Minimal important differences of the SRS-22 Patient Questionnaire following surgical treatment of idiopathic scoliosis

Adolescent idiopathic scoliosis: treatment outcomes, quality of life and implications for practice

Adolescent idiopathic scoliosis (AIS) is the most common spinal disorder among children and adolescents, with most cases being diagnosed around puberty. While the majority of people with AIS do not undergo treatment, a small but significant number are treated, depending on the extent of their spinal curvature. Treatment typically involves bracing, which requires substantial adherence, and/or surgery, which is invasive and permanent. Furthermore, decisions about treatment often need to be made at a critical stage of the person's development. This article examines the evidence on AIS and its treatment, synthesising the current literature and drawing from the authors' empirical work to explore the clinical outcomes of bracing and surgery, as well as the longer-term effects on people's quality of life. Drawing from this evidence, the authors provide guidance for nurses and healthcare professionals who care for people with AIS.

Clinical and radiological outcomes of gradual reduction and circumferential fusion of high-grade spondylolisthesis in adolescents: a prospective cohort study of 29 young patients

AIM

The objective of this study was to evaluate the safety and efficacy of a novel technique of formal reduction and circumferential fusion for pediatric high-grade spondylolisthesis (HGS).

PURPOSE

The safety and efficacy of formal reduction for high-grade spondylolisthesis (HGS) has never been thoroughly examined. This study reports the outcomes of 29 children with HGS who underwent a procedure of gradual reduction and circumferential fusion.

METHODS

29 children (13 males, 16 females) were recruited between 2006 and 2010. Radiographic measurements (including % of slip, lumbosacral angle-LSA, pelvic incidence-PI, pelvic tilt-PT, sacral slope-SS, and proximal femoral angle-PFA) and quality of life assessment (SRS-22 questionnaire) were prospectively obtained at baseline and at the last post-operative follow-up (> 2 years post-op). Radiological measurements were used to classify patients according to the Spine Deformity Study Group (SDSG) classification.

RESULTS

Mean baseline slip % was 69.9 ± 16.5%. There were 13 patients with a balanced pelvic (SDSG Type 4) and 16 with an unbalanced pelvis (SDSG Type 5 and 6). On average, a reduction of 45.5 ± 15.3% (range 20-86%) was achieved safely with no major complication. In particular, of the 29 patients, only 3 had a L5 radiculopathy postoperatively that was self-resolved at follow-up. From a radiological standpoint, we observed a mean improvement of LSA from 80.3 ± 17.9° to 91.7 ± 13.6°. We also observed a statistically significant improvement in global HRQOL, and in the function and body image domains.

CONCLUSION

This prospective study suggests that formal reduction of HGS followed by circumferential fusion is safe when using a standardized surgical technique based on gradual reduction. Performing this intervention could also help improve QOL in some patients.

Determining the association between the radiographic parameters and the SRS-22 scores in Chinese female patients with adolescent idiopathic scoliosis: does curve pattern matter?

Background: The Scoliosis Research Society (SRS)-22 outcomes have been shown to be correlated with radiographic parameter of adolescent idiopathic scoliosis (AIS). A recent study suggested that curve patterns might play a role in assessing the influence of deformity on patient's reported outcomes. The aim of this study was to examine the relationship between radiographic parameters and SRS-22 questionnaire outcomes in female patients with adolescent AIS among the Chinese population based on five curve patterns.Patients and Methods: The radiographic data and SRS-22 questionnaires of 259 female AIS patients were reviewed. Radiographic measurements included: Cobb angle of the major curve, T1 tilt angle, apical vertebral rotation, apical vertebral translation (AVT), thoracic kyphosis, and lumbar lordosis. Curve patterns included single thoracic (T), single thoracolumbar/lumbar (TL), double thoracic (DT), double major (DM), and triple major (TM). The correlation between radiographic measurements and each domain in SRS-22 was determined by Pearson's correlation coefficient.Results: The curve magnitude and AVT of the major curve were found to be significantly correlated with the self-image domain in all cases (Cobb angle: r = -0.426, p = 0.002; AVT: r = -0.281, p=0.006) and in all curve patterns except for TM. Compared to other groups, the TM group had a significantly larger major curve than the DT group and TL group (p ≤ 0.004). In TM group, the self-image scores were lower than TL group (p =0.018), and the function scores were lower than that in T, TL (p < 0.001) and DM groups (p =0.013). In the DT group, the T1 tilt was significantly correlated with the self-image domain (r = -0.376, p =0.004). In the T group, coronal curve magnitude was significantly correlated with function domain (r = -0.397, p < 0.001).Conclusion: Our findings suggested curve patterns should be considered in evaluating the correlations between radiographic parameters and SRS-22 outcomes in patients with AIS.

Incidence of back pain from initial presentation to 3 years of follow-up in subjects with untreated adolescent idiopathic scoliosis

BACKGROUND

Although back pain may be present in subjects with adolescent idiopathic scoliosis (AIS), its natural history is unknown. Therefore, this study evaluated the incidence of back pain in scoliotic adolescents longitudinally.

METHODS

This retrospective analysis examined prospectively collected pain subscale data of the Scoliosis Research Society questionnaire between the initial presentation and up to 3 years of follow-up. Consecutive subjects with AIS aged 10-18 at baseline managed by observation within the study period were included. Study subjects with at least one time point of follow-up data were considered. Alternatively, a group with physiotherapy-treated was also included for comparison.

RESULTS

We enrolled 428 subjects under observation. The incidence of back pain among study subjects was 14.7%, 18.8%, and 19.0% for the first year, second year, and third year of follow-up, respectively. Most experienced mild pain (1 out of 5 points) throughout the study. Neither incidence nor intensity of pain significantly differed between subjects under observation and received physiotherapy. Additionally, study subjects with a new onset of back pain had poorer function, self-image, and mental health scores than those without pain.

CONCLUSION

We investigated the incidence of back pain longitudinally in subjects suffering from AIS. Further validation of the current results is warranted.

Efficacy and safety of the orthopaedic manipulation techniques of the Lin School of Lingnan Region in the treatment of adolescent idiopathic scoliosis: protocol of a participant-and-assessor-blinded randomized controlled study

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the most common developmental spine disorder among children. It is characterized by a lateral deviation of the spine that gives rise to the distinctive "S" or "C" shaped bending of the spine. The Lin School of Lingnan Region (LSLR), one of the prominent schools for bare-handed orthopaedic manipulation in southern China, provides preliminary evidences that the orthopaedic manipulation techniques help to correct deviations of the spine. Previous research found that Orthopaedic Manipulation Techniques of LSLR (OMT-LSLR) could reduce the Cobb's angles in patients with AIS. Therefore, the current study aims to investigate the effectiveness and safety of the OMT-LSLR in treating teenagers with AIS.

METHODS

In this participant-and-assessor-blinded randomized controlled clinical trial, 50 participants identified AIS without surgical indications will be recruited and randomized into two groups to receive physiotherapy scoliosis-specific exercises training with either orthopaedic manipulation or sham manipulation treatment for 16 weeks, followed by post-treatment visits at week 24. Primary outcome measure is the change of Scoliosis Research Society-22 (SRS-22) questionnaire score. Secondary outcome measures include Traditional Chinese version of Spinal Appearance Questionnaire (TC-SAQ) score, Italian Spine Youth Quality of Life (ISYQOL) score, the change of Cobb's angle measured by Xray, and the change of Cobb's angle, spinal rotation and muscle volume measured by three-dimensional (3D) ultrasound. The trial will be conducted at the Chinese University of Hong Kong Chinese Medicine Specialty Clinic cum Clinical Teaching and Research Centre in Hong Kong (CUHK-CMSCTRC).

DISCUSSION

The results of this study will establish comprehensive clinical evidence about the efficacy and safety of the Orthopaedic Manipulation Techniques of the Lin School of Lingnan Region in the Treatment of Adolescent Idiopathic Scoliosis. One of the characteristics of this trial is that it is a participant-and-assessor-blinded randomized controlled clinical trial with sham manipulation. The study would also apply three-dimensional (3D) ultrasound technology to investigate the relationship between the change of the muscle volume and the spinal curve.

TRIAL REGISTRATION

The trial is registered on ClinicalTrials.gov (Identifier: NCT05639023 ) on December 6, 2022.

Cross-Cultural Adaptation and Psychometric Properties of the Traditional Chinese Version of the Italian Spine Youth Quality of Life (ISYQOL) Questionnaire

The Italian Spine Youth Quality of Life (ISYQOL) is a validated health-related quality of life (HRQOL) questionnaire for teenagers with adolescent idiopathic scoliosis (AIS). We culturally-adapted ISYQOL to traditional Chinese (ISYQOL-TC) and then recruited 133 conservatively treated teenagers with AIS to complete the ISYQOL-TC and the Chinese version of the Scoliosis Research Society-22 revised (SRS-22r) questionnaire, nine-item Patient Health Questionnaire (PHQ-9), seven-item Generalized Anxiety Disorder scale (GAD-7), and numeric pain rating scale (NPRS). They repeated ISYQOL-TC two weeks later. The internal consistency, unidimensionality, and test-retest reliability were measured using the Cronbach's alpha, Rasch measurement models, and intra-class correlation coefficients (ICC3,1), respectively. The concurrent validity of the ISYQOL-TC with SRS-22r, and its construct validity with other questionnaires were evaluated using Spearman correlation coefficients. The ISYQOL-TC demonstrated good internal consistency (Cronbach's alpha 0.90 and 0.89 for items 1-13 and items 1-20), and excellent test-retest reliability (ICC3,1 = 0.95-0.96). The Rasch analysis supported the unidimensionality of all 20 items in ISYQOL-TC. The ISYQOL-TC percentage scores were positively correlated with SRS-22r total scores (r = 0.65; p < 0.05), but were negatively related to PHQ-9, GAD-7, and NPRS scores (r = -0.46 to -0.39; p < 0.01). Collectively, the ISYQOL-TC is a reliable and valid instrument for evaluating HRQOL in Chinese teenagers with AIS.

Correlation of radiographic parameters and patient satisfaction in adolescent idiopathic scoliosis treated with posterior screw-dual-rod instrumentation

PURPOSE

In surgical treatment of adolescent idiopathic scoliosis (AIS), only a few studies measure both, radiological parameters and PROMs and correlate them.

METHODS

Prospectively collected AIS-data of one scoliosis-center within a multicenter German-Spine-Society-Study. All patients underwent instrumented posterior spinal correction and fusion with pedicle-screw-dual-rod-systems from 05/2019 to 01/2021. The data were retrospectively analyzed.

