (for Those Not Fitting in Previous Categories).

	Bone	Correction	Comor	Biologic	Hardware	Degen/Prog	Muscle	Other
Overall (N = 86)	16 (18.6%)	16 (18.6%)	8 (9.3%)	15 (17.4%)	21 (24.4%)	17 (19.8%)	2 (2.3%)	8 (9.3%)
Infection (N = 5)								5 (100%)
Painful implant (N = 6)			2 (33.3%)	1 (16.7%)	1 (16.7%)	2 (33.3%)		1 (16.7%)
PJF (N = 36)	14 (38.9%)	13 (36.1%)	3 (8.3%)		5 (13.9%)	10 (27.8%)	2 (5.6%)	1 (2.8%)
Pseudo (N = 24)	1 (4.2%)	1 (4.2%)	2 (8.3%)	14 (58.3%)	9 (37.5%)	1 (4.2%)
Technical issue (N = 7)					6 (85.7%)	1 (14.3%)
Mix (N = 8)	1 (12.5%)	2 (25%)	1 (12.5%)			3 (37.5%)		1 (12.5%)
Surgeon 1 (N = 8)	5 (62.5%)		1 (12.5%)	1 (12.5%)		1 (12.5%)	2 (25%)	1 (12.5%)
Surgeon 2 (N = 10)	5 (50%)	1 (10%)	2 (20%)		3 (30%)	1 (10%)		1 (10%)
Surgeon 3 (N = 13)			1 (7.7%)	2 (15.4%)	1 (7.7%)	8 (61.5%)		1 (7.7%)
Surgeon 4 (N = 14)	4 (28.6%)	5 (35.7%)	1 (7.1%)		3 (21.4%)	2 (14.3%)
Surgeon 5 (N = 22)	2 (9.1%)	5 (22.7%)	1 (4.5%)	5 (22.7%)	6 (27.3%)	3 (13.6%)		2 (9.1%)
Surgeon 6 (N = 19)		5 (26.3%)	2 (10.5%)	7 (36.8%)	8 (42.1%)	2 (10.5%)		3 (15.8%)

Patient Factors and Circumstances Associated with Revision

The most common circumstances or patient factors determined by the operating surgeon to contribute to an increased likelihood of revision surgery was bone quality (16 patients, 18.6%) defined as osteoporosis and/or osteopenia. The next most common patient factor was pre-operative alignment defined as fixed cervical kyphosis, coronal malalignment, and sagittal imbalance (13 patients, 15.1%). Out of the entire cohort, 12 patients (14.0%) were thought to have comorbidities such as high BMI, frailty, and history of prior fusion that contributed to revision surgery. Technical decision-making such as the use of pedicle subtracting osteotomies (PSO), iliac fixation, screw diameter was thought to contribute to revision surgery in 12 patients (14.0%). Among this cohort of 86 patients, 35 (40.7%) had no specific factors associated with the need for revision procedure according to the operating surgeon.

Would You do the Exact Same Surgery?

Regarding whether or not the surgeons would perform the same procedure, overall, 52.3% (45) stated that they would do the same surgery today, with answers ranging from 31.6% to 84.6% (Table 4). After stratification by reason for revision, 100% of infection cases would be treated using the exact same surgery while only 37.5% of the cases revised for pseudoarthrosis would have the exact same surgery. 50% of the cases revised for PJF would be treated with the exact same surgery, with rates ranging from 33.3% to 100% depending on the surgeon.

Table 4.

Rate of “Yes” to the Question “Would You do the Exact Same Surgery?” Despite Knowing the Patient Underwent Reoperation. Rates Reported Overall, as Well as by Surgeon, Stratified by Reason for Revision, Underlying Cause Leading to Revision, and by Patient Factors or Circumstances Leading to Revision.

