CHAPTER
74
Spinal Deformity Outcomes
Measurement
INTRODUCTION
The need to systematically collect, process, and utilize patient
outcome data is well recognized and is now at the forefront of
modern medicine. Many forces are driving the redirection and
restructuring of patient care, including the increasing eco-
nomic burden of delivering health care. Evidence-based medi-
cine is now the gold standard, which often requires the use of
instruments to measure the quality of care provided to patients
for a specific disease process. This has been recognized in
orthopedic surgery across various subspecialties.12,19 The devel-
opment of health-related quality of life outcome instruments is
a complex process, which requires the application of statistical-
based analysis to a patient population.
Surgical outcomes literature in the past has been based on
either anecdotal experiences of individual surgeons or clinical
case series. Although these studies have provided the founda-
tion on which many principles of spinal deformity surgery are
based, modern research demands a more rigorous approach.
Orthopedic- and spine-specific research has recently shifted
focus away from retrospective data collection to well-designed
prospective studies. Retrospective data collection and analysis
has many potential flaws in the scientific method and unbiased
conclusions are difficult to generate. As financial and economic
pressures begin to shape the delivery of health care, proving
that an intervention and subsequent patient outcome is better
than the natural history of the disease is paramount. The instru-
ment of choice to prove patient well-being is the health-related
quality of life (HRQL) questionnaire.
Spinal deformityspecific patient outcomes questionnaires
have been conceptualized, created, and redefined over the past
decade, but recognition of the needs in spinal surgery date well
before the recent efforts. This arduous process required atten-
tion to the fact that spinal deformity will often begin in the
preadolescent years and treatment typically continues into
adult and even elderly populations. A spinal deformityspecific
outcomes instrument, therefore, should be applicable across
multiple ages, and responsiveness to changes in the patients
spinal condition must be addressed.6 The study of spinal defor-
mity reaches across international boundaries, thus an instru-
ment adapted and translated for major population centers
would be most ideal. The objective of this chapter is to review
the history, the current use, validation, and the future of patient
outcomes research in spinal deformity.
728
LWBK836_Ch74_p728-737.indd 728
Rudolph Christopher Glattes
Douglas C. Burton
Sue Min Lai
CHOOSING OUTCOME MEASURES
Outcome measurement includes quantifying patients health
status and expectation, objective measurements of treatment,
and the cost associated with a treatment choice. When focusing
on quantifying patients health status, determination of the
type of question to be answered is paramount. This will help
the practitioner decide on what outcomes measurement tool
to select.
In general, patient outcome measurement tools can be cat-
egorized into four major subtypes (Table 74.1). Objective out-
comes measures evaluate a specific functional outcome follow-
ing treatment, such as ambulatory capacity following orthopedic
intervention. Generic measures are structured to allow the
patient to give insight to overall health status. The benefit of
these tools lies in the fact that they are well validated and used
throughout various disciplines of medicine. A generic instru-
ment such as the Short Form-36 (SF-36) allows for a general
comparison of treatment of spinal conditions to intervention
for other disease states. Disease-specific measures allow for
more critical evaluation of a treatment based on attributes spe-
cifically associated with the disease state. Clearly, there are cer-
tain aspects of spinal conditions that are unique in their effect
on patients health status. The use of disease-specific instru-
ments is, therefore, widely accepted (Oswestry and Roland-
Morris for degenerative conditions; SRS for deformity). Finally,
process measures such as spinal balance, correction, and effect
on pulmonary capacities play a major role in practitioners
decisions on operative technique to achieve a desired goal. The
use of new instrumentation technology and more complex
approaches should be weighed both by process measures, cost
of treatment, and patients health status outcomes.
HISTORICAL PERSPECTIVE
OF THE SRS INSTRUMENT
The first major publication of an English languagebased spi-
nal deformityspecific HRQL questionnaire in 1999 demon-
strated the potential application of outcomes instruments to
this population. The SRS Instrument (SRS-24) was born out of
recognition of the need to study patient-centered outcomes in
addition to process measures such as radiographic corrections.
Haher et al published a meta-analysis of scoliosis surgical
8/17/11 11:16:01 AM
 Chapter 74 Spinal Deformity Outcomes Measurement 729