INCLUSION CRITERIA

age 11-17 years, follow-up (FU) at least 12 months. Clinical data, radiographic parameters, and PROMs (SRS-30-questionnaire) were collected. 100% of patients had X-ray images, 88.2% completed SRS-30. Parameters were given as mean ± SD. Differences and subdivision by lower instrumented vertebra (LIV) were analyzed by students t-test (significancy a = 0.05), associations by Pearson's correlation.

RESULT

Total of 51 patients: 15 ± 1.4 years, BMI 20.7 ± 3.7 kg/m2, FU 16.6 ± 6.1 months, fusion length 9.2 ± 2.3 segments, implant density 93 ± 9%, surgical time 215 ± 71 min, mean blood loss 504 ± 360 ml. Mean preoperative Cobb angle of main curve 64 ± 14°, of secondary main curve 46 ± 12°, corrected by 68 ± 11%, 56 ± 17%, respectively. Mean thoracic rib and lumbar hump significantly decreased by - 8.5 ± 7.0° and - 7.7 ± 8.9° (p < 0.5). High thoracic rib hump almost unchanged, - 0.4 ± 2.8° (p = 0.3). Thoracic kyphosis (- 0.9 ± 12.8°, p = 0.6), lumbar lordosis (1.5 ± 10.1°, p = 0.3), clavicle angle (- 0.5 ± 2.7°) and spinopelvic parameters (p > 0.5) did not significantly change, only LIV-tilt from 24.5 ± 6.7° to 6.5 ± 4.3° (p < 0.05). PROMs significantly improved (p < 0.05), no significant improvement for function/activity (p = 0.4). Preoperative mean total-score was 3.6 ± 0.5, 4.2 ± 0.3 at FU(p < 0.05). Self-image improved in 67%. Moderately strong correlation for PROMs: the better LIV-tilt (r = - 0.5) correction and the shorter surgery time (r = - 0.4), the better SRS-30 total-score. No correlation for curve correction and patient's satisfaction.

CONCLUSION

In summary, results of this study demonstrate good surgical correction and significant improvement of most PROMs.

Review of the Most Cited Patient-Reported Outcome Measure (PROM) Studies Published in the Neurospine Surgical Literature

Patient-reported outcome measures (PROMs) are validated tools that are widely utilized in research and patient care. Their diversity, quality, and application remain matters of peak research interest. This article is a review of the PROMs that were utilized in high-impact publications in the neurospine surgical literature. The 50 most cited articles on the subject were selected and analysed. Most (42 articles) were published in spine journals and, in particular, in the journal Spine (Phila Pa 1976) (28 articles). A total of 34 PROMs were utilized, of which 24 were used only once in single studies. The four most common PROMs were Scoliosis Research Society-22 (SRS-22) (15 articles), Short Form-12 and Short Form-36 (SF-12 and SF-36) (11 articles), Ronald-Morris Disability Questionnaire (RMDQ) (nine articles), and Oswestry Disability Index (ODI) (five articles). Nineteen articles focused on validating translated versions of 11 PROMs to other languages. The languages that had the maximal number of tools translated to amongst the highly cited articles were Italian (six tools), Portuguese (four tools), German (three tools), and Japanese (three tools). The most common diagnoses and the PROMs used for them were back pain and cervical spine disorder (SF-12 and SF-36 (nine articles), RMDQ (eight articles), and ODI (five articles)), and idiopathic scoliosis (SRS-22) (14 articles)). The median (range) article citation number was 137 (78-675). The four most cited PROMs were SRS-22 (2,869), SF-12 and SF-36 (2,558), RMDQ (1,456), and ODI (852). Citation numbers were positively impacted by article age and participant number but not by tool type or clinical diagnosis. In conclusion, a wide range of PROMs was utilized in the 50 most cited publications in the neurospine surgical literature. The majority were disease-specific rather than generic and targeted particular spine pathology. Neurosurgical PROMs were under-represented amongst the most cited articles. Awareness of the PROMs used in high-impact studies may be helpful in tool selection in future research. PROMs are valuable in standardizing subjective outcomes. Their use in research and clinical settings in any validated language is highly encouraged.

Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To determine the incidence of medical complications in the pediatric population aged 10-20 years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes.

METHOD

Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression.

RESULTS

251/311pts had min 2 year f/u. 142F/109 M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68 days. Mean OR time was 459 min, blood loss averaged 1465 ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be an independent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2 year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group.

CONCLUSION

Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.

Benefits of Best Practice Guidelines in Spine Fusion: Comparable Correction in AIS with Higher Density and Fewer Complications

BACKGROUND

There is significant variability in surgeons' instrumentation patterns for adolescent idiopathic scoliosis surgery. Implant density and costs are difficult to correlate with deformity correction, safety, and quality of life measures.

MATERIALS AND METHODS

Two groups of postoperative adolescents were compared based on exposure to a best practice guidelines program (BPGP) introduced to decrease complications. Hybrid and stainless steel constructs were dropped, and posterior-based osteotomies, screws, and implant density were increased to 66.8 ± 12.03 vs. 57.5 ± 16.7% (p < 0.001). The evaluated outcomes were: initial and final correction, rate of correction loss, complications, OR returns, and SRS-22 scores (minimum two-year follow-up).

RESULTS

34 patients were operated on before BPGP and 48 after. The samples were comparable, with the exceptions of a higher density and longer operative times after BPGP. Initial and final corrections before BPGP were 67.9° ± 22.9 and 64.6° ± 23.7; after BPGP, the corrections were 70.6° ± 17.4 and 66.5° ± 14.9 (sd). A regression analysis did not show a relation between the number of implants and postoperative correction (beta = -0.116, p = 0.307), final correction (beta = -0.065, p = 0.578), or loss of correction (beta= -0.137, p = 0.246). Considering screw constructs only (n = 63), a regression model controlled for flexibility continued to show a slight negative effect of density on initial correction (b = -0.274; p = 0.019). Only with major curve concavity was density relevant in initial correction (b = 0.293; p = 0.038), with significance at 95% not being achieved for final correction despite a similar beta (b = 0.263; p = 0.069). Complications and OR returns dropped from 25.6% to 4.2%. Despite this, no difference was found in SRS-22 (4.30 ± 0.432 vs. 4.42 ± 0.39; sd) or subdomain scores pre- and post-program.

FINDINGS

Although it appears counterintuitive that higher density, osteotomies, and operative time may lead to fewer complications, the study shows the value of best practice guidelines in spinal fusions. It also shows that a 66% implant density leads to better safety and efficacy, avoiding higher costs.

Beware of open triradiate cartilage: 1 in 4 patients will lose > 10° of correction following posterior only fusion

PURPOSE

As 2-year follow-up may not be sufficient to assess the risk of curve progression following fusion in immature patients with adolescent idiopathic scoliosis (AIS), this study reports on 5-year outcomes of AIS patients, factoring in maturity and surgical approach, to determine whether immature patients are at risk of continued curve progression beyond 2 years.

METHODS

A multicenter database was reviewed for AIS patients who underwent spinal fusion with pedicle screw fixation and who had both 2 and 5-year follow-up. Radiographic and SRS-22 scores were compared between three groups: open triradiate cartilage-posterior fusion (OTRC-P), OTRC-combined anterior/posterior fusion (OTRC-APSF), and closed TRC (CTRC, matched to OTRC-P group).

RESULTS

142 subjects were included (67 OTRC-P, 8 OTRC-APSF, 67 CTRC). Main curve type (p = 0.592) and size (p = 0.117) were not different between groups at all timepoints. Compensatory curve size was similar at all timepoints for OTRC-P and CTRC, with a slight increase for OTRC-APSF from immediate postoperative to 5 years. At 5 years, OTRC-P had > 10° loss of correction in 25% of patients, which was greater than in the CTRC (6%) and OTRC-APSF (0%) groups (p = 0.002). No significant differences were found in loss of correction of the compensatory curve or in SRS-22 scores between groups.

CONCLUSIONS

Compared to those with CTRC and those treated with anterior/posterior fusion, patients with OTRC treated with posterior fusion had an increased risk of main curve progression greater than 10°, with some continued loss of correction after 2 years. This did not appear to affect patient-reported outcomes.

Health-related quality of life in adolescents with idiopathic scoliosis: a cross-sectional study including healthy controls

PURPOSE

To describe health-related quality of life in adolescents with idiopathic scoliosis and controls.

METHODS

This cross-sectional study analysed data from 307 individuals with idiopathic scoliosis and 80 controls without scoliosis (mean age 15.5 ± 2.1 and 14.0 ± 2.2 years, respectively). Health-related quality of life (HRQoL) was assessed using EuroQol 5-dimensions (EQ-5D) questionnaire, and the scoliosis specific Scoliosis Research Society-22r questionnaire (SRS-22r). HRQoL data in individuals with scoliosis were compared to controls, between treatment groups (untreated, ongoing brace, previously braced and surgically treated) and stratified according to curve size.

RESULTS

Adolescents with idiopathic scoliosis had reduced HRQoL compared with controls, observed through lower SRS-22r subscore (respective means 4.16 and 4.68, p < 0.001) and lower EQ-5D index (respective means 0.92 and 0.95, p = 0.032). No differences in SRS-22r subscore or EQ-5D index were detected when comparing different scoliosis treatment groups. Within the SRS-22r function domain the surgically treated group scored 4.40, significantly lower compared to the untreated (4.65) and ongoing brace groups (4.68, p = 0.005). The surgically treated and untreated group were more affected by pain, compared to the ongoing brace group (p = 0.01) with the surgically treated group scoring lowest. Non-surgically treated scoliosis individuals with larger curves (> 30 degrees) had a lower SRS-22r subscore (4.08) compared to those with smaller curves (4.31, p = 0.001).

CONCLUSION

Adolescents with idiopathic scoliosis had a reduced HRQoL compared to healthy controls. Minor differences were detected when comparing between idiopathic scoliosis treatment groups. Non-surgically treated scoliosis patients with larger curves had a lower HRQoL shown by lower SRS-22r values.

Cross-cultural French-Canadian adaptation and psychometric assessment of the Italian Spine Youth Quality of Life (ISYQOL) questionnaire

BACKGROUND CONTEXT

Idiopathic scoliosis (IS) can significantly alter the quality of life of adolescents. Some of the available questionnaires in French measuring the quality of life in this population show weak psychometric properties. The newly developed Italian Spine Youth Quality of Life (ISYQOL) questionnaire promises better properties.

PURPOSE

To provide a French-Canadian version of the ISYQOL and to verify its psychometric characteristics.

