Does Clinical Photography Influence Satisfaction With Surgery in Adult Patients Operated on for Spinal Deformity?
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* ALEJANDRO GOMEZ-RICE
* CRISTINA MADRID
* ENRIQUE IZQUIERDO
* FERNANDO MARCO-MARTÍNEZ
* JESÚS A.F. TRESGUERRES
* FELISA SANCHEZ-MARISCAL

## ABSTRACT

**Background:** Recently published data suggest that showing patients operated on for adolescent idiopathic scoliosis or kyphosis their preoperative and postoperative photographs may enhance their satisfaction and self-image as measured by Scoliosis Research Society Health-Related Quality of Life Questionnaire (SRS-22) scores. No data exist for adult spinal deformity (ASD) surgery. The aim of this study is to determine the effect on patient postoperative satisfaction and self-image of showing adult deformity patients their preoperative and postoperative whole body photographs.

**Methods:** This was a nonconcurrent prospective study. Patients operated on for ASD with a minimum 2-year postoperative follow-up who had preoperative full-body photographs taken by a professional photographer were included. Two follow-up visits were arranged 7 days apart. In the first visit, patients completed the SRS-22 questionnaire, and full-body standing photographs were taken. In the second visit, patients were asked to complete again questions 4, 6, 10, 14, 19 (self-image), 21, and 22 (satisfaction) of the SRS-22 after seeing their preoperative and postoperative full-body photographs.

**Results:** Thirty patients (28 female) were included. The median age at surgery was 50 years (26–76). The median follow-up was 51 months (24–120). SRS-22 results at first visit were: activity 2.79 ± 0.75; self-image 2.71 ± 0.82; pain 2.53 ± 1.10; mental health 3.08 ± 0.77; satisfaction 3.46 ± 1.20; global 2.74 ± 0.72. SRS22 results at second visit were: self-image 2.9 ± 0.75; satisfaction 4.02 ± 0.97. After seeing the preoperative and final follow-up photographs, patients experienced an improvement in SRS-22 self-image (*P* = .000) and satisfaction domains (*P* = .011).

**Conclusions:** In patients operated on for ASD, showing preoperative and postoperative photographs improves patient satisfaction with surgery and self-image.

**Level of Evidence:** 3.

**Clinical Relevance:** Our results could be a starting point for introducing full-body clinical photographs as a routine clinical tool in adult deformity patients undergoing surgery.

*   adult spinal deformity
*   quality of life
*   patient satisfaction
*   SRS-22
*   clinical photography

## BACKGROUND

Delivering patient-centered care is an important component of a high-quality health care system.1 Patient satisfaction after spinal surgery is currently being used as a proxy for quality of care, caregiver performance, and process measures for hospitals.2,3 Bearing this in mind, identification of factors that may influence patient satisfaction is important.

Previously conducted studies have shown that adolescents operated for scoliosis4 and kyphosis5 improved their satisfaction as measured by Scoliosis Research Society Health-Related Quality of Life Questionnaire (SRS-22) scores after showing them preoperative and postoperative full-spine photographs. The influence of clinical photography in patient satisfaction after adult deformity surgery has not been previously reported.

Although it was designed for patients with adolescent idiopathic scoliosis, the SRS-22 is now widely used as an outcome instrument in patients with adult spinal deformity (ASD),2,6–8 and it has proven an excellent 7-day test-retest reliability.9

The SRS-22 self-image domain has proven to have a strong correlation with patient satisfaction for adult scoliosis surgery.2 The purpose of this study is to determine the effect on patient postoperative satisfaction and self-image of showing adult deformity patients their preoperative and postoperative whole-body photographs.

## METHODS

### Study Design

This is a single-center single-surgeon nonconcurrent prospective study approved by the Institutional Research Ethics Committee. Written informed consent was obtained from all patients after they were provided with a detailed information sheet. The null hypothesis is that satisfaction and self-image in patients operated on for adult deformity are not affected by showing patients their preoperative and postoperative full-body photographs.

### Subject Inclusion

Inclusion criteria were as follows: age at surgery older than 25 years, having professional clinical photographs taken before surgery, minimum 2-year follow-up after surgery, and having undergone 5 or more levels of fusion for idiopathic or degenerative scoliosis with main Cobb angle greater than 40°, sagittal and/or coronal imbalance greater than 5 cm, T3–T12 kyphosis greater than 80°, and thoracolumbar kyphosis greater than 20°.

