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a:	Running title: Increasing demand of ASD surgery

Title: The Growing Demand for Adult Spinal Deformity Surgery in England: A National Health Data Review


1David C Kieser (MBChB, PhD, FRACS, FNZOA), 2Alan Silman (FMedSci), 3Dominique A Rothenfluh (MD, PhD) 

1Spinal surgeon, Department of Orthopaedics and Musculoskeletal Medicine, University of Otago, Christchurch School of Medicine, Christchurch, New Zealand (kieserdavid@gmail.com)
2Professor of musculoskeletal health, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, England (alan.silman@ndorms.ox.ac.uk)
3Spinal surgeon, University of Oxford, Division of Spinal Surgery, Oxford, England (dominique.rothenfluh@mac.com)

Corresponding author:
David Kieser
Department of Orthopaedic and Spinal Surgery
Oxford University Hospitals NHS Foundation Trust
Oxford
England
Phone: +64 211499829
Email:  HYPERLINK "mailto:kieserdavid@gmail.com" kieserdavid@gmail.com

Competing interests: 
The authors declare that they have no competing interests
Funding: 
No funding was attained for this study

Abstract

Objective
The rate of adult spinal deformity (ASD) surgery is increasing internationally. However, an understanding of the trends in England remains unknown. This study examines the trends in hospital admission and surgical intervention for complex ASD in order to predict the future health demands for NHS England.

Methods
Hospital Episode Statistics data for England were reviewed between 2005-2015 in order to determine the number of patients diagnosed and surgically treated for ASD. The future ten-year demand for surgery was modelled on demographic changes and admission trends, with the consequence on inpatient bed-days and costs calculated.

Results
Over the time-course, the number of patients admitted has more than doubled, with an almost 3-fold increase in those older than 60-years. This contrasts the less than 10% increase in the adult population of England over the same time-period. 
The volume of ASD surgery has increased 3.5-fold, with the greatest increase in those older than 60years (6.4-fold increase). The average length of stay (LOS) has reduced from 10.1 to 8.4 days. If these trends continue, we estimate an additional 330 patients per year receiving ASD surgery, equivalent to an annual increase of 4.5 inpatients per day per year and additional financial cost of �8.1-11.5 million per year.

Conclusions
Severe ASD, unresponsive to conservative therapy, is a growing problem within England. The complex surgery required needs to be matched by the availability of the necessary expertise and considerable resources to meet this inevitable growing demand. 

Key words: Spinal deformity, fusion, kyphosis, sagittal imbalance, scoliosis, alignment, spine, surgery, back painManuscript
Background
Spinal conditions are one of the most common groups of health disorders affecting adults  ADDIN EN.CITE  ADDIN EN.CITE.DATA (1). Amongst spinal disorders adult spinal deformity (ASD) is predominantly a problem of older ages, with a reported prevalence of up to 32% of patients over the age of 50 years and 68% of patients aged over 70 years  ADDIN EN.CITE  ADDIN EN.CITE.DATA (2).  ASD is, however, an overarching term for a complex spectrum of spinal deformities  ADDIN EN.CITE  ADDIN EN.CITE.DATA (3, 4). Although frequently mild, when severe, it results in a persisting problem affecting a patient�s global spinal balance. This prevents the normal �economic� resting posture resulting in increase physiological demands and subsequently fatigue, pain, neural compression and disability. The extent of these is directly related to the degree of spinal imbalance (Figure 1) ADDIN EN.CITE  ADDIN EN.CITE.DATA (5-8). 

Figure 1. Selective radiographs showing the convergence of disability in the sagittal plane. 

The functional and quality of life (QoL) consequences of an imbalanced spine can be devastating  ADDIN EN.CITE  ADDIN EN.CITE.DATA (2, 5-7, 9). Not surprisingly perhaps, compared to most other common long-term disorders, including arthritis, chronic lung disease, congestive heart failure, diabetes and ischaemic heart disease, ASD has a worse patient reported QoL and, hence, is the highest ranked disorder in estimates of global disease burden  ADDIN EN.CITE  ADDIN EN.CITE.DATA (10).  
The treatment of severe ASD is challenging. Non-operative treatment has a limited role, especially when significant anatomical abnormality and spinal imbalance is present  ADDIN EN.CITE  ADDIN EN.CITE.DATA (11, 12). In contrast, operative management offers long-lasting benefit in improving pain, functional outcomes and QoL, but carries significant risk and expense ADDIN EN.CITE  ADDIN EN.CITE.DATA (3, 13-17). The surgery for this condition has traditionally varied from single level neural decompression to global deformity correction. However, it is becoming clear that most patients with symptomatic ASD benefit from restoration of spinal balance (Figure 2) ADDIN EN.CITE  ADDIN EN.CITE.DATA (8, 18, 19), although the surgery to achieve this is amongst the most complex of all planned surgical procedures.

Figure 2. Pre-operative and post-operative radiographs showing two cases of coronal (a and b) and sagittal (c and d) malalignment corrected with operative intervention. The straight line in c and d represents the C7 plum line and the dashed line represents the sagittal vertical axis (SVA), which is normally less than 5cm.

Because of this growing body of evidence of the benefits of surgically restoring spinal balance, the number of complex operations being performed for ASD has doubled in the last decade in many countries, which contrasts with the 20% increase in all other spinal surgeries  ADDIN EN.CITE  ADDIN EN.CITE.DATA (4, 20, 21). This growth suggested that there was a growing unmet demand ADDIN EN.CITE <EndNote><Cite><Author>Schwab</Author><Year>2005</Year><RecNum>88</RecNum><DisplayText>(2)</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768401">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Dubey, A.</author><author>Gamez, L.</author><author>El Fegoun, A. B.</author><author>Hwang, K.</author><author>Pagala, M.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Spine Service, Maimonides Medical Center, Brooklyn, NY, USA. fschwab@worldnet.att.net</auth-address><titles><title>Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1082-5</pages><volume>30</volume><number>9</number><edition>2005/05/03</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New York City/epidemiology</keyword><keyword>*Nutritional Status</keyword><keyword>Prospective Studies</keyword><keyword>Scoliosis/*diagnosis/*epidemiology</keyword><keyword>Self Concept</keyword><keyword>Severity of Illness Index</keyword></keywords><dates><year>2005</year><pub-dates><date>May 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>15864163</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/15864163</url></related-urls></urls></record></Cite></EndNote>(2), although this is may have been fuelled by the availability of the resources to manage this disorder. In either event, if this trend were to continue it should be a concern to health policy planners.  
Rational planning of current and future service provisions needs to have robust data on current and future demands and their likely consequences on the National Health Service (NHS). Yet, within England, there remains a paucity of data on the future demands of this condition and the challenges this condition will bear on the NHS. 
Our objectives were therefore firstly, to identify current trends in the burden of disease from severe ASD based on admission to hospital and surgical intervention, and secondly, to predict future demand based on these trends. Lastly, we consider the health economic implications of these predictions.

Methods
We used published anonymised data and therefore did not seek ethical approval or patient consent.


The latest eleven years of available annual aggregate health data for all hospital admissions and procedures in England, from 2005 to 2015, were retrieved from Hospital Episode Statistics (HES), available from the Health and Social Care Information Centre (https://digital.nhs.uk). 
Patients were included in the analysis based on being as recorded for admission with ASD if any of the ICD10 diagnostic codes shown in Table 1. This range of codes largely reflects the variation in use of terms to describe the primary diagnosis related to ASD. The OPCS classification of interventions and procedures (version 8.4) was used as the procedural codes for complex ASD surgery (Table 1)  ADDIN EN.CITE <EndNote><Cite><Year>2017</Year><RecNum>196</RecNum><DisplayText>(22)</DisplayText><record><rec-number>196</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1516890708">196</key></foreign-keys><ref-type name="Book">6</ref-type><contributors></contributors><titles><title>OPCS Classification of Interventions and Procedures (Version 4.8)</title></titles><volume>1</volume><dates><year>2017</year></dates><publisher>NHS Digital</publisher><urls></urls></record></Cite></EndNote>(22). In order to restrict the analysis to those with complex procedures, isolated decompressive procedures without instrumentation, were excluded. Prior to 2009 the procedural code V41.4 did not exist but was incorporated into one of the other codes listed. Similarly, V40.4 was only introduced in 2011. An accompanying code, V55 (level of spine) is sometimes used to add to the coding but this is supplementary to the main surgical procedure code and was therefore excluded. 

Table 1. Diagnostic and procedural codes used in this analysis.

For the purposes of analysis, patients were separated, based on the available tabulations, into two age groups, namely 15-59 years and 60 years and older. Those older than 60 years were further subdivided in those under and over 75 years.
The main outcome of interest was the absolute number of (i) admissions and (ii) operations for complex ASD during the eleven years of observation.  Secondly, using regression analysis, we modelled the linear trend, after allowing for any demographic change. We then predicted the probable future numbers over the next ten years, assuming the linear trend in demand persisted and also allowing for the predicted demographic changes.
The average length of hospital stay (LOS), was attained from the HES data for each procedural code and then averaged per year according to the number of patients treated for each procedural code. 
In order to estimate the average cost, we utilised the Healthcare Resource Group (HRG) codes, which is the national coding system determining tariff payments. This code is derived from the diagnosis (described above), the procedural code (described above) and the complication code (CC), which is an algorithmic derivative of the patient�s comorbidities. We included only two or more spinal levels and only �elective� codes. All �non-elective� codes were excluded. As the comorbidities and therefore CC code varies for each patient we presented the range of national tariffs for complex ASD procedures. Additionally, the age differs from the diagnostic and procedural codes and therefore we elected to include only those for 19 years and older. We also considered the costs of any revision procedure based on current data.

