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Study design Retrospective. Objective To investigate the prevalence of decisional regret among older adults undergoing surgery for adult spinal deformity(ASD). Summary of background data Among older adults (> 65 years old), ASD is a leading cause of disability, with a population prevalence of 60-70%. While surgery is beneficial and results in functional improvement, in over 20% of older adults outcomes from surgery are less desirable. Methods Older adults with ASD who underwent spinal surgery at a quaternary medical center from 1/1/2016 to 3/1/2019, were enrolled in this study. Patients were categorized into medium/high or low-decisional regret cohorts based on their responses to the Ottawa decision regret questionnaire. Decisional regret assessments were completed 24 months after surgery. The primary outcome measure was prevalence of decisional regret after surgery. Factors associated with high decisional regret were analyzed by multivariate logistic regression. Results A total of 155 patients (mean age, 69.5 years) met the study inclusion criteria. Overall, 80% agreed that having surgery was the right decision for them, and 77% would make the same choice in future. A total of 21% regretted the choice that they made, and 21% responded that surgery caused them harm. Comparing patient cohorts reporting medium/high- versus low-decisional regret, there were no differences in baseline demographics, comorbidities, invasiveness of surgery, LOS, discharge disposition, or extent of functional improvement 12-months after surgery. After adjusting for gender, ASA score, invasiveness of surgery, and presence of a postoperative complication, older adults with pre-operative depression had a 4.0 fold increased odds of high-decisional regret (p = 0.04). Change in HRQOL measures were similar between all groups at 12-months after surgery. Conclusion While the majority of older adults were appropriately counselled and satisfied with their decision, one-in-five older adults regret their decision to undergo surgery. Preoperative depression was associated with medium/high decisional regret on multivariate analysis.Level of Evidence: 4.

STUDY DESIGN Retrospective. OBJECTIVE To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA Surgery for correction of adult spinal deformity is often beneficial, however, in over 20% of older adults (≥65 years of age), outcomes from surgery are less desirable. METHODS We conducted semi-structured, in-depth interviews with 6 patients and 5 spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS Patients themes: (1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; (2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; (3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and (4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: (1) surgeons varied substantially in their interpretations of shared decision making; (2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; (3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and (4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness.Level of Evidence: 3.