European Spine Journal (2020) 29:1340–1352

https://doi.org/10.1007/s00586-020-06365-z

ORIGINAL ARTICLE

What level of symptoms are patients with adult spinal deformity

prepared to live with? A cross‑sectional analysis of the 12‑month
follow‑up data from 1043 patients
A. F. Mannion1 · M. Loibl2 · J. Bago3 · A. Vila‑Casademunt4 · S. Richner‑Wunderlin1 · T. F. Fekete2 · D. Haschtmann2 ·
D. Jeszenszky2 · F. Pellisé3 · A. Alanay5 · I. Obeid6 · F. S. Pérez‑Grueso7 · F. S. Kleinstück2 · European Spine Study
Group (ESSG)4

Received: 12 September 2019 / Revised: 31 December 2019 / Accepted: 3 March 2020 / Published online: 18 March 2020
© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Introduction Previous studies suggest that a meaningful and easily understood measure of treatment outcome may be the
proportion of patients who are in a “patient acceptable symptom state” (PASS). We sought to quantify the score equivalent
to PASS for different outcome instruments, in patients with adult spinal deformity (ASD).
Methods We analysed the following 12-month questionnaire data from the European Spine Study Group (ESSG): Oswestry
Disability Index (ODI; 0–100); Numeric Rating Scales (NRS; 0–10) for back/leg pain; Scoliosis Research Society (SRS)
questionnaire; and an item “if you had to spend the rest of your life with the symptoms you have now, how would you feel
about it?” (5-point scale, dichotomised with top 2 responses “somewhat satisfied/very satisfied” being considered PASS+,
everything else PASS−). Receiver operating characteristics (ROC) analyses indicated the cut-off scores equivalent to PASS+.
Results Out of 1043 patients (599 operative, 444 non-operative; 51 ± 19 years; 84% women), 42% reported being PASS+ at
12 months’ follow-up. The ROC areas under the curve were 0.71–0.84 (highest for SRS subscore), suggesting the question-
naire scores discriminated well between PASS+ and PASS−. The scores corresponding to PASS+ were > 3.5 for the SRS
subscore (> 3.3–3.8 for SRS subdomains); ≤ 18 for ODI; and ≤ 3 for NRS pain. There were slight differences in cut-offs for
subgroups of age, treatment type, aetiology, baseline symptoms, and sex.
Conclusion Most interventions for ASD improve patients’ complaints but do not totally eliminate them. Reporting the
percentage achieving a score equivalent to an “acceptable state” may represent a more stringent and discerning target for
denoting treatment success in ASD.
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.

Results of ROC curve analyses to determine the score equivalent to PASS+

for SRS-16-item instrument (subscore and subdomain scores), NRS pain
(higher value of back pain or leg pain) and Oswestry Disability Index (ODI)

n* % AUC 95% CI Threshold Sens Spec

PASS+ for being % %
Key points PASS+ Take Home Messages
SRS subscore 1033 41.6% 0.84 0.81-0.86 > 3.5 78.4 75.0
1. In the spine field, outcome is commonly assessed in terms of "feeling 1. The "patient acceptable symptom state" (PASS), which focuses on "feeling well"
better" (achieving a minimal clinically important change in a PASS+, in a patient acceptable
SRS funcon 0.72 0.69-0.74 > 3.3 71.4 63.3 rather than just "feeling better", has been proposed as a meaningful and easily
questionnaire score) rather than "feeling well" (achieving a symptom symptom state - answers ‘very understood measure of treatment outcome.
satisfied’ and ‘somewhat satisfied’ on SRS pain 0.83 0.81-0.85 > 3.5 73.5 78.5
state that is considered acceptable). symptom-specific well-being item;
Sens sensitivity; Spec specificity
* some patients failed to complete all 2. In patients with degenerative or idiopathic adult spinal deformity (ASD), the
SRS self-image 0.83 0.80-0.85 > 3.3 75.1 76.6
2. We evaluated the "patient acceptable symptom state" (PASS) in the questionnaires or had missing
responses for some items, hence the
questionnaire scores equivalent to being in PASS were >3.5 for the SRS 16-item
patients with adult spinal deformity (ASD) and derived cut-off scores numbers are lower than 1043 for
some analyses. SRS mental 0.71 0.68-0.73 > 3.8 64.9 68.8
subscore (>3.3 to >3.8 for the four SRS subdomains); ≤ 18 for ODI; and ≤3 for
commensurate with being "in PASS" for different questionnaires. health NRS pain.

3. The relative influence of factors such as age, gender, aetiology of ASD, NRS pain 971 39.5% 0.83 0.80-0.85 ≤ 3.0 68.2 83.0 3. Reporting the percentage of patients achieving a score equivalent to an
treatment-type, and baseline symptom severity on PASS cut-off scores “acceptable state” may represent a more stringent and discerning target for
ODI 1029 41.5% 0.79 0.76-0.81 ≤ 18 67.3 76.0
was quantified. denoting treatment success in ASD.

Mannion AF, Loibl M, Bago J, Vila-Casademunt A, Richner-Wunderlin S, Fekete TF, Haschtmann D, Mannion AF, Loibl M, Bago J, Vila-Casademunt A, Richner-Wunderlin S, Fekete TF, Haschtmann D, Mannion AF, Loibl M, Bago J, Vila-Casademunt A, Richner-Wunderlin S, Fekete TF, Haschtmann D,
Jeszenszky D, Pellisé F, Alanay A, Obeid I, Pérez-Grueso FS, Kleinstück FS, European Spine Study Group Jeszenszky D, Pellisé F, Alanay A, Obeid I, Pérez-Grueso FS, Kleinstück FS, European Spine Study Group Jeszenszky D, Pellisé F, Alanay A, Obeid I, Pérez-Grueso FS, Kleinstück FS, European Spine Study Group
(ESSG) (2020) What level of symptoms are patients with adult spinal deformity prepared to live with? (ESSG) (2020) What level of symptoms are patients with adult spinal deformity prepared to live with? (ESSG) (2020) What level of symptoms are patients with adult spinal deformity prepared to live with?
A cross-sectional analysis of the 12-month follow-up data from 1043 patients. Eur Spine J; A cross-sectional analysis of the 12-month follow-up data from 1043 patients. Eur Spine J; A cross-sectional analysis of the 12-month follow-up data from 1043 patients. Eur Spine J;

Electronic supplementary material The online version of this

article (https​://doi.org/10.1007/s0058​6-020-06365​-z) contains
supplementary material, which is available to authorized users.