Statistical analysis
The raw data is presented for the diagnostic and operative volumes between 2005 and 2015. A trend line corresponding to the chronological change in operative volumes is incorporated and extrapolated to predict the future operative volumes in 2020 and 2025. Similarly, the change in LOS between 2005 and 2015 is extrapolated to 2025.

Results
Within the last decade, based on the admissions to secondary care, the number of patients admitted with a diagnosis of ASD has more than doubled (2.2-fold increase), with the biggest change in those aged over 60 years (2.9-fold increase) (Figure 3).

Figure 3. Graph of the number of patients being diagnosed with adult spinal deformity (ASD) in England per year according to age. Trend-lines are extended to 2025 to estimate future needs.

Figure 4 illustrates the number of patients surgically treated for ASD each year according to their age. This illustrates that within the last decade the number of patients treated with ASD has increased 3.5-fold and that the biggest change has been in those aged over 60 years (6.4-fold increase). If this trend continues it is estimated that by 2020, 5100 patients will require surgical intervention and by 2025, 6750 patients will receive ASD surgery, comprised of 3900 patients aged between 15 and 59 years and 2850 aged more than 60 years.

Figure 4. Graph of the number of patients being surgically treated for adult spinal deformity (ASD) and the trend-lines for future operative volumes.

When comparing the number of patients being surgically treated for ASD to the national population, the episode incidence of surgery continues to rise in all age groups (Figure 5). 

Figure 5. Episode incidence of adult spinal deformity surgery (ASD) and the future predicted rate per 100 000 population.

The estimated LOS per patient has reduced from 10.1 days in 2005 to 8.4 days in 2015. If this trend continues, and considering the 3.5 fold increase in ASD operations in the last decade, it is estimated that the total number of inpatient days required in 2020 will be 38500 and in 2025 will be 45200. This equates to 124 inpatients every day nationally in 2025 and an annual increase of 4.5 inpatients per day from current volumes. More importantly, bed days are not all equal in terms of resource use and requirement for expert skills; with the peri-operative period being the period at greatest costs. 
Despite the large number of combinations between diagnostic and procedural codes only four HRG codes are generated. The range of HRG codes and their national tariffs are shown in Table 2  ADDIN EN.CITE <EndNote><Cite><RecNum>199</RecNum><DisplayText>(23)</DisplayText><record><rec-number>199</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1518085457">199</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles></titles><dates></dates><urls><related-urls><url>https://improvement.nhs.uk/resources/national-tariff-1719/</url></related-urls></urls></record></Cite></EndNote>(23). There is an additional �224 per day funding for patients who exceed an expected LOS.

Table 2. Healthcare resource group (HRG) codes (2018) for complex adult spinal deformity procedures and their national tariff  ADDIN EN.CITE <EndNote><Cite><RecNum>199</RecNum><DisplayText>(23)</DisplayText><record><rec-number>199</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1518085457">199</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles></titles><dates></dates><urls><related-urls><url>https://improvement.nhs.uk/resources/national-tariff-1719/</url></related-urls></urls></record></Cite></EndNote>(23). 

Thus, the expected range of expenditure on national tariffs for ASD procedures in 2025 will be between �166 and 234 million based on the current prices. This represents an increase of �81-115 million from current spending. 
As mentioned above there is also a need to account for the costs of any revision surgery. The national complication rate and breakdown of subsequent treatment is unclear. However, the costing for the tariffs for such revision procedures depends on the coding interpretation, however the cost may vary from �34 704 (HC51A - complex instrumented correction of spinal deformity, CC score 7+) for removal of instrumentation and revision of correction, to �2 509 (WH07D - infections or other complications of procedures with single intervention, CC score 0-1) for wound washout and debridement.

Discussion
Surgical intervention for severe ASD, when indicated, is complex and the demands of a single case and impact on health services are disproportionately greater than those of other elective procedures, such as total hip joint replacement. These procedures can take over eight hours and can be associated with a large number of peri- and post-operative complications. However, for many severely affected patients, surgery offers the only option to improve quality of life.
Internationally, the diagnosis and treatment of ASD continues to increase at disproportionate rates to the increase in local populations  ADDIN EN.CITE <EndNote><Cite><Author>Schwab</Author><Year>2005</Year><RecNum>88</RecNum><DisplayText>(2)</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768401">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Dubey, A.</author><author>Gamez, L.</author><author>El Fegoun, A. B.</author><author>Hwang, K.</author><author>Pagala, M.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Spine Service, Maimonides Medical Center, Brooklyn, NY, USA. fschwab@worldnet.att.net</auth-address><titles><title>Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1082-5</pages><volume>30</volume><number>9</number><edition>2005/05/03</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New York City/epidemiology</keyword><keyword>*Nutritional Status</keyword><keyword>Prospective Studies</keyword><keyword>Scoliosis/*diagnosis/*epidemiology</keyword><keyword>Self Concept</keyword><keyword>Severity of Illness Index</keyword></keywords><dates><year>2005</year><pub-dates><date>May 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>15864163</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/15864163</url></related-urls></urls></record></Cite></EndNote>(2). If this increase in the occurrence of the underlying disorder is true, then it is not unexpected that at the severe end of the spectrum, there will be a growing demand for surgical intervention. Within England, we are experiencing a similar trend with the demand growing at a pace that is unsustainable with current resources, which include money, skilled surgeons and peri-operative teams, operating suites and hospital beds. Concerningly, this is despite the baby boomer population only just entering the predominant age groups for this condition. 
Our results suggest a 3.5-fold increase in patients requiring complex ASD surgery in the next decade with the biggest growth being in those aged over 60 years (6.4-fold increase). We calculate that this equates to an annual increase of 330 patients requiring surgery and 1644 inpatient days, even allowing for the trend of reducing LOS. Apart from age, there is no reason to believe there is an underlying increase in the incidence of ASD in the population, and thus the increase observed in our ten-year period, represents an increase in demand, possibly fuelled by increased availability of resources to manage this demand.
Our study did not address the non-operative costs of managing these patients. Within the published literature, there remains a lack of evidence supporting the use of non-operative therapy in ASD  ADDIN EN.CITE  ADDIN EN.CITE.DATA (11, 12). In contrast, the literature favours operative intervention in symptomatic patients, and this has further fuelled the increased volume of complex ASD surgery being performed nationally and internationally ADDIN EN.CITE  ADDIN EN.CITE.DATA (4, 13, 20, 21). Despite the paucity of data on non-operative care, the authors feel that the projected increasing demand in our study should not be interpreted as though surgery is mandatory but rather, that for many patients there remains no other option. Thus, ongoing research into alternative therapies, the development of accurate treatment algorithms and cost saving strategies during surgical intervention should be developed. 
Surgery for complex ASD is amongst the most expensive of all elective procedures. Within the USA, the average total hospital cost for a primary procedure is US$103 143, with the operating room cost (US$70 514) constituting the majority of this cost  ADDIN EN.CITE  ADDIN EN.CITE.DATA (15). The costs of ASD surgery have not been well defined within the UK. This is because the cost relates to the surgical expense (including operating room costs, instrumentation and personnel), the cost of the hospital stay (including intensive care, anaelgesia, rehabilitation) and the complications. We utilised the HRG codes to determine the national tariffs of these procedures, which ranged from �24 568 - 34 704. However, all referral centres treating ASD have a local financial agreement, which supersedes the national tariffs, therefore, these values underestimate actual costs in England. Nonetheless, utilising the national tariffs we found the expected expenditure in 2025 to be �166-234 million, which equates to an annual increase of �8.1-11.5 million from current expenditure. 
Management strategies are therefore necessary to control this increasing financial burden. Within the USA, the surgeon�s implant preference has been identified as the largest determinant of modifiable operating costs accounting for a US$14 780 difference between patients  ADDIN EN.CITE  ADDIN EN.CITE.DATA (15). This is likely to be similar within the UK and suggests that there are avenues to improve expenditure with nationalisation of surgical resources. 
It should be recognised that the surgical approach to this condition can vary, but that a restoration of spinal balance is important  ADDIN EN.CITE <EndNote><Cite><Author>Schwab</Author><Year>2010</Year><RecNum>82</RecNum><DisplayText>(8)</DisplayText><record><rec-number>82</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766624">82</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Patel, A.</author><author>Ungar, B.</author><author>Farcy, J. P.</author><author>Lafage, V.</author></authors></contributors><auth-address>NYU Hospital for Joint Diseases, New York, NY 10010, USA.</auth-address><titles><title>Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2224-31</pages><volume>35</volume><number>25</number><edition>2010/11/26</edition><keywords><keyword>Adult</keyword><keyword>Humans</keyword><keyword>Orthopedic Procedures/*adverse effects</keyword><keyword>Postoperative Period</keyword><keyword>*Postural Balance</keyword><keyword>Radiography</keyword><keyword>Spinal Curvatures/diagnostic imaging/*surgery</keyword><keyword>Spine/diagnostic imaging/*surgery</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>21102297</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/21102297</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181ee6bd4</electronic-resource-num></record></Cite></EndNote>(8). If this is not achieved there is a poorer patient outcome, higher complication rate and higher rate of revision ADDIN EN.CITE  ADDIN EN.CITE.DATA (8, 24, 25). Thus, undertaking minimal surgery without deformity correction in order to reduce initial costs may be counterintuitive. 
Furthermore, it should be recognised that operative intervention in ASD has a high complication rate and patients don't benefit equally  ADDIN EN.CITE  ADDIN EN.CITE.DATA (3, 14, 16, 17). The reported overall complication rate of ASD is 30-40%, with a major complication rate of 20% and a 30-day mortality of 2.4%  ADDIN EN.CITE  ADDIN EN.CITE.DATA (26, 27). Similarly, the revision rate for instrumented fusion in primary ASD is 9-26% ADDIN EN.CITE  ADDIN EN.CITE.DATA (28, 29). The average total hospital cost of a readmission in the USA is US$67 262, equating to 70% of the initial cost of the patient�s treatment  ADDIN EN.CITE  ADDIN EN.CITE.DATA (15). In addition, patients requiring revision have a worse longer-term outcome than those who do not require revision ADDIN EN.CITE  ADDIN EN.CITE.DATA (29). Therefore, it is in both the patient�s and the institutions best interest to optimise the first procedure, this being that although the initial costs may be greater, the longer-term costs will be lower. An approach to �getting it right first time� is therefore warranted  ADDIN EN.CITE  ADDIN EN.CITE.DATA (30). This process may be enhanced by a process of certifying spinal surgery centres in Europe based on their performance based on a robust registration process. This is very much a �work in progress� the debate for which, we hope this paper will contribute.
This analysis has a number of limitations. Firstly, patients diagnosed with ASD and registered with the Health and Social Care Information Centre are usually identified by the spinal surgeon, yet a number of patients with ASD may never seek surgical review, thus it is likely that this study significantly underestimates the national disease burden. Secondly, this study does not identify those patients with ASD who undergo less invasive procedures, such as isolated neural decompression. Thirdly, we have to rely on the accuracy of coding of the data within HES, an inevitable consequence of using routinely available secondary care data. We have attempted to cover all the codes used but changes in coding practice may, as always in these types of analysis, have influenced the trends. One small source of error for example is the use of the �V55� code level of spine surgery but not indicating another procedure code. In fact, in our data this was only the case in 20 patients in the one year we checked (2014) and would not have affected the results. Fourthly, we offer future predictions based on the last decade�s trends, but these are only gross predictions and the fluctuations cannot be predicted. Indeed, the levels of activity are related to growing demand, predominantly based on age, but also on the changing surgical opinion and practice, which is harder to model. Fifthly, we are limited by the availability of the public data. For example, the HES data is based on including all those over 15, whilst the costs data are based on those aged over 19. In practice this discrepancy will not have influence the results in an important manner. Given the HES data we have included all patients over the age of 15 as an �adult deformity�. This cut off excludes �juvenile scoliosis� (onset before age 10). More importantly, although surgery in late teens and early adult life are included, the data presented clearly shows that the growth in activity has been in those over aged 60, with a particular emphasis on those over 75. We have presented the early adult data for completeness. Sixthly, it is a challenging exercise to model the requirement for bed days. Indeed, LOS is reducing across many planned surgical procedures, but LOS is greater in those with the greatest health needs. Thus, any trend to intervene on more elderly frail patients, with greater needs, might arrest or increase the trend to a reduction in LOS. Lastly, the national tariff does not cover all of the costs incurred for each patient and therefore each trust has its own local agreement, which is significantly more than the national tariff. Therefore, the financial costs described in this study are an underestimate of the actual costs.  

