Outcome instruments to assess scoliosis surgery

Reliability of a New Digital Tool for Photographic Analysis in Quantifying Body Asymmetry in Scoliosis

Background: Advancements in non-ionizing methods for quantifying spinal deformities are crucial for assessing and monitoring scoliosis. In this study, we analyzed the observer variability of a newly developed digital tool for quantifying body asymmetry from clinical photographs. Methods: Prospective observational multicenter study. Initially, a digital tool was developed using image analysis software, calculating quantitative measures of body asymmetry. This tool was integrated into an online platform that exports data to a database. The tool calculated 10 parameters, including angles (shoulder height, axilla height, waist height, right and left waistline angles, and their difference) and surfaces of the left and right hemitrunks (shoulders, waists, pelvises, and total). Subsequently, an online training course on the tool was conducted for twelve observers not involved in its development (six research coordinators and six spine surgeons). Finally, 15 standardized back photographs of adolescent idiopathic scoliosis patients were selected from a multicenter image bank, representing various clinical scenarios (different age, gender, curve type, BMI, and pre- and postoperative images). The 12 observers measured the photographs at two different times with a three-week interval. For the second round, the images were randomly mixed. Inter- and intra-observer variabilities of the measurements were analyzed using intraclass correlation coefficients (ICCs), and reliability was measured by the standard error of measurement (SEM). Group comparisons were made using Student's t-test. Results: The mean inter-observer ICC for the ten measurements was 0.981, the mean intra-observer ICC was 0.937, and SEM was 0.3-1.3°. The parameter with the strongest inter- and intra-observer validity was the difference in waistline angles 0.994 and 0.974, respectively, while the highest variability was found with the waist height angle 0.963 and 0.845, respectively. No test-retest differences (p > 0.05) were observed between researchers (0.948 ± 0.04) and surgeons (0.925 ± 0.05). Conclusion: We developed a new digital tool integrated into an online platform demonstrating excellent reliability and inter- and intra-observer variabilities for quantifying body asymmetry in scoliosis patients from a simple clinical photograph. The method could be used for assessing and monitoring scoliosis and body asymmetry without radiation.

Outcome measures for young people with adolescent idiopathic scoliosis: A qualitative exploration of healthcare professionals' perceptions and practices

BACKGROUND

Limited knowledge exists on current use of patient reported outcome measures (PROMs) and performance measures for adolescents with idiopathic scoliosis (AIS), as well as health care professionals' (HCPs) perceived barriers and facilitators towards their use. This study's objectives were: 1) to explore current practice of HCPs when assessing outcomes for AIS 2) to understand perceived barriers and facilitators of HCPs to use PROMs 3) to understand perceived barriers and facilitators of HCPs to use performance measures.

METHODS

A qualitative study recruited a purposive sample of HCPs from a tertiary hospital in the United Kingdom. Mean years of experience managing individuals with AIS was 11.8 years; and included surgeons, physiotherapists and nurses, educated at Bachelor, Masters and Doctoral level. Consent to participate and demographic information were collected in advance of the interviews. In-depth, virtual semi-structured interviews were informed by a topic guide based on current evidence. Interviews of approximately 45 minutes were audio and video recorded and transcribed verbatim alongside written field notes. Data were coded and analysed using inductive thematic analysis, involving researchers with topic and methodological expertise and input from a patient representative.

RESULTS

Two themes emerged regarding current practice of using PROMs routine practice and personal evaluations. Four themes emerged as barriers to using PROMs for individuals with AIS: priority and support (e.g., HCPs focus on providing care), practical challenges (e.g., inadequate PROMs), patient-related challenges (e.g., patient preferences) and knowledge, education, and perceived value. Two themes emerged as facilitators: quality existing measure (e.g., sufficient psychometric properties), and priority and support (e.g., research department/culture). Themes for barriers to use performance measures were practicality (e.g., need physical space) and perceived value and knowledge (e.g., PROMs are more important), while the one theme for facilitators was practical consideration (e.g., acceptability).

CONCLUSIONS

Although HCPs perceived the value of using outcome measures, current practice indicates limited use for individuals with AIS. The findings revealed different barriers and facilitators to implement PROMs in practice. Adopting performance measure are limited due to lack of knowledge and perceived value alongside the practicality, while considering practical factors can improve the use of these measures in practice.

The impact of spinal fusion of adolescent idiopathic scoliosis in Salah (Islamic Prayer) movement: a case-control study

BACKGROUND

Corrective spine surgery is widely accepted for treating severe adolescent idiopathic scoliosis (AIS). Postoperative spinal range of motion (ROM) could be affected after such surgery. In certain populations, such as Muslims, this ROM change can impact daily life, as it may affect the five-times-a-day prayer (Salah). This study aims to assess the influence of spinal fusion (SF) in Adolescent Idiopathic Scoliosis (AIS) during the daily Islamic prayer (Salah).

METHODS

SF-AIS patients were videoed while performing Salah prayer. The kinematic documentation was assessed and compared to Salah movements of a control group of age-matched Muslim AIS patients, who had not had surgery. The prayer quality changes were subjectively classified into improved, no change/remained, and worsened, according to the Global Perceived Effect (GPE). Functional outcome and pain were assessed by the Scoliosis Research Society Questionnaire Version 30 (SRS-30).