the domains of pain, function, self-image, mental health, and

TABLE 74.1 Outcome Instrument Types
satisfaction (Table 74.2). Problems with a few specific questions
Instrument Type Examples were identified, and the respective questions were eliminated.2
The task of validation had been addressed in multiple studies
Objective GMFM (Gross Motor Function Measure) with the questionnaire version SRS-22 comparing favorably to
Functional Assessment Walking Score other accepted instruments, including the SF-36, SF-12, the
Generic SF-36 Oswestry Disability Index, and the Child Health Questionnaire-87
CHQ (Child Health Questionnaire) (CHQ-87).14 The final, fully mature, English language version
Disease specific Roland-Morris Disability Index
incorporating all changes and variations is the SRS-22r.
musculoskeletal Oswestry Disability Index
disorders) Neck Disability Index
Scoliosis Research Society HRQL
(SRS-24 and SRS-22) GENERIC AND SPINAL DISORDER
(PODCI) Pediatric Outcomes Data SPECIFIC OUTCOMES
Collection Instrument
PEDI (Pediatric Evaluation of Disability Other instruments certainly exist and are applicable in spinal
Inventory) surgery. The SF-12 and SF-36 are commonly used and are con-
POSNA Health Questionnaire sidered gold standards for generic outcome measurement. In
NASS Instrument
an effort to reduce the burden on patients, the SF-12 has been
Quebec Back Pain Disability Questionnaire
substituted for the SF-36 in various published reports.7 These
Process Radiographic impact
Volumetric lung measurement questionnaires can be applied across different specialties within
Angle of trunk inclination correction medicine and may be used to broadly compare disease pro-
cesses and the outcomes of treatment. Similar questionnaires
HRQL, health-related quality of life; SRS, Scoliosis Research Society. exist in the pediatric literature, such as the CHQ-87, utilized in
validation of the SRS-22r in the pediatric population.14 For
degenerative spine conditions, the Oswestry Disability Index
outcomes in 1995 marking the beginning of this effort.16 The and the Roland-Morris Questionnaire are used most com-
SRS-24 was devised utilizing questions adopted from past pub- monly.11 Both the Oswestry and the Roland-Morris are designed
lications and newly developed questions addressing multiple to be a spinal disorderspecific questionnaires. Recent publica-
domains. Haher et al15 led a multicenter effort to create a tions in major general medical journals involving the treatment
quickly administered, easily scored questionnaire, which would of lumbar disc herniations, spondylolisthesis, and degenerative
measure patient pain, general self-image, postoperative self- disc disease rely heavily on the SF-36 and the Oswestry. Although,
image, general function, overall level of activity, postoperative the SF-36 and modified Oswestry Disability Index are com-
function, and satisfaction. These domains, or groupings of monly applied in spinal deformity, the need exists to streamline
questions addressing specific patient attributes, would provide the volume of questions patients must answer at multiple time
a framework for refinement of the original questionnaire into points.
a more efficient tool.
As the SRS-24 instrument was applied to patient populations
after the original publication, it became apparent that some STATISTICAL VALIDATION OF AN
deficiencies existed. Questions based on recall, limited INSTRUMENT
responses for certain questions, and overlapping domains were
identified as potential negative aspects of the available instru- The study of spinal deformity patients has incorporated both
ment.1 Therefore, efforts were undertaken to address these process-based measures (i.e., curve correction and other radio-
shortcomings. The SRS-24 was modified to streamline the ques- graphic parameters) and patient-centered outcomes. The
tions and associated domains with the end product addressing application of the statistical method to human perception takes

TABLE 74.2 SRS-22r Domains and Sample Questions

Number of
Domain Questions (22 Total) Question Sample

Function 5 What is your current level of activity?

Pain 5 Which of the following best describes
the amount of pain you have
experienced over the last month?
Self-Image 5 How do you look in clothes?
Mental Health 5 Over the past 6 months have you been
a very nervous person?
Satisfaction/Dissatisfaction 2 Are you satisfied with the results of
your back management?

SRS, Scoliosis Research Society.

