title: Factors Influencing Surgical Decision Making in Adult Spine Deformity: A Cross-sectional Survey.
abstract: BACKGROUND
  There is little consensus regarding the surgical management of adult spine deformity (ASD) because of its variable presentation and lack of accepted standardized surgical indications and classifications. The objective of this study was to evaluate factors influencing surgeons' decision making regarding ASD based on patient clinical and radiographic data.
  
  
  METHODS
  A total of 28 international adult deformity surgeons were asked to complete an online survey of 10 spinal deformity cases. Case presentation included a clinical vignette with photographs, Oswestry Disability Index, and visual analog scores and imaging with 3-feet biplanar spinal radiographs with radiographic measurements. For each case, surgeons were asked whether surgical management would be beneficial, and to grade the factors influencing their decision according to a Likert scale. Descriptive statistics were used to evaluate surgeon demographics, surgical decision, and factors influencing it. Intra-observer and inter-observer reliability were studied using kappa statistics for the appropriateness of surgery and intra-class correlation coefficient statistics for factors influencing surgical decision.
  
  
  RESULTS
  The intra-rater and inter-rater reliability in surgeons' decision-making process were evaluated to kappa values of 0.48 and 0.17, respectively, representing moderate and no agreement. The highest recommendation among surgeons (84.14%) regarding the beneficial effect of surgery was found for cases with severe deformities and cases with neurology. In severe deformity cases, balance was the most important factor in decision making, whereas in deformity cases with neurologic manifestations, neurology was the most important factor. In general, balance and functional status were the most important factors. Inter- and intra-rater agreement on factors importance was good (0.65 and 0.72, respectively).
  
  
  CONCLUSIONS
  Agreement between surgeons about the factors influencing surgical decision was good, and about the need for surgery was poor. Yet, each surgeon seemed relatively consistent about the consideration given to factors leading to a surgical decision for a given ASD patient.
authors.affiliation: Departments of Orthopaedics and Rehabilitation, University of Ioannina, Ioannina 45110, Greece. Electronic address: aploumis@cc.uoi.gr.
authors.forename: Avraam
authors.initials: A
authors.lastname: Ploumis
authors.affiliation: Orthopaedic Department, Spine Service, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Philippe
authors.initials: P
authors.lastname: Phan
authors.affiliation: Orthopaedic Department, Spine Service, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Hess
authors.affiliation: Orthopaedic Department, Spine Service, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Kirkham B
authors.initials: KB
authors.lastname: Wood
keywords: Adult deformity; Decision making; Factor