	Surgeon 1	Surgeon 2	Surgeon 3	Surgeon 4	Surgeon 5	Surgeon 6	Total
Overall	4/8 (50%)	5/10 (50%)	11/13 (84.6%)	8/14 (57.1%)	11/22 (50%)	6/19 (31.6%)	45/86 (52.3%)
Reason for revision
Infection	1/1 (100%)				1/1 (100%)	3/3 (100%)	5/5 (100%)
Painful implant		1/2 (50%)	2/3 (66.7%)		1/1 (100%)		4/6 (66.7%)
PJF	2/6 (33.3%)	1/3 (33.3%)	5/5 (100%)	4/7 (57.1%)	4/9 (44.4%)	2/6 (33.3%)	18/36 (50%)
Pseudo	1/1 (100%)	2/2 (100%)	3/4 (75%)	2/4 (50%)	0/6 (0%)	1/7 (14.3%)	9/24 (37.5%)
Tech issue		1/1 (100%)	1/1 (100%)	0/1 (0%)	2/2 (100%)	0/2 (0%)	4/7 (57.1%)
Mix		0/2 (0%)		2/2 (100%)	3/3 (100%)	0/1 (0%)	5/8 (62.5%)
Underlying cause leading to revision
Bone	1/5 (20%)	2/5 (40%)		4/4 (100%)	2/2 (100%)		9/16 (56.3%)
Correction		0/1 (0%)		1/5 (20%)	1/5 (20%)	0/5 (0%)	2/16 (12.5%)
Comor	0/1 (0%)	2/2 (100%)	0/1 (0%)	1/1 (100%)	1/1 (100%)	2/2 (100%)	6/8 (75.0%)
Biologic	1/1 (100%)		2/2 (100%)		1/5 (20%)	1/7 (14.3%)	5/15 (33.3%)
Hardware		3/3 (100%)	0/1 (0%)	1/3 (33.3%)	3/6 (50%)	0/8 (0%)	7/21 (33.3%)
Degen/Prog	1/1 (100%)	0/1 (0%)	8/8 (100%)	2/2 (100%)	2/3 (66.7%)	2/2 (100%)	15/17 (88.2%)
Muscle	0/2 (0%)						0/2 (0%)
Other	1/1 (100%)	0/1 (0%)	1/1 (100%)		2/2 (100%)	3/3 (100%)	7/8 (87.5%)
Patient factors and circumstance
None	1/1 (100%)	0/1 (0%)	11/11 (100%)	1/2 (50%)	6/14 (42.9%)	4/6 (66.7%)	23/35 (65.7%)
Bone quality	1/5 (20%)	2/4 (50%)		4/5 (80%)	2/2 (100%)		9/16 (56.3%)
Comorbidities	1/3 (33.3%)	1/2 (50%)	0/1 (0%)	2/4 (50%)	1/1 (100%)	1/1 (100%)	6/12 (50%)
Technical decision	1/1 (100%)	3/3 (100%)		0/1 (0%)	2/3 (66.7%)	0/4 (0%)	6/12 (50%)
Soft Tissue failure	0/2 (0%)					1/2 (50%)	1/4 (25%)
Alignment	0/1 (0%)	1/3 (33.3%)		1/1 (100%)	0/1 (0%)	0/7 (0%)	2/13 (15.4%)
Bio Grafting		1/1 (100%)	0/1 (0%)		1/2 (50%)	1/3 (33.3%)	3/7 (42.9%)
Musculoskeletal		1/2 (50%)		0/2 (0%)	0/1 (0%)		1/5 (20%)
Other	1/1 (100%)					0/1 (0%)	1/2 (50%)

With respect to the main underlying cause leading to revision, the operating surgeons surveyed would perform the exact same surgery for 88.2% of patients having a degeneration and/or progression of the disease, 33.3% of patients revised due to biologic, 33.3% of patients revised due to hardware/instrumentation reasons, and 12.5% of the patients revised due to alignment issue. 65.7% of patients with no particular factor or circumstance playing a role in revision would be treated using the exact same surgery. Alignment factor was found to have the smallest rate (15.4%) of surgeons answering yes to the question “Would you do the same surgery”. Half of the cases presenting risk factor or circumstance related to bone quality (56.3%), comorbidities (50%), technical decision (50%) and biologic/Grafting (42.9%) would receive the same surgery today. A large proportion of patients for whom surgeons would do the same surgery have no particular circumstances/factor playing a role (51.1%). (Table 4).