RESULTS

Thirty-nine women and five men (mean age±SD: 14.8±2.3 years) met the inclusion criteria, and unoperated AIS patients were used as control (twenty-two women, mean age±SD: 15.32±1.43 years). The prostrations ROM of the SF-AIS group differed significantly from the control group (p<0.05). The GPE of the prayer movement showed improvement in 36.4%, no change in 59.1%, and worsening in 4.5% of the SF-AIS patients. The worsened group had a significantly lower bowing ROM and higher prostrations ROM compared to all groups of prayer quality changes (p<0.05). SRS-30 scores showed good outcomes (function 4.0±0.2, pain 4.2±0.5), along with the overall bowing ROM and prostrations ROM (84.2±12.0° and 53.4±9.6°, respectively). Moreover, a significant moderate positive correlation between the bowing ROM and pain (r=0.417, p=0.007) was also found.

CONCLUSION

Spinal fusion positively affects AIS Islamic patients in maintaining their daily Salah movement, ROM and prayer quality. Prayer quality assessment should be given extra attention as an adjuvant of the SRS-30 questionnaire to evaluate Muslim patients.

Outcomes Evaluating Quality of Life and Their Measurement Properties in Early-onset Scoliosis: A Systematic Review

INTRODUCTION

Early-onset scoliosis (EOS) is a spinal deformity affecting children under the age of 10. Understanding the impact of EOS on quality of life can be achieved through appropriate patient/carer-reported outcome measures (PROMs). The aim of this systematic review was to identify, evaluate and summarize the evidence for the measurement properties of health-related quality of life (HR-QoL) outcome measures in the EOS population.

METHODS

A 2-stage search methodology was conducted across the PubMed, MEDLINE, EMBASE, EMCARE, PsychINFO, and CINAHL databases. Search 1 identified PROMs used to evaluate the quality of life in EOS, and search 2 identified studies of the measurement properties of these PROMs. Two reviewers performed searching, study screening and selection and assessed studies for risk of bias using the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. One reviewer performed data extraction. Evidence for each measurement property per PROM was summarized and evaluated using a modified GRADE approach.

RESULTS

Search 1 identified 19 (10 disease-specific, 9 generic) PROMs that have been used to assess HR-QoL or a relevant domain in the EOS population. Search 2 identified only one PROM (the 24-item Early-Onset Scoliosis Questionnaire, EOSQ) with eligible studies (n=4) evaluating measurement properties. There is low-quality evidence for sufficient content validity, very low-quality evidence for sufficient reliability and low-quality evidence for sufficient criterion validity, specifically regarding the pulmonary function domain) of the EOSQ. Construct validity and responsiveness were rated as indeterminate. There were no studies on measurement error.

CONCLUSIONS

Our search strategy found that measurement properties have only been evaluated for one PROM, the EOSQ. There is low-quality evidence for sufficient measurement properties for the EOSQ in patients under the age of 10 with EOS. Further research is needed to improve the quality of evidence for EOSQ measurement properties and investigate other PROMs in this population.

LEVEL OF EVIDENCE

Level II.

Evaluating measures of quality of life in adult scoliosis: a systematic review and narrative synthesis

PURPOSE

To systematically review and synthesise the evidence on the measurement properties of patient-reported outcome measure (PROMs) used to assess the quality of life in patients with adult scoliosis.

METHOD

Based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines and a published protocol, a two-stage search was conducted and reported in line with the Preferred Reporting Items for Systematic review and Meta-analysis (PRISMA). Stage one identified all studies of patients with adult scoliosis which included PROMs of health-related quality of life (HR-QOL). Databases including AMED, CINAHL, EMBASE, Medline, PsychINFO and Pubmed were searched from inception until 31st December 2020. This derived list of PROMs, was then utilised for a stage 2 search to identify studies which evaluated the measurement properties of the PROMs. Two reviewers independently performed the searches, study screening, selection and risk of bias assessment using the COSMIN tool. The overall quality of the evidence was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Stage one yielded 16 PROMs of HR-QOL with the Oswestry Disability Index (ODI) and Scoliosis Research Society-22 (SRS-22) the most used. Stage two identified three stage one PROMs that fulfilled eligibility criteria: SRS-22, ODI and SRS-22r; with five studies investigating measurement properties in an adult scoliosis population. The SRS-22 was the most comprehensively evaluated PROM in this cohort with very low-quality evidence indicating indeterminate reliability, sufficient construct validity and sufficient responsiveness of the SRS-22. There is very low-quality evidence indicating sufficient responsiveness of the ODI. There is very low-quality evidence indicating indeterminate cross-cultural validity for the SRS-22r. All other measurement properties in the SRS-22, ODI and SRS-22r have not been evaluated.

CONCLUSION

A large number of PROMs are being utilised in the adult scoliosis population and of these, the most commonly utilised are the ODI and SRS-22. The SRS-22, ODI and SRS-22r are the only PROMs to have had their measurement properties evaluated in the adult scoliosis population. The findings of this systematic review are that there currently is not sufficient evidence on the measurement properties of any PROMs in adult scoliosis. Further research is now urgently required to assess the measurement properties of these PROMs.

Is self-image, in reference to the gravitational vertical, altered in adolescent idiopathic scoliosis? A multicenter, single-blind, case-control study

PURPOSE

Adolescent idiopathic scoliosis (AIS) is associated with perturbation of orthostatic postural control. In humans, orthostatic postural control is organized around the gravitational vertical (GV). Perception of the GV involves a bottom-up process (central integration of multisensorial information) and a top-down process that uses cognitive mechanisms relying on body image. This study hypothesized that AIS would be associated with an erroneous central representation of verticality. The objective was to demonstrate an altered top-down process of sense of verticality in AIS.