Conclusion
Severe ASD is an increasing health burden within England, particularly in those aged over 60 years. Although there will be a continuing debate on the role and value of non-surgical therapies for patients with such complex spinal problems it is sensible to attempt to predict the number of patients diagnosed and surgically treated to nearly double within the next decade. This conservatively equates to an additional 330 patients undergoing ASD per year and an additional annual increased requirement of 1644 inpatient days and between �8.1 and 11.5 million expenditure.
Abbreviations
ASD: Adult spinal deformity
CC: Complication code
HES: Hospital Episode Statistics 
HRG: Healthcare Resource Group 
LOS: Length of stay
NHS: National health service
QoL: Quality of life 
SVA: Sagittal vertical axis

Declarations
Ethics approval and consent to participate: 
Ethical approval was sought but deemed unnecessary as it was a review of HES data

Consent for publication: 
Not applicable

Availability of data and material: 
The datasets generated and/or analysed during the current study are available in the HES database

Competing interests: 
The authors declare that they have no competing interests

Funding: 
No funding was attained for this study

Authors' contributions: 
Kieser DC. Study design, data extraction and analysis, interpretation and write up
Silman A. Data analysis, interpretation and write up
Rothenfluh DA. Study design, data extraction and analysis, interpretation and write up

All authors have read and approved the manuscript

Acknowledgements:
Chris Middlemass for his input into the national coding
Glynny Kieser for her editorial input

References
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Figure legends
Figure 1. Selective radiographs showing the convergence of disability in the sagittal plane. 

Figure 2. Pre-operative and post-operative radiographs showing two cases of coronal (a and b) and sagittal (c and d) malalignment corrected with operative intervention. The straight line in c and d represents the C7 plum line and the dashed line represents the sagittal vertical axis (SVA), which is normally less than 5cm.

Figure 3. Graph of the number of patients being diagnosed with adult spinal deformity (ASD) in England per year according to age. Trend-lines are extended to 2025 to estimate future needs.

Figure 4. Graph of the number of patients being surgically treated for adult spinal deformity (ASD) and the trend-lines for future operative volumes.

Figure 5. Episode incidence of adult spinal deformity surgery (ASD) and the future predicted rate per 100 000 population.

Table legends
Table 1. Diagnostic and procedural codes used in this analysis.

Table 2. Healthcare resource group (HRG) codes (2018) for complex adult spinal deformity procedures and their national tariff  ADDIN EN.CITE <EndNote><Cite><RecNum>199</RecNum><DisplayText>(23)</DisplayText><record><rec-number>199</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1518085457">199</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles></titles><dates></dates><urls><related-urls><url>https://improvement.nhs.uk/resources/national-tariff-1719/</url></related-urls></urls></record></Cite></EndNote>(23). 