Extended author information available on the last page of the article

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European Spine Journal (2020) 29:1340–1352
Keywords Patient acceptable symptom state · Adult spinal deformity · Scoliosis Research Society (SRS) instrument ·
Oswestry Disability Index · Pain Numeric Rating Scale
Introduction
It is now commonly accepted that the outcome of elec-
tive spine surgery should be patient reported [1]. Self-
administered questionnaires represent the current gold
standard for evaluating symptom status, disability, self-
image, and health-related quality of life and have become
an indispensable part of the patient-assessment procedure.
However, the scores and their changes after treatment can
at times be difficult to interpret in a clinically meaning-
ful and understandable manner [2] and the statistical sig-
nificance of group mean changes may paint an unrealistic
picture of the success of treatment [3]. There is an increas-
ing demand for the reporting of health outcomes using
concepts that are relevant to the individual patient and are
readily understood by clinicians, e.g. binary measures of
“good” or “poor” outcome.
Most spine interventions result in some improvement
in patients’ complaints, but this may not suffice—in view
of the accompanying risks—especially for the complex
procedures typical of adult spinal deformity (ASD) sur-
gery. For these reasons, the concepts of the “minimal clini-
cally important change score ­(MCICimp)” [4, 5] or score
reflecting “substantial clinical benefit” (SCB) [6] have
become popular for quantifying the achievement of “rel-
evant” improvement. However, the best methods to be used
for determining the MCIC or SCB, whether statistical or
anchor-based, are controversial [3], and there is no consen-
sus on the interpretation of what constitutes “important” or
“meaningful”, and “to whom” or “for what” [7]. Further,
it is known that the achievement of a given change score
can sometimes be dependent on the starting point, being
easier to achieve in patients with initially more extreme
values [8]. Another criticism levelled at the interpreta-
tion of threshold change scores is that whilst they may
indicate the achievement of relevant improvement, they
still do not indicate whether an acceptable symptom state
has ultimately been reached (i.e. whether the patient “feels
good/well”), a factor that would be expected to govern
whether the patient returns to work [9, 10], requires fur-
ther healthcare/treatment [11], or improves his/her mental
well-being, etc. In relation to this, a more recent approach
to the interpretation of treatment success in spine patients
involves the reporting of the percentage of patients whose
symptoms have reduced to an acceptable level, such that
they consider themselves to be in a “patient acceptable
symptom state” (PASS) [12]. This has been shown to
be a more discerning measure of the success of surgery,
1341
exposing suboptimal results that were not detectable using
more traditional outcome measures [13, 14].
The assessment of patient-reported outcome in patients
with adult spinal deformity (ASD) has most commonly
involved use of the condition-specific Scoliosis Research
Society (SRS) questionnaire. This instrument was origi-
nally designed for use in patients with adolescent idi-
opathic scoliosis [15] and covers the domains of pain,
function, mental health, and body image. Having under-
gone refinement [16, 17] and validation as the SRS-22
[18, 19], it is now considered the instrument of choice
also in patients with ASD. A recent confirmatory factor
analyses of its 20 non-management items in such patients
revealed some consistently weak item loadings [20], and
it was suggested that 4 items (questions 3, 14, 15, 17) be
removed, to provide an improved, shorter, 16-item version
of the instrument. The present study sought to quantify the
scores that can be considered “acceptable”, on the differ-
ent domains of the 16-item SRS and other back-specific
outcome instruments commonly used in patients with
ASD, after operative and non-operative treatment.
Methods
Patients
The data were analysed from patients [N = 1043 (599
operative, 444 non-operative), 84% female, mean ± SD
age 51.4 ± 19 years (Table 1)] recruited into the observa-
tional study of the European Spine Study Group (ESSG),
a multicentre European research group evaluating the out-
come of operative and non-operative treatment for ASD
[21]. The main inclusion criteria for all patients enrolled
in the ESSG study (described in detail in [21]) comprised:
age ≥ 18 years; coronal spinal curvature ≥ 20° or sagittal
vertical axis (SVA) > 5 cm or pelvic tilt > 25° or thoracic
kyphosis > 60°; good understanding of one of the study
languages (Spanish, German, Turkish, French). Patients
were included in the present analysis if: they were enrolled
before March 2018 (such that they had reached 12 months’
follow-up by the time of the analysis); they had 12-month
data for the main dependent variable [patient acceptable
symptom state (PASS) question; see below]; the aetiology
of their deformity had been documented as either degen-
erative or idiopathic. There were no exclusion criteria. The
most appropriate treatment for the patient (non-operative
or operative, and the specific procedure to be used) was
decided based on the clinical expertise of the treating
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1342 European Spine Journal (2020) 29:1340–1352

Table 1  Baseline demographic, comorbidity, and self-reported clini- rate of approximately 80% of all patients included at base-
cal data (mean ± SD, or % values) for the study group (N = 1043 line, and approximately 90% of these complete the neces-
patients)
sary questionnaires. For the present study, 1469 patients
Variable Mean ± SD or N (%) fulfilled the medical inclusion criteria; 1164 of these had
attended a 12-month clinical follow-up, with 1043 of them
Age (years) 51.4 ± 19.4
completing the PASS question required for the analysis.
Gender 874 (84%) F
Hence, PASS was available for 1043/1469 (71%) poten-
169 (16%) M
tially eligible patients (63% for non-operative, 78% for
Country
operative).
France 238 (22.8%)
Spain 478 (45.8%)
Switzerland 209 (20.0%)
Questionnaires
Turkey 118 (11.3%)
The analyses were carried out using the 12-month follow-up
BMI (kg ⋅ m−2) 24.4 ± 4.6
data from the validated German, Spanish, French, and Turk-
Comorbidity, ASA g­ radea (%)
ish versions of the following questionnaires:
1 160 (26.9%)
2 320 (53.9%)
1. Scoliosis Research Society-22 instrument (SRS-22).
3 113 (19.0%)
This contains 20 questions distributed in 4 dimensions
4 1 (0.2%)
(function/activity, pain, self-image, and mental health);
Years with spine problem (%)
each dimension has five items that are scored from 1
Less than 1 year 35 (3.4%)
(worst possible) to 5 (best possible). Only the 4 items for
1–2 years 55 (5.3%)
each domain that were recently recommended for inclu-
2–5 years 110 (10.5%)
sion in the 16-item version of the SR [20] were used in
5–10 years 173 (16.6%)
the analysis. Scores are presented as the mean (scored
Greater than 10 years 668 (64.2%)
1–5) for each dimension and for the subscore (i.e. for
Missing 2 (0.2%)
Prior spine surgery
all 16 items); the higher the score the better the status.
No 733 (70.3%)
(The data from the two SRS-22 “management” items,
Yes 310 (29.7%)
administered post-treatment to assess patient satisfac-
Aetiology of adult deformity
tion, were not used in the present study.)
Degenerative 399 (38.3%)
2. Oswestry Disability Index (ODI; v2.1a), comprising 10
Idiopathic 644 (61.7%)
items, each scored 0–5, and expressed as a percent score
Treatment group
ranging from 0 (no disability) to 100 (severe disability).
Non-operative 444 (42.6%)
3. Pain Numeric Rating Scale (0–10) for (a) back pain and
Operative 599 (57.4%)
(b) leg pain, where 0 is no pain and 10 is the worst pain
Back pain intensity (0–10 NRS scale) 5.9 ± 2.8
imaginable. The higher of the two pain scores was used
Leg pain intensity (0–10 NRS scale) 3.9 ± 3.5
in the analysis (­ NRSpain-higher), in accordance with previ-
Greater of the two pain scores (back or leg), 6.3 ± 2.7
ous PASS studies on spine patients with differing loca-
(0–10 NRS scale) tions (axial or peripheral) for the chief pain complaint
Oswestry Disability Score (ODI) 33.2 ± 20.6 [12].
SRS-16 item 4. The Core Outcome Measures Index (COMI) question-
Function 3.2 ± 1.1 naire [22, 23]. The COMI contains (amongst other
Pain 2.8 ± 1.0 items) an item known as “symptom-specific well-being”
Self-image 2.6 ± 0.9 which enquires about the acceptability of the current
Mental health 3.4 ± 0.9 symptoms: “if you had to spend the rest of your life with
Subscore (16 items) 3.0 ± 0.8 the symptoms you have now, how would feel about it?”,
a
answered on a 5-point Likert scale from “very satisfied”
Surgical patients only; and 5 patients with missing ASA grade
to “very dissatisfied”.
  The answers on the latter were dichotomised, with
physician. Patients with previous surgery at least 2 years the top two categories (very satisfied and somewhat sat-
ago that were not candidates for further surgical treatment isfied) being considered an acceptable symptom state
upon admission to the ESSG were considered non-opera- (PASS+), and all others (neither satisfied nor dissatis-
tive patients. The ESSG study has a 12-month follow-up fied, somewhat dissatisfied, dissatisfied) as not accept-

