Psychological evaluations of patients operated for idiopathic scoliosis by the Harrington method

Shoulder and Neck Balance in Adolescent Idiopathic Scoliosis: Which Radiographic Indices are Reliable and Practical?

Introduction

Deformities of the spine and thorax in adolescent idiopathic scoliosis affect appearance. They are a cause of inferiority, affecting psychological well-being and the social life of the patients. To contribute to curve evaluation, planning in curve correction, and improving the post-operative aesthetics, many studies on the correlation between appearance and radiography in the assessment of shoulder and neck balance have been reported recently. In general, these studies did not clarify which indices are required to evaluate shoulder and neck balance. This study aimed to learn about indices to assess shoulder and neck balance in adolescent idiopathic scoliosis in correlation between clinical appearance and radiography.

Materials and methods

This observational study recruited 50 patients with adolescent idiopathic scoliosis who were 12 to 18 years of age with Cobb angle >10°. Based on Pearson correlation coefficient, radiographic parameters such as coracoid height difference (CHD), clavicle rib intersection distance (CRID), clavicle angle (CA), clavicle chest cage angle difference (CCAD), and T1 tilt angle were evaluated in correlation with clinical shoulder and neck balance by difference of inner shoulder height (SHi), difference of outer shoulder height (SHo), and neck tilt angle.

Results

SHi was moderately correlated with T1 tilt angle (r [hereafter] = 0.45), CA (0.47), and CHD (0.57), high-moderately correlated with CRID (0.64), very-highly correlated with CCAD (0.84). SHo was moderately correlated with T1 tilt angle (0.43), highly correlated with CHD (0.60), CA (0.63), and CRID (0.72), and very-highly correlated with CCAD (0.89). T1 tilt angle was high-moderately correlated with neck tilt angle (0.76). The correlation coefficients between clinical and radiographic shoulder and neck balance according to sex, BMI, type of main curve, severity of main curve did not change significantly.

Conclusion

There was a very high correlation between SHo (shoulder tilt) and CCAD (0.89); the correlation between SHo and CRID was high-moderate (0.72), but CRID is easier than CCAD to evaluate on radiographs. On the other hand, T1 tilt angle, which is the easiest radiographic parameter to evaluate, had a high-moderate correlation with neck tilt angle (0.76) but a moderate correlation with SHo (0.43).

Long-Term Effects on Sexual Function in Women Treated With Scoliosis Correction for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective cohort study with a cross-sectional comparison.

OBJECTIVES

To assess sexual function and experience in adult women who had scoliotic correction for adolescent idiopathic scoliosis (AIS).

METHODS

Women ages 18-40 years with a history of scoliosis, who were braced or underwent uncomplicated posterior scoliosis correction for AIS, followed for two years or more since treatment were included. Sexual function was assessed using the Female Sexual Distress Scale-Revised (FSDS-R) and the Female Sexual Function Index (FSFI) questionnaires. Participants' scores were compared to those of a control group consisting of age-matched healthy women.

RESULTS

Of 115 women who responded to the questionnaires, 40 (35%) had surgical treatment (mean age 25.1; range 19-35 years; mean time since surgery 8.2 years; range 3-12 years) and 35 (30%) were braced (mean age 23.3; range 18-27 years; mean time since treatment 3.6 years; range 3-5 years). The control group consisted of a cohort of 40 (35%) aged-matched healthy women. According to the FSDS-R, significantly more women with scoliotic correction for AIS reported sexual distress compared to healthy controls (25% vs 12%, respectively), and the difference in the total mean scores (7.05 vs 5.34, respectively), was significant (P < .001). Additionally, the mean overall FSFI score for scoliotic-corrected women was 24.2 (range 17.5-29.1) within the pathological range (<26.55) of sexual dysfunction.

CONCLUSIONS

High rates of sexual distress and dysfunction were reported in women with a history of AIS, thus, there appears to be long-term consequences years after deformity correction by brace or surgical correction.

Does anterior shoulder balance in adolescent idiopathic scoliosis correlate with posterior shoulder balance clinically and radiographically?

PURPOSE

Patients with adolescent idiopathic scoliosis (AIS) often present with a disfiguring shoulder imbalance. Shoulder balance (Sh.B) is of significant importance to the patient's self-perception. Previous studies have correlated Sh.B with respect to only the clinical posterior view correlated with radiographs. It is important, however, to address Sh.B with respect to anterior view of the patients' shoulders as if patients were viewing in a mirror. In this study, we evaluated the anterior Sh.B and correlated it with posterior Sh.B clinically and radiographically in Lenke type 1 and 2 curves.

METHOD

An online scoliosis database was queried to identify 74 AIS patients with Lenke 1 (n = 55, age 15.28 ± 3.35) and 2 (n = 19, age 15.66 ± 3.72) curves with a complete set of PA radiographs and anterior and posterior photos. Radiographic measures for Sh.B included Cobb angles, T1 tilt, first rib angle, and clavicle-rib intersection angle. Clinical measures for Sh.B included inner shoulder angle, outer shoulder angle, and axillary fold angle. Regression analysis with Pearson's correlation and ANOVA for statistical significance was used for analysis.