METHODS

This multicenter, single-blind, case-control study evaluated 63 adolescent girls with AIS divided into two groups (major AIS (n = 31) and minor AIS (n = 32)) and 30 matched non-scoliotic adolescents. Participants scored their perception of trunk appearance in an upright position using a pictographic scale. The outcome measure was the difference between perception score and real trunk deformity.

RESULTS

Participants with major AIS presented with misperception of their trunk appearance in an upright position when compared with those with minor AIS or controls.

CONCLUSION

Adolescents with major AIS underestimate their trunk deformity in an upright position. This suggests an altered representation of body image, affecting top-down control of sense of verticality.

Evaluating measures of quality of life in adult scoliosis: a protocol for a systematic review and narrative synthesis

BACKGROUND

Adult scoliosis represents a distinct subgroup of scoliosis patients for whom the diagnosis can have a large impact on their health-related quality of life (HR-QOL). Therefore, HR-QOL patient-reported outcome measures (PROMs) are essential to assess disease progression and the impact of interventions. The objective of this systematic review is to evaluate the measurement properties of HR-QOL PROMs in adult scoliosis patients.

METHODS

We will conduct a literature search, from their inception onwards, of multiple electronic databases including AMED, CINAHL, EMBASE, Medline, PsychINFO and PubMed. The searches will be performed in two stages. For both stages of the search, participants will be aged 18 and over with a diagnosis of scoliosis. The primary outcome of interest in the stage one searches will be studies which use PROMs to investigate HR-QOL as defined by the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy, the secondary outcome will be to assess the frequency of use of the various PROMs. In stage two, the primary outcome of interest will be studies which assess the measurement properties of the HR-QOL PROMs identified in stage one. No specific measurement property will be given priority. No planned secondary outcomes have been identified but will be reported if discovered. In stage one, the only restriction on study design will be the exclusion of systematic reviews. In Stage two the only restriction on study design will be the exclusion of full-text articles not available in the English language. Two reviewers will independently screen all citations and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or risk of bias) will be appraised using the Consensus-based Standards for the selection of Health Measurement Instruments (COSMIN) checklist. The overall strength of the body of evidence will then be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A narrative synthesis will be provided with information presented in the main text and tables to summarise and explain the characteristics and findings of the included studies. The narrative synthesis will explore the evidence for currently used PROMs in adult scoliosis patients and any areas that require further study.

DISCUSSION

The review will help clinicians and researchers identify a HR-QOL PROM for use in patients with adult scoliosis. Findings from the review will be published and disseminated through a peer-reviewed journal and conference presentations.

SYSTEMATIC REVIEW REGISTRATION

This systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), reference number: CRD42020219437.

Outcomes evaluating quality of life and their measurement properties in early-onset scoliosis: protocol for a systematic review

INTRODUCTION

Early-onset scoliosis (EOS) is a rare spinal deformity affecting children under the age of 10. Both the condition and its treatment have associated morbidity and can impact quality of life. Understanding this impact can be achieved by using appropriate patient-reported and/or carer-reported outcome measures. The aim of the review described in this protocol is to evaluate the evidence on measurement properties relevant to health-related quality of life outcomes in the EOS population. The focus will be on outcome measures relevant to patients undergoing treatment of EOS under the age of 10.

METHODS/ANALYSIS

This protocol is reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology. The MEDLINE, EMBASE, EMCARE, PubMed, PsychINFO and CINAHL databases will be searched using a two-stage search strategy. The first stage will identify measures of HRQoL used in EOS through screening of titles and abstracts. The second stage will assess the measurement properties of those measures identified through screening of full-text articles. The measurement properties of interest are the 'reliability', 'validity' and 'responsiveness' of the instrument. Only English language articles will be considered. Two reviewers will independently review the search results against the eligibility criteria, perform data extraction and assess for risk of bias, with disputes handled by a third reviewer. Data will be quantitatively pooled where possible or reported as a narrative synthesis. The summarised results for each measurement property will be rated against the criteria for good measurement properties following the COSMIN methodology. Two reviewers will assess the body of evidence for each measurement property using modified Grading of Recommendations, Assessment, Development and Evaluation guidelines.

ETHICS AND DISSEMINATION

No ethical approval is required for this review and the results will be submitted for publication in peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42020219721.

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.

Discrimination Ability of Patient Reported Outcome Measurement Information System Pediatric Domains Compared With Scoliosis Research Society-22r and Legacy Patient Reported Outcome Measures in Juvenile and Adolescent Idiopathic Scoliosis

STUDY DESIGN

Comparative cohort study.

OBJECTIVE

To compare patient reported outcome measures (PROMs) in children and adolescents with varying extent of spinal deformity.

SUMMARY OF BACKGROUND DATA

Several PROMs have been proposed to help assess health-related quality-of-life (HRQoL) in pediatric spinal deformity surgery and research, but it is unclear which are sensitive to deformity severity.

METHODS

Pediatric patients diagnosed with spinal asymmetry or juvenile/adolescent idiopathic scoliosis completed the patient-reported outcomes management information system (PROMIS) pediatric computer adaptive test bank (Domains: Mobility, Pain Interference, Physical Activity, Physical Stress Experiences, Psychological Stress Experiences), Scoliosis Research Society-22r (SRS-22r), Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) activity scale, and Trunk Appearance Perception Scale. Patients were grouped as spinal asymmetry, mild deformity, and substantial deformity by major Cobb angle measuring less than 10°, between 10° and 40°, and greater than 40° respectively. One-way analysis of variance with a Tukey post-hoc correction was used to determine score differences between groups.