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European Spine Journal (2020) 29:1340–1352
able (PASS−), in accordance with previous studies [12,
14, 24].
Statistical analyses
Descriptive data are presented as means ± standard devia-
tions (SD) and % distributions of responses regarding the
acceptability of the symptom state. The differences between
groups were analysed using analysis of variance (ANOVA)
with post hoc Fisher’s PLSD tests for continuous data and
contingency analyses with Chi-squared/Fisher’s exact P test
for categorical variables.
Receiver operating characteristics (ROC) curves were
used to describe the probability of the instrument scores
(SRS and its subdomains; ODI; ­NRSpain-higher) correctly clas-
sifying patients who considered their state to be acceptable
(PASS+) and those who did not (PASS−) according to the
external criterion, the dichotomised response for PASS (see
earlier). This is considered analogous to evaluating a diag-
nostic test, in which the instrument score is the diagnostic
test and the dichotomised PASS response is the gold stand-
ard. The ROC curve combines information on sensitivity
and specificity for detecting PASS and comprises a plot of
“true-positive rate” (sensitivity) versus “false positive rate”
(1-specificity) for each of several possible cut-off points in
instrument score. The area under the curve (AUC) (with
exact binomial confidence intervals) was used to indicate the
probability of correctly discriminating between the dichot-
omised outcome (i.e. being in PASS or not) based on the
instrument’s score. An AUC of 0.5 indicates discrimination
no better than chance, and an AUC of 1.0 indicates perfect
discrimination (100% sensitivity and 100% specificity). The
cut-off giving the best combination of sensitivity and speci-
ficity (Youden index) was used to indicate the value on the
given instrument equivalent to PASS+. This represents the
lowest overall misclassification (i.e. minimum of false posi-
tives and false negatives or the maximum sum of specificity
and sensitivity [25]).
Separate analyses of the following subgroups were car-
ried out to assess the robustness of the findings: treatment
(operative vs non-operative); aetiology of deformity (degen-
erative vs idiopathic); age group (< 50, ≥ 50 years); baseline
status (dichotomised by the group median value for SRS-16
subscore); and sex (male, female).
Logistic regression analyses with either forward condi-
tional or simultaneous entry of the independent variables
(depending on the analysis in question) were used to: (1)
evaluate the relative importance of the different outcome
instruments’ 12-month scores (the 4 SRS subdomains,
ODI, ­NRSpain-higher; forward conditional entry) in explaining
whether a patient was in PASS+ or not; (2) predict PASS+
1343
from the binary subgroup variables (treatment, aetiology,
age group, baseline status, and sex) together with the given
instrument’s 12-month score (all variables simultaneously
entered, with separate analyses for each of the three outcome
instruments, SRS, ODI, N ­ RSpain-higher) to evaluate the statis-
tical significance of the effect of the subgroup variables on
the likelihood of being PASS+, controlling for 12-month
instrument score and adjusting for all other subgroup effects.
The analyses were carried out using StatView 5.0 (SAS
Institute Inc, San Francisco, USA), MedCalc (MedCalc Sta-
tistical Software, Mariakerke, Belgium) and SPSS version
24 (IBM Corp., USA, 2013). p values < 0.05 were consid-
ered to be statistically significant.
Results
Satisfaction with symptom state at 12 months’
follow‑up
The distribution of ratings for satisfaction with the symp-
tom state at 12 months’ follow-up for all patients was: very
satisfied, 181/1043 (17.3%); somewhat satisfied, 250/1043
(24.0%); neither satisfied nor dissatisfied, 207/1043 (19.8%);
somewhat dissatisfied, 225/1043 (21.6%); very dissatisfied,
180/1043 (17.3%). Hence, a PASS+ state (very/somewhat
satisfied with state; see methods) was achieved by 431/1043
(41.3%) patients. The proportion in PASS+ at 12 months’
follow-up differed significantly in relation to the base-
line symptom status (51% for those with a baseline SRS
subscore equal to or better than the median, and 33% for
those with a score worse than the median; p < 0.001), and
treatment received (47% for operative, and 34% for non-
operative; p < 0.0001) but other subgroups showed no dif-
ferences: 39% for degenerative and 43% for idiopathic aeti-
ologies (p = 0.31); 44% for patients < 50 years and 39% for
those ≥ 50 years (p = 0.13); 46% for men and 40% for women
(p = 0.16).
Relationship between 12‑month instrument scores
and satisfaction with state
The mean SRS subscores corresponding to each of the cat-
egories of “satisfaction with state” at 12 months’ FU for
the whole group are shown in Fig. 1. There was a steady
decrease in the mean score from “very satisfied” down to
“very dissatisfied”, with significant differences (p < 0.0001)
between each subsequent step. The Spearman’s rank cor-
relation coefficients between the 5-point “satisfaction with
state” ratings and the 12-month scores for each instrument
are shown in Table 2. The highest coefficients were for the
correlations with the SRS-16 subtotal score (rho = 0.70) and
13
1344
Fig. 1  Mean (95% CI) SRS-16 subscores for each response category
of the “symptom-specific well-being” item of the COMI enquiring
how the patient would feel if they had to spend the rest of their life
with the symptoms they have now (0 very satisfied, 1 somewhat sat-
isfied, 2 neither satisfied nor dissatisfied, 3 somewhat dissatisfied, 4
very dissatisfied)
Fig. 2  Box and whisker plot for the SRS-16 subscore and SRS sub-
domain scores for patients in a patient acceptable symptom state
(PASS+) or not (PASS−) at 12 months’ follow-up (p < 0.0001 for all
variables)
with the SRS subdomain scores for “pain” and “self-image”
(each rho = 0.66), although those with ­NRSpain-higher and ODI
were also each > 0.60, indicating that the “satisfaction with
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European Spine Journal (2020) 29:1340–1352
Table 2  Spearman’s rank correlation coefficients between outcome
instrument scores at 1-year follow-up and responses to the 5-point
PASS question
Variable Na Spearman’s rho
SRS subscore 1033 − 0.70
SRS function 1033 − 0.48
SRS pain 1031 − 0.66
SRS self-image 1033 − 0.66
SRS mental health 1033 − 0.46
NRS pain 971 0.64
ODI 1029 0.60
a
Some patients failed to complete all the questionnaires or had miss-
ing responses for some items; hence, the numbers are lower than
1043 for some analysis
state” item was a valid external criterion (or “anchor”) for
the ROC analyses with these variables; for SRS function
(Rho = 0.45) and SRS mental health (Rho = 0.44), the cor-
relations were somewhat lower than the recommended 0.5
[26].
Figure 2 shows the SRS subscores and subdomain scores
for the dichotomised “satisfaction with state” groups; there
was a significant (p < 0.001) difference in scores for the
PASS+ and PASS− groups for each variable, with the great-
est differences being seen for the SRS subscore and the SRS
pain and self-image subdomains.
Receiver operating characteristics analysis
of 12‑month scores
The ROC areas under the curve (AUC) were between 0.71
and 0.84 (p < 0.001; Table 3) for the different instruments,
suggesting the questionnaire scores discriminated well
between those patients who were in an acceptable state and
those who were not. AUCs were highest for the SRS sub-
score (0.84), SRS self-image, SRS pain, and ­NRSpain-higher
(each 0.83), indicating that these domains were the strong-
est determinants of being in a satisfactory state or not.
This was also confirmed with multiple logistic regression
which showed that, out of the ODI, N ­ RSpain-higher and four
SRS domain scores, only SRS self-image (OR 3.57; 95%
CI 2.67–4.76; p < 0.0001), SRS pain (OR 1.72, 95% CI
1.26–2.34; p = 0.001), and ­NRSpain-higher scores (OR 0.76;
95% CI 0.69–0.84; p < 0.0001) made a significant unique
contribution to explaining whether the patient was in an
acceptable state (PASS+) or not.
The cut-off scores corresponding to being in PASS+ were
as follows: SRS subscore > 3.5 (with the subdomains vary-
ing depending on the specific SRS domain); ODI ≤ 18; and
­NRSpain-higher ≤ 3 (Table 3). The sensitivity with which the
different instruments indicated being in PASS+ ranged from
65% (for SRS mental health) to 78% (for SRS subscore) and
European Spine Journal (2020) 29:1340–1352 1345