LWBK836_Ch74_p728-737.indd 729 8/17/11 11:16:02 AM

 730 Section VII Idiopathic Scoliosis
root in the science of psychometrics, or the study of quantifying
an individuals physical and emotional attributes. The basis of
accepting a questionnaire for patient use lies in the study of
validity. The definition of validity is the capacity of an instru-
ment to measure what is intended. When undertaking the bur-
den of proof demonstrating validity, different avenues may be
utilized. Concurrent validity is perhaps the most common
approach when a new questionnaire is studied. Concurrent
validity means that the questionnaire under investigation per-
forms similarly to an already validated questionnaire measuring
the same variable. Concurrent validity is typically measured
using a Pearson coefficient. The SRS-22 has been validated in
this manner with the SF-12, SF-36, and CHQ-87, as previously
described.
There are many other critical psychometric properties that
make a questionnaire acceptable; concepts including score dis-
tribution, reliability, and responsiveness to change. Score distri-
bution is important in identifying various degrees of the disease
state. For example, a questionnaire that generates many high
responses across a wide range of disease severity would not dis-
criminate amongst patients with mild disease. A questionnaire
that generates very low responses would not discriminate
between patients with severe disease. The measure of score dis-
tribution is quantified as the ceiling and floor effect. The ideal
questionnaire will generate a response pool that limits these
effects.
Reliability minimizes random errors. When designing ques-
tionnaires, the grouping of questions into domains creates
more user-friendly data. Internal consistency, statistically
described by the Cronbachs , measures how well questions
fit within a domain. Reproducibility, also a component of reli-
ability, is the test/retest similarity of scores over time. The mea-
sure of reproducibility is the intraclass correlation coefficient.
Perhaps the most critical factor with lifelong disease-specific
instruments is the responsiveness to change. As with other chronic
conditions, the treatment of spinal deformity is often instituted at
a young age and the nature of the disease process changes over
time. Taking this into account, the SRS instrument was designed
to cross age groups. In addition to changes with age, the SRS
instrument was also designed to reflect changes associated with
spine treatment. The responsiveness of the SRS instrument to sur-
gical intervention has been recently confirmed.3
CROSS-CULTURAL ADAPTATION
The final key aspect of an outcomes instrument is adaptation
across cultures. Spinal deformity and its treatment are neither
unique to one specific nationality nor ethnic group. Creating a
questionnaire that yields consistent results regardless of the
patients culture is demanding. Very small variations in transla-
tion can lead to significant changes in interpretation. Transla-
tion of the SRS instrument into Spanish, for example, proved
to be very challenging. Questions relating to function and
financial and social relations with friends had to be reassessed
to improve internal consistency. Means of remedying these
issues include modifying the stem portion, which is the actual
form of the question posed. Alternatively, the pool of responses
may also be modified to improve a questions performance
within a domain. To date, validation studies of the SRS instru-
ment have been published for translations in the Spanish,
Turkish, Chinese, and Japanese languages (Table 74.3).
LWBK836_Ch74_p728-737.indd 730
TABLE 74.3 SRS-22 Language Adaptations
Language Author Date of Publication
Spanish Bago et al 2004
Turkish Alanay et al 2005
Japanese Hashimoto et al 2007
Chinese Cheung et al 2007
CLINICAL APPLICATION
The ease of completing and scoring an outcomes questionnaire
is a pivotal characteristic of a useful instrument. With the
demands of busy clinical practice, time and personnel required
to collect and process data come at a premium cost. The SRS-
22r is typically straightforward for a patient to complete and is
easily hand scored by either the clinician or assistants. As previ-
ously stated, the SF-12 has been shown to substitute adequately
for the SF-36 in deformity populations. The Oswestry Disability
Index utilizes just 10 questions and can be scored quickly in the
clinical setting. Versions of these instruments are available in
formats that allow computerized data entry, which creates easily
pooled data combined into larger study populations.
Multiple studies have demonstrated that patients perception
of their treatment does not always correlate with process mea-
sures such as radiographic parameters and certain correction
measurements.4,9 In the adult population, sagittal balance and
maintenance or restoration of lumbar lordosis are radiographic
parameters that do correlate well with patient perceived out-
comes.13 The following two patients treated for adolescent idio-
pathic scoliosis of very similar preoperative curve characteristics
suggest that equivalent radiographic outcomes may not trans-
late into equivalence in measured patient outcome.
NEUROMUSCULAR DEFORMITY
Treatment of patients with neuromuscular deformity is a unique
entity as the disease state often has profound impact on the
patients overall health status. The patients condition extends
to immediate family and the caretakers involved with activities
of daily living. The majority of questionnaires aimed at this
population are filled out by the parents or caretakers, which
adds some difficulty in interpreting the patients real under-
standing of treatment and its effect on quality of life. In cere-
bral palsy, the Gross Motor Function Measure (GMFM) and the
Pediatric Evaluation of Disability Inventory (PEDI) are vali-
dated responsive measures of health status in this population.8
The Functional Assessment Walking Score and Pediatric Out-
comes Data Collection Instrument (PODCI) have been utilized
when evaluating the effects of multiple soft tissue procedures,
and the PODCI has been shown to detect improvement in
function in the ambulatory cerebral palsy population. Authors
have successfully applied more disease-specific tailored instru-
ments focusing on spinal deformity in flaccid neuromuscular
conditions. The use of such instruments in the context of surgi-
cal management of neuromuscular scoliosis revealed an improve-
ment in sitting balance for most patients and a successful surgery
from the perspective of most patients/parents.5
8/17/11 11:16:02 AM
 Chapter 74 Spinal Deformity Outcomes Measurement 731