Learning Points

According to the operating surgeon, most cases (91.9%) led to a learning opportunity including rod related choice (23.3%: contouring, multi-rod construct for PSO or obesity, kickstand rod), level selection (19.8%: extended fusion to thoracic, choice of UIV, extension to cervical spine), PJF prevention (15.1%: tether, cement, thoracic rod contouring), correction related choice (11.6%: use of appropriate goal, transitional anatomy, correction and flexibility), patient selection (10.5%: patient optimization, frail patient and surgical treatment), bone quality (9.3%: osteoporosis, osteopenic), interbody fusion (9.3%: use of interbody lumbar expandable device in lower levels of fusion, IBF and PSO, cage material) and biologic (8.1%: use of BMP).

Discussion

In the cohort of patients included in this study, revision rates were found to be approximately 20%, a high rate consistent with the literature.^8-10 The most common indications for revision surgery were PJF and pseudoarthrosis at 41.9% and 27.9% respectively, with underlying causes of revisions determined to be instrumentation failure, degenerative or progression of deformity, and biologics. These underlying factors were further broken down into categories such as bone quality, alignment correction, comorbidities, and technical decisions (PSO, iliac fixation, screw, etc.…). Although revision rates were high, over half of the surgeons were congruent with the original choice of surgery, and reviewing their own cases provided a large opportunity for learning for almost every surgeon surveyed. To our knowledge, this is the first study investigating surgeons’ self-review of adult spinal deformity corrective surgery that required subsequent revision.

Research has shown that two-thirds of PJF occurs within 3 months after the initial surgery and around 80% of PJF presents within a year and a half,²⁰ with the median time to revision in ASD cases occurring at 308 days.⁹ Given this short timeframe, it is likely that the same surgeon will perform the revision procedure and will have the opportunity to adjust the approach. It is important to understand why 52% of surveyed surgeons maintain confidence in their choice of primary procedure, particularly because in 40% of cases, the reason for revision surgery remains unexplained. However, this confidence may not always reflect objective reality, as surgeons’ responses could be influenced by subjective perceptions and biases present at the time of the survey, leading to potential inaccuracies in reporting. Changing a surgeon’s behavior or thought process is inherently challenging and typically requires very significant circumstances to prompt a shift.²¹ Spinal alignment issues represented the smallest percentage of underlying cause for maintaining the original surgical strategy, while reasons such as bone degeneration, hardware failure, and biologics were cited as common indications. One area of justification for repeating the original procedure that was unanimously agreed upon was the treatment of infection. ASD specific research regarding technical aspects of ASD surgery such as multiple rod construct or the use of bone morphogenetic protein impact the risk of adverse outcomes and alter the quality of life of patients after surgery,^22,23 but infection itself is not an ASD-specific problem and thus is not wholly dependent on the particular technical approach utilized. Although there are high failure rates of primary ASD procedures, surgeons with access to updated guidelines are able to carefully evaluate options for treating patients, and new technologies are yet to be developed that may reduce the risks.

As our study showed, when surgeons were given another opportunity to critically review their own cases in a structured way, more than 90% of cases demonstrated a learning point for future implementation. The formula for making change in ASD surgery is clear, but it requires a multi-pronged approach; knowledge of new techniques, capacity for training and implementation of better solutions, demonstrated improvements in patient reported outcomes measurements, working within a well-resourced health system, and positive interpersonal interactions all lead to faster and more widespread uptake of a new practice^24–26. Even with a clear formula, strategies that have been implemented thus far have mixed opinions. Public outcome reporting has been shown in survey studies to be opposed by surgeons due to concerns of mistaking the context of information revealed during a review of cases.²⁷ Newer standardized education programs for both surgeons and patients have been created in accordance with national physician organizations like the American Orthopaedic Association (AOA) and are expanding to more clinic sites nationwide but are not yet widely implemented for adult spinal deformity. It may be the case that the learning curve for new concept integration is too steep to expect practicing surgeons to adapt in their already limited time.