RESULTS

For Lenke 1 curves, there was moderate statistically significant correlation between anterior and posterior clinical Sh.B (R = 0.35-0.41). There was only weak to moderate correlation between radiographic and clinical measures. For Lenke 2 curves, there was a weak to moderate correlation between anterior and posterior clinical Sh.B (R = 0.25-0.45), though not statistically significant. There was no statistically significant correlation between any radiographic measures and posterior Sh.B. There was, however, moderate and significant correlation between radiographic measures and anterior Sh.B.

CONCLUSION

There is no strong correlation between anterior and posterior clinical Sh.B, and surgeons should evaluate both sides in planning deformity correction, especially in Lenke 2 curves. None of the radiographic measures showed strong correlation (R > 0.8) with anterior or posterior clinical Sh.B. A stronger correlation existed between radiographic measures and anterior Sh.B measurements compared with posterior clinical Sh.B measurements in Lenke 2 curves further necessitating anterior evaluation in this group.

Right adolescent idiopathic thoracic curve (Lenke 1 A and B): does cost of instrumentation and implant density improve radiographic and cosmetic parameters?

In adolescent idiopathic scoliosis (AIS) there has been a shift towards increasing the number of implants and pedicle screws, which has not been proven to improve cosmetic correction. To evaluate if increasing cost of instrumentation correlates with cosmetic correction using clinical photographs. 58 Lenke 1A and B cases from a multicenter AIS database with at least 3 months follow-up of clinical photographs were used for analysis. Cosmetic parameters on PA and forward bending photographs included angular measurements of trunk shift, shoulder balance, rib hump, and ratio measurements of waist line asymmetry. Pre-op and follow-up X-rays were measured for coronal and sagittal deformity parameters. Cost density was calculated by dividing the total cost of instrumentation by the number of vertebrae being fused. Linear regression and spearman's correlation were used to correlate cost density to X-ray and photo outcomes. Three independent observers verified radiographic and cosmetic parameters for inter/interobserver variability analysis. Average pre-op Cobb angle and instrumented correction were 54° (SD 12.5) and 59% (SD 25) respectively. The average number of vertebrae fused was 10 (SD 1.9). The total cost of spinal instrumentation ranged from $6,769 to $21,274 (Mean $12,662, SD $3,858). There was a weak positive and statistically significant correlation between Cobb angle correction and cost density (r = 0.33, p = 0.01), and no correlation between Cobb angle correction of the uninstrumented lumbar spine and cost density (r = 0.15, p = 0.26). There was no significant correlation between all sagittal X-ray measurements or any of the photo parameters and cost density. There was good to excellent inter/intraobserver variability of all photographic parameters based on the intraclass correlation coefficient (ICC 0.74-0.98). Our method used to measure cosmesis had good to excellent inter/intraobserver variability, and may be an effective tool to objectively assess cosmesis from photographs. Since increasing cost density only improves mildly the Cobb angle correction of the main thoracic curve and not the correction of the uninstrumented spine or any of the cosmetic parameters, one should consider the cost of increasing implant density in Lenke 1A and B curves. In the area of rationalization of health care expenses, this study demonstrates that increasing the number of implants does not improve any relevant cosmetic or radiographic outcomes.

The impact of patient self assessment of deformity on HRQL in adults with scoliosis

Background

Body image and HRQL are significant issues for patients with scoliosis due to cosmetic deformity, physical and psychological symptoms, and treatment factors. A selective review of scoliosis literature revealed that self report measures of body image and HRQL share unreliable correlations with radiographic measures and clinician recommendations for surgery. However, current body image and HRQL measures do not indicate which aspects of scoliosis deformity are the most distressing for patients. The WRVAS is an instrument designed to evaluate patient self assessment of deformity, and may show some promise in identifying aspects of deformity most troubling to patients. Previous research on adolescents with scoliosis supports the use of the WRVAS as a clinical tool, as the instrument shares strong correlations with radiographic measures and quality of life instruments. There has been limited use of this instrument on adult populations.

Methods

The WRVAS and the SF-36v2, a HRQL measure, were administered to 71 adults with scoliosis, along with a form to report age and gender. Preliminary validation analyses were performed on the WRVAS (floor and ceiling effects, internal consistency and collinearity, correlations with the SF-36v2, and multiple regression with the WRVAS total score as the predictor, and SF-36v2 scores as outcomes).

Results

The psychometric properties of the WRVAS were acceptable. Older participants perceived their deformities as more severe than younger participants. More severe deformities were associated with lower scores on the Physical Component Summary Score of the SF-36v2. Total WRVAS score also predicted Physical Component Summary scores.