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�.:p��|. ��A!�"�#��$��%��������D<EndNote><Cite><Author>Salomon</Author><Year>2015</Year><RecNum>198</RecNum><DisplayText>(1)</DisplayText><record><rec-number>198</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1518071929">198</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Salomon, J. A.</author><author>Haagsma, J. A.</author><author>Davis, A.</author><author>de Noordhout, C. M.</author><author>Polinder, S.</author><author>Havelaar, A. H.</author><author>Cassini, A.</author><author>Devleesschauwer, B.</author><author>Kretzschmar, M.</author><author>Speybroeck, N.</author><author>Murray, C. J.</author><author>Vos, T.</author></authors></contributors><auth-address>Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA. Electronic address: jsalomon@hsph.harvard.edu.&#xD;Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.&#xD;Public Health England, London, UK.&#xD;Institute of Health and Society, Universite catholique de Louvain, Belgium.&#xD;Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands.&#xD;Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.&#xD;European Centre for Disease Prevention and Control, Stockholm, Sweden.&#xD;Institute of Health and Society, Universite catholique de Louvain, Belgium; Department of Virology, Parasitology and Immunology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium.&#xD;Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands; National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, Netherlands.&#xD;Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.</auth-address><titles><title>Disability weights for the Global Burden of Disease 2013 study</title><secondary-title>Lancet Glob Health</secondary-title></titles><periodical><full-title>Lancet Glob Health</full-title></periodical><pages>e712-23</pages><volume>3</volume><number>11</number><edition>2015/10/18</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Cost of Illness</keyword><keyword>*Disability Evaluation</keyword><keyword>Europe</keyword><keyword>Female</keyword><keyword>*Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Quality-Adjusted Life Years</keyword><keyword>Regression Analysis</keyword><keyword>Young Adult</keyword></keywords><dates><year>2015</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>2214-109X (Electronic)&#xD;2214-109X (Linking)</isbn><accession-num>26475018</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/26475018</url></related-urls></urls><electronic-resource-num>10.1016/S2214-109X(15)00069-8</electronic-resource-num></record></Cite></EndNote>�D<EndNote><Cite><Author>Salomon</Author><Year>2015</Year><RecNum>198</RecNum><DisplayText>(1)</DisplayText><record><rec-number>198</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1518071929">198</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Salomon, J. A.</author><author>Haagsma, J. A.</author><author>Davis, A.</author><author>de Noordhout, C. M.</author><author>Polinder, S.</author><author>Havelaar, A. H.</author><author>Cassini, A.</author><author>Devleesschauwer, B.</author><author>Kretzschmar, M.</author><author>Speybroeck, N.</author><author>Murray, C. J.</author><author>Vos, T.</author></authors></contributors><auth-address>Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA. Electronic address: jsalomon@hsph.harvard.edu.&#xD;Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.&#xD;Public Health England, London, UK.&#xD;Institute of Health and Society, Universite catholique de Louvain, Belgium.&#xD;Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands.&#xD;Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.&#xD;European Centre for Disease Prevention and Control, Stockholm, Sweden.&#xD;Institute of Health and Society, Universite catholique de Louvain, Belgium; Department of Virology, Parasitology and Immunology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium.&#xD;Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands; National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, Netherlands.&#xD;Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.</auth-address><titles><title>Disability weights for the Global Burden of Disease 2013 study</title><secondary-title>Lancet Glob Health</secondary-title></titles><periodical><full-title>Lancet Glob Health</full-title></periodical><pages>e712-23</pages><volume>3</volume><number>11</number><edition>2015/10/18</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Cost of Illness</keyword><keyword>*Disability Evaluation</keyword><keyword>Europe</keyword><keyword>Female</keyword><keyword>*Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Quality-Adjusted Life Years</keyword><keyword>Regression Analysis</keyword><keyword>Young Adult</keyword></keywords><dates><year>2015</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>2214-109X (Electronic)&#xD;2214-109X (Linking)</isbn><accession-num>26475018</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/26475018</url></related-urls></urls><electronic-resource-num>10.1016/S2214-109X(15)00069-8</electronic-resource-num></record></Cite></EndNote>pD<EndNote><Cite><Author>Schwab</Author><Year>2005</Year><RecNum>88</RecNum><DisplayText>(2)</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768401">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Dubey, A.</author><author>Gamez, L.</author><author>El Fegoun, A. B.</author><author>Hwang, K.</author><author>Pagala, M.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Spine Service, Maimonides Medical Center, Brooklyn, NY, USA. fschwab@worldnet.att.net</auth-address><titles><title>Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1082-5</pages><volume>30</volume><number>9</number><edition>2005/05/03</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New York City/epidemiology</keyword><keyword>*Nutritional Status</keyword><keyword>Prospective Studies</keyword><keyword>Scoliosis/*diagnosis/*epidemiology</keyword><keyword>Self Concept</keyword><keyword>Severity of Illness Index</keyword></keywords><dates><year>2005</year><pub-dates><date>May 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>15864163</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/15864163</url></related-urls></urls></record></Cite><Cite><Author>Schwab</Author><Year>2005</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768401">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Dubey, A.</author><author>Gamez, L.</author><author>El Fegoun, A. 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P.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Spine Service, Maimonides Medical Center, Brooklyn, NY, USA. fschwab@worldnet.att.net</auth-address><titles><title>Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1082-5</pages><volume>30</volume><number>9</number><edition>2005/05/03</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New York City/epidemiology</keyword><keyword>*Nutritional Status</keyword><keyword>Prospective Studies</keyword><keyword>Scoliosis/*diagnosis/*epidemiology</keyword><keyword>Self Concept</keyword><keyword>Severity of Illness Index</keyword></keywords><dates><year>2005</year><pub-dates><date>May 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>15864163</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/15864163</url></related-urls></urls></record></Cite></EndNote>$
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Leatherman Spine Center, Louisville, KY, USA. tallgeyer@spinemds.com</auth-address><titles><title>The impact of positive sagittal balance in adult spinal deformity</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2024-9</pages><volume>30</volume><number>18</number><edition>2005/09/17</edition><keywords><keyword>Cohort Studies</keyword><keyword>Disability Evaluation</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Kyphosis/complications/*diagnostic imaging/*physiopathology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Multicenter Studies as Topic</keyword><keyword>Orthopedics/*methods</keyword><keyword>Pain/etiology/physiopathology</keyword><keyword>Radiography</keyword><keyword>Retrospective Studies</keyword><keyword>Scoliosis/complications/*diagnostic imaging/*physiopathology</keyword></keywords><dates><year>2005</year><pub-dates><date>Sep 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>16166889</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/16166889</url></related-urls></urls></record></Cite><Cite><Author>Lafage</Author><Year>2009</Year><RecNum>87</RecNum><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513767956">87</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lafage, V.</author><author>Schwab, F.</author><author>Patel, A.</author><author>Hawkinson, N.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>NYU Hospital for Joint Diseases, New York, NY 10010, USA. virginie.lafage@gmail.com</auth-address><titles><title>Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>E599-606</pages><volume>34</volume><number>17</number><edition>2009/08/01</edition><keywords><keyword>Activities of Daily Living</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Anthropometry/*methods</keyword><keyword>Cohort Studies</keyword><keyword>*Disability Evaluation</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pelvis/*diagnostic imaging/pathology/physiopathology</keyword><keyword>Posture/*physiology</keyword><keyword>Quality of Life</keyword><keyword>Radiography</keyword><keyword>Self-Assessment</keyword><keyword>Severity of Illness Index</keyword><keyword>Spinal Curvatures/*diagnostic imaging/pathology/physiopathology</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Young Adult</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>19644319</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/19644319</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181aad219</electronic-resource-num></record></Cite><Cite><Author>Schwab</Author><Year>2013</Year><RecNum>86</RecNum><record><rec-number>86</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513767756">86</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F. J.</author><author>Blondel, B.</author><author>Bess, S.</author><author>Hostin, R.</author><author>Shaffrey, C. I.</author><author>Smith, J. S.</author><author>Boachie-Adjei, O.</author><author>Burton, D. C.</author><author>Akbarnia, B. A.</author><author>Mundis, G. M.</author><author>Ames, C. P.</author><author>Kebaish, K.</author><author>Hart, R. A.</author><author>Farcy, J. P.</author><author>Lafage, V.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Spine Division, NYU Hospital for Joint Diseases, New York, NY, USA.</auth-address><titles><title>Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>E803-12</pages><volume>38</volume><number>13</number><edition>2013/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>*Disability Evaluation</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Linear Models</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pelvis/*diagnostic imaging</keyword><keyword>Prognosis</keyword><keyword>Prospective Studies</keyword><keyword>Quality of Life</keyword><keyword>Radiography/methods</keyword><keyword>Reproducibility of Results</keyword><keyword>Scoliosis/diagnosis/diagnostic imaging/*surgery</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Spine/*diagnostic imaging</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Young Adult</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>23722572</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/23722572</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e318292b7b9</electronic-resource-num></record></Cite><Cite><Author>Schwab</Author><Year>2010</Year><RecNum>82</RecNum><record><rec-number>82</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766624">82</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Patel, A.</author><author>Ungar, B.</author><author>Farcy, J. P.</author><author>Lafage, V.</author></authors></contributors><auth-address>NYU Hospital for Joint Diseases, New York, NY 10010, USA.</auth-address><titles><title>Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2224-31</pages><volume>35</volume><number>25</number><edition>2010/11/26</edition><keywords><keyword>Adult</keyword><keyword>Humans</keyword><keyword>Orthopedic Procedures/*adverse effects</keyword><keyword>Postoperative Period</keyword><keyword>*Postural Balance</keyword><keyword>Radiography</keyword><keyword>Spinal Curvatures/diagnostic imaging/*surgery</keyword><keyword>Spine/diagnostic imaging/*surgery</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>21102297</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/21102297</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181ee6bd4</electronic-resource-num></record></Cite></EndNote>f(D<EndNote><Cite><Author>Schwab</Author><Year>2013</Year><RecNum>86</RecNum><DisplayText>(2, 5-7, 9)</DisplayText><record><rec-number>86</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513767756">86</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F. J.