Table 3  Results of ROC curve na % PASS+ AUC​ 95% CI Threshold for Sens% Spec%
analyses to determine the being PASS+
score equivalent to PASS+
for SRS-16-item instrument SRS subscore 1033 41.6 0.84 0.81–0.86 > 3.5 78.4 75.0
subscore and subdomain scores,
SRS function 0.72 0.69–0.74 > 3.3 71.4 63.3
NRS pain higher value of back
pain or leg pain and Oswestry SRS pain 0.83 0.81–0.85 > 3.5 73.5 78.5
Disability Index (ODI) SRS self-image 0.83 0.80–0.85 > 3.3 75.1 76.6
SRS mental health 0.71 0.68–0.73 > 3.8 64.9 68.8
NRS pain 971 39.5 0.83 0.80–0.85 ≤ 3.0 68.2 83.0
ODI 1029 41.5 0.79 0.76–0.81 ≤ 18 67.3 76.0

PASS+, in a patient acceptable symptom state with answers “very satisfied” and “somewhat satisfied” on
symptom-specific well-being item; Sens sensitivity; Spec specificity
a
Some patients failed to complete all the questionnaires or had missing responses for some items; hence,
the numbers are lower than 1043 for some analyses

Table 4  Results of ROC and of multiple regression analyses examining PASS cut-offs for the SRS-16-item subscore in subgroups of patients
Num- % PASS+ AUC​ AUC 95% CI Threshold for Sens % Spec % p in multiple reg OR (95% CI)
ber of being in PASS
­patientsa

All patients
12 mo FU 1033 41.6 0.84 0.81–0.86 > 3.5 78.4 75.0
Treatment ­group#
Operative 590 47.1 0.85 0.81–0.87 > 3.3 85.6 68.9 0.02 1.53 (1.06–2.21) for
Non-operative 443 34.3 0.83 0.79–0.87 > 3.6 82.2 72.9 operative versus
non-op
Aetiology
Degenerative 391 40.2 0.86 0.82–0.89 > 3.2 85.4 70.9 0.99
Idiopathic 642 42.5 0.84 0.80–0.86 > 3.7 75.1 78.3
Age (years)#
≥ 50 609 39.9 0.85 0.82–0.88 > 3.3 80.3 76.5 0.0005 2.08 (1.38–3.15)
< 50 424 44.1 0.84 0.80–0.87 > 3.7 82.9 69.6 for older versus
younger
Baseline ­symptoms#,b
High (< median) 522 33.5 0.87 0.83–0.89 > 3.3 73.7 85.6 0.049 1.53 (1.003–2.33)
Low (≥ median) 488 51.2 0.79 0.75–0.82 > 3.8 72.0 71.4 for high versus low
symptoms
Sex
Women 865 40.7 0.85 0.82–0.87 > 3.8 73.0 82.3 0.26
Men 168 46.4 0.73 0.65–0.79 > 3.7 74.4 66.7