Conclusion

The results of the current study indicate that the WRVAS is a reliable tool to use with adult patients, and that patient self assessment of deformity shared a relationship with physical rather than psychological aspects of HRQL. The current and previous studies concur that revision of the WRVAS is necessary to more accurately represent the diversity of scoliosis deformities. Ability to identify disturbing aspects of deformity could potentially be improved by evaluating each WRVAS items against indicators of pain, physical/psychosocial function, and self image from previous measures such as the SRS, SF-36 or BSSQ-deformity.

Impact of spine surgery on signs and symptoms of spinal deformity

Paediatric scoliosis is associated with signs and symptoms including reduced pulmonary function, increased pain and impaired quality of life, all of which worsen during adulthood, even when the curvature remains stable. Spinal fusion has been used as a treatment for nearly 100 years. In 1941, the American Orthopedic Association reported that for 70% of patients treated surgically, outcome was fair or poor: an average 65% curvature correction was reduced to 27% at >2 year follow-up and the torso deformity was unchanged or worse. Outcome was worse in children treated surgically before age 10, despite earlier intervention. Today, a reduced magnitude of curvature obtained by spinal fusion in adolescence can be maintained for decades. However, successful surgery still does not eliminate spinal curvature and it introduces irreversible complications whose long-term impact is poorly understood. For most patients there is little or no improvement in pulmonary function. Some report improved pain after surgery, some report no improvement and some report increased pain. The rib deformity is eliminated only by rib resection which can dramatically reduce respiratory function even in healthy adolescents. Outcome for pulmonary function and deformity is worse in patients treated surgically before the age of 10 years, despite earlier intervention. Research to develop effective non-surgical methods to prevent progression of mild, reversible spinal curvatures into complex, irreversible structural deformities, is long overdue.

A review of quality of life and psychosocial issues in scoliosis

STUDY DESIGN

Recent literature regarding the psychological impact of scoliosis was reviewed.

OBJECTIVE

To determine the impact of scoliosis on health-related quality of life (HRQL), psychosocial functioning, and body image to improve patient outcomes.

SUMMARY OF BACKGROUND DATA

Adolescents and adults with adolescent idiopathic scoliosis have been known to score lower than healthy controls on HRQL measures. However, HRQL instruments may not adequately capture psychological distress experienced by patients.

METHODS

Research papers concerning HRQL and psychosocial factors in patients with scoliosis were reviewed.

RESULTS

Studies of psychosocial health and body image have revealed that functioning in these domains may affect compliance behavior and satisfaction with treatment outcomes among adolescent patients. Psychosocial and body image disturbance is less marked in patients with good social or family functioning, or patients who exercise regularly or are psychologically healthy. Adults with scoliosis generally display fewer psychological problems than adolescents. However, adults with scoliosis may experience psychosocial limitations due to poor physical health or body image disturbance. Support group membership can improve psychosocial health in adults with scoliosis.

CONCLUSIONS

Adolescent patients with scoliosis may experience psychosocial difficulties, especially while undergoing treatment for scoliosis. Interventions aimed at managing psychosocial or body image disturbances may help to ameliorate the potentially negative impact of scoliosis on these facets of life.

Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper

Background

Medicine is a scientific art: once science is not clear, choices are made according to individual and collective beliefs that should be better understood. This is particularly true in a field like adolescent idiopathic scoliosis, where currently does not exist definitive scientific evidence on the efficacy either of conservative or of surgical treatments.

Aim of the study

To verify the philosophical choices on the final outcome of a group of people believing and engaged in a conservative treatment of idiopathic scoliosis.

Methods

We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and a careful Consensus reaching procedure between experts in the conservative treatment of scoliosis (SOSORT members).

Results

The Consensus reaching procedure has shown to be useful: answers changed in a statistically significant way, and 9 new outcome criteria were included. The most important final outcomes were considered Aesthetics (100%), Quality of life and Disability (more than 90%), while more than 80% of preferences went to Back Pain, Psychological well-being, Progression in adulthood, Breathing function, Scoliosis Cobb degrees (radiographic lateral flexion), Needs of further treatments in adulthood.

Discussion

In the literature prevail outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems (even if it seems that usual clinical and radiographic methods are given much more importance than more complex Disability or Quality of Life instruments). SOSORT members give importance to a wide range of outcome criteria, in which clinical and radiographic issues have the lowest importance.

Conclusion

We treat our patients for what they need for their future (Breathing function, Needs of further treatments in adulthood, Progression in adulthood), and their present too (Aesthetics, Disability, Quality of life). Technical matters, such as rib hump or radiographic lateral alignment and rotation, but not lateral flexion, are secondary outcomes and only instrumental to previously reported primary outcomes. We advocate a multidimensional, comprehensive evaluation of scoliosis patients, to gather all necessary data for a complete therapeutic approach, that goes beyond x-rays to reach the person and the family.