STUDY DESIGN

Prospective validation of a cross-cultural adaptation of the ISYQOL questionnaire.

PATIENT SAMPLE

A total of 111 participants with idiopathic scoliosis (77.5% female, 10-18 years old, mean Cobb angle=28°) were included in the study.

OUTCOME MEASURE

The French-Canadian version of the Italian Spine Youth Quality of Life (ISYQOL-F) questionnaire.

MATERIALS AND METHODS

The ISYQOL was translated into French using a forward-backward approach. We then verified the understanding of the translated items with two scoliosis experts and 10 adolescents. Afterward, 111 adolescents with IS were recruited by convenience at the scoliosis clinic and they completed the ISYQOL on three occasions (before seeing the specialist, 1 week, and 2 weeks after). Cronbach's alpha, intra-class (ICC), and Pearson correlation coefficients were used to respectively determine internal consistency, test-retest reliability, and concurrent validity with the SRS-22r and SF-12. The standard error of measurement (SEM) and 95% confidence minimal detectable change (MDC₉₅) were also calculated. The ceiling effect was quantified as the percentage of participants who scored the maximum on ISYQOL-F.

RESULTS

The ISYQOL-F showed good internal consistency with a Cronbach alpha of 0.81 and 0.85 respectively for items 1-13 (n=55; ISYQOL-F mean score ± SD = 63.9±13.5) and 1-20 (n=56; ISYQOL-F mean score ± SD=60.7±10.3). Test-retest reliability was excellent (ICC_3,1=0.94). The SEM is 3.1 and the MDC₉₅ is 8.6. Correlations between ISYQOL-F and SRS-22r and between ISYQOL-F and SF-12 were moderate for total scores (r=0.56 and 0.50 respectively, p<.001), but low for each domain (between 0.20 and 0.48, p<.05). No significant ceiling effects were observed for ISYQOL-F (≤2.5%). In contrast, ceiling effects ranged from 3.6% to 30.6% for SRS-22r and 0%-68.5% for SF-12.

CONCLUSIONS

The internal consistency and reliability of ISYQOL-F are good. The total score correlates moderately with the SRS-22r and SF-12. Unlike SRS-22r, the ISYQOL-F does not appear to have a ceiling effect. The ISYQOL-F may thus be suitable to assess quality of life in a population of French-Canadian adolescents with IS.

Is quality of life after surgery for adolescent idiopathic scoliosis affected by the presence of a concomitant low-grade isthmic spondylolisthesis non-surgically treated? A retrospective cohort study

PURPOSE

The HRQoL after surgery for adolescent idiopathic scoliosis (AIS) is not affected by the presence of concomitant isthmic spondylolisthesis non-surgically treated. Improvement in QoL after surgery was similar for AIS patients with and without concomitant spondylolisthesis. The purpose is to compare preoperative and postoperative Health-Related Quality of Life (HRQoL) scores in operated AIS patients with and without concomitant isthmic spondylolisthesis.

METHODS

A retrospective study of a prospective cohort of 464 individuals undergoing AIS surgery between 2008 and 2018 was performed. All patients undergoing surgery for AIS with a minimum 2-year follow-up were included. We excluded patients with prior or concomitant surgery for spondylolisthesis. HRQoL scores were measured using the SRS-22 questionnaire. Comparisons were performed between AIS patients with versus without concomitant spondylolisthesis treated non-surgically.

RESULTS

AIS surgery was performed for 36 patients (15.2 ± 2.5 y.o) with concomitant isthmic spondylolisthesis, and 428 patients (15.5 ± 2.4 y.o) without concomitant spondylolisthesis. The two groups were similar in terms of age, sex, preoperative and postoperative Cobb angles. Preoperative and postoperative HRQoL scores were similar between the two groups. HRQoL improved significantly for all domains in both groups, except for pain in patients with spondylolisthesis. There was no need for surgical treatment of the spondylolisthesis and no slip progression during the follow-up duration after AIS surgery.

CONCLUSION

Patients undergoing surgical treatment of AIS with non-surgical management of a concomitant isthmic grade I spondylolisthesis can expect improvement in HRQoL scores, similar to that observed in patients without concomitant spondylolisthesis.

Relevant impact of surgery on quality of life for adolescent idiopathic scoliosis : a registry-based two-year follow-up cohort study

AIMS

To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

METHODS

AIS patients were systematically enrolled in an institutional registry. In all, 144 AIS patients aged ≤ 25 years undergoing primary surgery (median age 15 years (interquartile range 14 to 17) were included. Patient-reported (condition-specific and health-related quality of life (QoL); functional status; back and leg pain intensity) and clinician-reported outcomes (complications, revision surgery) were recorded. Changes in patient-reported outcome measures (PROMs) were analyzed using Friedman's analysis of variance. Clinical relevancy was determined using minimally important changes (Scoliosis Research Society (SRS)-22r), cut-off values for relevant effect on functioning (pain scores) and a patient-acceptable symptom state (PASS; Oswestry Disability Index).

RESULTS

At baseline, 65 out of 144 patients (45%) reported numerical rating scale (NRS) back pain scores > 5. All PROMs significantly improved at two-year follow-up. Mean improvements in SRS-22r function (+ 1.2 (SD 0.6)), pain (+ 0.6 (SD 0.8)), and self-image (+ 1.1 (SD 0.7)) domain scores, and the SRS-22r total score (+ 0.5 (SD 0.5)), were clinically relevant. At two-year follow-up, 14 out of 144 patients (10%) reported NRS back pain > 5. Surgical site infections did not occur. Only one patient (0.7%) underwent revision surgery.

CONCLUSION

Relevant improvement in functioning, condition-specific and health-related QoL, self-image, and a relevant decrease in pain is shown at two-year follow-up after fusion surgery for AIS, with few adverse events. Contrary to the general perception that AIS is a largely asymptomatic condition, nearly half of patients report significant preoperative back pain, which reduced to 10% at two-year follow-up. Cite this article: Bone Joint J 2022;104-B(2):265-273.

The body image disturbance questionnaire-scoliosis better correlates to quality of life measurements than the spinal assessment questionnaire in pediatric idiopathic scoliosis

PURPOSE

Idiopathic scoliosis (IS) patients can have body dissatisfaction which can affect their perception of health. Two body image measures, the Spinal Appearance Questionnaire (SAQ) and the Body Image Disturbance Questionnaire-Scoliosis (BIDQ-S), have been used in pediatric IS with variable correlation to the SRS-22r and radiographs, but have not been compared to each other. As patient reported outcomes (PROs) continue to be highlighted in large database studies and national hospital ranking system scoring, we should narrow use to the best and most efficient. We aim to determine which of two better correlates to pediatric IS patients' radiographs and quality of life (QoL) scores.

METHODS

Consecutive IS patients aged 10-19 years old without surgery prospectively completed BIDQ-S, SAQ, SRS-22r, and PedsQL self-reported outcome measures. BIDQ-S and SAQ were compared in correlation to the two QoL surveys, as well as to radiographic major curve, shoulder asymmetry, lateral upright ribcage offset at apex, and coronal/sagittal balance. Spearman's r was used for correlations.

RESULTS

104 surveys with mean age 14.4 years and mean major curve 42° (14°-74°) were included. BIDQ-S and SAQ scores strongly correlated to each other (r = 0.76), but BIDQ-S had a stronger correlation to total SRS-22r (- 0.75 vs - 0.61 SAQ), PedsQL total (- 0.76 vs - 0.55) and better or no difference in each SRS-22r and PedsQL domain. Both poorly correlated to radiographs (main curve: r = 0.32 BIDQ-S, 0.31 SAQ).

CONCLUSION

The BIDQ-S correlates better to SRS-22r and PedsQL for pediatric IS patients than the SAQ. Neither correlate well to radiographs.

LEVEL OF EVIDENCE

III.

What is the effect of intraoperative traction on correction of adolescent idiopathic scoliosis (AIS)?

PURPOSE

Determine the efficacy of intraoperative traction (IOT) on curve correction in AIS.

METHODS

A prospective, multicenter, longitudinal database identified patients with major thoracic AIS (Lenke 1-4) treated with surgery using IOT and follow-up of 2 years. These cases were matched to comparable cases treated without traction (non-IOT). All patients were treated with single-stage posterior only surgery with pedicle screw constructs. Perioperative, radiographic and clinical outcome data at 2 years post-op were compared between the groups.

RESULTS

104 cases treated with IOT were matched to 104 treated without IOT. Operating room time was significantly greater in the IOT group (339 vs. 306 min, p =  < 0.001). Neuromonitoring alerts were more frequent in the IOT group (23% vs. 5%, p < 0.001). There were no postoperative neurological deficits in either group. The IOT group showed significantly greater MT curve correction (IOT 71% vs. non-IOT 66.7%, p < 0.003), with the effect most pronounced in curves > 70° (IOT 72% vs. non-IOT 64%, p = 0.04). IOT was associated with a significant reduction in 2D T5-T12 kyphosis measurements (IOT - 6.5° vs non-IOT + 0.48°, p < 0.001), yet significant improvements in estimated 3D thoracic kyphosis were made in both groups, with the non-IOT group making greater improvement when compared to the IOT group (IOT + 18.1° vs. non-IOT + 22.3° vs., p = 0.008).

CONCLUSIONS

IOT is associated with modestly enhanced coronal deformity correction. Surgeons should be aware of the increased rates of neuromonitoring alerts when using this technique and its affect on the sagittal profile. Given this IOT may be best suited to larger curves.

LEVEL OF EVIDENCE

3.

Transient fixation of L4 vertebra preserves lumbar motion and function in Lenke Type 5C and 6C scoliosis

This study investigated the efficacy of a novel surgical method that relies on the transient fixation of L4 in Lenke Type 5C and 6C adolescent idiopathic scoliosis. Thirty-six transient surgically treated L4 fixation patients were retrospectively evaluated. The first surgery involved mechanical correction of scoliosis; the lowest instrumented vertebra (LIV) was L4. After an average of 1.3 years (range, 0.3-3.4), the second surgery to remove transient L4 pedicle screws was performed. Radiographic parameters and SRS-22 scores were measured. Cobb's angle, coronal balance, LIV tilting angle, and LIV coronal disc angle clearly improved after the first surgery (p < 0.01). After the second surgery, the corrected Cobb angle (p = 0.446) and coronal balance were maintained (p = 0.271). Although L3/S1 lumbar lordosis decreased after the first surgery (p < 0.01), after removal of transient L4 pedicle screws, it recovered slightly (p = 0.03). Similarly, the preoperative L3/4 lateral disc mobility eventually recovered after transient L4 screw removal (p < 0.01). The function domain of the SRS-22 showed better scores after removal of transient L4 screws (p = 0.04). L4 transient fixation surgery is beneficial for Lenke Type 5C and 6C scolioses that do not fully satisfy LIV (L3) criteria. It preserves L3/4 disc motion, increases functional outcomes, and maintains spinal correction and coronal balance.