Bold values indicate p < 0.05

PASS+, patient acceptable symptom state—answers “very satisfied” and “somewhat satisfied” on symptom-specific well-being item; AUC, area
under the receiver operating characteristics curve; 95% CI, 95% confidence intervals; Sens sensitivity; Spec specificity; p in multiple reg, p value
for the significance of this variable in multiple logistic regression analysis to predict PASS+ (see text for further details); OR, odds ratio for this
variable in multiple logistic regression to predict being PASS+
a
Some patients had missing responses for some items in the questionnaire; hence, the numbers are lower than 1043 for some analysis
b
Based on the median value for SRS subtotal score for the SRS 16-item instrument
#
Significant variable in multivariable logistic regression to predict PASS from all 5 subgroup variables and SRS-16-item subscore at 12 months’
follow-up

the specificity for PASS−, from 63% (for SRS function) to
83% (for ­NRSpain-higher) (Table 3).
The results of the ROC subgroup analyses for the cut-off
scores for SRS subscore, ODI, and ­NRSpain-higher are shown
in Tables 4, 5, and 6, respectively. There was less subgroup
variability between the thresholds for the SRS subscore than
for ODI and ­NRSpain-higher, but generally, across all instru-
ments, in univariable analyses a worse status was considered
acceptable at 12 months by patients that had a degenerative
aetiology, had a worse baseline status (SRS subscore < median

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1346 European Spine Journal (2020) 29:1340–1352

Table 5  Results of ROC and of multiple regression analyses examining PASS cut-offs for the ODI in subgroups of patients
Number of % PASS+ AUC​ AUC 95% CI Threshold for Sens % Spec % p in multiple reg OR (95% CI)
­patientsa being in PASS

All patients
12 mo FU 1029 41.5 0.79 0.76–0.81 ≤ 18 67.3 76.0
Treatment ­group#
Operative 590 46.9 0.80 0.77–0.84 ≤ 22 71.5 68.9 < 0.0001 2.30 (1.63–
Non-operative 439 34.4 0.80 0.76–0.84 ≤ 16 72.2 75.0 3.25) for
operative
versus non-
op
Aetiology
Degenerative 390 40.0 0.80 0.76–0.84 ≤ 29 73.1 73.5 0.23
Idiopathic 639 42.6 0.80 0.77–0.83 ≤ 13 67.7 79.0
Age (years)#
≥ 50 607 39.9 0.81 0.77–0.84 ≤ 29 76.9 69.9 0.0007 1.98 (1.34–
< 50 422 44.1 0.80 0.76–0.84 ≤ 11 72.0 77.1 2.94) for
older versus
younger
Baseline ­symptomsb
High (< median) 519 33.5 0.80 0.76–0.83 ≤ 32 76.4 68.7 0.64
Low (≥ median) 487 51.1 0.75 0.71–0.79 ≤ 12 69.9 69.3
Sex
Women 861 40.7 0.81 0.78–0.83 ≤ 22 76.6 70.5 0.42
Men 168 46.4 0.70 0.62–0.76 ≤ 10 50.0 81.1

Bold values indicate p < 0.05

PASS+, patient acceptable symptom state—answers “very satisfied” and “somewhat satisfied” on symptom-specific well-being item; AUC, area
under the receiver operating characteristics curve; 95% CI, 95% confidence intervals; Sens, sensitivity; Spec, specificity; p in multiple reg, p
value for the significance of this variable in multiple logistic regression analysis to predict PASS+ (see text for further details); OR, odds ratio
for this variable in multiple logistic regression to predict being PASS+
a
Some patients had missing responses for some items in the questionnaire; hence, the numbers are lower than 1043 for some analysis
b
Based on the median value for SRS subtotal score for the SRS 16-item instrument
#
Significant variable in multivariable logistic regression to predict PASS from all 5 subgroup variables and ODI at 12 months’ follow-up

value), were older, were female, or had received surgery, com-
pared with their respective counterparts. To an extent, these
subgroup characteristics overlapped, and in logistic regression
analysis, the statistically significant factors for predicting the
likelihood of being in PASS+, controlling for the 12-month
outcome score and all other subgroup variables were: for the
SRS subscore—being older, having received surgery, and hav-
ing a worse baseline status; for ODI—being older and hav-
ing received surgery; and for ­NRSpain-higher—having a better
baseline status and being female (Tables 4, 5, 6).
Discussion
or restore them to a normally aligned and fully functional
state. Accepting that the achievement of perfect results is
uncommon, and that many patients inevitably experience
residual problems [27], it was considered useful to know the
maximum level of symptoms that patients regarded as accept-
able and felt they could live with. Each of the questionnaire
scores that we evaluated (16-item SRS subscore; ODI; and
­NRSpain-higher) was highly predictive of whether the patient
was in PASS+ 1 year after inclusion in the study, confirm-
ing the validity of the approach. The cut-off scores for the
whole collective were > 3.5 points (1–5 scale) for SRS sub-
score, ≤ 18 points (0–100 scale) for ODI, ≤ 3 for NRS (higher
of the back pain and leg pain scores; 0–10 scale).

Summary of findings Comparison with the literature

Most interventions for the treatment of adult spinal deformity It is difficult to compare the values defined for the patient
result in some improvement in symptoms, disability, and self- acceptable symptom state (PASS) for the SRS, since no pre-
image; however, they rarely render patients totally pain-free vious studies have investigated this phenomenon. At most,

13
European Spine Journal (2020) 29:1340–1352 1347

Table 6  Results of ROC and of multiple regression analyses examining PASS cut-offs for NRS pain (the higher of the values for back pain and
leg pain) for subgroups of patients
Number of % PASS+ AUC​ AUC 95% CI Threshold for Sens % Spec % p in multiple reg OR (95% CI)
­patientsa being in PASS

All patients
12 mo FU 971 39.5 0.83 0.80–0.85 ≤ 3.0 68.2 83.0
Treatment group
Operative 533 43.9 0.81 0.77–0.84 ≤ 3.0 68.8 79.3 0.18
Non-operative 438 34.2 0.84 0.81–0.88 ≤ 3.0 67.3 86.8
Aetiology
Degenerative 368 38.0 0.80 0.76–0.84 ≤ 4.9 67.1 80.3 0.28
Idiopathic 603 40.5 0.84 0.81–0.87 ≤ 3.0 75.4 80.2
Age (years)
≥ 50 576 37.8 0.82 0.79–0.85 ≤ 4.9 70.6 79.1 0.22
< 50 395 42.0 0.83 0.79–0.86 ≤ 3.0 78.3 76.9
Baseline ­symptomsb,#
High (< median) 499 31.7 0.83 0.79–0.86 ≤ 4.9 69.6 80.9 0.03 0.61 (0.40–
Low (≥ median) 451 49.2 0.80 0.76–0.83 ≤ 3.0 75.2 74.2 0.93) for high
versus low
symptoms
Sex#
Women 819 38.8 0.85 0.82–0.87 ≤ 4.9 75.5 79.0 0.02 1.65 (1.07–
Men 152 43.4 0.72 0.64–0.79 ≤ 3.0 72.3 68.6 2.53) for
women
versus men