The revision rates found in our study are in line with those found in literature over 10 year follow up periods,^8–10,28 and other investigations also observed PJF as the most common complication.^29,30 These complication rates further increase as more osteotomies are needed for correction,³¹ especially with confounding poor bone quality, osteoporosis, and other comorbidities.^10,32 In an attempt to mitigate the risk of instrumentation complications, recent research has focused on multi-rods techniques across three-column osteotomy sites, use of patient-specific alignment targets based on age, PI, and lordosis distribution, contouring the proximal extremity of the rod, and/or to create semi-rigid junctional fixation through the use of tethers and cement^33–38. Despite these complications and attempts at solutions, surgery remains the cornerstone of ASD management despite the increased risk for very sick patients.^12,39

The major limitations of this survey-based study include variance in surgical practice at the multiple institutions, the small sample size, and as such the limited statistical analysis. Survey questions were limited to objective findings unless necessary, but inherent recall or response biases may have been present. Although gathering responses from the same surgeons who performed the primary procedure allowed for continuity of responses and self-reflection, the sample size was only able to capture the cases of the 6 participating surgeons. Each of the 6 surgeons may be operating under differing circumstances with regards to patient population and institution policies as well, with variance not entirely represented by the data. Another challenge in collecting responses was the discrepancy in the time elapsed since the revision cases were completed and subsequently reviewed in this study. Some surgeons might have benefitted from being able to better recall a surgery that happened recently as opposed to those who performed revisions close to a decade ago. Additionally, there was no method of external validation for determining whether the reported indications for revision surgery by the performing surgeon were agreed upon by third parties, which limits the generalizability of the results. The majority support of the primary surgical approach in the majority of cases was perhaps due to the paucity of literature available for revision techniques, or similarities in the practice of surgeons operating to standards set by their shared institution, which may be a strength as the results could be focused into tangible points.

Future studies should focus on understanding the clinical reasons behind the failure of primary ASD surgery. Given that learning points were identified, this survey offers a useful exercise for health systems to adopt as they pursue quality improvement measures. Surgical decision making may be influenced in a positive manner via self-review if repeat surveys are administered to an individual surgeon in a private or deidentified manner and correctable patterns are identified. Surgeon behavior is not standardized across health systems and is dependent on training and experience, but this study emphasizes the need for continuous education and access to the latest information after fellowship to ensure the most up-to-date and effective care.

Conclusions

From this study we gained valuable key insights into the decision-making process for spine surgery to treat adult spinal deformity and factors that can influence the decision on revising the initial procedure. In this survey, the most common indications for revision surgery were PJF and pseudoarthrosis (42% and 28%, respectively). Surgeons most common evolving strategies were rod-related techniques, upper and lower instrumented vertebrae, PJF prophylactic strategy and better understanding of sagittal alignment objectives. Despite the large variability in their retrospective opinions about their own revisions, nearly 50% of cases saw opportunities for improvement. This learning potential will hopefully translate to better patient outcomes, and we need ongoing surgeon feedback loops to drive incremental change. ASD surgical treatment is continually evolving, and we must also ensure that surgeons are actively learning and training to adopt newer approaches to mitigate the need for revision surgery. Further research is needed to explore the clinical explanation as to why revision surgeries occurred in this patient population, specifically if no particular factors were identified.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Institutional Review Board

IRB approvals were obtained from all collaborating institutions (ClinicalTrials.gov identifier: NCT00738439).