</author><author>Blondel, B.</author><author>Bess, S.</author><author>Hostin, R.</author><author>Shaffrey, C. I.</author><author>Smith, J. S.</author><author>Boachie-Adjei, O.</author><author>Burton, D. C.</author><author>Akbarnia, B. A.</author><author>Mundis, G. M.</author><author>Ames, C. P.</author><author>Kebaish, K.</author><author>Hart, R. A.</author><author>Farcy, J. P.</author><author>Lafage, V.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Spine Division, NYU Hospital for Joint Diseases, New York, NY, USA.</auth-address><titles><title>Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>E803-12</pages><volume>38</volume><number>13</number><edition>2013/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>*Disability Evaluation</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Linear Models</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pelvis/*diagnostic imaging</keyword><keyword>Prognosis</keyword><keyword>Prospective Studies</keyword><keyword>Quality of Life</keyword><keyword>Radiography/methods</keyword><keyword>Reproducibility of Results</keyword><keyword>Scoliosis/diagnosis/diagnostic imaging/*surgery</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Spine/*diagnostic imaging</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Young Adult</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>23722572</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/23722572</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e318292b7b9</electronic-resource-num></record></Cite><Cite><Author>Lafage</Author><Year>2009</Year><RecNum>87</RecNum><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513767956">87</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lafage, V.</author><author>Schwab, F.</author><author>Patel, A.</author><author>Hawkinson, N.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>NYU Hospital for Joint Diseases, New York, NY 10010, USA. virginie.lafage@gmail.com</auth-address><titles><title>Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>E599-606</pages><volume>34</volume><number>17</number><edition>2009/08/01</edition><keywords><keyword>Activities of Daily Living</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Anthropometry/*methods</keyword><keyword>Cohort Studies</keyword><keyword>*Disability Evaluation</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pelvis/*diagnostic imaging/pathology/physiopathology</keyword><keyword>Posture/*physiology</keyword><keyword>Quality of Life</keyword><keyword>Radiography</keyword><keyword>Self-Assessment</keyword><keyword>Severity of Illness Index</keyword><keyword>Spinal Curvatures/*diagnostic imaging/pathology/physiopathology</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Young Adult</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>19644319</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/19644319</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181aad219</electronic-resource-num></record></Cite><Cite><Author>Glassman</Author><Year>2005</Year><RecNum>80</RecNum><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513765878">80</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Glassman, S. D.</author><author>Bridwell, K.</author><author>Dimar, J. R.</author><author>Horton, W.</author><author>Berven, S.</author><author>Schwab, F.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, University of Louisville School of Medicine, The Kenton D. Leatherman Spine Center, Louisville, KY, USA. tallgeyer@spinemds.com</auth-address><titles><title>The impact of positive sagittal balance in adult spinal deformity</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2024-9</pages><volume>30</volume><number>18</number><edition>2005/09/17</edition><keywords><keyword>Cohort Studies</keyword><keyword>Disability Evaluation</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Kyphosis/complications/*diagnostic imaging/*physiopathology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Multicenter Studies as Topic</keyword><keyword>Orthopedics/*methods</keyword><keyword>Pain/etiology/physiopathology</keyword><keyword>Radiography</keyword><keyword>Retrospective Studies</keyword><keyword>Scoliosis/complications/*diagnostic imaging/*physiopathology</keyword></keywords><dates><year>2005</year><pub-dates><date>Sep 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>16166889</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/16166889</url></related-urls></urls></record></Cite><Cite><Author>Schwab</Author><Year>2003</Year><RecNum>115</RecNum><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513779368">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Dubey, A.</author><author>Pagala, M.</author><author>Gamez, L.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>Spine Center, Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, USA. fschwab@worldnet.att.net</auth-address><titles><title>Adult scoliosis: a health assessment analysis by SF-36</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>602-6</pages><volume>28</volume><number>6</number><edition>2003/03/19</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age of Onset</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Back Pain/epidemiology</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Hypertension/epidemiology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neuropsychological Tests/statistics &amp; numerical data</keyword><keyword>Prospective Studies</keyword><keyword>Scoliosis/*diagnosis/epidemiology</keyword><keyword>*Self Concept</keyword><keyword>Severity of Illness Index</keyword><keyword>Sickness Impact Profile</keyword><keyword>*Surveys and Questionnaires</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2003</year><pub-dates><date>Mar 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>12642769</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/12642769</url></related-urls></urls><electronic-resource-num>10.1097/01.BRS.0000049924.94414.BB</electronic-resource-num></record></Cite><Cite><Author>Schwab</Author><Year>2005</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768401">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Dubey, A.</author><author>Gamez, L.</author><author>El Fegoun, A. B.</author><author>Hwang, K.</author><author>Pagala, M.</author><author>Farcy, J. P.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Spine Service, Maimonides Medical Center, Brooklyn, NY, USA. fschwab@worldnet.att.net</auth-address><titles><title>Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1082-5</pages><volume>30</volume><number>9</number><edition>2005/05/03</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New York City/epidemiology</keyword><keyword>*Nutritional Status</keyword><keyword>Prospective Studies</keyword><keyword>Scoliosis/*diagnosis/*epidemiology</keyword><keyword>Self Concept</keyword><keyword>Severity of Illness Index</keyword></keywords><dates><year>2005</year><pub-dates><date>May 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>15864163</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/15864163</url></related-urls></urls></record></Cite></EndNote>	D<EndNote><Cite><Author>Pellise</Author><Year>2015</Year><RecNum>112</RecNum><DisplayText>(10)</DisplayText><record><rec-number>112</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513778186">112</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pellise, F.</author><author>Vila-Casademunt, A.</author><author>Ferrer, M.</author><author>Domingo-Sabat, M.</author><author>Bago, J.</author><author>Perez-Grueso, F. 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F.</author><author>Acaroglu, E.</author><author>European Spine Study Group, Essg</author></authors></contributors><auth-address>Spine Surgery Unit, Hospital Vall d&apos;Hebron, Traumathology Building 2nd Floor, Passeig Vall Hebron 119-129, Barcelona, 08035, Spain, 24361fpu@comb.cat.</auth-address><titles><title>Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions</title><secondary-title>Eur Spine J</secondary-title></titles><periodical><full-title>Eur Spine J</full-title></periodical><pages>3-11</pages><volume>24</volume><number>1</number><edition>2014/09/15</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Chronic Disease</keyword><keyword>*Cost of Illness</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Databases, Factual</keyword><keyword>Female</keyword><keyword>Health Status Indicators</keyword><keyword>Health Surveys</keyword><keyword>Humans</keyword><keyword>*Kyphosis/physiopathology/psychology/surgery</keyword><keyword>Linear Models</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Prospective Studies</keyword><keyword>*Quality of Life</keyword><keyword>*Scoliosis/physiopathology/psychology/surgery</keyword><keyword>Self Report</keyword></keywords><dates><year>2015</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1432-0932 (Electronic)&#xD;0940-6719 (Linking)</isbn><accession-num>25218732</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/25218732</url></related-urls></urls><electronic-resource-num>10.1007/s00586-014-3542-1</electronic-resource-num></record></Cite></EndNote>�D<EndNote><Cite><Author>Glassman</Author><Year>2010</Year><RecNum>116</RecNum><DisplayText>(11, 12)</DisplayText><record><rec-number>116</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513779658">116</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Glassman, S. 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H.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA. tallgeyer@spinemds.com</auth-address><titles><title>The costs and benefits of nonoperative management for adult scoliosis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>578-82</pages><volume>35</volume><number>5</number><edition>2010/02/02</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Analgesics/therapeutic use</keyword><keyword>*Cost of Illness</keyword><keyword>Female</keyword><keyword>*Health Care Costs</keyword><keyword>*Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Physical Therapy Modalities</keyword><keyword>Prospective Studies</keyword><keyword>Quality of Life</keyword><keyword>Scoliosis/*economics/*therapy</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Mar 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>20118843</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/20118843</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181b0f2f8</electronic-resource-num></record></Cite><Cite><Author>Glassman</Author><Year>2006</Year><RecNum>119</RecNum><record><rec-number>119</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513785402">119</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Glassman, S. 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P.</author></authors></contributors><auth-address>Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA. jss7f@virginia.edu</auth-address><titles><title>Clinical and radiographic evaluation of the adult spinal deformity patient</title><secondary-title>Neurosurg Clin N Am</secondary-title></titles><periodical><full-title>Neurosurg Clin N Am</full-title></periodical><pages>143-56</pages><volume>24</volume><number>2</number><edition>2013/04/09</edition><keywords><keyword>Aged</keyword><keyword>Humans</keyword><keyword>Kyphosis/diagnosis/diagnostic imaging</keyword><keyword>Magnetic Resonance Angiography</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Myelography</keyword><keyword>Neurologic Examination</keyword><keyword>Orthopedic Procedures</keyword><keyword>Physical Examination</keyword><keyword>Scoliosis/diagnosis/diagnostic imaging/surgery</keyword><keyword>Spinal Diseases/*diagnosis/*diagnostic imaging/surgery</keyword><keyword>Spine/diagnostic imaging</keyword><keyword>Spondylolisthesis/diagnosis/diagnostic imaging</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>2013</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1558-1349 (Electronic)&#xD;1042-3680 (Linking)</isbn><accession-num>23561553</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/23561553</url></related-urls></urls><electronic-resource-num>10.1016/j.nec.2012.12.009</electronic-resource-num></record></Cite><Cite><Author>Liu</Author><Year>2014</Year><RecNum>102</RecNum><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513774446">102</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Liu, S.</author><author>Schwab, F.</author><author>Smith, J. 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A.</author><author>Bess, S.</author><author>Lafage, V.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY.&#xD;Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA.&#xD;Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA.&#xD;San Diego Center for Spinal Disorders, La Jolla, CA.&#xD;Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX.&#xD;Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD.&#xD;Department of Orthopaedic Surgery, University of California-San Francisco Medical Center, San Francisco, CA.&#xD;Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.&#xD;Department of Orthopaedic Surgery, Oregon Health &amp; Science University, Portland, OR.&#xD;Department of Orthopaedic Surgery, Rocky Mountain Hospital for Children, Denver, CO.</auth-address><titles><title>Likelihood of reaching minimal clinically important difference in adult spinal deformity: a comparison of operative and nonoperative treatment</title><secondary-title>Ochsner J</secondary-title></titles><periodical><full-title>Ochsner J</full-title></periodical><pages>67-77</pages><volume>14</volume><number>1</number><edition>2014/04/02</edition><keywords><keyword>Disability evaluation</keyword><keyword>pain management</keyword><keyword>quality of life</keyword><keyword>spinal cord diseases</keyword><keyword>surgical procedures-operative</keyword></keywords><dates><year>2014</year><pub-dates><date>Spring</date></pub-dates></dates><isbn>1524-5012 (Print)&#xD;1524-5012 (Linking)</isbn><accession-num>24688336</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/24688336</url></related-urls></urls><custom2>PMC3963055</custom2></record></Cite><Cite><Author>Baron</Author><Year>2006</Year><RecNum>105</RecNum><record><rec-number>105</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513776751">105</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baron, E. 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Electronic address: ian.mccarthy@baylorhealth.edu.&#xD;Baylor Scoliosis Center, 4708 Alliance Blvd, Suite 800, Plano, TX 75093, USA.&#xD;University of California-San Francisco, Department of Neurosurgery, 400 Parnassus Ave, San Francisco, CA 94143, USA.&#xD;Hospital for Special Surgery, Department of Orthopaedic Surgery, 535 East 70th St, New York, NY 10021, USA.&#xD;University of Virginia, Department of Neurosurgery, PO Box 800212, Charlottesville, VA 22908, USA.&#xD;New York Spine Institute, Department of Orthopaedic Surgery, 761 Merrick Ave, Westbury, NY 11590, USA.&#xD;University of California Davis, Department of Orthopaedic Surgery, 3301 C St, Suite 1500, Sacramento, CA 95816, USA.&#xD;University of Minnesota, Department of Orthopaedic Surgery, 2512 South 7th St, Suite R200, Minneapolis, MN 55454, USA.</auth-address><titles><title>Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study</title><secondary-title>Spine J</secondary-title></titles><periodical><full-title>Spine J</full-title></periodical><pages>2326-33</pages><volume>14</volume><number>10</number><edition>2014/01/29</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Hospital Costs/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Operating Rooms/*economics</keyword><keyword>Orthopedic Procedures/*economics</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Scoliosis/*economics/surgery</keyword><keyword>Time Factors</keyword><keyword>Young Adult</keyword><keyword>Adult spinal deformity</keyword><keyword>Cost-effectiveness</keyword><keyword>Hospital costs</keyword><keyword>Implant costs</keyword><keyword>Physician preference</keyword><keyword>Spine fusion</keyword></keywords><dates><year>2014</year><pub-dates><date>Oct 1</date></pub-dates></dates><isbn>1878-1632 (Electronic)&#xD;1529-9430 (Linking)</isbn><accession-num>24469004</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/24469004</url></related-urls></urls><electronic-resource-num>10.1016/j.spinee.2014.01.032</electronic-resource-num></record></Cite><Cite><Author>Smith</Author><Year>2011</Year><RecNum>93</RecNum><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768854">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smith, J. 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H.</author><author>Spinal Deformity Study, Group</author></authors></contributors><auth-address>Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA. jss7f@virginia.edu</auth-address><titles><title>Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>817-24</pages><volume>36</volume><number>10</number><edition>2010/08/05</edition><keywords><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Databases, Factual</keyword><keyword>Decompression, Surgical/*adverse effects</keyword><keyword>Disability Evaluation</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteotomy/*adverse effects</keyword><keyword>Pain/etiology/physiopathology</keyword><keyword>*Postoperative Complications</keyword><keyword>Prospective Studies</keyword><keyword>Retrospective Studies</keyword><keyword>Risk Assessment</keyword><keyword>Scoliosis/physiopathology/rehabilitation/*surgery</keyword><keyword>Severity of Illness Index</keyword><keyword>Spinal Fusion/*adverse effects</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2011</year><pub-dates><date>May 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>20683385</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/20683385</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181e21783</electronic-resource-num></record></Cite><Cite><Author>Smith</Author><Year>2016</Year><RecNum>131</RecNum><record><rec-number>131</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513788026">131</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smith, J. S.</author><author>Klineberg, E.</author><author>Lafage, V.</author><author>Shaffrey, C. I.</author><author>Schwab, F.</author><author>Lafage, R.</author><author>Hostin, R.</author><author>Mundis, G. M., Jr.</author><author>Errico, T. J.</author><author>Kim, H. J.</author><author>Protopsaltis, T. S.</author><author>Hamilton, D. K.</author><author>Scheer, J. K.</author><author>Soroceanu, A.</author><author>Kelly, M. P.</author><author>Line, B.</author><author>Gupta, M.</author><author>Deviren, V.</author><author>Hart, R.</author><author>Burton, D. C.</author><author>Bess, S.</author><author>Ames, C. P.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;&#xD;Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California;&#xD;Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, and.&#xD;Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas;&#xD;Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;&#xD;Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;&#xD;University of California San Diego School of Medicine, San Diego, California;&#xD;Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada;&#xD;Department of Orthopedic Surgery, Washington University, St. Louis, Missouri;&#xD;Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado;&#xD;Departments of 11 Orthopedic Surgery and.&#xD;Department of Orthopaedic Surgery, Oregon Health &amp; Science University, Portland, Oregon; and.&#xD;Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas.&#xD;Neurosurgery, University of California, San Francisco, California;</auth-address><titles><title>Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery</title><secondary-title>J Neurosurg Spine</secondary-title></titles><periodical><full-title>J Neurosurg Spine</full-title></periodical><pages>1-14</pages><volume>25</volume><number>1</number><edition>2016/02/27</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteotomy/*adverse effects/methods</keyword><keyword>Perioperative Period</keyword><keyword>Postoperative Complications/*epidemiology</keyword><keyword>Prospective Studies</keyword><keyword>Spinal Curvatures/*epidemiology/*surgery</keyword><keyword>Spinal Fusion/*adverse effects/methods</keyword><keyword>Spine/surgery</keyword><keyword>Young Adult</keyword><keyword>ASA = American Society of Anesthesiologists</keyword><keyword>ASD = adult spinal deformity</keyword><keyword>BMI = body mass index</keyword><keyword>CCI = Charlson Comorbidity Index</keyword><keyword>EBL = estimated blood loss</keyword><keyword>HRQOL = health-related quality of life</keyword><keyword>LL = lumbar lordosis</keyword><keyword>PCS = Physical Component Summary</keyword><keyword>PI = pelvic incidence</keyword><keyword>PI-LL = mismatch between pelvic incidence and lumbar lordosis</keyword><keyword>PJK = proximal junctional kyphosis</keyword><keyword>PT = pelvic tilt</keyword><keyword>SRS = Scoliosis Research Society</keyword><keyword>SVA = sagittal vertical axis</keyword><keyword>adult spinal deformity</keyword><keyword>complications</keyword><keyword>prospective</keyword><keyword>scoliosis</keyword><keyword>surgery</keyword></keywords><dates><year>2016</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1547-5646 (Electronic)&#xD;1547-5646 (Linking)</isbn><accession-num>26918574</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/26918574</url></related-urls></urls><electronic-resource-num>10.3171/2015.11.SPINE151036</electronic-resource-num></record></Cite></EndNote>`D<EndNote><Cite><Author>Schwab</Author><Year>2010</Year><RecNum>82</RecNum><DisplayText>(8, 18, 19)</DisplayText><record><rec-number>82</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766624">82</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Patel, A.</author><author>Ungar, B.</author><author>Farcy, J. 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An overview of key parameters in assessing alignment and planning corrective surgery</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2224-31</pages><volume>35</volume><number>25</number><edition>2010/11/26</edition><keywords><keyword>Adult</keyword><keyword>Humans</keyword><keyword>Orthopedic Procedures/*adverse effects</keyword><keyword>Postoperative Period</keyword><keyword>*Postural Balance</keyword><keyword>Radiography</keyword><keyword>Spinal Curvatures/diagnostic imaging/*surgery</keyword><keyword>Spine/diagnostic imaging/*surgery</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>21102297</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/21102297</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181ee6bd4</electronic-resource-num></record></Cite><Cite><Author>Bridwell</Author><Year>2009</Year><RecNum>92</RecNum><record><rec-number>92</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768814">92</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bridwell, K. H.</author><author>Glassman, S.</author><author>Horton, W.</author><author>Shaffrey, C.</author><author>Schwab, F.</author><author>Zebala, L. P.</author><author>Lenke, L. G.</author><author>Hilton, J. F.</author><author>Shainline, M.</author><author>Baldus, C.</author><author>Wootten, D.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA. bridwellk@wudosis.wustl.edu</auth-address><titles><title>Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2171-8</pages><volume>34</volume><number>20</number><edition>2009/09/16</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>*Evidence-Based Medicine</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain/etiology/physiopathology</keyword><keyword>Pain Management</keyword><keyword>*Physical Therapy Modalities</keyword><keyword>*Quality of Life</keyword><keyword>Scoliosis/complications/physiopathology/*therapy</keyword><keyword>Severity of Illness Index</keyword><keyword>*Spinal Fusion</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2009</year><pub-dates><date>Sep 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>19752703</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/19752703</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181a8fdc8</electronic-resource-num></record></Cite><Cite><Author>Scheer</Author><Year>2015</Year><RecNum>135</RecNum><record><rec-number>135</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513789559">135</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Scheer, J. K.</author><author>Smith, J. S.</author><author>Clark, A. J.</author><author>Lafage, V.</author><author>Kim, H. J.</author><author>Rolston, J. D.</author><author>Eastlack, R.</author><author>Hart, R. A.</author><author>Protopsaltis, T. S.</author><author>Kelly, M. P.</author><author>Kebaish, K.</author><author>Gupta, M.</author><author>Klineberg, E.</author><author>Hostin, R.</author><author>Shaffrey, C. I.</author><author>Schwab, F.</author><author>Ames, C. P.