Bold values indicate p < 0.05

PASS+, patient acceptable symptom state—answers “very satisfied” and “somewhat satisfied” on symptom-specific well-being item; AUC, area
under the receiver operating characteristics curve; 95% CI, 95% confidence intervals; Sens, sensitivity; Spec, specificity; p in multiple reg, p
value for the significance of this variable in multiple logistic regression analysis to predict PASS+ (see text for further details); OR, odds ratio
for this variable in multiple logistic regression to predict being PASS+
a
Some patients had missing responses for some items in the questionnaire; hence, the numbers are lower than 1043 for some analysis
b
Based on the median value for SRS subtotal score for the SRS 16-item instrument
#
Significant variable in multivariable logistic regression to predict PASS from all 5 subgroup variables and ­NRSpain-higher at 12 months’ follow-up

mean values for so-called normal adults, with no history
of spine disease are available for comparison [28, 29] and
reveal a value of approximately 4.2 for the SRS subscore
(mean of 20 non-management items) in patients of compara-
ble age and gender distribution to those in the current study.
Strictly speaking, it is illogical to calculate “normal healthy”
scores for condition-specific questionnaires, since without
the condition there can be no valid response to the specific
questions regarding its associated consequences. However,
these values at least provide a ball-park figure for reference,
appearing slightly higher than the threshold value for being
in PASS of 3.5, but almost identical to the mean value for
the group that was “very satisfied with their symptom state”
(4.2; see Fig. 1) in the present study.
For pain, as measured using a NRS or VAS, a score
equivalent to ≤ 3 out of 10, as found in the present study,
has frequently been identified as an acceptable threshold in
studies investigating painful musculoskeletal pathologies of
middle-aged and older adults. For example, a cut-off of ≤ 3
was reported for patients with various spine degenerative
disorders, including adult spinal deformity [12], patients
referred to outpatient physical therapy for general ortho-
paedic conditions (pathology of the cervical spine, lumbar
spine, upper or lower extremity) [30], and patients with hip
and knee osteoarthritis [11, 31]. The similarity in cut-off
across these studies raises the interesting possibility that the
definition of an acceptable level of pain may be independent
of the disease or condition [30], and the threshold of ≤ 3/10
could be applied as a “one size fits all” figure to other pain-
ful medical conditions in patients of a similar demographic.
The values defined in the present study for PASS+ for
the ODI, i.e. ≤ 18 points for the whole group and ≤ 22
points in the operative group, compare well with the
score of ≤ 22 reported by van Hooff et al. [24] for 1288
patients with various types of degenerative lumbar spine
disorders who had undergone elective spine surgery and
were registered in the EUROSPINE Spine Tango Spine
Surgery Registry. In the latter study, sensitivity analyses