ORCID iDs

Connor Sheehan

Renaud Lafage

Virginie Lafage

References

Choudhry

Ahmad

Verma

. Adolescent idiopathic scoliosis. Open Orthop J. 2016;10(1):143-154. doi:10.2174/1874325001610010143

Wilson

Buchowski

Bridwell

Lenke

. Post-traumatic deformity. In: ; 2012:369-384. doi:10.1016/B978-0-444-52137-8.00023-1

Diebo

Shah

Boachie-Adjei

, et al. Adult spinal deformity. Lancet. 2019;394(10193):160-172. doi:10.1016/S0140-6736(19)31125-0

Youssef

Orndorff

Patty

, et al. Current status of adult spinal deformity. Global Spine J. 2013;3(1):051-062. doi:10.1055/s-0032-1326950

Schwab

Dubey

Gamez

, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine. 2005;30(9):1082-1085. doi:10.1097/01.brs.0000160842.43482.cd

Ailon

Smith

Shaffrey

, et al. Patients with adult spinal deformity with previous fusions have an equal chance of reaching substantial clinical benefit thresholds in health-related quality of life measures but do not reach the same absolute level of improvement. World Neurosurgery. 2018;116:e354-e361. doi:10.1016/j.wneu.2018.04.204

Reid

DBC

Daniels

Ailon

, et al. Frailty and health-related quality of life improvement following adult spinal deformity surgery. World Neurosurgery. 2018;112:e548-e554. doi:10.1016/j.wneu.2018.01.079

Soroceanu

Burton

Oren

, et al. Medical complications after adult spinal deformity surgery. Spine. 2016;41(22):1718-1723. doi:10.1097/BRS.0000000000001636

Pitter

Lindberg-Larsen

Pedersen

Dahl

Gehrchen

. Revision risk after primary adult spinal deformity surgery: a nationwide study with two-year follow-up. Spine deformity. 2019;7(4):619-626. doi:10.1016/j.jspd.2018.10.006

10.

Varshneya

Stienen

Medress

, et al. Risk factors for revision surgery after primary adult thoracolumbar deformity surgery. Clinical spine surgery. 2022;35(1):E94-E98. doi:10.1097/BSD.0000000000001124

11.

Katiyar

Reyes

Coury

Lombardi

Sardar

. Preoperative optimization for adult spinal deformity surgery: a systematic review. Spine. 2024;49(5):304-312. doi:10.1097/BRS.0000000000004823

12.

Dalton

Mohamed

Akioyamen

Schwab

Lafage

. PreOperative planning for adult spinal deformity goals. Neurosurg Clin. 2023;34(4):527-536. doi:10.1016/j.nec.2023.06.016

13.

Grol

. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39:II46. doi:10.1097/00005650-200108002-00003

14.

Edmondson

. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 1996;32(1):5-28. doi:10.1177/0021886396321001

15.

Edmondson

. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999

16.

Steinmetz

Fishbach

Zhang

. Being observed magnifies action. J Pers Soc Psychol. 2016;111(6):852-865. doi:10.1037/pspi0000065

17.

Treacy

Toonson

Blackadder

. Effective peer review audit and identification of the surgeon outlier. ANZ J Surg. 2023;93(5):1176-1180. doi:10.1111/ans.18343

18.

Gordon

Obermair

. Potential hospital cost-savings attributed to improvements in outcomes for colorectal cancer surgery following self-audit. BMC Surg. 2010;10:4. doi:10.1186/1471-2482-10-4

19.

Milman

Murji

Matelski

Shirreff

. Accuracy of surgeon self-reflection on hysterectomy quality metrics. Obstet Gynecol. 2022;140(1):39-47. doi:10.1097/AOG.0000000000004841

20.

Yagi

King

Boachie-Adjei

. Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine. 2012;37(17):1479-1489. doi:10.1097/BRS.0b013e31824e4888

21.

Cunningham

Bakker

Parikh

Johal

Swiontkowski

. Physician behavior change: a systematic review. J Orthop Trauma. 2019;33(Suppl 7):S62-S72. doi:10.1097/BOT.0000000000001616

22.

Bourghli

Boissière

Kieser

, et al. Multiple-rod constructs do not reduce pseudarthrosis and rod fracture after pedicle subtraction osteotomy for adult spinal deformity correction but improve quality of life. Neurospine. 2021;18(4):816-823.