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois;</auth-address><titles><title>Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction</title><secondary-title>J Neurosurg Spine</secondary-title></titles><periodical><full-title>J Neurosurg Spine</full-title></periodical><pages>540-53</pages><volume>22</volume><number>5</number><edition>2015/02/24</edition><keywords><keyword>Back Pain/etiology/*surgery</keyword><keyword>Decompression, Surgical</keyword><keyword>Disability Evaluation</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Leg</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteotomy</keyword><keyword>Pain/etiology/*surgery</keyword><keyword>Pain Measurement</keyword><keyword>*Patient Satisfaction</keyword><keyword>Quality of Life</keyword><keyword>Retrospective Studies</keyword><keyword>Spine/*abnormalities/surgery</keyword><keyword>Treatment Outcome</keyword><keyword>United States</keyword><keyword>ASD = adult spinal deformity</keyword><keyword>FU = follow-up</keyword><keyword>HRQOL = health-related quality of life</keyword><keyword>MCID = minimum clinically import difference</keyword><keyword>NRS = numerical rating scale</keyword><keyword>ODI = Oswestry Disability Index</keyword><keyword>PCS = physical component summary</keyword><keyword>Pso</keyword><keyword>SCB = substantial clinical benefit</keyword><keyword>SF-36 = 36-Item Short Form Health Survey</keyword><keyword>SRS = Scoliosis Research Society</keyword><keyword>SRS-Schwab classification</keyword><keyword>Vcr</keyword><keyword>adult spinal deformity</keyword><keyword>back pain</keyword><keyword>leg pain</keyword><keyword>satisfaction</keyword><keyword>scoliosis</keyword><keyword>spinal disorders</keyword></keywords><dates><year>2015</year><pub-dates><date>May</date></pub-dates></dates><isbn>1547-5646 (Electronic)&#xD;1547-5646 (Linking)</isbn><accession-num>25700238</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/25700238</url></related-urls></urls><electronic-resource-num>10.3171/2014.10.SPINE14475</electronic-resource-num></record></Cite></EndNote>�D<EndNote><Cite><Author>McCarthy</Author><Year>2014</Year><RecNum>113</RecNum><DisplayText>(4, 20, 21)</DisplayText><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513779040">113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McCarthy, I.</author><author>O&apos;Brien, M.</author><author>Ames, C.</author><author>Robinson, C.</author><author>Errico, T.</author><author>Polly, D. W., Jr.</author><author>Hostin, R.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Center for Clinical Effectiveness, Baylor Scott &amp; White Health, Dallas, Texas;</auth-address><titles><title>Incremental cost-effectiveness of adult spinal deformity surgery: observed quality-adjusted life years with surgery compared with predicted quality-adjusted life years without surgery</title><secondary-title>Neurosurg Focus</secondary-title></titles><periodical><full-title>Neurosurg Focus</full-title></periodical><pages>E3</pages><volume>36</volume><number>5</number><edition>2014/05/03</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Cost-Benefit Analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Quality of Life</keyword><keyword>*Quality-Adjusted Life Years</keyword><keyword>Retrospective Studies</keyword><keyword>Spinal Fusion/economics/methods</keyword><keyword>Spine/*surgery</keyword><keyword>Young Adult</keyword></keywords><dates><year>2014</year><pub-dates><date>May</date></pub-dates></dates><isbn>1092-0684 (Electronic)&#xD;1092-0684 (Linking)</isbn><accession-num>24785485</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/24785485</url></related-urls></urls><electronic-resource-num>10.3171/2014.3.FOCUS1415</electronic-resource-num></record></Cite><Cite><Author>http://hcup-us.ahrq.gov/nisoverview.jsp</Author><Year>2014</Year><RecNum>114</RecNum><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513779106">114</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>http://hcup-us.ahrq.gov/nisoverview.jsp</author></authors></contributors><titles></titles><dates><year>2014</year></dates><urls></urls></record></Cite><Cite><Author>Good</Author><Year>2011</Year><RecNum>81</RecNum><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766118">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Good, C. 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Leatherman Spine Center, Louisville, KY, USA. tallgeyer@spinemds.com</auth-address><titles><title>Nonsurgical resource utilization in adult spinal deformity</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>941-7</pages><volume>31</volume><number>8</number><edition>2006/04/20</edition><keywords><keyword>Adult</keyword><keyword>Female</keyword><keyword>Health Resources</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Multicenter Studies as Topic</keyword><keyword>Retrospective Studies</keyword><keyword>Scoliosis/*epidemiology/*therapy</keyword></keywords><dates><year>2006</year><pub-dates><date>Apr 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>16622386</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/16622386</url></related-urls></urls><electronic-resource-num>10.1097/01.brs.0000209318.32148.8b</electronic-resource-num></record></Cite><Cite><Author>Glassman</Author><Year>2010</Year><RecNum>116</RecNum><record><rec-number>116</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513779658">116</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Glassman, S. 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H.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA. tallgeyer@spinemds.com</auth-address><titles><title>The costs and benefits of nonoperative management for adult scoliosis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>578-82</pages><volume>35</volume><number>5</number><edition>2010/02/02</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Analgesics/therapeutic use</keyword><keyword>*Cost of Illness</keyword><keyword>Female</keyword><keyword>*Health Care Costs</keyword><keyword>*Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain Measurement</keyword><keyword>Physical Therapy Modalities</keyword><keyword>Prospective Studies</keyword><keyword>Quality of Life</keyword><keyword>Scoliosis/*economics/*therapy</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Mar 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>20118843</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/20118843</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181b0f2f8</electronic-resource-num></record></Cite></EndNote>>D<EndNote><Cite><Author>Good</Author><Year>2011</Year><RecNum>81</RecNum><DisplayText>(4, 13, 20, 21)</DisplayText><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766118">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Good, C. R.</author><author>Auerbach, J. D.</author><author>O&apos;Leary, P. T.</author><author>Schuler, T. C.</author></authors></contributors><auth-address>Virginia Spine Institute, 1831 Wiehle Avenue, Reston, VA, 20190, USA, crgood@SpineMD.com.</auth-address><titles><title>Adult spine deformity</title><secondary-title>Curr Rev Musculoskelet Med</secondary-title></titles><periodical><full-title>Curr Rev Musculoskelet Med</full-title></periodical><pages>159-67</pages><volume>4</volume><number>4</number><edition>2011/10/25</edition><dates><year>2011</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1935-9748 (Electronic)&#xD;1935-9748 (Linking)</isbn><accession-num>22021017</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/22021017</url></related-urls></urls><custom2>PMC3261243</custom2><electronic-resource-num>10.1007/s12178-011-9101-z</electronic-resource-num></record></Cite><Cite><Author>Liu</Author><Year>2014</Year><RecNum>102</RecNum><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513774446">102</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Liu, S.</author><author>Schwab, F.</author><author>Smith, J. 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W., Jr.</author><author>Hostin, R.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Center for Clinical Effectiveness, Baylor Scott &amp; White Health, Dallas, Texas;</auth-address><titles><title>Incremental cost-effectiveness of adult spinal deformity surgery: observed quality-adjusted life years with surgery compared with predicted quality-adjusted life years without surgery</title><secondary-title>Neurosurg Focus</secondary-title></titles><periodical><full-title>Neurosurg Focus</full-title></periodical><pages>E3</pages><volume>36</volume><number>5</number><edition>2014/05/03</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Cost-Benefit Analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Quality of Life</keyword><keyword>*Quality-Adjusted Life Years</keyword><keyword>Retrospective Studies</keyword><keyword>Spinal Fusion/economics/methods</keyword><keyword>Spine/*surgery</keyword><keyword>Young Adult</keyword></keywords><dates><year>2014</year><pub-dates><date>May</date></pub-dates></dates><isbn>1092-0684 (Electronic)&#xD;1092-0684 (Linking)</isbn><accession-num>24785485</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/24785485</url></related-urls></urls><electronic-resource-num>10.3171/2014.3.FOCUS1415</electronic-resource-num></record></Cite><Cite><Author>http://hcup-us.ahrq.gov/nisoverview.jsp</Author><Year>2014</Year><RecNum>114</RecNum><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513779106">114</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>http://hcup-us.ahrq.gov/nisoverview.jsp</author></authors></contributors><titles></titles><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>V
D<EndNote><Cite><Author>McCarthy</Author><Year>2014</Year><RecNum>130</RecNum><DisplayText>(15)</DisplayText><record><rec-number>130</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513787844">130</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McCarthy, I. M.</author><author>Hostin, R. A.</author><author>Ames, C. P.</author><author>Kim, H. J.</author><author>Smith, J. S.</author><author>Boachie-Adjei, O.</author><author>Schwab, F. J.</author><author>Klineberg, E. O.</author><author>Shaffrey, C. I.</author><author>Gupta, M. C.</author><author>Polly, D. W.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Institute for Health Care Research and Improvement, Baylor Health Care System, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206, USA; Southern Methodist University, Department of Economics, 3110 University Blvd, Dallas, TX 75205, USA. Electronic address: ian.mccarthy@baylorhealth.edu.&#xD;Baylor Scoliosis Center, 4708 Alliance Blvd, Suite 800, Plano, TX 75093, USA.&#xD;University of California-San Francisco, Department of Neurosurgery, 400 Parnassus Ave, San Francisco, CA 94143, USA.&#xD;Hospital for Special Surgery, Department of Orthopaedic Surgery, 535 East 70th St, New York, NY 10021, USA.&#xD;University of Virginia, Department of Neurosurgery, PO Box 800212, Charlottesville, VA 22908, USA.&#xD;New York Spine Institute, Department of Orthopaedic Surgery, 761 Merrick Ave, Westbury, NY 11590, USA.&#xD;University of California Davis, Department of Orthopaedic Surgery, 3301 C St, Suite 1500, Sacramento, CA 95816, USA.&#xD;University of Minnesota, Department of Orthopaedic Surgery, 2512 South 7th St, Suite R200, Minneapolis, MN 55454, USA.</auth-address><titles><title>Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study</title><secondary-title>Spine J</secondary-title></titles><periodical><full-title>Spine J</full-title></periodical><pages>2326-33</pages><volume>14</volume><number>10</number><edition>2014/01/29</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Hospital Costs/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Operating Rooms/*economics</keyword><keyword>Orthopedic Procedures/*economics</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Scoliosis/*economics/surgery</keyword><keyword>Time Factors</keyword><keyword>Young Adult</keyword><keyword>Adult spinal deformity</keyword><keyword>Cost-effectiveness</keyword><keyword>Hospital costs</keyword><keyword>Implant costs</keyword><keyword>Physician preference</keyword><keyword>Spine fusion</keyword></keywords><dates><year>2014</year><pub-dates><date>Oct 1</date></pub-dates></dates><isbn>1878-1632 (Electronic)&#xD;1529-9430 (Linking)</isbn><accession-num>24469004</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/24469004</url></related-urls></urls><electronic-resource-num>10.1016/j.spinee.2014.01.032</electronic-resource-num></record></Cite></EndNote>V