13
1348
showed that the ODI threshold was robust at two follow-
up time points (1 year and 2 years post-operatively) and
was relatively stable across subgroups of age, gender,
previous surgery, type of surgery, and complication sta-
tus. The same authors had previously reported a score
of ≤ 22 for the threshold, indicating the functional status
of “normal healthy individuals” [32] (although the afore-
mentioned caveat must again be borne in mind, regard-
ing the scores recorded on condition-specific instruments
by people without the condition). A survey of a random
sample of 1200 registered members of a Japanese Inter-
net research company found that the mean ODI score of
individuals with LBP but no disability was 11.9, whereas
in those with LBP and disability it was 22.1; a cut-off for
ODI of ≥ 12 best discriminated between the two groups
[33]. In another study of a series of 774 inpatients being
treated non-surgically for low back pain, the ODI that
distinguished those who were satisfied from those who
were not satisfied with their current state was ≤ 30 [34].
The optimal cut-off scores derived for all the instru-
ments differed slightly depending on whether the patient
had undergone surgery, his/her age, sex and baseline
symptom state, and the aetiology of the deformity.
Many of these factors carried overlapping information,
e.g. operative patients were more likely to have a worse
baseline status; older patients were more likely to have
degenerative ASD, etc. When all factors were considered
together in multiple regression analysis, patients that had
undergone surgery, were older, and had a worse baseline
status were more likely to consider their state acceptable,
for a given level of “impairment” as measured by the SRS
subscore. Similarly, for a given 12-month ODI disability
score, the surgical and older patients were more accepting
of their symptom state. Hence, in general, it would appear
that older patients, and those who have more severe base-
line symptoms, and have undergone surgery, are more
accepting of their remaining symptomology 12 months
after treatment. The effect of baseline status has been
observed before, especially for “functional impairment”
[11, 30]. Possibly, patients that are older have fewer
demands in terms of their everyday activity levels and
cosmetic appearance. Similarly, those with more severe
and prolonged disability at baseline may be more resigned
to their functional impairment, adapting to their limita-
tions with time. If they once struggled to perform simple
daily activities, they may report their state of health as
acceptable when they find themselves able to complete
those same tasks with just minor or moderate difficulty;
in contrast, those reporting very little disability to begin
with may be seeking a perfect state of health and report
anything less than this as unacceptable [30]. In the present
study, in multivariable analyses, worse baseline status did
not significantly increase the odds of being in PASS+
13
European Spine Journal (2020) 29:1340–1352
for a given level of pain; instead, it slightly decreased
the odds (as did being male), although the effects were
not marked. A greater variability in PASS estimates for
disability/functional impairment than for pain has been
reported before, where it was suggested that patients may
be better able to adapt to functional impairments over
time than to high levels of pain, resulting in more similar
cut-offs for pain across subgroups [30, 31].
The use of PASS in clinical practice and research
There are many advantages to the use of PASS cut-off
scores in both clinical practice and research. For many
years the minimal clinically important change score
(MCIC) has been considered the best metric to confer
clinical importance to any observed numeric change in an
instrument’s score. However, whilst the MCIC indicates
whether the change is substantial enough to be consid-
ered clinically relevant, it says nothing about the actual
state that the patient finds himself in after treatment. For
example, a patient may reduce their pain score from 8 to 5
and hence achieve the 2-point MCIC for pain, but a post-
treatment pain score of 5 points is unlikely to be considered
an “acceptable state”. It has been suggested that the PASS
may be preferable to the MCIC because it seems to best
reflect what is important to patients: the MCIC concerns
the concept of improvement (i.e. feeling better, even if not
feeling great in the end), whereas the PASS reflects a state
of well-being or remission of symptoms (i.e. feeling well)
[11]. Arguably, fulfilment of both conditions (achieving
MCIC and PASS) may be what is required to consider the
outcome an overall success.
At a time when subtle differences in the results of new
treatments and techniques are becoming harder to detect
using established metrics, the PASS cut-offs may represent
a more discerning outcome measure and be considered a
more clinically relevant treatment target. Evaluation of the
proportion of patients achieving this “acceptable” level
would provide an easily interpretable indication of treatment
success. A knowledge of the score most patients could live
with and the likelihood of achieving it, along with the fact
that complete recovery is unlikely, may also provide a use-
ful framework for discussing realistic expectations with the
patient regarding the potential outcome of treatment. Real-
istic expectations are pivotal to patient satisfaction [35, 36].
It is possible that the achievement of PASS may also serve
as a more stringent target in prognostic models identifying
predictors of success. Since PASS appears to be harder to
achieve than MCIC, it “raises the bar” in terms of what we
consider a good outcome and this might allow for a more
differentiated prognosis of outcome and the identification of
different predictors to those that simply predict some mini-
mal level of improvement.
European Spine Journal (2020) 29:1340–1352
The PASS is sometimes preferred to the MCIC because
it is reputedly less sensitive to baseline levels of symp-
toms [31]. For example, a previous study in patients with
knee osteoarthritis revealed that, for low, middle, and high
baseline pain tertiles, the MCICs were 10.8, 27.4, and 36.6
points out of 100, respectively (i.e. an almost fourfold dif-
ference from the lowest to the highest), whilst the respec-
tive scores for the PASS were 27.0, 34.5, and 36.4 points
for the three tertiles (i.e. much more constant across the
baseline pain tertiles) [31]. The authors concluded that
the MCIC appears to be equivalent to the change in score
needed to achieve the PASS, whatever the baseline level
of symptoms, making the PASS the more relevant target to
strive for. In the present study, whilst there was some influ-
ence of baseline symptom severity on the scores equivalent
to PASS+ for the different instruments (see earlier), for the
SRS subscore the effect (about 15% difference between the
high and low symptom groups) was small and much less
than that reported by Tubach et al. [31] (approximately
30–40% for a joint-specific measure in knee OA and rota-
tor cuff patients), although even the latter was considered
minimal compared with the corresponding variation in
MCIC that they recorded. Another advantage of the PASS
over the MCIC is that if baseline questionnaire scores
are not available for a given patient—whether within the
confines of a study or in the clinical setting—the success
(or otherwise) of treatment can still be assessed by inter-
pretation of the individual’s post-treatment questionnaire
score alone. Assessment according to the MCIC, in con-
trast, always needs a baseline score in order to calculate
the extent of the change in score, post-operatively. This
makes the PASS more practicable for assessing treatment
outcome where the timely acquisition of baseline data is
perhaps difficult, e.g. due to emergency admissions, or in
busy clinical departments that do not have the infrastruc-
ture for organising the administration of questionnaires
prior to treatment, but are able to collect data under less
time pressure at follow-up.
Theoretically, the derived PASS cut-off scores could
assist in guiding decisions as to when, whether, and what
type of treatment should be initiated, by indicating whether
and to what extent a patient exceeds the cut-off value for
“acceptable symptoms” at presentation. The presence of
a given minimum level of symptoms is commonly one of
the criteria for the “appropriate use of surgery” in various
fields of orthopaedics [37–40]. For example, one of the key
criteria of Chen et al., for the appropriateness of surgery
for degenerative scoliosis, was “at least moderate to severe”
symptoms [37–40]; in the criteria for hip joint replacement,
it was “severe” pain [39]; and the criteria for degenerative
spondylolisthesis, severe disability [40].
Interestingly, in the present study, using the generic cut-
offs derived from the whole-group ROC analyses it was
1349
seen that before surgery 13.2% of the operative patients1
were already PASS+ according to their SRS subscore,
16.1% according to their ODI, and 8.3% according to
their ­NRSpain-higher (detailed data not shown). This may at
first sight suggest a shortcoming of the PASS concept, if
interpreted as evidence for a ceiling effect, beyond which
no improvement could have been detected. However, with
conditions such as ASD that can manifest themselves in
a variety of ways—with pain, cosmetic appearance, pos-
ture, walking, or neurological deficits each being of greater
or lesser importance to the given patient, and with some
patients simply requiring prophylactic procedures—it is
conceivable that patients may be deemed PASS+ based on
one measure but not based on another (most likely the one
describing their specific motivation for treatment). Indeed, in
the present study, before surgery only a fraction of patients
(4/583; 0.7%) were PASS+ on all three main measures (SRS