FUTURE PERSPECTIVE Clinically Relevant Change

TABLE 74.4 (Minimal Important
The introduction of the SRS-24 questionnaire was met with
Change or MIC)
great enthusiasm and its use as a tool for data collection and
study was widespread. The use of longitudinal assessment has Improvement
been emphasized including the need for long-term follow-up Instrument MIC from Baseline (%)
whenever possible. The SRS instrument has since evolved into
its current version (Appendix A, sample score sheet Appendix VAS (100-point scale) 15-point change 30
B), leaving enormous numbers of data points from earlier Numeric Pain 2-point change 30
questionnaires. This has created some consternation amongst Scale (0--10)
Roland-Morris 5-point change 30
some researchers with older databases. In order to capture the
Oswestry 10-point change 30
data, current studies are ongoing evaluating the usefulness of Quebec Back Pain/ 20-point change 30
conversion systems from the SRS-24 to the SRS-22r, therefore Disability
allowing direct comparison with future measures. SRS-22 ?
Recognizing the effects of comorbidities on outcomes may
explain deviations in outcomes. Patient comorbidities includ- SRS, Scoliosis Research Society; VAS, Visual Analogue Scale.
Adapted from Ostelo RW, Deyo RA, Stratford P, et al. Interpreting
ing depression and other issues such as compensation in the
change scores for pain and functional status in low back pain:
adult population have effects on patient outcomes, which may towards international consensus regarding minimal important
provide explanation for deviation in measured results.20 change. Spine 2008;33:90--94.
Childhood and adolescent obesity has significant effects on
baseline scores of domains measured by the PODCI instru-
ment, which certainly may contribute to suboptimal outcomes
in spinal conditions.18 Comorbidities may compound over time creates a convenient method of transmitting information.
as spinal deformity patients age, adding another confounding Finally, automation through Electronic Medical Record Systems
factor. The creation of an additional scale or modifier to should allow the clinician to effectively capture outcomes.
account for the effects of comorbidities both preoperatively Proactive rather than reactive acceptance of technology will
and when examining postoperative data may be helpful. This help drive research within the field.
could initially be difficult to add to the battery of testing, but
may prove necessary.
More clearly defining the measurement of clinical impact of CONCLUSION
a disease state and quantifying impact of treatment will be a
major focus of future efforts. Improvement or deterioration of The use of questionnaires to measure outcomes and follow
a condition, measuring the effect of treatment, and capturing patients longitudinally has become a cornerstone of clinical
this with available instruments require a definition of clinically research. As this review demonstrates, there are a large number
important change. When utilizing the Oswestry, for example, it of potential questionnaires to apply to each population. The
was proposed by the U.S. Food and Drug Administration that a decision of which instrument to use depends on the question
minimum change of 15 points is required before meaningful being asked. Prospective collection of data in anticipation of
clinical impact is perceived. In the past, the Roland Morris min- evolving questions regarding treatment may require the
imal change was published as between 2 and 3 points.10 More clinician-researcher to apply more than one questionnaire
recent studies published by an international consensus group type. Perhaps the best solution is to utilize both a generic and
suggest slight differences in minimal important change (MIC) a disease-specific instrument to allow comparison across disease
criteria17 (Table 74.4). As further studies delve into the usage of spectrums and for longitudinal conformity. The SRS-22r in par-
the SRS instrument, these clinical impact scores will evolve. ticular was the culmination of multinational efforts of constant
Pooling of data is necessary to produce statistically powerful examination and refinement. Proactive collection of patient
populations. The advent of study groups of surgeons focused outcomes utilizing these instruments is critical to the advance-
on specific aspects of spine treatment has allowed collection of ment of spinal deformity treatment and understanding this life-
large volumes of data. Communication through the Internet long disease state.

