In the last twenty years, the number of surgical procedures performed to address adult spinal deformity has greatly increased. Since spinal biomechanical principles have been better understood and spinopelvic parameters have been introduced in clinical practice, surgical spinal procedures have been more complex and accurate. Complexity in surgical procedures to treat adult spinal deformity and the advanced age of most patients treated for such a deformity are the main reasons for the high complication rate, which has been reported to be as high as 95% in patients older than seventy years of age. Although increased age associated with greater baseline disability represents a risk factor for major complication in the surgical procedure to treat adult spinal deformity, the recovery process seems to be better in elderly patients with high baseline disability than in young patients, as recently reported by the International Spine Study Group. This surprising result has been attributed to the different perceptions of disability between young adults and older adults. In any case, revision procedures are necessary in about 10% to 25% of the adult spinal deformity cases, mostly because of failure of mechanical origin as proximal junctional kyphosis or implant breakage or loosening, but also because of other postoperative complications such as neurologic deficits, dural lesions, or infection.

In this article, Passias et al. question whether a revision surgical procedure could modify the health-related quality-of-life score and patient satisfaction at a minimum two-year follow-up excluding wound infections when patients who underwent the procedure were compared with patients who did not undergo the revision surgical procedure because it was not required. The study identifies characteristics independently associated with revision indicating sagittal vertebral axis and total body mass as positive predictors for complications, and the use of bone morphogenetic protein-2 (BMP-2) and thicker rods were negative predictors and were associated with decreased odds of revision. Eighty-five percent of the revisions reported in this study occurred between six weeks and two years following the index procedure and were predominantly caused by proximal junctional kyphosis above the upper instrumented vertebra or by rod breakage secondary to pseudarthrosis. These data may suggest that, to reduce the prevalence of reoperation in the cases of adult spinal deformity in overweight patients with increased preoperative sagittal malalignment, thicker rods and BMP-2 should be used, particularly when vertebral osteotomies are necessary to correct the deformity.

In a surgical procedure to treat adult spinal deformity, decision-making processes are very complex and, as already highlighted, surgeons’ expectations were predictive for patients’ satisfaction; the surgeon-patient relationship is paramount for outcome expectations, given that the highest patient satisfaction will be found in patients with the most realistic expectations. The data in the current article by Passias et al. provide additional potential predictive factors for complication, enabling the surgeon to properly inform the patient about problems associated with the surgical procedure to treat adult spinal deformity and the timing of when an eventual revision procedure might be necessary.

In all of the patients treated for adult spinal deformity, an improvement of health-related quality-of-life measurements at a two-year follow-up is reported but with lower overall improvement from baseline when the revision surgical procedure was required. Revision status did not predict two-year patient satisfaction, but the health-related quality-of-life score improved more slowly than in patients who did not undergo a revision surgical procedure.

This article suggests that an appropriate evaluation of each patient with adult spinal deformity and accurate patient information are essential for patient-reported functional improvement and satisfaction with the process of care.