RESULTS

Final analyses included 206 patients, of which 135 (66%) were female. The mean age was 13.0 ± 2.2 years, and the mean major Cobb angle was 20.1 ± 14.1° (range: 0-74.2°). Compared with both spinal asymmetry and mild deformity patients, patients with substantial deformity reported worse outcomes, including lower function, more pain, and decreased psychological health by legacy PROMs and PROMIS. PROMIS Physical Activity and Psychological Stress Experiences did not capture any significant differences between all groups. There were no significant differences in outcomes between the spinal asymmetry and mild deformity groups for all PROMs measured.

CONCLUSION

Patients with substantial spinal deformity reported lower activity and function, more pain, and greater physical and psychological stress compared with patients without clinical spinal deformity by legacy PROMs and several PROMIS domains. As PROMIS Physical Activity and Psychological Stress Experiences did not capture these differences, these PROMs may measure different constructs than the legacy PROMs as they relate to spinal curvature and may be less relevant to measure HRQoL in this population.Level of Evidence 3.

Patient-reported Outcomes Following Surgical Intervention for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

This was a systematic review and meta-analysis.

OBJECTIVE

This study aims to perform a systematic review and quantitative meta-analysis of patient-reported outcome measures after spinal fusion for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Radiographic correction of scoliosis is extensively reported in the literature but there is a need to study the impact of spinal fusion on patient-reported outcome measures. Prior reviews lacked homogeneity in outcome measures, did not perform quantitative meta-analysis of pooled effect size, or interpret the results in light of minimally clinically important difference thresholds.

MATERIALS AND METHODS

A systematic review of medical databases identified all studies that prospectively reported Scoliosis Research Society (SRS)-22 questionnaire data after spinal fusion for AIS. We screened 2314 studies for eligibility. Studies were included that reported preoperative and postoperative data at 24- or >60-month follow-up. Studies were excluded that failed to report means and SDs which were needed to calculate Cohen d effect sizes and 95% confidence intervals in estimating the magnitude and precision of the effect.

RESULTS

A total of 7 studies met eligibility criteria for inclusion in quantitative meta-analysis of effect sizes and 95% confidence intervals. Patients report large improvements in total score, self-image, and satisfaction; and moderate improvements in pain, function and mental health at 2 and 5 years after spinal fusion for AIS. All domains showed statistically significant improvement at all times except function at >60 months. All domains surpassed the minimally clinically important difference at all times except mental health.

CONCLUSIONS

Moderate evidence suggests that spinal fusion improves quality of life for adolescents with idiopathic scoliosis in medium and long-term follow-up. Our results may help inform patient expectations regarding surgery.

OCEMB LEVEL OF EVIDENCE

Level I-systematic review and meta-analysis of prospective studies.

Adolescent Idiopathic Scoliosis Care in an Underserved Inner-City Population: Screening, Bracing, and Patient- and Parent-Reported Outcomes

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVES

This preliminary investigation sought to identify the quality of care adolescent idiopathic scoliosis (AIS) patients from our large, underserved community had received before presenting at this institution's clinic.

SUMMARY OF BACKGROUND DATA

AIS affects 1% to 4% of children between ages 10 and 16. Barriers to health care for patients in underserved populations have not been well studied.

METHODS

Patients who visited a single surgeon's clinic for primary AIS between June 2016 and January 2017 were enrolled. Patients had 36-inch full-spine radiographs and completed a survey of demographics, prior AIS care received (screening, bracing, etc), socioeconomic parameters, and patient-reported outcomes (PROs; Scoliosis Research Society [SRS]-30 Questionnaire and Body Image Disturbance Questionnaire [BIDQ]). Parametric and nonparametric analyses were used and percentages and mean/median values were reported.

RESULTS

47 patients (age: 15 ± 3 years; 82.7% female) were included. Overall, 25.5% of patients reported a family history of scoliosis, and 42.6% had no prior knowledge of scoliosis. Per Scoliosis Research Society (SRS) recommendations, 15 patients required observation (main Cobb angle: <25°), 22 patients were eligible for bracing (25°-45°), and 10 patients were surgical candidates (>45°). In addition, 21.3% of all patients were never screened for scoliosis; of these, 50% had a main scoliosis curve >25°. Seventy percent of surgical candidates never wore a brace, and 59.3% of screened patients who were eligible for bracing were not braced at initial presentation. Patients who were left unbraced when eligible exhibited worse BIDQ scores (1.7 vs. 1.4, p < .05).

CONCLUSIONS

One of five children in our population was never screened for scoliosis, and nearly three of five children did not receive optimal care as recommended by SRS. AIS patients in our inner-city populations are potentially at risk of continuing to experience a significant disadvantage in health care access.

LEVEL OF EVIDENCE

Level IV case series.

Rasterstereography versus radiography for assessing shoulder balance in idiopathic scoliosis: A validation study relative to patients' self-image

BACKGROUND

Shoulder imbalance is a problem for scoliosis patients. Rasterstereography uses radiation-free surface topography to follow up these patients. Its use for assessing shoulder level has not been investigated earlier.

OBJECTIVE

This study aimed to determine the accuracy of shoulder assessment using rasterstereography (versus radiography) and to analyze its relationship with patients' self-image.

METHODS

In a cross-sectional setting, the reliability and validity of five rasterstereographic shoulder variables were measured in comparison with six radiographic shoulder parameters, using correlation analysis. The patients' self-perception was documented using the Scoliosis Research Society-22 (SRS-22) questionnaire and Trunk Appearance Perception Scale (TAPS).