Minimally invasive scoliosis surgery for adolescent idiopathic scoliosis using posterior mini-open technique

The purpose of this study aimed to analyze and evaluate the radiologic and clinical outcomes of minimally invasive scoliosis surgery (MISS) for correcting adolescent idiopathic scoliosis (AIS) using the mini-open technique. Thirty-four AIS patients who underwent MISS using the mini-open technique for deformity correction. Using two to four 3-centimeter-long skin incisions (mini-open) and tubular retractors, we performed screw fixations, rod assembly, rod derotation maneuver (RD), and bone graft. For thoracoplasty, four to six ribs were resected using the same incisions. Correction was attempted using rod translation and RD maneuvers. Radiological outcomes and clinical outcomes (SRS-22) were evaluated. Mean preoperative Cobb's angle was 61.3° and curve flexibility (major curve) was 26.1%. This angle was corrected to 21.6° with a correction rate of 65.2% (P < 0.001). The coronal balance was not changed significantly. Sagittal vertical axes were corrected from -3.5 mm to 8.6 mm (-22 to 36.3 mm) (P = 0.009). Thoracic kyphosis angles and lumbar lordosis angles were not changed significantly but the values were within normal range. Each score of self-image in the SRS-22 questionnaire as well as the total score were improved significantly (P < 0.001). In conclusion, the MISS for correcting AIS using the mini-open technique showed comparable radiologic and clinical outcomes with fewer complications in patients with non-rigid scoliosis with Cobb's angle between 50° and 80°. Long-term results of this novel MISS using the mini-open technique could further strengthen the rationale for adopting this technique for curve correction in selected cases of AIS.

Long-term Patient Perception Following Surgery for Adolescent Idiopathic Scoliosis if Dissatisfied at 2-year Follow-up

STUDY DESIGN

Longitudinal.

OBJECTIVES

To evaluate whether the rate of patients who report low health-related quality of life (HRQOL) scores at 2 years following surgical correction of adolescent idiopathic scoliosis (AIS) improves by 5 years postoperatively.

SUMMARY OF BACKGROUND DATA

HRQOL scores are dependent upon a number of factors and even in instances of good surgical correction of a spinal deformity, are not guaranteed to be high postoperatively. Understanding how a low HRQOL score varies over the postoperative period can help surgeons more effectively counsel patients and temper expectations.

METHODS

A multicenter database was reviewed for patients with both 2 and 5-year follow-up after spinal fusion and instrumentation for AIS. From a cohort of 916 patients, 52 patients with low HRQOL scores at their 2-year follow-up were identified and reevaluated at 5-year follow-up. A low HRQOL outcome was defined as having SRS-22 domain or total scores less than 2 standard deviations below the mean score. Reoperations were also evaluated to determine if they were associated with HRQOL scores.

RESULTS

Of those patients with low SRS-22 HRQOL scores at 2 years postoperatively, improvements were seen in all SRS-22 domains and total scores at the 5-year time point. The greatest change was seen in the satisfaction category where 41 patients showed improvement. The rate of reoperations during this period did not significantly impact patient-reported outcomes.

CONCLUSIONS

Having a low HRQOL score 2 years after surgery for AIS does not guarantee a low score 5 years after surgery. Promisingly, most patients demonstrate some improvement in all domains for patient-reported SRS-22 scores at 5-year compared to 2-year follow-up. Understanding the longer term postoperative evolution in patient-reported outcomes may help surgeons to effectively manage and counsel patients who are dissatisfied in the short term.Level of Evidence: 3.

Determining validity, discriminant ability, responsiveness, and minimal clinically important differences for PROMIS in adult spinal deformity

OBJECTIVE

The aim of this study was to determine the concurrent validity, discriminant ability, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) in adult spinal deformity (ASD) and to calculate minimal clinically important differences (MCIDs) for PROMIS scores.

METHODS

The authors used data obtained in 186 surgical patients with ASD. Concurrent validity was determined through correlations between preoperative PROMIS scores and legacy measure scores. PROMIS discriminant ability between disease severity groups was determined using the preoperative Oswestry Disability Index (ODI) value as the anchor. Responsiveness was determined through distribution- and anchor-based methods, using preoperative to postoperative changes in PROMIS scores. MCIDs were estimated on the basis of the responsiveness analysis.

RESULTS

The authors found strong correlations between PROMIS Pain Interference and ODI and the Scoliosis Research Society 22-item questionnaire Pain component; PROMIS Physical Function and ODI; PROMIS Anxiety and Depression domains and the 12-Item Short Form Health Survey version 2, Physical and Mental Components, Scoliosis Research Society 22-item questionnaire Mental Health component (anxiety only), 9-Item Patient Health Questionnaire (anxiety only), and 7-Item Generalized Anxiety Disorder questionnaire; PROMIS Fatigue and 9-Item Patient Health Questionnaire; and PROMIS Satisfaction with Participation in Social Roles (i.e., Social Satisfaction) and ODI. PROMIS discriminated between disease severity groups in all domains except between none/mild and moderate Anxiety, with mean differences ranging from 3.7 to 8.4 points. PROMIS showed strong responsiveness in Pain Interference; moderate responsiveness in Physical Function and Social Satisfaction; and low responsiveness in Anxiety, Depression, Fatigue, and Sleep Disturbance. Final PROMIS MCIDs were as follows: -6.3 for Anxiety, -4.4 for Depression, -4.6 for Fatigue, -5.0 for Pain Interference, 4.2 for Physical Function, 5.7 for Social Satisfaction, and -3.5 for Sleep Disturbance.

CONCLUSIONS

PROMIS is a valid assessment of patient health, can discriminate between disease severity levels, and shows responsiveness to changes after ASD surgery. The MCIDs provided herein may help clinicians interpret postoperative changes in PROMIS scores, taking into account the fact that they are pending external validation.

No added value of 2-year radiographic follow-up of fusion surgery for adolescent idiopathic scoliosis

PURPOSE

For fusion surgery in adolescent idiopathic scoliosis (AIS) consensus exists that a 2-year radiographic follow-up assessment is needed. This standard lacks empirical evidence. The purpose of this study was to investigate the radiographic follow-up after corrective surgery in AIS, from pre-until 2 years postoperative.

METHODS

In this historical cohort study, 63 patients surgically treated for AIS, age ≤ 25 years, with 2-year radiographic follow-up, were enrolled. The primary outcome measure was the major Cobb angle. Secondary outcomes were coronal and sagittal spino-pelvic parameters, including proximal junction kyphosis (PJK) and distal adding-on. Change over time was analyzed using a repeated measures ANOVA.

RESULTS

The major curve Cobb angle showed a statistically significant change for pre- to 1 year postoperative, but not for 1- to 2-year follow-up. Seven out of 63 patients did show a change exceeding the error of measurement (5°) from 1- to 2-year follow-up (range -8° to +7°), of whom 2 patients showed curve progression and 5 showed improvement. PJK or distal adding-on was not observed.

CONCLUSIONS

No statistically significant changes in major curve Cobb angle were found during postsurgical follow-up, or in adjacent non-fused segments. The findings of this study are not supportive for routine radiographs 2 years after fusion surgery in AIS patients.

Associations between three-dimensional measurements of the spinal deformity and preoperative SRS-22 scores in patients undergoing surgery for major thoracic adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the relationships between three-dimensional (3D) measurements of spinal deformity and Scoliosis Research Society-22 (SRS-22) scores in preoperative patients with major thoracic adolescent idiopathic scoliosis (AIS). Previous studies reported 2D measurements were not or only weakly correlated with preoperative SRS-22 scores. However, 2D measures do not always accurately represent the 3D deformity.

METHODS

A multicenter prospective registry of surgically treated AIS patients was reviewed for patients with right major thoracic AIS (Lenke type 1-4) who underwent biplanar radiography and completed the SRS-22 questionnaire preoperatively. For the 3D measurements, two reference frames were utilized: global (gravity/patient-based) and local (vertebra/disc-based). To obtain regional measurements, the individual segments in the appropriate reference plane were summed between the levels of interest. Patients were divided into two groups for each SRS-22 domain according to their scores: low (< 4) and high (≥ 4) score groups. Group differences and correlations with SRS-22 scores were analyzed with p < 0.01 as the threshold for significance.

RESULTS

There were 405 eligible patients (mean age, 14.4 years). The mean 3D thoracic curve was 59° (45°-115°). The only significant group difference of 3D measurements occurred in the local lumbar lordosis (LL) with a small mean difference (- 3.4°, p = 0.008) in the mental health domain. In the correlation analyses, global and local thoracic kyphosis (TK) and TK/LL ratio demonstrated significant, but weak, correlations with function and total scores (|r|< 0.2, p < 0.01).

CONCLUSION

3D measurements of scoliosis severity have only weak associations with preoperative SRS-22 scores, which might indicate a limit to the discriminative capacity of the SRS-22 within surgical range major thoracic AIS curves. Interestingly, the sagittal plane was the principle 3D plane in which significant correlations existed.

LEVEL OF EVIDENCE

II, prognostic.

The Epidemiology of Back Pain in American Children and Adolescents

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

To determine the prevalence of back pain in American children and adolescents, with a focus on anatomic region, duration, severity, and treatment patterns, and to investigate for any predictive variables.

SUMMARY OF BACKGROUND DATA

No study has examined the prevalence of back pain in American children and adolescents in the last 15 years. Because the prevalence of back pain varies greatly by country and year of investigation, previous studies are not generalizable.

METHODS

A United States epidemiologic cross-sectional survey-based investigation was performed in children and adolescents ages 10 and 18 years old, equally split by age and sex, and representing census-weighted distributions of state of residence, race/ethnicity, and health insurance status. Prevalence of back pain was evaluated and described.

RESULTS

In total, 1236 (33.7%) participants reported experiencing back pain within the last year and 325 (8.9%) reported severe back pain within the last year. Prevalence of back pain increased with age and was significantly more common in females, P < 0.001 for both. Treatment for back pain was sought by 505 (40.9%) of the participants with pain, of which physical therapy was the most common. Invasive procedural treatment (e.g., injections, surgery) were rare and comprised only 61 (1.6%) of study participants. In addition, government insurance and lack of insurance coverage was associated with low treatment seeking behavior compared to private insurance users (P = 0.010 and P = 0.006, respectively).

