When Shay Bess, MD, adult and pediatric orthopedic spine surgeon at Greenwood Village-based Colorado Scoliosis and Spine Specialists, helped formalize the International Spine Study Group more than a decade ago, adult spinal deformity research was still a fragmented field. Individual surgeons and centers were studying complex conditions largely in isolation, often with limited patient numbers and inconsistent data.
The model Dr. Bess envisioned was different: a global collaborative engine capable of producing rigorous prospective research, and ultimately redefining how spinal deformity is understood and treated.
“Prior to that, it really wasn’t a research engine at all. It was just a user group,” Dr. Bess told Becker’s. “But then subsequently we layered in the ability to do prospective research, and all our efforts at this point now are prospective observational trials.”
That shift transformed the ISSG into one of the largest collaborative research networks in spine deformity surgery, bringing together dozens of surgeons and scientists to generate high-quality data across institutions and continents.
Building a new research model
Dr. Bess, who is now the president, joined the effort in 2007, and by 2010 helped establish the ISSG as a formal nonprofit research organization. The group’s mission was ambitious: conduct large multicenter prospective studies capable of answering some of the most complex questions in adult spinal deformity.
“We register all of our hypotheses as a priority with the Institutional Review Board and the National Institutes of Health prior to doing the research,” he said. “So it really establishes true prospective research settings.”
That framework allowed the group to examine long-standing questions that had received little systematic attention, from the impact of spinal alignment and spinopelvic parameters to outcomes and complications in adult cervical deformity.
“Looking at adult cervical spine deformity, there was essentially no data on it prior to this,” Dr. Bess said.
Over time, the network expanded its work to include risk stratification tools, frailty indices and complication scales designed to better predict outcomes for patients undergoing complex deformity surgery.
From Western medicine to global care
As the ISSG grew, it became clear that research conducted primarily in Western health systems could miss important cultural and functional differences that shape patient outcomes around the world.
“What can happen typically is if you’re at a single site or in a single area of the world, you tend to be very myopic,” Dr. Bess said.
One example emerged when researchers examined surgical outcomes for patients in Asia.
“We found that the alignment parameters and surgeries worked very well for Western patients,” he said. “But when those same treatments are applied to patients in Japan, Korea or India, where floor sitting is extremely important, patients with long fusions, despite significant improvements in pain, had very low social domain scores.”
The reason was simple but striking: the procedures had reduced patients’ ability to sit on the floor, a key part of social life in many cultures.
“They were being ostracized from social activities that included floor sitting because they lost range of motion from their fusion,” he said.
For Dr. Bess, the finding underscored the need for a more inclusive research model capable of capturing how cultural norms shape patient outcomes. “Much of the research has been very Western medicine-centric,” he said. “This allows us to incorporate health and care treatment preferences for patients from Asia-Pacific countries.”
Toward a new outcomes framework
One of the ISSG’s most ambitious initiatives is the development of a new outcomes tool specifically designed for adult spinal deformity, something the field has never had.
“If you look at it now, the outcomes tools that are being used are either developed for children or for degenerative lumbar disorders,” Dr. Bess said. “There really is no outcomes tool specific for patients with adult spinal deformity.”
The new model aims to move beyond traditional patient-reported outcomes and capture a broader, multidimensional picture of recovery.
That includes physical function, treatment preferences and real-world activity data, along with cultural context.
“Steps data doesn’t really tell you that much,” Dr. Bess said. “You have to contextualize what patients are doing with their activities. Are they going to cafes and movies and restaurants and socializing with their friends and families, or are they confined to going just to medical providers?”
By combining these insights with surgical data, the network hopes to identify treatment strategies that better match the needs of individual patients. “Ultimately it allows us to develop algorithm-based treatment plans geared more toward the patient’s function and desires, as well as their culture,” he said.
From frailty to resilience
Another area of focus is understanding how patient physiology influences outcomes. While frailty has become a major topic in surgical risk prediction, Dr. Bess believes the concept should be reframed as a spectrum.
“There’s all this talk about frailty, but there’s not a whole lot of talk about creating a spectrum that looks at the individual from a resilient to a frail standpoint,” he said.
In this framework, resilient patients may recover even when complications occur, while frail patients may struggle despite seemingly low-risk procedures. Understanding that continuum could help surgeons modify risk factors and improve outcomes.
“Can we modify their frailty so that they become resilient?” Dr. Bess said.
Training the next generation
Beyond research, education has become a central pillar of the ISSG’s mission.
Each year the group hosts what Dr. Bess describes as the largest teaching course for spine residents and fellows in the world. Last year, they hosted over 380 attendees.
The course blends surgical education with research training and networking, helping young surgeons connect with mentors and collaborators across the global spine community.
“We use that meeting as a platform for collaboration and networking for the residents and fellows to either get a job or to get their fellowship,” Dr. Bess said. “Or to create the next generation of ISSG clinical scientists.”
The future of spine deformity research
As the ISSG’s global infrastructure continues to expand, Dr. Bess believes collaborative networks will play a growing role in shaping the future of spine care. “In the world we live in, we shouldn’t be isolating our findings or our research to one center or one region,” he said. “It needs to expand beyond.”
The goal is to generate research that improves outcomes while reducing variation in care, delivering treatments that are not only clinically effective, but also culturally meaningful for patients around the world.
“The only way you can expand beyond that is by being collaborative and initiating relationships, so you can work toward a common goal together,” Dr. Bess said.