RESULTS

Forty patients were included in the study. The test-retest reliability of all rasterstereographic shoulder parameters was excellent (ICC > 0.95). The validity was moderate in comparison with six radiographic parameters (highest coefficient: 0.582). The radiographic and rasterstereographic shoulder levels correlated with the results in the SRS-22 questionnaire (highest coefficient: -0.463) and TAPS (highest coefficient: 0.413).

CONCLUSIONS

Rasterstereography is a reliable and valid method for assessing shoulder level in idiopathic scoliosis. The parameters can be recommended as a complement to radiography and clinical evaluation for follow-up purposes. Radiographic and rasterstereographic shoulder parameters are significantly related to patients' self-perception. Shoulder variables thus need to be considered in scoliosis patients.

Reliability and validity of the Spinal Appearance Questionnaire (SAQ) and the Trunk Appearance Perception Scale (TAPS)

Background

The Spinal Appearance Questionnaire (SAQ) and the Trunk Appearance Perception Scale (TAPS) are questionnaires that mostly rely on drawings to assess scoliosis patients’ subjective viewpoints on their trunk deformity. Our aim was to perform an in-depth assessment of the psychometric quality of both measures, the SAQ (version 1.1) and TAPS, and compare them to provide practical recommendations.

Methods

Web-based survey study with 255 patients suffering from idiopathic scoliosis (age 30.0 ± 16.7 years, Cobb angle 43.5 ± 20.9°) and 189 matched healthy control individuals. Participants answered a broad set of validated questionnaires including SRS 22-r, PHQ-9, PANAS, FKS, WHO-5, BFI-S, and PTQ. We calculated reliability (Cronbach’s α, test–retest correlations) as well as factorial, convergent, divergent, concurrent, and discriminant validity.

Results

Reliability was high (Cronbach’s α ≥ .86; test–retest r ≥ .80), except for test–retest correlation of the SAQ Expectations scale (r = 0.67). Both the SAQ and TAPS measures showed clear factor solutions, indicating factorial validity. High correlations with theoretically related measures (e.g., SRS 22-r, overall stress, Cobb angle) indicated convergent validity. Moderate correlations occurred with concurrent criteria such as mood, depression, body dysmorphic disorder, and well-being. The matched-pair analysis revealed strong evidence for discriminant validity (Cohen’s d > 2 for SAQ total score and TAPS). Subgroup analyses showed that patients with more severe Cobb angles (≥ 40°) and those ≥ 46 years of age had significantly worse SAQ and TAPS scores.

Conclusion

We recommend using the TAPS for future clinical workups and research, as it is much shorter and revealed slightly higher psychometric quality in comparison to the SAQ.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0980-1) contains supplementary material, which is available to authorized users.

The Turkish version of the Brace Questionnaire in brace-treated adolescents with idiopathic scoliosis

BACKGROUND

Evaluation of the effects of brace treatment on quality of life in adolescent idiopathic scoliosis is important.

OBJECTIVES

To analyze the validity and reliability of the Turkish version of the Brace Questionnaire.

STUDY DESIGN

Cohort study, evaluation of reliability and validity of the Turkish version of the Brace Questionnaire.

METHODS

Twenty-eight patients undergoing brace treatment for adolescent idiopathic scoliosis (median age: 14.6 years) were included in the study. The Brace Questionnaire was translated into Turkish and administered to the patients twice at an interval of 5 days. Reliability was assessed using the test-retest method (Pearson's correlation coefficient); internal consistency was analyzed using Cronbach's alpha. Validity was assessed by correlating the Brace Questionnaire with the Bad Sobernheim Stress Questionnaire-Brace and Scoliosis Research Society-22 questionnaire.

RESULTS

The mean Cobb angles were 31.1° ± 8.3° and 29.7° ± 9° for thoracic and lumbar regions, respectively. Cronbach's alpha was 0.94. Intraclass correlation coefficient was 0.95 in test-retest reliability analysis. The correlations between Brace Questionnaire and Bad Sobernheim Stress Questionnaire-Brace and Scoliosis Research Society-22 were r = 0.67 and r = 0.64, respectively.

CONCLUSION

The Turkish version of the Brace Questionnaire to measure the effects of brace treatment on quality of life in adolescent idiopathic scoliosis was found to have good validity, excellent reliability, and high internal consistency. Clinical relevance We recommend routine use of the Brace Questionnaire in scoliosis patients to evaluate brace-related quality of life and relevant factors and to support the individual when necessary during such treatment.

Persian adaptation of Quality of Life Profile for Spinal Deformities questionnaire

BACKGROUND

The Quality of Life Profile for Spinal Deformities (QLPSD) is the first specific questionnaire to evaluate health-related quality-of-life (HRQoL) in adolescents with spinal deformities. Measuring HRQoL is important because spinal deformities and their management may negatively affect quality of life (QoL), thereby importantly affecting treatment effectiveness.

OBJECTIVE

This study aimed to examine the validity and reliability of a Persian version of the QLPSD through patients with adolescent idiopathic scoliosis and Scheuermann's kyphosis.

METHODS

A cross-sectional design was used to determine the validity and reliability of the Persian version of the QLPSD based on the IQOLA protocols.

RESULTS

The QLPSD was successfully culturally adapted, showing acceptable internal consistency (cronbach's α= 0.88) and intraclass correlation coefficients (ICC = 0.91). Concurrent validity was supported by comparing scores on corresponding dimensions of the Persian versions of QLPSD and the Scoliosis Research Society-22r (SRS-22r) questionnaires (function, pain, and body-image). Discriminant validity was supported though observation of significant differences between participants who had different clinical characteristics (p< 0.05).