CONCLUSION

Despite how commonly it presents, the majority of young patients with back pain do not report procedural treatment such as injections or surgery. However, because many American children and adolescents seek treatment, future research on the etiology, treatment, and prevention of back pain in children and adolescents is essential to reducing a common and financially demanding problem.

LEVEL OF EVIDENCE

4.

Two-Level Osteotomy for the Corrective Surgery of Severe Kyphosis From Ankylosing Spondylitis: A Retrospective Series

STUDY DESIGN

Retrospective study.

OBJECTIVE

To describe the treatment results of patients with severe ankylosing spondylitis (AS) kyphosis who underwent two-level osteotomy and correction surgery.

SUMMARY OF BACKGROUND DATA

The best solution for the fixed kyphotic deformity of AS is corrective osteotomy. Many osteotomy options are available: pedicle subtraction osteotomy (PSO), Smith-Peterson osteotomy (SPO), and vertical column resection (VCR). These procedures all provide multiplanar deformity correction. Nevertheless, when the AS deformity is severe, an additional osteotomy site to get more correction, achieve more ideal, and smooth curvature of the spine than single osteotomy.

METHODS

From May, 2008 to August, 2016, 19 patients of severe AS kyphosis underwent two-level spinal osteotomy and correction surgery. The patients had an average kyphosis angle greater than 90°. The radiological features and clinical evaluation, including Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 components were assessed before surgery and at follow-up. The patients underwent either one-level PSO combined with one-level SPO (n = 9) or two-level PSO (n = 10).

RESULTS

The height was increased after surgery in all patients (P < 0.05). The median follow-up was 24 months. The kyphosis angle improved from 92.0 ± 16.6° to 30.0 ± 17.2°. The chin-brow vertical angle improved from 37.6 ± 19.2° to -0.6 ± 2.5°. The sacral slope improved from 3.9 ± 11.8° to 21.7 ± 7.4°. Sagittal imbalance improved from 241.4 ± 115.3 mm to 74.6 ± 48.5 mm (P < 0.05). Lumbar lordosis improved from -3.9 ± 20.8° to 29.4 ± 14.1° (all P < 0.05). There were significant improvements in the ODI, VAS, and all components of SRS-22 (all P < 0.05). All patients with pseudarthrosis (n = 5) underwent PSO + SPO and achieved satisfactory results. Six complications were observed perioperatively, but without permanent sequelae.

CONCLUSION

Two-level osteotomy and correction procedure can achieve satisfactory results in severe AS kyphosis. PSO + SPO could be a good option for patients with pseudarthrosis because of relatively easier and faster operation.

LEVEL OF EVIDENCE

4.

Body Image Disturbance Improvement After Operative Correction of Adolescent Idiopathic Scoliosis

HYPOTHESIS

Body Image Disturbance Questionnaire-Scoliosis version (BIDQ-S) is a sensitive outcomes instrument to evaluate improvements in body image-related psychosocial effects with surgical correction.

DESIGN

Prospective observational study.

INTRODUCTION

The BIDQ-S was previously validated (convergent validity, internal consistency) as a tool to assess body image-related distress and psychosocial impairment in adolescent idiopathic scoliosis (AIS). This study was conducted to evaluate responsiveness to change in the BIDQ-S associated with surgical treatment of AIS two years postoperatively to complete the validation of this questionnaire.

METHODS

Seventy-five consecutive operative AIS patients were enrolled and completed BIDQ-S and Scoliosis Research Society-22 (SRS-22) at preoperative and two-year postoperative visits. Demographic and radiographic data were collected. Preoperative and two-year postoperative BIDQ-S (1 = best, 5 = worst) and SRS-22 scores (1 = worst, 5 = best) were compared using paired t test. Correlations between BIDQ-S and SRS-22 scores were evaluated by linear regression.

RESULTS

Eighty-four percent of the subjects were females, with average age at surgery of 14.4 ± 1.6 years. The mean follow-up was 2.26 years (range 2.0-4.5). The major Cobb was corrected from 50.0° ± 7.2° to 14.2° ± 5.8° (Δ = 71.3% ± 12.1%; p < .0001). There was a significant improvement in BIDQ-S scores after surgery (1.64 ± 0.51 to 1.21 ± 0.38, p < .0001). BIDQ-S improvements were correlated with change in SRS self-image (p = .0055), activity (p = .0057), mental (p = .0018), and overall mean (p = .0007) domains. Preoperative, two-year postoperative, and Δ BIDQ-S score were not associated with major Cobb magnitude, truncal rotation, or Lenke curve type. Patients who reached SRS-22r minimal clinically important difference (MCID) in activity and self-image domains had worse preoperative BIDQ scores than those who did not reach MCID (activity 1.91 vs. 1.54 [1 = best, 5 = worst], p = .0099; self-image 2.08 vs. 1.51, p < .0001). Greater improvement in BIDQ-S was noted in patients who reached MCID in SRS-22 self-image than those who did not (Δ = 0.77 vs. 0.38, p = .0052).

CONCLUSION

BIDQ-S is responsive to surgical correction of AIS. The BIDQ-S is a valuable clinical outcome tool to assess the psychosocial effects of scoliosis in adolescents augmenting existing outcome instruments.

Clinical Relevance of Preoperative MRI in Adolescent Idiopathic Scoliosis: Is Hydromyelia a Predictive Factor of Intraoperative Electrophysiological Monitoring Alterations?

STUDY DESIGN

This was a prospective cohort study.

OBJECTIVES

The main objectives of this study were to evaluate the prevalence and clinical relevance of neuroaxial anomalies in adolescent idiopathic scoliosis (AIS) patients as well as to evaluate different clinical and radiologic variables as potential predictors of the presence of a magnetic resonance imaging (MRI) abnormality.

SUMMARY OF BACKGROUND DATA

The usefulness of preoperative magnetic resonance imaging in AIS is still debated in the literature as well as the clinical relevance of the neuroaxial anomalies detected.

MATERIALS AND METHODS

We performed an analysis on 88 patients affected by AIS with normal neurological examination undergoing a posterior arthrodesis intervention. Patients were stratified according to the presence and type of neuroaxial abnormalities and were compared by age, sex, Risser grading, Lenke curve type, coronal and sagittal curve parameters, presence of alterations at intraoperative neuromonitoring, and "pain" and "function" scores at the SRS-22 test.

RESULTS

Neuroaxial abnormalities were reported in 23 patients (26.14%): 14 hydromyelias, 7 syringomyelias, 1 case of Chiari I syndrome, and 1 case of spinal ependymoma. Age, sex, Risser grading, curve type, and coronal and sagittal curve parameters did not differ between normal patients and patients with any neuroaxial abnormality. Alterations of motor-evoked potential/somatosensory-evoked potential monitoring during surgery were reported in 23 patients; the difference in their incidence between normal (20%) and hydromyelia (64%) patients was significant (P<0.01). In evaluating the subareas of the SRS-22 test, we found that the "function" scores differed significantly by comparing normal (21.5±1.6) and hydromyelia (20.4±1.8) patients (P<0.05).

CONCLUSIONS

The prevalence of neuroaxial abnormalities in AIS patients is relatively high, but we could not identify any definitive clinical or radiologic predictor of their presence. Hydromyelia was correlated with intraoperative motor-evoked potential/somatosensory-evoked potential electrophysiological alterations.

Outcome Measures in Adult Spine Surgery: How Do We Identify the Outcomes of Greatest Utility for Research?

The goal of any surgical intervention in spine surgery is to restore function, relieve pain, and improve quality of life. Traditional assessments of patient outcomes failed to accurately reflect patient's quality of life improvement. Patient-reported outcome measures (PROM) were designed to translate the patients perceived health into quantitative data. The data can help providers gauge the severity of a condition, develop a treatment plan, and follow the patient over time to determine treatment efficacy. Both in clinical practice and research, PROMs are helpful in comparing treatment options and advancing the field of spine surgery. This article discusses the utility and reliability of patient-reported outcomes, utilization in research, and provides examples of the most widely utilized PROMs in spine surgery.

The Assessment of Clinically Significant Differences in Treating Spinal Deformity Using the SRS Questionnaire: What Is the Threshold of Change That Is Meaningful to Patients?

BACKGROUND

The measurement of health-related quality of life is important in spinal deformity surgery. The Scoliosis Research Society questionnaire has allowed disease-specific research in this area, and determining the minimal clinically important difference (MCID) is as important as it is elusive. We seek to further refine our estimations of clinically perceived improvements by the patient.

METHODS

We used an anchor-based approach for each domain of the SRS questionnaire to compare changes at 1 year after treatment. We set the MCID as the upper 95% boundary of the "no change" group bordering the "improvement" arm, where the patients may start to perceive their own change toward the better. We compared this with the mean change.

RESULTS

The threshold value for the MCID was 0.54 for the pain domain, 0.31 for function, 0.62 for self-image, and 0.5 for mental health. The mean changes in our group's pain and self-image exceeded their MCID.

CONCLUSIONS

Compared with our previous work, we further attempted to refine our assessment of the MCID in spinal deformity. Pain continues to show clinically significant improvement, and self-image also demonstrated mean improvement over its estimated MCID.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

This result in self-image is an important addition to the MCID literature, given its lack of consistency in previous work.

Quality of Life in Males and Females With Idiopathic Scoliosis

STUDY DESIGN

Cross-sectional.

OBJECTIVE

To describe quality of life in males and females with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Idiopathic scoliosis is a three-dimensional deformity affecting the growing spine. The prevalence of larger curves, requiring treatment, is higher in females.

METHODS

This cross-sectional study comprised 1519 individuals with idiopathic scoliosis (211 males) with a mean (SD) age of 35.3 (14.9) years. They all answered the Scoliosis Research Society 22 revised (SRS-22r) questionnaire and EuroQol 5-dimension-index (EQ-5D). Five hundred twenty eight were surgically treated (78 males), 535 were brace treated (50 males), and 456 were untreated (83 males). The SRS-22r subscore (excluding the satisfaction domain), the SRS-22r domains and the EQ-5D index score were calculated. Subgroup analyses based on treatment and age were performed. Statistical comparisons were performed using analysis of covariance with adjustments for age and treatment. A P-value less than 0.05 was considered as statistical significant.