LWBK836_Ch74_p728-737.indd 731 8/17/11 11:16:02 AM

 732 Section VII Idiopathic Scoliosis

CASE EXAMPLES

CASE 74.1

A 12-year, 5-month-old girl presented with a Lenke 1CN 9-months postoperative. At 12 years, 2 months postopera-
adolescent idiopathic scoliosis. Figures 74.1A and B show tive, her SRS-22r questionnaire scores were Function 5, Pain
preoperative standing posteroanterior and lateral radio- 4.2, Self Image 5, Mental Health 5, and Satisfaction/Dissat-
graphs. Figures 74.1C and D show radiographs at 6-years, isfaction 5.

+6 mm

57 mm

5
+33

21 mm

52
(B36) 1520

0 mm
10

12

+42 5 mm
15
(B+10)
+25 mm 57

A B

2
18 5

20

10

8
12

62

Figure 74.1. Preoperative standing posteroanterior (A) and lat-

S eral (B) radiographs of a 12-year, 5-month-old girl with a Lenke
1CN adolescent idiopathic scoliosis. Posteroanterior (C) and lat-
C D
eral (D) radiographs at 6 years, 9 months postoperative.

LWBK836_Ch74_p728-737.indd 732 8/17/11 11:16:02 AM

 Chapter 74 Spinal Deformity Outcomes Measurement 733

CASE 74.2

An 11-year, 10-month-old girl presented with a Lenke 1B at 11 years, 10 months postoperative. At 11 years, 10 months
adolescent idiopathic scoliosis. Figures 74.2A and B show postoperative, her SRS-22r questionnaire scores were Func-
standing posteroanterior and lateral radiographs taken tion 4.6, Pain 2.2, Self-Image 2.6, Mental Health 2.8, and
preoperative, and Figures 74.2C and D show radiographs Satisfaction/Dissatisfaction 3.

5 mm
5

30 B+22

+12

68 62 mm

B45 24 mm

12
12

Regional
+30
Apex
B+13 33
+9 mm
+25
+13
4

A B

10

22

12
12

17
41

4
Figure 74.2. Preoperative standing poster-
oanterior (A) and lateral (B) radiographs of
an 11-year, 10-month-old girl with a Lenke 1B S

adolescent idiopathic scoliosis. Posteroante-

rior (C) and lateral (D) radiographs at C D
11 years, 10 months postoperative.