23.

Poorman

Jalai

Boniello

Worley

McClelland

Passias

. Bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2017;26(8):2094-2102. doi:10.1007/s00586-016-4841-5

24.

Telem

Dimick

Skolarus

. Dissecting surgeon behavior. Ann Surg. 2018;267(3):432-434. doi:10.1097/SLA.0000000000002506

25.

Arroyo

Gessert

Hitchcock

, et al. What promotes surgeon practice change? A scoping review of innovation adoption in surgical practice. Ann Surg. 2021;273(3):474-482. doi:10.1097/SLA.0000000000004355

26.

Gramlich

Sheppard

Wasylak

, et al. Implementation of Enhanced Recovery after Surgery: a strategy to transform surgical care across a health system. Implement Sci. 2017;12(1):67. doi:10.1186/s13012-017-0597-5

27.

Jarral

Baig

Pettengell

, et al. National survey of UK consultant surgeons’ opinions on surgeon-specific mortality data in cardiothoracic surgery. Circ Cardiovasc Qual Outcomes. 2016;9(4):414-423. doi:10.1161/CIRCOUTCOMES.116.002749

28.

Lafage

Fong

Klineberg

, et al. Complication rate evolution across a 10-year enrollment period of a prospective multicenter database. J Neurosurg Spine. 2022;36(6):1012. doi:10.3171/2021.10.SPINE21795

29.

Glattes

Bridwell

Lenke

Kim

Rinella

Edwards

. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine. 2005;30(14):1643-1649. doi:10.1097/01.brs.0000169451.76359.49

30.

Hart

McCarthy

Oʼbrien

, et al. Identification of decision criteria for revision surgery among patients with proximal junctional failure after surgical treatment of spinal deformity. Spine. 2013;38(19):E1223. doi:10.1097/BRS.0b013e31829fedde

31.

Ayhan

Aykac

Yuksel

, et al.

Safety and efficacy of osteotomies in adult spinal deformity: what happens in the first year?

Eur Spine J. 2016;25(8):2471-2479. doi:10.1007/s00586-015-3981-3

32.

Gupta

Cha

Schwab

, et al. Osteoporosis increases the likelihood of revision surgery following a long spinal fusion for adult spinal deformity. Spine J. 2021;21(1):134-140. doi:10.1016/j.spinee.2020.08.002

33.

Lafage

Schwab

Glassman

, et al. Age-Adjusted alignment goals have the potential to reduce PJK. Spine. 2017;42(17):1275-1282. doi:10.1097/BRS.0000000000002146

34.

Lafage

Smith

Elysee

, et al. Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications. Spine deformity. 2022;10(1):121-131. doi:10.1007/s43390-021-00397-1

35.

Sun

, et al. Correlation between lordosis distribution index, lordosis tilt, and occurrence of proximal junctional kyphosis following surgery for adult degenerative scoliosis. Society. 2022;31(2):267-274. doi:10.1007/s00586-021-07090-x. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research.

36.

Yang

Wang

, et al. Unmatched rod contouring at the proximal end predisposes to occurrence of junctional kyphosis in early-onset scoliosis patients undergoing traditional growing rods treatment. BMC Muscoskel Disord. 2022;23(1):624. doi:10.1186/s12891-022-05564-7

37.

Passias

Williamson

Joujon-Roche

, et al. The impact of lumbopelvic realignment versus prevention strategies at the upper-instrumented vertebra on rates of junctional failure following adult spinal deformity surgery. 2023. doi:10.1097/BRS.000000000000473

38.

Gupta

Farooqi

, et al. Use of multiple rods and proximal junctional kyphosis in adult spinal deformity surgery. J Neurosurg Spine. 2023;39(3):320-328. doi:10.3171/2023.4.SPINE23209

39.

Barone

Giudici

Martinelli

, et al. Mechanical complications in adult spine deformity surgery: retrospective evaluation of incidence, clinical impact and risk factors in a single-center large series. J Clin Med. 2021;10(9).