CONCLUSIONS

The Persian QLPSD is valid and reliably measures QoL among adolescents with spinal deformities; it may be used in clinical evaluations and future research.

Health-Related Quality of Life in Early-Onset Scoliosis Patients Treated Surgically: EOSQ Scores in Traditional Growing Rod Versus Magnetically Controlled Growing Rods

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To compare quality of life and caregiver burden in traditional growing rod (TGR) and magnetic controlled growing rods (MCGR) patients.

SUMMARY OF BACKGROUND DATA

MCGR decrease surgical sessions associated with treatment of early onset scoliosis (EOS), hoping to minimize the burdens seen with repetitive invasive surgeries in TGR treatment. Although the clinical indications for these treatments have largely been agreed upon, there is a lack of understanding of their impact on patients' and families' quality of life.

METHODS

Inclusion criteria: ≤10 years of age at index procedure, major curve ≥30°, no previous spine surgery, minimum 1-year postoperative follow-up. The previously validated 24-item early onset scoliosis questionnaire (EOSQ-24) was utilized to assess quality of life. Statistic methods were applied to compare domain scores between TGR and MCGR patients.

RESULTS

Forty-four children with EOS were enrolled; 25 TGR and 19 MCGR. Groups were similar in sex and age at index surgery. Age at time of questionnaire and mean length of follow-up were significantly different; patients were older (14.0 vs. 8.8 yr) and had longer follow-up (101.3 vs. 34.3 mo) in TGR (P < 0.01). Deformity correction and complication rates were similar between groups. At the time of questionnaire, scores of economic burden and overall satisfaction in MCGR were significantly superior to those in TGR by univariate analysis. When controlled for duration of follow-up, some domain scores trended towards statistical significance, some remained stable, and others regressed to non-significance.

CONCLUSION

Health related quality of life data reveal superior outcomes in overall satisfaction and financial burden domains in the MCGR group. However, the positive effects of MCGR decrease when controlled for length of follow up, indicating that the MCGR is not yet a magic fix-all, and that the TGR remains an option in the treatment of EOS.

LEVEL OF EVIDENCE

3.

Do the SRS-22 self-image and mental health domain scores reflect the degree of asymmetry of the back in adolescent idiopathic scoliosis?

Background

Patient-reported outcomes are becoming increasingly recognised in the management of patients with adolescent idiopathic scoliosis (AIS). Integrated Shape Imaging System 2 (ISIS2) surface topography is a validated tool to assess AIS. Previous studies have failed to demonstrate strong correlations between AIS and patient-reported outcomes highlighting the need for additional objective surface parameters to define the deformities associated with AIS. The aim of this study was to examine whether the Scoliosis Research Society-22 (SRS-22) outcome questionnaire reflects the degree of measurable external asymmetry of the back in AIS and thus is a measure of patient outcome for external appearance.

Methods

A total of 102 pre-operative AIS patients were identified retrospectively. Objective parameters were measured using ISIS2 surface topography. The associations between these parameters and the self-image and mental health domains of the SRS-22 questionnaire were investigated using correlation coefficients.

Results

All correlations between the parameters of asymmetry and SRS-22 self-image score were of weak strength. Similarly, all correlations between the parameters of asymmetry and SRS-22 mental health score were of weak strength.

Conclusion

The SRS-22 mental health and self-image domains correlate poorly with external measures of deformity. This demonstrates that the assessment of mental health and self-image by the SRS-22 has little to do with external torso shape. Whilst the SRS-22 assesses the patient as a whole, it provides little information about objective measures of deformity over which a surgeon has control.

German validation of the quality of life profile for spinal disorders (QLPSD)

BACKGROUND

The Quality of Life Profile for Spine Deformities (QLPSD) is a self-reporting questionnaire designed for studying patients with spinal deformities.

PURPOSE

The aim of the present study was to systematically translate the QLPSD into German (G-QLPSD) and to test its reliability and validity. Special emphasis was intended to be given to patients with different Cobb angles and ages.

METHODS

The QLPSD was systematically translated into German and was responded to in a web-based online survey by patients with idiopathic scoliosis and by healthy control individuals to carry out a matched-pair analysis. Participants aged 14 years and older were included. All participants answered a battery of validated questionnaires (SRS 22-r, PHQ-9, PANAS, FKS, WHO-5, BFI-S, PTQ). Reliability testing included Cronbach's alpha and test-retest reliability (retest 8 weeks after initial testing). Factorial, convergent, divergent, concurrent, and discriminant validity were calculated.

RESULTS

A total of 255 scoliosis patients (age 30.0 ± 16.7 years, Cobb angle 43.5° ± 20.9°) and 189 matched healthy control individuals were finally included. Cronbach's alpha for the G-QLPSD total score was 0.93 and the test-retest reliability was 0.84. The G-QLPSD total score correlated with the SRS 22-r total score (r = -0.86). All concurrently applied scores showed strong correlations with the G-QLPSD (e.g., depression score PHQ-9: r = 0.70). The matched-pair analysis of 189 pairs showed strong discriminant validity (Cohen's d = 0.78). Patients with more severe Cobb angles (≥40°) and those ≥18 years of age had significantly poorer results than patients with minor curves and younger patients.

CONCLUSION

The G-QLPSD proved to be a highly reliable and valid instrument that can be recommended for clinical use in scoliosis patients.