LWBK836_Ch74_p728-737.indd 733 8/17/11 11:16:04 AM

 734 Section VII Idiopathic Scoliosis

10. Deyo RA, Battie M, Beurskens AJ, et al. Outcome measures for low back pain research: a
REFERENCES proposal for standardized use. Spine 1998;23:20032013.
11. Fairbank JC. The Oswestry Disability Index. Spine 2000;25:29402953.
1. Asher MA, Lai SM, Burton DC. Further development and validation of the Scoliosis
12. Gartland JJ. Orthopaedic clinical research. Deficiencies in experimental design and deter-
Research Society (SRS) outcomes instrument. Spine 2000;25:23812386.
mination of outcome. J Bone Joint Surgery [Am] 1988;70:13571364.
2. Asher MA, Lai SM, Glattes RC, et al. Refinement of the SRS-22 health-related quality of life
13. Glassman SD, Berven S, Bridwell KH, et al. Correlation of radiographic parameters and
questionnaire function domain. Spine 2006;31:593597.
clinical symptoms in adult scoliosis. Spine 2005;30:682688.
3. Asher M, Min Lai S, Burton D, et al. Scoliosis Research Society-22 patient questionnaire:
14. Glattes RC, Burton DC, Lai SM. The reliability and concurrent validity of the scoliosis
responsiveness to change associated with surgical treatment. Spine 2003;28:7073.
research society-22r patient questionnaire compared with the child health questionnaire-
4. Berven S, Deviren V, Demir-Deviren S, et al. Studies in the modified Scoliosis Research
cf87 patient questionnaire for adolescent spinal deformity. Spine 2007;32:17781784.
Society outcomes instrument in adults: validation, reliability and discriminatory capacity.
15. Haher TR, Gorup JM, Shin TM, et al. Scoliosis Research Society instrument for evaluation
Spine 2003;28:21642169.
of surgical outcome in adolescent idiopathic scoliosis: a multicenter study of 244 patients.
5. Bridwell KH, Baldus C, Iffrig TM, et al. Process measures and patient/parent evaluation of
Spine 1999;24:14351440.
surgical management of spinal deformities in patients with progressive flaccid neuromus-
16. Haher TR, Merola A, Zipnick RI, et al. Meta-analysis of surgical outcome in adolescent
cular scoliosis (Duchennes muscular dystrophy and spinal muscular atrophy). Spine
idiopathic scoliosis: a 35-year English literature review of 11,000 patients. Spine
1999;24:13001306.
1995;20:15751584.
6. Bridwell KH, Berven S, Glassman S. Is the SRS-22 instrument responsive to change in adult
17. Ostelo RW, Deyo RA, Stratford P, et al. Interpreting change scores for pain and functional
scoliosis patients having primary spinal deformity surgery? Spine 2007;32:22202225.
status in low back pain: towards international consensus regarding minimal important
7. Bridwell KH, Cats-Baril W, Harrast J, et al. The validity of the SRS-22 instrument in an adult
change. Spine 2008;33:9094.
spinal deformity population compared with the Oswestry and SF-12. Spine 2005;30:
18. Podeszwa DA, Stanko KJ, Mooney JF III, et al. An analysis of the functional health of obese
455461.
children and adolescents utilizing the PODC instrument. J Pediatr Orthop 2006;26:
8. Damiano DL, Gilgannon MS, Abel MF. Responsiveness and uniqueness of the pediatric
140143.
outcomes data collection instrument compared to the gross motor function measure for
19. Sledge CB. Crisis, challenge and credibility. J Bone Joint Surgery [Am] 1985;67:
measuring orthopaedic and neurosurgical outcomes in cerebral palsy. J Pediatr Orthop
658662.
2005;25:641645.
20. Slover J, Abdu WA, Hanscom B, et al. The impact of comorbidities on the change in
9. DAndrea LP, Betz RR, Lenke LG, et al. Do radiographic parameters correlate with clinical
Short-Form 36 and Oswestry scores following lumbar spine surgery. Spine 2006;31:
outcomes in adolescent idiopathic scoliosis? Spine 2000;25:17951802.
19741980.

LWBK836_Ch74_p728-737.indd 734 8/17/11 11:16:06 AM

 APPENDIX

A
SRS-22r Patient Questionnaire

(Note : This is a sample questionnaire with both the responses from an imaginary patient and the numerical value of each possible
response listed in bold. The numerical values are not present on the questionnaires given to patients.)

Patient Name: ( )
First MI Last (Maiden; if applicable

Todays Date: Date of Birth: Age: +

Mo Day Year Mo Day Year Year Mo

Medical Record #:

INSTRUCTIONS: We are carefully evaluating the condition of your back, and it is

IMPORTANT THAT YOU ANSWER EACH OF THESE QUESTIONS YOURSELF.
Please CIRCLE THE ONE BEST ANSWER TO EACH QUESTION.

1. Which one of the following best describes the amount of pain you have experienced during the past 6 months?

5. None 4. Mild 3. Moderate 2. Moderate to severe 1. Severe

2. Which one of the following best describes the amount of pain you have experienced during the last month?

5. None 4. Mild 3. Moderate 2. Moderate to severe 1. Severe

3. During the past 6 months have you been a very nervous person?

5. None of the time 4. A little of the time 3. Some of the time 2. Most of the time 1. All of the time

4. If you had to spend the rest of your life with your back shape as it is right now, how would you feel about it?

5. Very happy 4. Somewhat happy 3. Neither happy nor unhappy 2. Somewhat unhappy 1. Very unhappy

5. What is your current level of activity?

1. Bedridden 2. Primarily no activity 3. Light labor and light sports 4. Moderate labor and moderate sports 5. Full activities without restriction

6. How do you look in clothes?

5. Very good 4. Good 3. Fair 2. Bad 1. Very bad

7. In the past 6 months have you felt so down in the dumps that nothing could cheer you up?

1. Very often 2. Often 3. Sometimes 4. Rarely 5. Never

8. Do you experience back pain when at rest?

1. Very often 2. Often 3. Sometimes 4. Rarely 5. Never

735

LWBK836_Ch74_p728-737.indd 735 8/17/11 11:16:06 AM

 736 Section VII Idiopathic Scoliosis

9. What is your current level of work/school activity?

5. 100% normal 4. 75% normal 3. 50% normal 2. 25% normal 1. 0% normal

10. Which of the following best describes the appearance of your trunk; defined as the human body except for the head and extremities?

