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The SRS-Schwab Adult Spinal Deformity Classification: Assessment and Clinical Correlations Based on a Prospective Operative and Nonoperative Cohort

Terran, Jamie BS*; Schwab, Frank MD*; Shaffrey, Christopher I. MD; Smith, Justin S. MD, PhD; Devos, Pierre MS*; Ames, Christopher P. MD§; Fu, Kai-Ming G. MD, PhD; Burton, Douglas MD; Hostin, Richard MD#; Klineberg, Eric MD**; Gupta, Munish MD**; Deviren, Vedat MD‡‡; Mundis, Gregory MD§§; Hart, Robert MD¶¶; Bess, Shay MD‖‖; Lafage, Virginie PhD*; International Spine Study Group

doi: 10.1227/NEU.0000000000000012
Research-Human-Clinical Studies: Editor's Choice
Editor's Choice
CNS University of Neurosurgery

BACKGROUND: The SRS-Schwab classification of adult spinal deformity (ASD) is a validated system that provides a common language for the complex pathology of ASD. Classification reliability has been reported; however, correlation with treatment has not been assessed.

OBJECTIVE: To assess the clinical relevance of the SRS-Schwab classification based on correlations with health-related quality of life (HRQOL) measures and the decision to pursue operative vs nonoperative treatment.

METHODS: Prospective analysis of consecutive ASD patients (18 years of age and older) collected through a multicenter group. The SRS-Schwab classification includes a curve type descriptor and 3 sagittal spinopelvic modifiers (sagittal vertical axis, pelvic tilt, pelvic incidence/lumbar lordosis mismatch). Differences in demographics, HRQOL (Oswestry Disability Index, SRS-22, Short Form-36), and classification between operative and nonoperative patients were evaluated.

RESULTS: A total of 527 patients (mean age, 52.9 years; range, 18.4-85.1 years) met inclusion criteria. Significant differences in HRQOL were identified based on SRS-Schwab curve type, with thoracolumbar and primary sagittal deformities associated with greater disability and poorer health status than thoracic or double curve deformities. Operative patients had significantly poorer grades for each of the sagittal spinopelvic modifiers, and progressively higher grades were associated with significantly poorer HRQOL (P < .05). Patients with worse sagittal spinopelvic modifier grades were significantly more likely to require major osteotomies, iliac fixation, and decompression (P ≤ .009).

CONCLUSION: The SRS-Schwab classification provides a validated language to describe and categorize ASD. This study demonstrates that the SRS-Schwab classification reflects severity of disease state based on multiple measures of HRQOL and significantly correlates with the important decision of whether to pursue operative or nonoperative treatment.

ABBREVIATIONS: ASD, adult spinal deformity

CCI, Charlson Comorbidity Index

HRQOL, health-related quality of life

ODI, Oswestry Disability Index

PI-LL, pelvic incidence minus lumbar lordosis

PT, pelvic tilt; SVA, sagittal vertical axis

*Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;

§Department of Neurosurgery, University of California San Francisco, San Francisco, California;

Department of Neurosurgery, Weill Cornell Medical College, New York, New York;

Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

#Department of Orthopedic Surgery, Baylor Scoliosis Center, Plano, Texas;

**Department of Orthopedic Surgery, University of California Davis, Sacramento, California;

‡‡Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California;

§§Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California;

¶¶Department of Orthopedic Surgery, Oregon Health Sciences University, Portland, Oregon;

‖‖Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado

Correspondence: Justin S. Smith, MD, PhD, University of Virginia, Department of Neurosurgery, PO Box 800212, Charlottesville, VA 22908. E-mail:

Received February 14, 2013

Accepted May 29, 2013

Copyright © by the Congress of Neurological Surgeons