An observational study on surgically treated adult idiopathic scoliosis patients' quality of life outcomes at 1- and 2-year follow-ups and comparison to controls

Background

Prospective data on health-related quality of life in patients with idiopathic scoliosis treated surgically as adults is needed. We compared preoperative and 1- and 2-year follow-up data in surgically treated adults with idiopathic scoliosis with juvenile or adolescent onset. Results were compared to untreated adults with scoliosis and population normative data.

Methods

A comparison of preoperative and 1- and 2-year follow-up data of 75 adults surgically treated for idiopathic scoliosis at a mean age of 28 years (range 18 to 69) from a prospective national register study, as well as a comparison with age- and sex-matched data from 75 untreated adults with less severe scoliosis and 75 adults without scoliosis, was made. Outcome measures were EuroQol-5 dimensions (EQ-5D) and Scoliosis Research Society (SRS)-22r questionnaire.

Results

In the surgically treated, EQ-5D and SRS-22r scores had statistically significant improvements at both 1- and 2-year follow-ups (all p  < 0.015). The effect size of surgery on EQ-5D at 1-year follow-up was large (r = −0.54) and small-medium (r = −0.20) at 2-year follow-up. The effect size of surgery on SRS-22r outcomes was medium-large at 1- and 2-year follow-ups (r = −0.43 and r = −0.42 respectively). At the 2-year follow-up, the EQ-5D score and the SRS-22r subscore were similar to the untreated scoliosis group (p = 0.56 and p = 0.91 respectively), but lower than those in the adults without scoliosis (p < 0.001 for both comparisons).

Conclusions

Adults with idiopathic scoliosis experience an increase in health-related quality of life following surgery at 2-year follow-up, approaching the health-related quality of life of untreated individuals with less severe scoliosis, but remain lower than normative population data.

Trends in the use of patient-reported outcome instruments in neurosurgical adult thoracolumbar deformity and degenerative disease literature

Objective:

Shifting national healthcare trends place increased emphasis on patient-centered care and value-based outcomes, and thus, patient-reported outcome instruments (PROIs) are often used. We sought to characterize the trends in PROI use over the past decade with regard to thoracolumbar degenerative spine disease and spinal deformity in major neurosurgical journals.

Methods:

Articles were screened for PROI use through a PubMed search among five major neurosurgical journals from 2006 to 2016. Articles focusing on adult thoracolumbar deformity and degenerative disease were selected with stringent criteria to further characterize PROI use.

Results:

A total of 29 different PROIs were used among 102 articles identified from 2006 to 2016 using our search strategy. Journal of Neurosurgery: Spine contained the most articles utilizing PROIs with 35.3% of all articles meeting search criteria. The most frequently used PROIs were Oswestry Disability Index, visual analog scale, and the European Quality of Life Five-dimension questionnaire used in 79.4%, 59.8%, and 29.4% of articles, respectively. Linear regression identified a significant increase in the number of articles employing PROIs from 2006 to 2016 (Y = 1.85, R²= 0.77, P < 0.01). The total number of PROIs per article was relatively stagnant over time and did not significantly change (Y = 0.03, R²= 0.05, P = 0.51).

Conclusions:

PROI use as an outcome tool in the adult thoracolumbar disease literature has increased during the past decade, which may be an indicative of PROI use to define patient expectations. This may also represent a trend toward PROI use as a surrogate measure of value-based care.

Patient-Reported Outcome Instruments in Spine Surgery

STUDY DESIGN

A critical review of the current literature.

OBJECTIVE

The purpose of this study was to determine frequency, trends, and methods of utilization of spine-related PROIs over the last 10 years.

SUMMARY OF BACKGROUND DATA

Patient-reported outcome instruments (PROIs) have become the gold standard to assess the efficacy of various medical and surgical treatments. Currently, however, there is an expansive range of PROIs without a clear consensus or guideline addressing which PROIs should be used for a particular diagnosis or surgical intervention.

METHODS

A PubMed search was conducted from 2004 to 2013 of 5 orthopedic journals (The Journal of Bone and Joint Surgery, The Bone and Joint Journal, The Spine Journal, The European Spine Journal, and Spine) that publish spine articles, chosen on the basis of readership and impact factor. Journal abstracts were inspected for spine surgery and inclusion of at least 1 PROI. All articles containing PROIs and investigating a surgical intervention with a level of evidence (LOE) 1 to 4 were included for analysis. Article title, LOE, journal, and chosen PROI were recorded for selected articles.

RESULTS

Out of 19,736 articles published in our selected time frame, 1,079 utilized PROIs. Most studies were LOE 4 (32.7%). Nearly half (48.9%) of all articles addressed degenerative thoracolumbar conditions. In total, there were 206 unique PROIs in the studies chosen for inclusion. The top 6 instruments utilized were the (1) visual analog scale, (2) Oswestry disability index, (3) Short Form-36, (4) Japanese Orthopaedic Association Outcome Questionnaire, (5) Neck Disability Index, and (6) Scoliosis Research Society-22.

CONCLUSION

The breadth of PROIs in spine surgery is extensive. Although there are preferred patient-reported outcome measures, a consensus or guideline addressing which instruments should be used for a particular diagnosis or procedure may be warranted.

LEVEL OF EVIDENCE

4.

Patient-Reported Outcome Instruments in Pediatric Deformity Surgery: A Bibliometric Analysis

STUDY DESIGN

Bibliometric analysis.

OBJECTIVES

To identify patient-reported outcomes instruments (PROIs) used in pediatric deformity surgery research over the past decade and their frequency and usage trends.