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Electronic address: ian.mccarthy@baylorhealth.edu.&#xD;Baylor Scoliosis Center, 4708 Alliance Blvd, Suite 800, Plano, TX 75093, USA.&#xD;University of California-San Francisco, Department of Neurosurgery, 400 Parnassus Ave, San Francisco, CA 94143, USA.&#xD;Hospital for Special Surgery, Department of Orthopaedic Surgery, 535 East 70th St, New York, NY 10021, USA.&#xD;University of Virginia, Department of Neurosurgery, PO Box 800212, Charlottesville, VA 22908, USA.&#xD;New York Spine Institute, Department of Orthopaedic Surgery, 761 Merrick Ave, Westbury, NY 11590, USA.&#xD;University of California Davis, Department of Orthopaedic Surgery, 3301 C St, Suite 1500, Sacramento, CA 95816, USA.&#xD;University of Minnesota, Department of Orthopaedic Surgery, 2512 South 7th St, Suite R200, Minneapolis, MN 55454, USA.</auth-address><titles><title>Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study</title><secondary-title>Spine J</secondary-title></titles><periodical><full-title>Spine J</full-title></periodical><pages>2326-33</pages><volume>14</volume><number>10</number><edition>2014/01/29</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Hospital Costs/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Operating Rooms/*economics</keyword><keyword>Orthopedic Procedures/*economics</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Scoliosis/*economics/surgery</keyword><keyword>Time Factors</keyword><keyword>Young Adult</keyword><keyword>Adult spinal deformity</keyword><keyword>Cost-effectiveness</keyword><keyword>Hospital costs</keyword><keyword>Implant costs</keyword><keyword>Physician preference</keyword><keyword>Spine fusion</keyword></keywords><dates><year>2014</year><pub-dates><date>Oct 1</date></pub-dates></dates><isbn>1878-1632 (Electronic)&#xD;1529-9430 (Linking)</isbn><accession-num>24469004</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/24469004</url></related-urls></urls><electronic-resource-num>10.1016/j.spinee.2014.01.032</electronic-resource-num></record></Cite></EndNote>D<EndNote><Cite><Author>Schwab</Author><Year>2010</Year><RecNum>82</RecNum><DisplayText>(8, 24, 25)</DisplayText><record><rec-number>82</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766624">82</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwab, F.</author><author>Patel, A.</author><author>Ungar, B.</author><author>Farcy, J. 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An overview of key parameters in assessing alignment and planning corrective surgery</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>2224-31</pages><volume>35</volume><number>25</number><edition>2010/11/26</edition><keywords><keyword>Adult</keyword><keyword>Humans</keyword><keyword>Orthopedic Procedures/*adverse effects</keyword><keyword>Postoperative Period</keyword><keyword>*Postural Balance</keyword><keyword>Radiography</keyword><keyword>Spinal Curvatures/diagnostic imaging/*surgery</keyword><keyword>Spine/diagnostic imaging/*surgery</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>21102297</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/21102297</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e3181ee6bd4</electronic-resource-num></record></Cite><Cite><Author>Kim</Author><Year>2006</Year><RecNum>83</RecNum><record><rec-number>83</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513766929">83</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kim, Y. 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daggerInstitute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX; double daggerSouthern Methodist University, Department of Economics Dallas, TX; section signDepartment of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO; paragraph signDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY; ||Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS; **Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA daggerdaggerDepartment of Neurosurgery, University of California San Francisco, San Francisco, CA; double daggerdouble daggerDepartment of Orthopaedic Surgery, University of California San Francisco, CA; section sign section signDepartment of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD; paragraph sign paragraph signDepartment of Neurosurgery, University of Virginia, Charlottesville, VA; || ||Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; ***Department of Orthopaedic Surgery, Oregon Health Sciences University, Portland, OR; daggerdaggerdaggerDenver, CO.</auth-address><titles><title>Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1008-15</pages><volume>38</volume><number>12</number><edition>2012/09/19</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Disease Progression</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Kyphosis/diagnosis/epidemiology/physiopathology/*surgery</keyword><keyword>Lordosis/diagnosis/epidemiology/physiopathology/*surgery</keyword><keyword>Lumbar Vertebrae/physiopathology/*surgery</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Risk Factors</keyword><keyword>Scoliosis/diagnosis/epidemiology/physiopathology/*surgery</keyword><keyword>Spinal Fractures/diagnosis/*epidemiology</keyword><keyword>Spinal Fusion/*adverse effects</keyword><keyword>Thoracic Vertebrae/physiopathology/*surgery</keyword><keyword>Time Factors</keyword><keyword>Treatment Failure</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2013</year><pub-dates><date>May 20</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>22986834</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/22986834</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e318271319c</electronic-resource-num></record></Cite></EndNote>$*D<EndNote><Cite><Author>Smith</Author><Year>2011</Year><RecNum>93</RecNum><DisplayText>(3, 14, 16, 17)</DisplayText><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513768854">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smith, J. 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P.</author></authors></contributors><auth-address>Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA. jss7f@virginia.edu</auth-address><titles><title>Clinical and radiographic evaluation of the adult spinal deformity patient</title><secondary-title>Neurosurg Clin N Am</secondary-title></titles><periodical><full-title>Neurosurg Clin N Am</full-title></periodical><pages>143-56</pages><volume>24</volume><number>2</number><edition>2013/04/09</edition><keywords><keyword>Aged</keyword><keyword>Humans</keyword><keyword>Kyphosis/diagnosis/diagnostic imaging</keyword><keyword>Magnetic Resonance Angiography</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Myelography</keyword><keyword>Neurologic Examination</keyword><keyword>Orthopedic Procedures</keyword><keyword>Physical Examination</keyword><keyword>Scoliosis/diagnosis/diagnostic imaging/surgery</keyword><keyword>Spinal Diseases/*diagnosis/*diagnostic imaging/surgery</keyword><keyword>Spine/diagnostic imaging</keyword><keyword>Spondylolisthesis/diagnosis/diagnostic imaging</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>2013</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1558-1349 (Electronic)&#xD;1042-3680 (Linking)</isbn><accession-num>23561553</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/23561553</url></related-urls></urls><electronic-resource-num>10.1016/j.nec.2012.12.009</electronic-resource-num></record></Cite><Cite><Author>Baron</Author><Year>2006</Year><RecNum>105</RecNum><record><rec-number>105</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513776751">105</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baron, E. 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P.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;&#xD;Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California;&#xD;Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, and.&#xD;Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas;&#xD;Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;&#xD;Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;&#xD;University of California San Diego School of Medicine, San Diego, California;&#xD;Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada;&#xD;Department of Orthopedic Surgery, Washington University, St. Louis, Missouri;&#xD;Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado;&#xD;Departments of 11 Orthopedic Surgery and.&#xD;Department of Orthopaedic Surgery, Oregon Health &amp; Science University, Portland, Oregon; and.&#xD;Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas.&#xD;Neurosurgery, University of California, San Francisco, California;</auth-address><titles><title>Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery</title><secondary-title>J Neurosurg Spine</secondary-title></titles><periodical><full-title>J Neurosurg Spine</full-title></periodical><pages>1-14</pages><volume>25</volume><number>1</number><edition>2016/02/27</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteotomy/*adverse effects/methods</keyword><keyword>Perioperative Period</keyword><keyword>Postoperative Complications/*epidemiology</keyword><keyword>Prospective Studies</keyword><keyword>Spinal Curvatures/*epidemiology/*surgery</keyword><keyword>Spinal Fusion/*adverse effects/methods</keyword><keyword>Spine/surgery</keyword><keyword>Young Adult</keyword><keyword>ASA = American Society of Anesthesiologists</keyword><keyword>ASD = adult spinal deformity</keyword><keyword>BMI = body mass index</keyword><keyword>CCI = Charlson Comorbidity Index</keyword><keyword>EBL = estimated blood loss</keyword><keyword>HRQOL = health-related quality of life</keyword><keyword>LL = lumbar lordosis</keyword><keyword>PCS = Physical Component Summary</keyword><keyword>PI = pelvic incidence</keyword><keyword>PI-LL = mismatch between pelvic incidence and lumbar lordosis</keyword><keyword>PJK = proximal junctional kyphosis</keyword><keyword>PT = pelvic tilt</keyword><keyword>SRS = Scoliosis Research Society</keyword><keyword>SVA = sagittal vertical axis</keyword><keyword>adult spinal deformity</keyword><keyword>complications</keyword><keyword>prospective</keyword><keyword>scoliosis</keyword><keyword>surgery</keyword></keywords><dates><year>2016</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1547-5646 (Electronic)&#xD;1547-5646 (Linking)</isbn><accession-num>26918574</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/26918574</url></related-urls></urls><electronic-resource-num>10.3171/2015.11.SPINE151036</electronic-resource-num></record></Cite></EndNote>�D<EndNote><Cite><Author>Pateder</Author><Year>2008</Year><RecNum>120</RecNum><DisplayText>(26, 27)</DisplayText><record><rec-number>120</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513785625">120</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pateder, D. 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P.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>University of California, San Diego, School of Medicine;</auth-address><titles><title>Reoperation rates and impact on outcome in a large, prospective, multicenter, adult spinal deformity database: clinical article</title><secondary-title>J Neurosurg Spine</secondary-title></titles><periodical><full-title>J Neurosurg Spine</full-title></periodical><pages>464-70</pages><volume>19</volume><number>4</number><edition>2013/08/27</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Databases, Factual</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Prospective Studies</keyword><keyword>*Quality of Life</keyword><keyword>Radiography</keyword><keyword>Reoperation</keyword><keyword>Risk Factors</keyword><keyword>Spinal Curvatures/diagnostic imaging/*surgery</keyword><keyword>Spinal Fusion/instrumentation/*methods</keyword><keyword>Spine/diagnostic imaging/*surgery</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2013</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1547-5646 (Electronic)&#xD;1547-5646 (Linking)</isbn><accession-num>23971763</accession-num><urls><related-urls><url>https://www.ncbi.nlm.nih.gov/pubmed/23971763</url></related-urls></urls><electronic-resource-num>10.3171/2013.7.SPINE12901</electronic-resource-num></record></Cite></EndNote>V
D<EndNote><Cite><Author>McCarthy</Author><Year>2014</Year><RecNum>130</RecNum><DisplayText>(15)</DisplayText><record><rec-number>130</rec-number><foreign-keys><key app="EN" db-id="z259rf5avxzfvvedwetxtffw2atvfavepe2t" timestamp="1513787844">130</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McCarthy, I. M.</author><author>Hostin, R. A.</author><author>Ames, C. P.</author><author>Kim, H. J.</author><author>Smith, J. S.</author><author>Boachie-Adjei, O.</author><author>Schwab, F. J.</author><author>Klineberg, E. O.</author><author>Shaffrey, C. I.</author><author>Gupta, M. C.</author><author>Polly, D. W.</author><author>International Spine Study, Group</author></authors></contributors><auth-address>Institute for Health Care Research and Improvement, Baylor Health Care System, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206, USA; Southern Methodist University, Department of Economics, 3110 University Blvd, Dallas, TX 75205, USA. 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C.</author><author>Diebo, B. G.</author><author>Smith, J. S.</author><author>Hostin, R.</author><author>Shaffrey, C. I.</author><author>Boachie-Adjei, O.</author><author>Mundis, G. M., Jr.</author><author>Ames, C.</author><author>Errico, T. J.</author><author>Bess, S.</author><author>Gupta, M. C.</author><author>Hart, R. A.</author><author>Schwab, F. 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