subscore, ODI, and NRS pain) as well as the specific sub-
domains of the SRS.
Our analyses showed, not wholly surprisingly (see [31]),
that patients with a better symptom status to start with were
generally more likely to be PASS+ at 12 months’ follow-up.
In other words, those with fewer symptoms preoperatively
had “less distance to go” in order to achieve an acceptable
symptom state after surgery. If using the PASS as a measure
of success, the logical corollary of this would then be that
surgeons should preferentially treat “relatively well” patients
(who are just short of the PASS+ threshold before surgery)
to increase the chances of their reaching PASS+ afterwards.
Clearly such a strategy would not be viable or make sense
pragmatically, although the question of whether surgery
would be more beneficial at a somewhat earlier stage of the
disease, before patients are extremely symptomatic, may be
worthy of further investigation. The present study cannot,
and was never intended to, shed any light on this issue.
Limitations of the study
A number of limitations of our study must be recognised.
Whilst the data obtained were from a prospective study, the
analysis was retrospective in nature, with the inherent weak-
nesses of such a study design, e.g. data items were not spe-
cifically designed to answer the given research question. The
follow-up rate for the ESSG study, 1-year post-inclusion, is
approximately 80%, but only approximately 90% of these
1
The same data are not presented in detail for the non-operative
patients, since many who were included in the database were not
actively seeking treatment but were simply under observation or were
presenting for routine follow-up from a previous surgery, more than
2 years prior to recruitment in ESSG. Overall, 12% (54/442) reported
being in PASS for all of the three main outcome measures as well as
the SRS subdomains at baseline.
13
1350
typically complete the patient-rated questionnaires. Hence,
the data from approximately 30% of patients in the database
were not represented in the analysis. Further, the non-oper-
ative patients had a lower compliance with questionnaire
completion than did the operative patients. This is perhaps
to be expected, since surgical patients are more likely to
return for post-operative check-ups, but this may nonetheless
have introduced bias into the analyses. It has been suggested
that follow-up rates should ideally be at least 80% to avoid
major bias [41].
The PASS concept was originally conceived as a sin-
gle question requiring a binary answer (yes/no) to indicate
whether the current symptom state would be considered
acceptable, if it were to persist for the next few months
[42], for the rest of one’s life [43], or without reference to
any particular time frame [11]. This item was then used
as the external criterion (anchor) to determine the cut-off
scores, indicating achievement of an acceptable symptom
state at follow-up. In our study, the 5-point SSWB item
from the COMI (which employs the “rest of your life” time
frame) was used to determine PASS, with the responses
being dichotomised as described in other studies [12, 14,
24]. Although the PASS concept has been generally well-
accepted and integrated into the field of rheumatology, its
implementation in assessing the outcome of spine surgery
is not without criticism [44]. The response categories have
been described as non-specific, ambiguous and requiring
abstraction, and their dichotomisation, arbitrary, and objec-
tions have been raised to the notion that patients with just
minimal pain changes may be considered surgical “failures”,
despite their severe and complex symptoms at baseline [44].
In an attempt to evaluate whether the SSWB item was psy-
chometrically valid as an anchor in our analyses, we exam-
ined the relationship between the 12-month scores on each
instrument and the responses on the SSWB’s 5-point scale,
seeking correlation coefficients ≥ 0.5 [26]. These were found
to be sufficiently strong [45], being 0.6–0.7 for all variables
except SRS mental health and function (which were just
0.44 and 0.45, respectively). The latter finding indicates that
function and mental health were less influential in govern-
ing whether the current state was viewed as acceptable or
not, further confirmed by the lower areas under the ROCs
for these two variables. In the present study, we used the
responses “very satisfied” and “somewhat satisfied” on the
COMI SSWB item to define an acceptable symptom state,
as used in previous studies [12, 14, 24]. However, the deci-
sion as to what should count as an “acceptable state”, and
especially whether “neither satisfied nor dissatisfied” should
be included as “acceptable”, remains somewhat arbitrary,
and we cannot assume that patients would have answered
similarly to a different question with a different number of
response options. Future studies should evaluate this 5-point
answer with a direct binary response (“yes/no”), in relation
13
European Spine Journal (2020) 29:1340–1352
to satisfaction with having to spend the rest of one’s life with
the current symptoms. And, finally, our analysis involved
a large cohort of patients from a multicentre prospective
study including 6 centres in 4 countries. Intercultural differ-
ences may have influenced the relationship between PASS
and symptom levels for specific centres. However, the dif-
ferent countries did not always refer the same proportions
of operative/non-operative, degenerative/idiopathic, old/
young patients, and these factors would need to be taken into
account for a valid analysis of the “country/language” effect
per se. This will be done when the sample size has increased,
as the database grows. A benefit of the multicentre study
was that our results as a whole are generalisable to a broader
range of patient demographic characteristics, cultures, and
hospital settings than those of a single-centre study would
be. Further studies should externally validate the PASS cut-
off values in other patient collectives. We had few patients
with acute or subacute symptoms (only 3% with their spine
problem for less than 1 year; see Table 1), preventing mean-
ingful analyses of the influence of duration of symptoms on
the PASS cut-offs, a factor previously considered of possible
importance [12].
Conclusion
It is useful to know the maximum level of symptoms that
the patient considers “acceptable” and could live with.
The questionnaire cut-off scores equivalent to an accept-
able state were relatively robust, although, in general, older
patients with more severe baseline symptoms were satisfied
with greater impairment than were their younger counter-
parts with a better baseline status. Reporting the percentage
of patients achieving an outcome score equivalent to the
acceptable symptom state represents a novel outcome met-
ric in the field of adult spinal deformity and may be a more
stringent target for denoting “success” in its treatment.
Compliance with ethical standards
Conflict of interest None of the authors have any conflict of interest in
relation to the current work. The ESSG is partially funded by research
grants from Depuy Synthes Spine and Medtronic.
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Affiliations
A. F. Mannion1 · M. Loibl2 · J. Bago3 · A. Vila‑Casademunt4 · S. Richner‑Wunderlin1 · T. F. Fekete2 · D. Haschtmann2 ·
D. Jeszenszky2 · F. Pellisé3 · A. Alanay5 · I. Obeid6 · F. S. Pérez‑Grueso7 · F. S. Kleinstück2 · European Spine Study
Group (ESSG)4
* A. F. Mannion
anne.mannion@yahoo.com
1
Department of Teaching, Research and Development,
Spine Center Division, Schulthess Klinik, Lengghalde 2,
8008 Zurich, Switzerland
2
Spine Center, Schulthess Klinik, Lengghalde 2, 8008 Zurich,
Switzerland
3
Spine Unit, Hospital Universitari Vall Hebron, Passeig Vall
Hebron 119‑129, 08035 Barcelona, Spain
13
European Spine Journal (2020) 29:1340–1352
39. Quintana JM, Arostegui I, Azkarate J, Goenaga JI, Elexpe X,
Letona J, Arcelay A (2000) Evaluation of explicit criteria for total
hip joint replacement. J Clin Epidemiol 53:1200–1208
40. Mannion AF, Pittet V, Steiger F, Vader JP, Becker HJ, Porchet F
(2014) Development of appropriateness criteria for the surgical
treatment of symptomatic lumbar degenerative spondylolisthesis
(LDS). Eur Spine J 23:1903–1917. https​://doi.org/10.1007/s0058​
6-014-3284-0
41. Straus SE, Glasziou PP, Richardson S, Haynes RB (2018) Evi-
dence-based medicine: how to practice and teach EBM. Elsevier,
Amsterdam
42. Pham T, Tubach F (2009) Patient acceptable symptomatic state
(PASS). Joint Bone Spine 76:321–323. https​://doi.org/10.1016/j.
jbspi​n.2009.03.008
43. Tubach F, Ravaud P, Martin-Mola E, Awada H, Bellamy N, Bom-
bardier C, Felson DT, Hajjaj-Hassouni N, Hochberg M, Logeart I,
Matucci-Cerinic M, van de Laar M, van der Heijde D, Dougados
M (2012) Minimum clinically important improvement and patient
acceptable symptom state in pain and function in rheumatoid
arthritis, ankylosing spondylitis, chronic back pain, hand osteoar-
thritis, and hip and knee osteoarthritis: results from a prospective
multinational study. Arthritis Care Res (Hoboken) 64:1699–1707.
https​://doi.org/10.1002/acr.21747​
44. Hobart J (2016) Measuring spinal surgical success: the proportion
achieving acceptable symptoms: keep it simple but not simplistic.
Spine J 16:S19–S20. https:​ //doi.org/10.1016/j.spinee​ .2016.01.221
45. Cohen J (1988) Statistical power analysis for the behavioural sci-
ences. Lawrence Earlbaum Associates, Hillsdale
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
4
Spine Research Unit, Spine Research Unit, Vall d’Hebron
Institute of Research (VHIR), Passeig Vall Hebron 119‑129,
08035 Barcelona, Spain
5
Department of Orthopaedics and Traumatology, Acibadem
University School of Medicine, Büyükdere cad, 40 Maslak,
344457 Istanbul, Turkey
6
Pellegrin Bordeaux University Hospital, Place Amélie Raba
Léon, 33000 Bordeaux, France
7
Hospital Universitario, La Paz Paseo de la Castellana 261,
28046 Madrid, Spain