Appropriate Use Criteria in Adult Scoliosis

The management of adult spinal deformity is characterized by significant variability.1–3 Indications for surgery, preoperative preparations, intraoperative strategies, and postoperative care are variable between providers and within the community of physicians who care for patients with spinal disorders.4–6 The presence of variability is clear evidence of the absence of an evidence-based approach to care. A consensus on evaluation and management of adults with spinal deformity is challenging, and a monolithic approach to adult deformity would not be responsive to important considerations such as patient values and preferences, physician preferences and skills, and cost and value considerations.7,8 Appropriate use criteria are based upon assessment of care for specific scenarios, with appropriate care defined as care in which the expected benefits of treatment exceed the expected risks and costs of care. Appropriate care for adults with spinal deformity may encompass a broad range of approaches and strategies, and may be responsive to specific considerations and priorities of the patient, the care provider, and the health care system. The purpose of this presentation is to describe appropriate management of adult deformity across the spectrum of care, including preoperative, intraoperative, and postoperative considerations. The AOSpine Knowledge Forum Deformity performed a modified Delphi survey of 53 experienced spine deformity surgeons representing 24 countries. Surgeons rated appropriateness of procedures and management strategies. Procedures were defined as “inappropriate” when the expected negative consequences exceed the expected health benefit; “reasonable” when the balance of risk and benefit is unknown but a reasonable chance of positive benefit exists; and “appropriate” when the expected health benefit exceeds anticipated negative consequences by a wide margin. The study involved three Web-based surveys and one physical meeting. Consensus on each question required ≥70% agreement. Appropriate goals of surgery include improvements in mobility, pain, and neural function. Important preoperative considerations for which consensus was reached include history elements (symptoms, comorbidities, smoking, and prior surgery), physical examination, imaging with full-length standing films, bone quality, and cardiovascular and pulmonary testing. Consensus is greater for identifying inappropriate rather than appropriate surgical approaches. Long fusion with deformity correction is considered appropriate for patients with severe sagittal and coronal plane deformity and limited comorbidities. Decompression alone is viewed as inappropriate for patients with progressive deformity. Decompression alone and decompression with limited fusion is inappropriate for patients with sagittal plane deformity. Anterior column support has been deemed appropriate for patients with fusion above T12 to S1, pelvic fixation appropriate for patients with sagittal deformity and osteoporosis, pedicle subtraction osteotomy appropriate for patients with rigid deformity and no comorbidities, and percutaneous posterior fixation inappropriate for patients with more severe deformity in the coronal or sagittal plane. Local bone is the only material on which consensus was reached for use in adult deformity. Forum participants agreed that use of neuromonitoring with MEP and SSEP is appropriate in adult deformity reconstruction, postoperative mechanical prophylaxis is appropriate for patients with low risk of DVT, and chemical prophylaxis is appropriate for patients at high risk. They concur that return to sedentary work is appropriate within 3 months for patients with fusion in fewer than five segments and return to contact sports is inappropriate for patients with fusion in more than seven segments. Deformity of the spine is an important disorder affecting the adult spine, and management of spinal deformity accounts for a significant and increasing portion of our health care economy. Operative and nonoperative management of symptomatic adult spinal deformity is characterized by significant variability. The optimal strategy will lead to the greatest possible improvement in patient-reported health-related quality of life with the least risk and cost. An optimal choice of surgical approach requires consideration of patient preferences, values, comorbidities, and goals of care. Therefore, a monolithic or dogmatic approach to care is not appropriate, and each case requires informed choice in discussion between patient and physician. Appropriate care for adults with spinal deformity must be responsive to specific considerations of the patient, the care provider, and the health care system.

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