RESULTS

The mean (SD) SRS-22r subscore was 4.19 (0.61) in males and 4.05 (0.61) in females (P = 0.010). The males had higher scores on the SRS-22r domains function (4.56 vs. 4.42), pain (4.20 vs. 4.00), and mental health (4.14 vs. 3.92) (all P < 0.05). The mean (SD) EQ-5D index score was 0.85 (0.22) for males and 0.81 (0.21) for females (P = 0.10). There were minor differences when comparing males and females in treatment and age groups, but both treated and untreated groups had reduced quality of life compared with the national norms.

CONCLUSION

When compared with females, males with idiopathic scoliosis tend to have slightly higher scores in the scoliosis specific SRS-22r but not in the generic quality of life measurement EQ-5D. Quality of life is overall similar between males and females in treatment and age groups, but reduced in comparison with the general population.

LEVEL OF EVIDENCE

3.

Self-Image and Health-Related Quality of Life Three Decades After Fusion In Situ for High-Grade Isthmic Spondylolisthesis

STUDY DESIGN

Observational study.

OBJECTIVES

To evaluate self-image after in situ fusion for high-grade isthmic spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Certain clinical findings such as short trunk or waistline skin folds are often seen in high-grade spondylolisthesis. Since treatment with spinal fusion in situ does not address appearance, self-image and also health-related quality of life might be negatively affected in the short-term as well as the long-term perspective. This observational study evaluated health-related quality of life outcome including self-image three decades after in situ fusion for high-grade isthmic spondylolisthesis in relation to healthy controls.

METHODS

Thirty-eight of 39 consecutive patients, fused in situ for high-grade isthmic spondylolisthesis at a young age, completed the Scoliosis Research Society (SRS)-22r questionnaire 28-41 years after surgery. The results were compared with the results of an age- and gender-matched control group.

RESULTS

We found that the SRS-22r self-image domain scores were statistically significantly lower in patients than in controls whereas the pain and mental health scores were similar in patients and controls. Also, the SRS-22r function domain scores were statistically significantly lower in patients but the difference in means was small. We found no correlation between severity of slip and SRS-22r outcome.

CONCLUSIONS

In situ fusion for high-grade isthmic spondylolisthesis is a safe treatment option in the long term from a function and pain perspective, but the results of our study suggest that self-image is negatively affected long into adult life.

LEVEL OF EVIDENCE

Level IV.

Quality of Life Improvement Following Surgery in Adolescent Spinal Deformity Patients: A Comparison Between Scheuermann Kyphosis and Adolescent Idiopathic Scoliosis

STUDY DESIGN

Preoperative and two-year follow-up health-related quality of life (HRQOL) data were prospectively collected in 82 Scheuermann kyphosis (SK) and 995 adolescent idiopathic scoliosis (AIS) patients using the Scoliosis Research Society-22 patient questionnaire (SRS-22) outcomes instrument in a multicenter study. Visual analog scale (VAS) scores were also collected for the SK population.

OBJECTIVES

This study assessed changes in HRQOL prospectively and compared them to those occurring in AIS.

SUMMARY OF BACKGROUND DATA

There has been limited evaluation of patient-reported HRQOL changes with operative management of SK.

METHODS

Median SRS values for the SK and AIS cohorts were compared using a repeated measure of analysis of variance with age as a covariate and using a Mann-Whitney U nonparametric comparison.

RESULTS

Kyphosis was corrected from 73.9° to 45.8° (p < .001); the major curve in AIS was corrected from 55.5 to 20.2 (p < .001). Preoperative and magnitude of radiographic correction, kyphosis apex and body mass index in SK were not correlated with baseline or change in HRQOL. SK SRS scores improved after surgery in all domains with the greatest change (2.8-4.4) in self-image (p < .001). Changes in SRS Pain, Activity, and Self-Image domains met the minimal clinically important difference. Baseline SK and AIS scores differed significantly in the Self-Image, Mental Health and Total Score domains, with SK having worse scores (p < .001). At two years postoperatively, the greatest improvements were made in Self-Image, along with Mental Health and Total Score, and the SK group achieved greater gains (p < .001). At two years postoperatively, the SK scores improved to reach equivalent values to the AIS scores. VAS scores improved from 3.69 to 1.51, and these changes were correlated with change in the Pain, Mental Health, and Total Score SRS domains (p < .001).

CONCLUSIONS

Surgery for SK in the adolescent population results in significant improvements in HRQOL, which outpace those of the AIS population.

LEVEL OF EVIDENCE

Level II.

Anterior Spinal Fusion and Posterior Spinal Fusion Both Effectively Treat Lenke Type 5 Curves in Adolescent Idiopathic Scoliosis: A Multicenter Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Retrospective comparison of radiographic and clinical outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in surgical treatment of Lenke 5 curves.

SUMMARY OF BACKGROUND DATA

ASF and PSF are used for treatment of Lenke 5 curves in patients with adolescent idiopathic scoliosis (AIS). Currently, no consensus exists for optimal surgical treatment of Lenke 5 curves.

METHODS

Patients with Lenke 5 curves treated with either ASF or PSF were prospectively enrolled in a multicenter database and then retrospectively reviewed. Demographic data, perioperative measures, radiographic data, and SRS-22R scores were collected and compared for statistical significance.

RESULTS

A total of 149 patients were included in the study; 51 underwent PSF and 98 underwent ASF. There was no difference in demographics between groups. The PSF group was fused one level longer than the ASF group (5.9 levels PSF, 4.6 levels ASF, p < .0001). The PSF group had shorter operative times (223 minutes PSF, 297 minutes ASF; p < .0001) and a higher proportion of patients who received a postoperative blood transfusion (45% vs. 5%, p < .0001). PSF patients had longer hospital stays (6.1d PSF vs. 5d ASF, p = .031). The ASF group had larger preoperative major curve (48.2° ASF, 44.2° PSF; p < .01). Coronal balance, thoracolumbar/lumbar Cobb angle, shoulder height, trunk shift, and overall sagittal balance were not different between groups at two-year follow-up. Curve correction at two-year follow-up was similar between groups (66% ASF vs. 62% PSF). There were no significant differences in clinical outcomes or complication rates between groups.

CONCLUSION

There is no difference in radiographic or clinical outcomes in patients treated with ASF or PSF for Lenke 5 curves. ASF may save a fusion level, but has longer operative time than PSF. Ultimately, the risks and benefits of each approach merit consideration by surgeon and patient.

LEVEL OF EVIDENCE

Level II.

Minimum clinically important difference of the health-related quality of life scales in adult spinal deformity calculated by latent class analysis: is it appropriate to use the same values for surgical and nonsurgical patients?

BACKGROUND CONTEXT

Health-related quality of life (HRQOL) parameters have been shown to be reliable and valid in patients with adult spinal deformity (ASD). Minimum clinically important difference (MCID) has become increasingly important to clinicians in evaluating patients with a threshold of improvement that is clinically relevant.

PURPOSE

To calculate MCID and minimum detectable change (MDC) values of total scores of the Core Outcome Measures Index (COMI), Oswestry Disability Index (ODI), Physical Component Summary (PCS), Mental Component Summary (MCS) of the Short Form 36 (SF-36), and Scoliosis Research Society 22R (SRS-22R) in surgically and nonsurgically treated ASD patients who have completed an anchor question at pretreatment and 1-year follow-up.

STUDY DESIGN/SETTING

Prospective cohort.

PATIENT SAMPLE

Surgical and nonsurgical patients from a multicenter ASD database.

OUTCOME MEASURES

Self-reported HRQOL measures (COMI, ODI, SF-36, SRS-22R, and anchor question).

METHODS

A total of 185 surgical and 86 nonsurgical patients from a multicenter ASD database who completed pretreatment and 1-year follow-up HRQOL scales and the anchor question at the first year follow-up were included. The anchor question was used to determine MCID for each HRQOL measure. MCIDs were calculated by an anchor-based method using latent class analysis (LCA) and MDCs by a distribution-based method.

RESULTS

All differences between means of baseline and first year postoperative total score measures for all scales demonstrated statistically significant improvements in the overall population as well as the surgically treated patients but not in the nonsurgical group. The calculated MDC and MCID values of HRQOL parameters in the entire study population were 1.34 and 2.62 for COMI, 10.65 and 14.31 for ODI, 6.09 and 7.33 for SF-36 PCS, 6.14 and 4.37 for SF-36 MCS, and 0.42 and 0.71 for SRS-22R. The calculated MCID values for surgical and non-surgical treatment groups were 2.76 versus 1.20 for COMI, 14.96 versus 2.45 for ODI, 7.83 versus 2.15 for SF-36 PCS, 5.14 versus 2.03 for SF-36 MCS, and 0.94 versus 0.11 for SRS-22R; the MDC values for surgical and nonsurgical treatment groups were 1.22 versus 1.51 for COMI, 10.27 versus 9.45 for ODI, 5.16 versus 6.77 for SF-36 PCS, 6.05 versus 5.67 for SF-36 MCS, and 0.38 versus 0.43 for SRS-22R.

CONCLUSIONS

This study has demonstrated that MCID calculations for the HRQOL scales in ASD using LCA yield values comparable to other studies that had used different methodologies. The most important finding was the significantly different MCIDs for COMI, ODI, SF-36 PCS and SRS-22 in the surgically and nonsurgically treated cohorts. This finding suggests that a universal MCID value, inherent to a specific HRQOL for an entire cohort of ASD may not exist. Use of different MCIDs for surgical and nonsurgical patients may be warranted.

Impact of Surgery on the Quality of Life of Adolescent Idiopathic Scoliosis

BACKGROUND

The impact of surgery on the quality of life of adolescents with idiopathic scoliosis (AIS) remains to be clarified as most of the studies are retrospective and few include quality of life questionnaires completed in the pre- and postoperative periods.

METHODS

Operated patients with AIS who completed preoperative and postoperative SRS-22 questionnaires were selected for evaluation. The demographic data were collected and quality of life improvement was assessed by comparing deviation to the means with standard deviation at both moments. Using the Minimal Important Clinical Difference (MICD) concept, individual improvement was also assessed.

RESULTS

28 patients (27 females) with an average age of 14.4 years (min: 12 - max: 18) and an average Cobb angle of 61.46º (min: 35º- max: 98º) were retrospectively reviewed. The correction rate was 68% with a final Cobb angle of 18.97º (min: 7.37º - max: 37.6º). The Global SRS22 score and all sub domains showed a significant variation (p<0,01). Self-image, followed by mental health, were the subdomains where the mean differences was more relevant, with the highest effect dimension given by d-Cohen analyses (Self-image d-Cohen 2.51; Mental health -d-Cohen 0.86). Both mean score differences as well as global SRS22 score reached the MICD but, while 96.4% of the patients did so for self-image ,the same only happened in 50% of the patients in Mental health and global score. No clinical relevant change occurred in pain or activity domains.