Exclusion criteria: tumors or neuromuscular, congenital, or traumatic deformity. Patients with a longer than 10-year follow-up were excluded in order to avoid that the natural aesthetic changes associated with aging could bias self-image assessment.

Out of 130 patients operated on for adult deformity between January 2007 and December 2016, 39 met our inclusion criteria. Two patients were deceased, 2 patients could not be contacted, and 4 patients lived far away and could not participate for logistic reasons. One patient refused to participate in our study. Thirty patients were finally included. Demographic data and patient's characteristics are summarized in Table 1.

View this table:
[Table 1](http://ijssurgery.com//content/14/6/1037/T1)

Table 1 
Patient characteristics.

### Data Collection

Two outpatient visits were arranged 7 days apart. Data were collected by 2 researchers not involved in patient treatment. In the first visit, informed consent granting permission to use the photographs for this study was obtained from all individual participants included in the study. Subjects completed the SRS-22 questionnaire, and full-body standing photographs were taken by a professional clinical photographer. All photographs—preoperative and postoperative—were taken by the same professional clinical photographer using similar camera settings and lighting in the same room and at the same distance.

Subjects were asked to stand relaxed during the photographic sessions. Photographs were taken from anterior, posterior, and lateral views in both the upright and the forward-bending positions (Figure 1).

![Figure 1](http://ijssurgery.com//https://www.ijssurgery.com/content/ijss/14/6/1037/F1.medium.gif)

[Figure 1](http://ijssurgery.com//content/14/6/1037/F1)

Figure 1 
Preoperative photographs of an adult idiopathic scoliosis patient.

In the second visit, patients were shown their preoperative and final follow-up photographs (Figure 2). After seeing the clinical photographs, they were asked again to answer questions 4, 6, 10, 14, 19 (self-image), 21, and 22 (satisfaction) of the SRS-22 questionnaire.

![Figure 2](http://ijssurgery.com//https://www.ijssurgery.com/content/ijss/14/6/1037/F2.medium.gif)

[Figure 2](http://ijssurgery.com//content/14/6/1037/F2)

Figure 2 
Final follow-up photographs of an adult idiopathic scoliosis patient (same patient as Figure 1).

### Statistical Methods

The collected data were analyzed using IBM SPSS Statistics 23 for Windows. Descriptive statistics are presented as mean, median, standard deviation, and range. A paired Wilcoxon test was performed to compare prephotography and postphotography SRS-22 results. A *P* value of <0.05 was considered statistically significant.

## RESULTS

Thirty patients were included in this study. Twenty-eight female and 2 male subjects were recruited. Median age at surgery was 50 years (range 26–76). Median postoperative follow-up was 51 months (range 24–120). The median number of fused levels was 13 (range 5–18). Six patients were treated by combined anterior and posterior approach (double approach), while 24 patients were treated by a posterior-only approach.

Eighteen patients were operated on for idiopathic scoliosis, 3 for degenerative scoliosis with a coronal Cobb angle greater than 30°, and 4 patients for thoracic hyperkyphosis. Twelve patients presented with a sagittal imbalance greater than 5 cm, 1 patient with a coronal imbalance greater than 5 cm, and 3 patients with a combined sagittal and coronal imbalance (Table 1). Twenty-two patients underwent primary surgery, while 8 patients had been submitted to previous surgery. Five patients had a multilevel fusion mass following a Harrington rod surgery, 1 patient had a history of a previous double approach for deformity surgery, and 2 patients had undergone prior lumbar fusion.

At first visit, before the photographs were taken, SRS-22 scores were as follows: activity 2.79 ± 0.75; self-image 2.71 ± 0.82; pain 2.53 ± 1.10; mental health 3.08 ± 0.77; satisfaction 3.46 ± 1.20; global 2.74 ± 0.72. At second visit, after showing patients their preoperative and final follow-up full-body photographs, SRS-22 scores were as follows: self-image 2.9 ± 0.75; satisfaction 4.02 ± 0.97.

A statistically significant improvement was found in both self-image (*P* = .000) and satisfaction (*P* = .011) after showing patients their preoperative and final follow-up full-body photographs (Table 2). The null hypothesis was rejected.

View this table:
[Table 2](http://ijssurgery.com//content/14/6/1037/T2)

Table 2 
Comparison of Scoliosis Research Society Health-Related Quality of Life Questionnaire (SRS-22) satisfaction and self-image domains before and after showing patients their preoperative and final follow-up photographs.

