Traumatic spinal injuries represent a major global health concern, contributing substantially to morbidity, long-term disability, and economic burden [1]. These injuries exert an especially profound impact in low and middle-income regions, where environmental, infrastructural, and occupational factors intersect to increase vulnerability. The Global Burden of Disease Study consistently ranks spinal trauma among the leading causes of years lived with disability, particularly in South Asia, where rapid urbanization and inadequate trauma systems exacerbate the problem [2].

Road traffic collisions, falls from height, and workplace injuries remain the predominant mechanisms of spinal trauma, frequently affecting individuals during their most economically productive years of life [3]. Functional recovery following such injuries is complex and multidimensional, encompassing mobility, self-care, pain, emotional well-being, and reintegration into social and occupational roles. To comprehensively assess these domains, patient-reported outcome measures (PROMs) are essential in both clinical practice and research. PROMs capture the patient’s perspective and serve as key indicators of treatment efficacy, quality of life, and long-term rehabilitation outcomes [4].

Although generic PROMs such as the 36-Item Short-Form Health Survey and EuroQoL 5-Dimension 3-Level (EQ-5D-3L) are commonly used, they often lack the sensitivity required to capture the specific consequences of spine trauma [5,6]. To address this limitation, the AO Spine Knowledge Forum Trauma developed the AO Spine Patient-Reported Outcome Spine Trauma (AO Spine PROST) questionnaire—a 19-item instrument based on the International Classification of Functioning, Disability and Health framework. The PROST evaluates the impact of spinal trauma on physical, emotional, and social functioning by comparing postinjury performance with preinjury status on a 0–100 scale, across domains including mobility, pain, interpersonal relationships, and occupational participation [7].

Since its development, the AO Spine PROST has been translated and validated in several languages, including German, English, and Nepali, each demonstrating excellent psychometric performance, with Cronbach’s alpha values above 0.95, strong test–retest reliability, and robust construct validity compared with established PROMs [8–10]. However, until now, no validated version has been available in Hindi.

Hindi is among the most widely spoken languages in the world. Recent data ranks it third globally in total number of speakers, with over 341 million native (L1) speakers and approximately 615 million total users [11,12]. It serves as the primary language of communication across vast regions of South Asia and is extensively used in healthcare delivery, patient education, and clinical documentation. The absence of a validated Hindi version of the AO Spine PROST represents a significant barrier to equitable outcome assessment in spine trauma care. Without a culturally and linguistically adapted instrument, clinicians lack the means to assess patient-reported function accurately, and researchers are unable to adequately include Hindi-speaking populations in multicentric studies or registries. This limitation not only restricts individualized care planning and rehabilitation monitoring but also hinders efforts to harmonize global spine trauma outcome evaluation.

Accordingly, this study aimed to translate and cross-culturally adapt the AO Spine PROST into Hindi and to evaluate its psychometric properties—including internal consistency, test–retest reliability, and construct validity—within a representative cohort of Hindi-speaking patients with spinal trauma. We hypothesized that the Hindi version would demonstrate reliability and validity comparable to previously validated editions and would facilitate broader clinical and research applicability across Hindi-speaking populations.

This cross-sectional, observational study was conducted at a tertiary-level trauma center in northern India between July 2024 and January 2025. The study adhered to the ethical principles outlined in the Declaration of Helsinki. Approval was obtained from the Institutional Review Board (IRB) of Orthopaedic Surgery PGIMER (IRB no., DRB/Ortho/2023/50), and all participants provided written informed consent before inclusion.

The primary objective was to translate and culturally adapt the AO Spine PROST questionnaire into Hindi and to evaluate its psychometric properties, specifically internal consistency, test–retest reliability, and construct validity, in a cohort of Hindi-speaking individuals with recent spinal trauma.

A total of 101 patients were prospectively recruited from the inpatient and outpatient services of the Department of Orthopedics and Trauma Surgery. The inclusion criteria were as follows: (1) age between 18 and 65 years; (2) diagnosis of traumatic spinal column injury (cervical, thoracic, or lumbar) within the preceding three months; (3) fluency in both Hindi and English; and (4) clinical and cognitive ability to provide informed consent and self-report functional status.

Patients were excluded if they had concurrent polytrauma or traumatic brain injury impairing cognitive participation, or if they had preexisting neurological or musculoskeletal conditions that could independently influence functional outcomes.

A total of 101 patients with traumatic spinal column injuries were enrolled between July 2024 and January 2025. The mean age of participants was 37.3 years (standard deviation [SD]=11.6), with a marked male predominance (90.1%). Approximately 73% of participants were employed prior to injury, and nearly half (49.5%) resided in rural areas. Cervical and lumbar spine injuries each accounted for 41.6% of cases, while thoracic and multilevel injuries were less common. The majority of injuries were caused by road traffic accidents (57.4%) and falls from height (33.7%). The mean interval between injury and assessment was 83.2 days (SD=18). A detailed summary of patient demographics and clinical characteristics is provided in Tables 2 and 3.