CONCLUSION

Taking into consideration the AIS natural history and the fact that the most relevant change after surgery occurs in patients' self-esteem, the advantages of a surgical treatment should be thoroughly evaluated not only based on curve severity but also by looking at which quality of life subdomains are mostly affected and which are expected to improve in order to meet proper patient expectations.Level of evidence: III.

Impact of early unanticipated revision surgery on health-related quality of life after adult spinal deformity surgery

BACKGROUND CONTEXT

Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes.

PURPOSE

The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery.

DESIGN

This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database.

PATIENT SAMPLE

The present study included 280 patients from a multicenter international prospective database.

OUTCOME MEASURE

Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work.

METHODS

Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models.

RESULTS

Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups. At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group.

CONCLUSIONS

Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up.

Health-Related Quality of Life in Adulthood in Untreated and Treated Individuals with Adolescent or Juvenile Idiopathic Scoliosis

BACKGROUND

Health-related quality of life in adults with idiopathic scoliosis diagnosed before maturity has been reported to be similar between brace-treated and surgically treated individuals. The aim of this study was to compare health-related quality of life in untreated, brace-treated, and surgically treated adults with idiopathic scoliosis diagnosed before skeletal maturity. Subgroup analyses were performed on the basis of age at the time of the study, age of onset, surgical characteristics, and curve magnitude.

METHODS

We included 1,187 adults with juvenile or adolescent idiopathic scoliosis with a mean age (and standard deviation) of 38.8 ±12.7 years. Of these, 347 were untreated, 459 had been brace-treated, and 381 had been surgically treated. The Scoliosis Research Society-22r (SRS-22r) and EuroQol 5-Dimensions (EQ-5D) were used. Statistical analyses were performed using analysis of covariance.

RESULTS

The mean SRS-22r subscore was 4.15 ± 0.59 points for the untreated group, 4.10 ± 0.57 points for the previously braced group, and 4.01 ± 0.64 points for the surgically treated group (p = 0.007 adjusted for age and sex). The EQ-5D index was 0.82 ± 0.20 for the untreated group, 0.82 ± 0.20 for the previously brace-treated group, and 0.79 ± 0.24 for the surgically treated group (p = 0.026, adjusted for age and sex). Brace cessation was at the mean age of 16.2 ± 1.5 years, and the surgical procedure had been performed at the mean age of 15.3 ± 2.1 years. A more caudal fusion was associated with a lower SRS-22r subscore and EQ-5D index. No differences were observed when comparing individuals with juvenile or adolescent onset scoliosis (all p > 0.05).

CONCLUSIONS

Untreated adults with idiopathic scoliosis had similar health-related quality of life to previously brace-treated individuals, and they had marginally higher health-related quality of life compared with surgically treated individuals. Therefore, both surgical and brace treatments for idiopathic scoliosis could be considered successful from a health-related quality-of-life point of view in adulthood. The age of onset of idiopathic scoliosis does not seem to influence quality of life in adulthood.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Whether Orthotic Management and Exercise are Equally Effective to the Patients With Adolescent Idiopathic Scoliosis in Mainland China?: A Randomized Controlled Trial Study

STUDY DESIGN

A prospective randomized controlled trial.

OBJECTIVE

The aim of this study was to investigate the effectiveness of orthotic management versus exercise on spinal curvature, body symmetry, and quality of life.

SUMMARY OF BACKGROUND DATA

A number of well-designed studies comparing conservative treatment of adolescent idiopathic scoliosis (AIS) have been conducted and the evidence becomes stronger. However, there is a lack of the information on the effectiveness of orthotic management versus exercise.

METHODS

The inclusion criteria recommended by the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) were used during enrollment. Eligible patients were randomly assigned to either bracing group or exercise group. Patients in the bracing group were prescribed with a rigid thoracolumbosacral orthosis and requested to wear 23 h/day, while patients in the exercise group were treated with the protocol of the Scientific Exercise Approach to Scoliosis. Data regarding angle of trunk inclination, Cobb angle, shoulder balance, body image, and quality of life (QoL) were collected every 6 months.

RESULTS

Twenty-four patients in the bracing group and 29 patients in the exercise group participated in this study. For the intergroup comparison, the bracing group showed better results about the correction of spinal curvature (Cobb angle at the first 12 months of intervention, P = 0.039), scores concerning QoL, especially function (P < 0.001), mental health (P < 0.001), and total score (P < 0.001), were higher than that of the exercise group. The results of body symmetry evaluation did not differ significantly between the two groups. For the intragroup comparison, parameters of spinal curvature (baseline vs. 12-month, P < 0.03 in the exercise group and P < 0.001 in the bracing group), QoL (baseline vs. 12-month, P < 0.001), and TAPS (baseline vs. 12-month, P < 0.033) significantly improved over the studied period. Shoulder balance (baseline vs. 12-month, P < 0.005) showed significant improvement only in the bracing group.

CONCLUSION

Both interventions of bracing and exercise showed significant treatment effectiveness on the patients with AIS. Bracing was superior to capture corrections in parameters of spinal curvature and body symmetry, while the QoL, especially in aspect of the functional and psychological status, was significantly better in the exercise group.

LEVEL OF EVIDENCE

1.

SRS-22r Scores in Nonoperated Adolescent Idiopathic Scoliosis Patients With Curves Greater Than Forty Degrees

STUDY DESIGN

Case control comparative series.

OBJECTIVE

Describe surgical range adolescent idiopathic scoliosis (AIS) patients electing to forgo surgery and compare health-related quality-of-life outcomes to a similar cohort of operated AIS patients by the same single surgeon.

SUMMARY OF BACKGROUND DATA

No data have been published either documenting SRS-22r scores of nonoperated patients with curves ≥40° or comparing these scores to a demographically similar operated cohort.

METHODS

Individuals with curves ≥40°, age ≥18 years, and electing to forgo surgery were identified. All patients completed an SRS-22r questionnaire. This nonoperated cohort's SRS-22r scores were compared to those of a large demographically similar cohort operated by the same surgeon. Group differences between the SRS-22r scores were evaluated by comparing these to published Minimal Clinically Important Differences (MCID) for the SRS-22r.

RESULTS

One hundred ninety subjects with nonoperated curves were compared to 166 individuals who underwent surgery. The nonoperated cohort averaged 23.5 years of age, averaged 7.7 years since curve reached 40°, and had an average 50° Cobb angle at last follow-up. No statistical significant differences were found between the groups on the Pain, Function, or Mental Health domains of the SRS-22r. Statistically significant differences in favor of the operative cohort were found for self-image, satisfaction, and total score. The observed group differences did not meet the established thresholds for minimal clinically important differences in any of the domain scores, the average total score, or raw scores.

CONCLUSION

There are no meaningful clinically significant differences in SRS-22r scores at average 8-year follow-up between AIS patients with curves ≥40° treated with or without surgery. These data in conjunction with an absence of long-term evidence of serious medical consequences with nonsurgical management of curves ≥40° should encourage surgeons to reevaluate the benefits of routine surgical care.

LEVEL OF EVIDENCE

3.

Midlife changes of health-related quality of life in adolescent idiopathic scoliosis patients who underwent spinal fusion during adolescence

PURPOSE

Our previous study reported a good health-related quality of life (HRQOL) in adolescent idiopathic scoliosis (AIS) patients 21 years or more after surgery. The purpose of this study is to investigate midlife changes in HRQOL among AIS patients who passed further 5 years from the previous survey.

METHODS

Subjects were 252 individuals who underwent spinal fusion for AIS between 1968 and 1988. The survey was administered twice-in 2009 and in 2014 using Scoliosis Research Society Patient Questionnaire (SRS-22). We analysed survey responses from 42 individuals (39 females, 3 males) who responded to both surveys.

RESULTS

The average scores for each respective domain of the SRS-22 in 2009 and 2014, respectively, were: function, 4.3 and 4.2; pain, 4.3 and 4.3; self-image, 3.0 and 2.9; mental, 3.9 and 3.8; satisfaction, 3.6 and 3.5. There were no significant differences in any domain of the SRS-22 between 2009 and 2014. Comparing non-fused segments of the lumbar spine of patients with fewer than four discs remaining with patients with four discs or more remaining, SRS-22 satisfaction score decreased more in patients with fewer than four discs (change in patients with four discs or more: -0.02; change in patients with fewer than four discs: -0.38; P = 0.05).

CONCLUSION

Each SRS-22 subscore was similar between 2009 and 2014 surveys. Those scoliosis patients who underwent spinal fusion during adolescence had good HRQOL scores in midlife. Even after five years passed, good conditions were maintained.

A Normative Baseline for the Srs-22 From Over 1000 Healthy Adolescents in India: Which Demographic Factors Affect Outcome?

STUDY DESIGN

A prospective analysis.

OBJECTIVE

This study aims to 1) establish a baseline for the SRS-22 in South East Asia and 2) evaluate the influence of patient demographics on the SRS-22.

SUMMARY OF BACKGROUND DATA

Previous studies have established a baseline for the SRS-22 in the US and described the impact of patient demographics. While the SRS-22 is used internationally, limited normative data are available.

METHODS

After approval from the local hospital and school board, 1200 adolescents (age 10-18 years) were asked to anonymously complete the SRS-22 in English. The following demographic factors were assessed: height, weight, age, gender, household income (range <$30K to >$200K), and household status (single/dual parent income). Participants with a prior spine history or active medical problems were excluded. Statistical analysis was done with a Pearson correlation followed by an analysis of variance (ANOVA).

RESULTS

One thousand nineteen unaffected adolescents completed the SRS-22 (mean age 14.4 ± 1.6 years). Demographics were as follows: gender (42%F, 58%M), household status (640 single/379 dual), height (157 ± 12 cm), weight (46 ± 11.2 kg), body mass index (BMI; 18.5 ± 3.6). SRS-22 score for all patients and by gender: Mean [4.0 ± 0.4, (F)4.0 ± 0.4, (M)3.9 ± 0.4, P < 0.0001], Activity [3.9 ± 0.4, (F)4.0 ± 0.5, (M)3.9 ± 0.6], Pain [4.3 ± 0.6; (F)4.4 ± 0.6, (M)4.2 ± 0.7, P < 0.001], Image [3.9 ± 0.6, (F)3.9 ± 0.6, (M)3.9 ± 0.6], and Mental [3.7 ± 0.6, (F)3.8 ± 0.6, (M)3.7 ± 0.6, P < 0.001]. Male gender was associated with worse pain (-0.15), mental health (-0.11), and overall SRS-22 score (-0.11). Age was correlated with a worse image (r = -0.17, P = < 0.000), while higher BMI was associated with less pain (0.07/0.02).