## DISCUSSION

Patient-reported outcome questionnaires have become the standard measure for treatment effectiveness after ASD surgery.10,11 The SRS-22 questionnaire has been validated in an adult deformity population12,13 and is one the most widely used health-related quality-of-life instruments in adult deformity patients.6–8,14–18

Although it is unclear if patient satisfaction is associated with the extent of improvement in surgical outcome measures after spinal surgery,9 there is no doubt that the use of patient satisfaction metrics represents an important movement toward patient-centered care.2,3 However, determinants of patient satisfaction in ASD surgery have proven to be complex.19

We are unaware of any study that has previously examined if the use of clinical photography may have an influence in patient satisfaction after ASD surgery.

Only 2 prior studies4,5 have examined the effects of clinical photography in clinical results after spinal deformity surgery. In 2015, Albayarak et al4 compared the SRS-22 scores in 2 groups of 30 patients operated on for adolescent idiopathic scoliosis. Patients in group 1 were shown the preoperative and most recent follow-up photographs, while patients in group 2 were not shown their photographs. They found a statistically significant difference between the groups for question 10 (self-image), 18 (function), and 21 (satisfaction). No significant difference was found between the 2 groups in the SRS-22 domains. One year later,5 the same study group conducted a similar study in a population of 40 hyperkyphotic subjects with a mean age of 19 years. They proved that showing patients their preoperative and postoperative photographs improved postoperative patient satisfaction as measured by SRS-22R scores. This second study employed a different methodology using the same patients as the control group. We decided to adopt this approach for our study since we are under the impression that many confounding factors can be avoided using the same patients as the control group.20

It should be noted that, contrary to our study, none of these 2 studies used a standardized identical photographic technique including the same equipment, lighting, and background. Another methodological difference that merits comment is that none of these 2 papers used full-body clinical photographs. ASD patients assume many different compensatory postures, including a retroverted pelvis, extended hips, flexed knees, and ankle dorsiflexion.21,22 Although in some patients a full-spine photograph may be sufficient to evaluate aesthetic changes after surgery, full-body photographs provide a better appreciation of the entire musculoskeletal system's participation in ASD compensation (Figure 3). Recent efforts to describe compensation in response to malalignment using the pelvis and lower limbs have demonstrated success using full-body stereoradiographic imaging (EOS imaging).22,23 Analogously, we used full-body photographs in our study since they allow clinicians and patients to better assess changes in compensatory mechanisms following surgery21 (Figure 3).

![Figure 3](http://ijssurgery.com//https://www.ijssurgery.com/content/ijss/14/6/1037/F3.medium.gif)

[Figure 3](http://ijssurgery.com//content/14/6/1037/F3)

Figure 3 
Preoperative and postoperative right-side upright position clinical photographs of a patient operated on for thoracolumbar kyphosis. Patient preoperative picture shows pelvic retroversion and knee flexion as compensatory mechanisms. Final follow-up photograph shows reversal of compensatory mechanisms.

The main limitation of the present study is the small sample size; however, this is a limitation shared with the 2 previous studies evaluating the influence of clinical photography in patient satisfaction following spinal deformity surgery.4,5 Like the vast majority of studies on ASD surgery2,6–8,11,12,16–21 our study included patients with deformity caused by different etiological factors. Due to the heterogeneity in clinical settings, any potential change found in SRS-22 activity, pain, and mental health domains after showing patients their photographs could be difficult to interpret. For this reason, we decided to focus our study on patient satisfaction, bearing in mind that the SRS-22 self-image domain has a strong correlation with patient satisfaction following ASD surgery.2 Although our patients experienced improvement in the SRS self-image domain that barely reached a minimal clinically important difference calculated by standard error of measurement,17 a statistically significant improvement in SRS satisfaction was found. Unfortunately, the present study lacked longitudinal data that would allow us to be sure whether the improvement in patient satisfaction after seeing their photographs will be temporary or long lasting.

Despite these limitations, we provide the first evidence that patient satisfaction and self- image may improve after ASD surgery by the use of clinical photography. This could be an important starting point for introducing full-body clinical photographs as a routine clinical tool in adult deformity patients undergoing surgery.

## ACKNOWLEDGMENTS

The authors wish to acknowledge Jose Dominguez Pallas, clinical photographer, for his involvement. This study was approved by the Institutional Research Ethics Committee.

## Footnotes

*   **Disclosures and COI:** The authors state no conflict interest in relation to this study.

*   This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2020 ISASS

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