5. Very good 4. Good 3. Fair 2. Poor 1. Very poor

11. Which one of the following best describes your pain medication use for back pain?
5. None 4. Nonnarcotics weekly or less 3. Nonnarcotics daily 2. Narcotics weekly or less 1. Narcotics daily
(e.g., aspirin, Tylenol, Ibuprofen) (e.g., Tylenol III, Lorcet, Percocet)

12. Does your back limit your ability to do things around the house?

5. Never 4. Rarely 3. Sometimes 2. Often 1. Very often

13. Have you felt calm and peaceful during the past 6 months?

5. All of the time 4. Most of the time 3. Some of the time 2. A little of the time 1. None of the time

14. Do you feel that your back condition affects your personal relationships?

5. None 4. Slightly 3. Mild 2. Moderately 1. Severely

15. Are you and/or your family experiencing financial difficulties because of your back?

1. Severely 2. Moderately 3. Mildly 4. Slightly 5. None

16. In the past 6 months have you felt down hearted and blue?

5. Never 4. Rarely 3. Sometimes 2. Often 1. Very often

17. In the last 3 months have you taken any days off of work, including household work, or school because of back pain?

5. 0 days 4. 1 day 3. 2 days 2. 3 days 1. 4 or more days

18. Does your back condition limit your going out with friends/family?

5. Never 4. Rarely 3. Sometimes 2. Often 1. Very often

19. Do you feel attractive with your current back condition?

5. Yes, very 4. Yes, somewhat 3. Neither attractive nor unattractive 2. No, not very much 1. No, not at all

20. Have you been a happy person during the past 6 months?

5. None of the time 4. A little of the time 3. Some of the time 2. Most of the time 1. All of the time

21. Are you satisfied with the results of your back management?

5. Very satisfied 4. Satisfied 3. Neither satisfied nor unsatisfied 2. Unsatisfied 1. Very unsatisfied

22. Would you have the same management again if you had the same condition?

5. Definitely yes 4. Probably yes 3. Not sure 2. Probably not 1. Definitely not

Thank you for completing this questionaire. Please comment if you wish.

LWBK836_Ch74_p728-737.indd 736 8/17/11 11:16:06 AM

 APPENDIX

B
SRS-22r Patient Questionnaire/
Score Sheet (Sample to accompany
sample questionnaire in Appendix A.)

Patient Name: ( )
First MI Last (Maiden; if applicable

Todays Date: Date of Birth: Age: +

Mo Day Year Mo Day Year Year Mo

Domain Score Score Score Score Score Sum of No. of No. of Mean
[Question [Question [Question [Question [Question Responses Questions Questions Score
No.] No.] No.] No.] No.] (A) Answered Possible (A/B)
(B)

Function 3 [5] 4 [9] 3 [12] X [15] 2 [18] 12 4 (5) 3

Pain 2 [1] 4 [2] 4 [8] 1 [11] 1 [17] 12 5 (5) 2.4

Self-Image 3 [4] 3 [6] 3 [10] 4 [14] 4 [19] 17 5 (5) 3.4

++
Mental Health 4 [3] 4 [7] 3 [13] 4 [16] 4 [20] 19 5 (5) 3.8

Subtotal: 60 19 (20) 3.16

Satisfaction/dissatisfaction 4 [21] 4 [22] 8 2 (2) 4

with management

Total: 68 21 (22) 3.24

SCORING INSTRUCTIONS
5 = best; 1 = worst
Unanswered questions: Reduce questions answered denominator by appropriate number.
Deleted questions with more than one response.
Domain cannot be scored if fewer than three questions answered for that domain.

737

LWBK836_Ch74_p728-737.indd 737 8/17/11 11:16:06 AM