This study reports the translation, cross-cultural adaptation, and psychometric validation of the Hindi version of the AO Spine PROST, a spine trauma–specific PROM. The findings demonstrate that the Hindi instrument possesses strong reliability, construct validity, and high cultural acceptability among Hindi-speaking patients with recent spinal injuries.

The Hindi version exhibited excellent internal consistency and robust item-total correlations, comparable to or surpassing those reported in previous language adaptations. The Cronbach’s alpha in this cohort (0.984) was nearly identical to values reported for the Dutch (0.96), German (0.96), and Nepali (0.95) versions. Temporal stability, reflected by test–retest reliability (ICC=0.658, Spearman’s ρ=0.897), was somewhat lower than in prior validations but still indicated moderate reproducibility. This difference may relate to the heterogeneity in injury types and recovery patterns during at early subacute phase, when minor clinical changes can occur within short intervals, as well as to relatively small retest group (n=30), which may have introduced variability. Nonetheless, the instrument’s overall performance remained consistent with its intended purpose across different populations. The SEM (6.0) reflected high measurement precision, while the SDC (16.6) represented the minimum detectable change required to distinguish genuine clinical improvement or decline from measurement error. Together, these metrices provide useful benchmarks for interpreting longitudinal outcome changes.

Construct validity was strongly supported by convergent correlations with EQ-5D-3L domains and the EQ-VAS, paralleling findings from earlier validations. For instance, the correlation between PROST “walking” and EQ-5D “mobility” (ρ=−0.84) in this cohort closely matched that reported in the German (ρ=−0.81) and Nepali (ρ=−0.79) versions. Such domain-specific associations confirm that the translated instrument successfully captures core functional dimensions central to recovery after spine trauma. Moreover, the significantly high correlation between the Hindi and English versions of the PROST (ρ=0.999) establishes strong conceptual and scoring equivalence, an essential requirement for translations intended for international research.

Beyond its psychometric soundness, this study advances the broader goal of promoting linguistic and cultural inclusivity in spinal trauma research. Hindi, spoken by over 528 million native speakers in India, ranks among the world’s most widely used languages; yet, until now, no validated PROM specific to spine trauma existed in Hindi [11,12]. The successful adaptation of the AO Spine PROST into Hindi therefore enables standardized outcome assessment in clinical practice and allows a large, previously underrepresented population to be included in global and multicentric spine trauma research initiatives.

The cognitive debriefing phase yielded several valuable cultural observations. Many patients had difficulty differentiating between stiffness and pain, reflecting overlap in the everyday Hindi usage of these terms. Others reported discomfort or confusion when responding to the item related to sexual function, largely attributable to cultural taboos surrounding sexual discussions in South Asian contexts, particularly among older adults and those from rural communities. Additionally, the broad phrasing of “sexual activity”— encompassing behaviors ranging from solitary activities to physically demanding partnered intercourse, was not uniformly understood. The absence of explicit contextual framing may have contributed to varied interpretations and reduced response reliability. These challenges illustrate that even with methodologically rigorous translations must undergo iterative field testing remains essential to ensure functional, not just linguistic, equivalence. They also highlight the need for culturally sensitive phrasing and appropriate clinician guidance during PROM administration. Future refinements could include clearer wording for overlapping items (e.g., stiffness vs. pain) and clinician support for sensitive domains such as sexual function to improve response consistency.

This study offers several key strengths. It adhered strictly to internationally accepted guidelines for translation and cross-cultural adaptation, including forward and backward translation, expert panel review, and cognitive testing with representative end-users. Psychometric testing was conducted in a clinically diverse sample encompassing various injury levels, severities, and treatment modalities. The inclusion of established instruments such as the EQ-5D and EQ-VAS further supports the validity of the findings.

However, a few limitations warrant consideration. The study was conducted at a single tertiary center and involved bilingual participants, which may restrict generalizability to monolingual, lower-literacy, or rural populations. Responsiveness to clinical change and minimally important difference thresholds were not assessed due to the cross-sectional study design. Future longitudinal studies are needed to evaluate these properties and to confirm the tool’s applicability in long-term follow-up and rehabilitation settings. The predominantly male sample (>90%), also limits the generalizability of results to female patients.

In summary, the Hindi version of AO Spine PROST preserves the psychometric robustness of the original instrument and is suitable for assessing functional outcomes among Hindi-speaking patients with spinal trauma. Its availability enhances clinical communication, supports standardized documentation of recovery, and fosters broader inclusion of Hindi-speaking populations in international spine trauma research collaborations.

The Hindi translation and cross-cultural adaptation of the AO Spine PROST demonstrated excellent reliability, validity, and feasibility for evaluating functional outcomes in patients with traumatic spinal injuries. By overcoming linguistic and cultural barriers, the Hindi version enables accurate patient-reported assessment across a broad segment of the Hindi-speaking population. This adaptation not only supports standardized outcome measurement in clinical practice but also promotes greater inclusion of Hindi-speaking patients in multicenter studies and international spine trauma registries. Future longitudinal studies should aim to evaluate responsiveness to clinical change and to establish minimal clinically important difference values, thereby further enhancing the instrument’s applicability in both clinical and research settings.