SUMMARY OF BACKGROUND DATA

The emphasis on PROIs is increasing along with the demand for evidence-based medicine and cost-effectiveness research. Therefore, investigators and PROI consensus writers should be aware of the PROIs used in pediatric deformity and usage trends.

METHODS

Five top orthopedics journals were reviewed from 2004 to 2013 for clinical studies of surgical intervention in pediatric deformity that report PROIs. Publication year, level of evidence (LOE), and PROIs were reported for each article. Mean and range scores for the most frequently used PROIs were analyzed at 2-year follow-up.

RESULTS

A total of 79 studies using PROIs were published in the pediatric deformity literature over the period studied. The researchers identified 21 named PROIs and 6 additional custom questionnaires. The Scoliosis Research Society (SRS)-22 was the most frequently used instrument (32.9%), followed by the SRS-24 (29.1%), Oswestry disability index (17.7%), visual analog scale (12.7%), SRS-30 (10.1%), and Short Form-36 (6.3%). Level of evidence III was most common (39.2%) and 1 LOE I study was identified. Mean preoperative and postoperative SRS instrument scores were 4.0 (95% confidence interval, 3.8-4.1) and 4.5 (95% confidence interval, 4.4-4.6), respectively, in SRS-22r equivalents. No studies met the criteria for mean and range calculation for the other top instruments.

CONCLUSIONS

Scoliosis Research Society instruments are used in 74.7% of pediatric deformity studies reporting PROIs. Therefore, there is a consensus that SRS instruments should be used in pediatric deformity outcome studies; yet, consistent use of the most up-to-date version, the SRS-22r, is still needed. General health questionnaires are currently underused in pediatric deformity research. Version reporting and use of the latest versions of PROIs need to be improved in future studies.

Does scoliosis-specific exercise treatment in adolescence alter adult quality of life?

OBJECTIVE

Health-related quality of life in adults, who in adolescence participated in a scoliosis-specific exercise program, was not previously studied. Design. Cross-sectional study, with retrospective data collection.

MATERIAL AND METHODS

Homogenous groups of 68 persons (43 women) aged 30.10 (25-39) years, with mild or moderate scoliosis, and 76 (38 women) able-bodied persons, aged 30.11 (24-38) years, who 16.5 (12-26) years earlier had completed scoliosis-specific exercise or observation regimes, participated. Their respiratory characteristics did not differ from predicted values. The WHOQOL-BREF questionnaire, Oswestry Disability Questionnaire, and pain scale (VAS) were applied.

RESULTS

The transformed WHOQOL-BREF scores ranged from 54.6 ± 11.19 in the physical domain in the mild scoliotic subgroup to 77.1 ± 16.05 in the social domain in the able-bodied subgroup. The ODQ values did not generally exceed 5.3 ± 7.53. Inter- and intragroup differences were nonsignificant. Age, marital status, education, and gender were significantly associated with the ODQ scores. Significant association between the ODQ and WHOQOL-BREF social relationships domain scores with the participation in exercise treatment was found.

CONCLUSIONS

Participants with the history of exercise treatment generally did not differ significantly from their peers who were only under observation. This study cannot conclude that scoliosis-specific exercise treatment in adolescence alters quality of life in adulthood.

Six-year follow-up study on the effect of combined anterior and posterior spinal fusion on lung function and quality of life in young people with adolescent idiopathic scoliosis

OBJECTIVES

The effects of spinal surgery on lung function and quality of life (QoL) are important patient outcomes. Long-term follow-up of lung function and QoL in those undergoing combined anterior and posterior spinal fusion (A/PSF) for adolescent idiopathic scoliosis (AIS) is poorly documented with only one study extending beyond 2 years, though available evidence points to a decrement in lung function. Our study evaluated long-term change in lung function and QoL following A/PSF for AIS.

DESIGN

Prospective cohort study.

PATIENTS

Patients with AIS.

SETTING

Tertiary paediatric respiratory centre and national spinal service.

DESIGN

Spirometry was performed along with QoL (Scoliosis Research Society-22 (SRS-22) questionnaire). Paired t test and one-way analysis of variance were used to compare pre-A/PSF and post-A/PSF data.

RESULTS

Data were available for 12 patients (9 female) who underwent A/PSF at mean 13.8 (range 11.8-15) years. Mean follow-up was undertaken 5.8 (range 4.1-6.8) years postoperatively. Height increased from mean (SD) 169 (9) cm preoperatively to 175 (5) cm at follow-up (p<0.01). Scoliosis corrected from 100 (15)° to 29 (11)° (p<0.001). Mean (SD) forced expiratory volume in 1 s was -3.4 (1.4) z scores preoperatively versus -3.3 (1) z scores postoperatively (p=0.85); and forced vital capacity was -3.4 (1.7) ) z scores pre-A/PSF and -3.4 (1.1) z scores post-A/PSF (p=0.83). SRS-22 scores improved mean (SD) of 3.6 (0.3) preoperatively to 4.2 (0.3) at 2 years postoperatively, and 4.4 (0.4) at 6 year follow-up (p<0.001, analysis of variance). High patient satisfaction rates (4.8 (0.3)) were recorded. No correlation was noted between changes in forced expiratory volume in 1 s (r=-0.15, p=0.63) or forced vital capacity (r=-0.12, p=0.71) and change in long-term SRS-22 score.

CONCLUSIONS

Long-term follow-up of patients with AIS suggests no deficit in pulmonary function, while QoL shows incremental improvement and patient satisfaction is high over 6 years after A/PSF.