CONCLUSION

Younger age, female gender, and higher BMI correlated with a better SRS-22 score. Income and household status did not affect SRS-22. These findings contrast data gathered in the US but should be considered in conjunction with the minimal clinically important difference (MCID). This study establishes the first normative baseline for the SRS-22 in SE Asia and analyzed the effect of demographics on the outcome score.

LEVEL OF EVIDENCE

2.

Responsiveness and Minimal Important Changes of the Scoliosis Research Society-22 Patient Questionnaire in Subjects With Mild Adolescent and Moderate Adult Idiopathic Scoliosis Undergoing Multidisciplinary Rehabilitation

STUDY DESIGN

Single-center, prospective study.

OBJECTIVE

Evaluating the responsiveness and minimal important changes (MICs) for the Scoliosis Research Society-22 Patient Questionnaire (SRS-22) in adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AS).

SUMMARY OF BACKGROUND DATA

Despite the SRS-22 properties have been investigated in various different languages, there is still a lack of information concerning responsiveness and MIC, limiting the use of SRS-22 for clinical and research purposes.

METHODS

At the beginning and end of multidisciplinary rehabilitation programs, 149 subjects with mild AIS (Cobb angle <25°) and 140 subjects with moderate AS (Cobb angle <35°) completed the SRS-22. Upon completing the programs, subjects also performed the global perceived effect (GPE) scales test, which was divided to produce a dichotomous outcome (improved vs. stable). Responsiveness was calculated for all SRS-22 domains but satisfaction with management by distribution (effect size; standardized response mean) and anchor-based methods (receiver operating characteristic [ROC] curves; correlations between change scores of the SRS-22 and GPE). ROC curves were also used to compute the MICs.

RESULTS

The effect size ranged from 1.23 to 1.50 in AIS and from 1.02 to 1.37 in AS. The standardized response mean ranged from 0.95 to 1.27 in AIS and from 0.66 to 0.90 in AS. The ROC analyses revealed the following MIC values (area under the curve; sensitivity; specificity): function, 0.70 (0.739;66;70) for AIS and 0.60 (0.842;84;76) for AS; pain, 0.70 (0.731;71;70) for AIS and 0.40 (0.817;81;70) for AS; mental health, 0.50 (0.708;83;58) for AIS and 0.55 (0.750;69;78) for AS; self-perceived image, 0.40 (0.609;79;42) for AIS and 0.60 (0.751;61;82) for AS. Correlations between change scores of the SRS-22 domains and GPE were low to moderate, ranging from -0.347 to -0.667.

CONCLUSION

The SRS-22 was sensitive in detecting clinical changes in subjects with adolescent and adult scoliosis. We recommend taking the MICs provided into account when assessing patients' improvement or planning studies in these clinical contexts.

LEVEL OF EVIDENCE

3.

Adolescent idiopathic scoliosis and back pain

This broad narrative review addresses the relationship between adolescent idiopathic scoliosis (AIS) and back pain. AIS can be responsible for low back pain, particularly major cases. However, a linear relationship between back pain and the magnitude of the deformity cannot be expected for any individual patient. A large number of juvenile patients can remain pain-free. The long-term prognosis is rather benign for many cases and thus a tailored approach to the individual patient seems mandatory. The level of evidence available does not allow stringent recommendations for any of the disorders included in this review.

Transsacral transdiscal L5-S1 screws for the management of high-grade spondylolisthesis in an adolescent

The surgical management of high-grade spondylolisthesis in adolescents remains a controversial issue. Because the basic procedure, posterolateral fusion, is associated with a significant rate of pseudarthrosis and listhesis progression, there is a pressing need for alternative surgical techniques. In the present report, the authors describe the case of an adolescent patient with significant low-back pain who was found to have Grade IV spondylolisthesis at L5-S1 that was treated with transsacral transdiscal screw fixation. Bilateral pedicle screws were placed starting from the top of the S-1 pedicle, across the L5-S1 intervertebral disc space, and into the L-5 body. At 14 months after surgery, the patient had considerable improvement in his pain and radiographic fusion across L5-S1. The authors conclude that transsacral transdiscal pedicle screws may serve as an efficacious and safe option for the correction of high-grade spondylolisthesis in adolescent patients.

Active Treatment for Idiopathic Adolescent Scoliosis (ACTIvATeS): a feasibility study

BACKGROUND

The feasibility of conducting a definitive randomised controlled trial (RCT) evaluating the clinical effectiveness and cost-effectiveness of scoliosis-specific exercises (SSEs) for adolescent idiopathic scoliosis (AIS) is uncertain.

OBJECTIVES

The aim of this study was to assess the feasibility of conducting a large, multicentre trial of SSE treatment for patients with AIS, in comparison with standard care, and to refine elements of the study design. The objectives were to (1) update a systematic review of controlled trials evaluating the efficacy of SSE in AIS; (2) survey UK orthopaedic surgeons and physiotherapists to determine current practice, patient populations and equipoise; (3) randomise 50 adolescents to a feasibility trial of either usual care or SSE interventions across a range of sites; (4) develop, document and assess acceptability and adherence of interventions; (5) assess and describe training requirements of physiotherapists; and (6) gain user input in all relevant stages of treatment and protocol design.

DESIGN

Multicomponent feasibility study including UK clinician survey, systematic literature review and a randomised feasibility trial.

SETTING

The randomised feasibility study involved four secondary care NHS trusts providing specialist care for patients with AIS.

PARTICIPANTS

The randomised feasibility study recruited people aged 10-16 years with mild AIS (Cobb angle of < 50°).

INTERVENTIONS

The randomised study allocated participants to standard practice of advice and education or a physiotherapy SSE programme supported by a home exercise plan. Our choice of intervention was informed by a systematic review of exercise interventions for AIS.

MAIN OUTCOME MEASURES

The main outcome was feasibility of recruitment to the randomised study. Other elements were to inform choice of outcomes for a definitive trial and included curve severity, quality of life, requirement for surgery/brace, adverse events, psychological symptoms, costs and health utilities.

RESULTS

A UK survey of orthopaedic consultants and physiotherapists indicated a wide variation in current provision of exercise therapy through physiotherapy services. It also found that clinicians from at least 15 centres would be willing to have their patients involved in a full study. A systematic review update found five new studies that were generally of low quality but showed some promise of effectiveness of SSE. The randomised study recruited 58 patients from four NHS trusts over 11 months and exceeded the pre-specified target recruitment rate of 1.4 participants per centre per month, with acceptable 6-month follow-up (currently 73%). Adherence to treatment was variable (56% of participants completed treatment offered). The qualitative study found the exercise programme to be highly acceptable. We learnt important lessons from patient and public involvement during the study in terms of study and intervention presentation, as well as practical elements such as scheduling of intervention sessions.

CONCLUSIONS

A definitive RCT evaluating clinical effectiveness and cost-effectiveness of SSE for idiopathic scoliosis is warranted and feasible. Such a RCT is a priority for future work in the area. There is a sufficiently large patient base, combined with willingness to be randomised within specialist UK centres. Interventions developed during the feasibility study were acceptable to patients, families and physiotherapists and can be given within the affordability envelope of current levels of physiotherapy commissioning.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90480705.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 55. See the NIHR Journals Library website for further project information.

Effect of surgical correction of adolescent idiopathic scoliosis on the quality of life: a prospective study with a minimum 5-year follow-up

PURPOSE

To prospectively evaluate the quality of life (QoL), functionality, and body image of subjects who had undergone surgery for adolescent idiopathic scoliosis (AIS) 5-12 years previously, and to identify the outcome predictors.

METHODS

The sample consisted of 87 patients for whom follow-up data were available out of a series of 91 patients who had surgery for AIS between 2002 and 2009. We assessed the preoperative, 1-year postoperative, and 5-year or more postoperative SF-36 and SRS-23 questionnaire scores. Longitudinal clinical and radiographic data also were evaluated. Changes in the patient-oriented outcomes were compared with age and sex-adjusted normative values. A multiple regression analysis was used to identify possible outcome predictors.

RESULTS

Preoperatively, patients had impaired QoL, functionality, and body image compared to age- and sex-matched healthy controls. Surgery led to significant improvement of the SF-36 and SRS scores at the one-year and final control date, but the final scores on SF-36's physical indexes were lower than control subjects' scores. No clinically relevant differences with the normative values were detected in the final SRS scores. The height of the residual rib hump negatively predicted the total SRS and self-image scores; a more caudal level of fusion correlated with more postoperative pain.

CONCLUSIONS

Patients who underwent surgery for AIS a minimum of 5 years earlier had impaired self-reported physical QoL compared to control subjects, but they nevertheless performed better than before their surgery. Greater size of the residual hump and greater distal extension of the fusion area are negatively correlated with final self reported outcome.

The effect of metal density in thoracic adolescent idiopathic scoliosis

PURPOSE

Determine impact of metal density on curve correction and costs in thoracic adolescent idiopathic scoliosis (AIS). Ascertain if increased metal density is required for larger or stiffer curves.

METHODS

Multicentre retrospective case series of patients with Lenke 1-2 AIS treated with single-stage posterior only surgery using a standardized surgical technique; constructs using >80 % screws with variable metal density. All cases had >2-year follow up. Outcomes measures included coronal and sagittal radiographic outcomes, metal density (number of instrumented pedicles vs total available), fusion length and cost.

RESULTS

106 cases included 94 female. 78 Lenke 1. Mean age 14 years (9-26). Mean main thoracic (MT) Cobb angle 63° corrected to 22° (66 %). No significant correlations were present between metal density and: (a) coronal curve correction rates of the MT (r = 0.13, p = 0.19); (b) lumbar curve frontal correction (r = -0.15, p = 0.12); (c) correction index in MT curve (r = -0.10, p = 0.32); and (d) correction index in lumbar curve (r = 0.11, p = 0.28). Metal density was not correlated with change in thoracic kyphosis (r = 0.22, p = 0.04) or lumbosacral lordosis (r = 0.27, p = 0.01). Longer fusions were associated with greater loss of thoracic kyphosis (r = -0.31, p = 0.003). Groups differing by preoperative curve size and stiffness had comparable corrections with similar metal density. The pedicle screw cost represented 21-29 % of overall cost of inpatient treatment depending on metal density.

CONCLUSIONS

Metal density affects cost but not the coronal and sagittal correction of thoracic AIS. Neither larger nor stiffer curves necessitate high metal density.