The influence of pregnancy on women with adolescent idiopathic scoliosis

Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature

A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.

Pregnancy and Childbirth After Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Little data exist on pregnancy and childbirth for adolescent idiopathic scoliosis (AIS) patients treated with a spinal fusion. The current literature relies on data from patients treated with spinal fusion techniques and instrumentation, such as Harrington rods, that are no longer in use. The objective of our study is to understand the effects of spinal fusion in adolescence on pregnancy and childbirth.

METHODS

Prospectively collected data of AIS patients undergoing posterior spinal fusion that were enrolled in a multicenter study who have had a pregnancy and childbirth were reviewed. Results were summarized using descriptive statistics and compared with national averages using χ 2 test of independence.

RESULTS

A total of 78 babies were born to 53 AIS patients. As part of their pre-natal care, 24% of patients surveyed reported meeting with an anesthesiologist before delivery. The most common types of delivery were spontaneous vaginal delivery (46%, n=36/78) and planned cesarean section (20%, n=16/78). Compared with the national average, study patients had a higher rate of cesarean delivery ( P =0.021). Of the women who had a spontaneous vaginal birth, 53% had no anesthesia (n=19/36), 19% received intravenous intermittent opioids (n=7/36), and 31% had regional spinal or epidural anesthesia (n=11/36). spontaneous vaginal delivery patients in our study cohort received epidural or spinal anesthesia less frequently than the national average ( P <0.001). Of those (n=26 pregnancies) who did not have regional anesthesia (patients who had no anesthesia or utilized IV intermittent opioids), 19% (n=5 pregnancies) were told by their perinatal providers that it was precluded by previous spine surgery.

CONCLUSION

The majority of AIS patients reported not meeting with an anesthesiologist before giving birth and those who had a planned C-section did so under obstetrician recommendation. The presence of instrumentation after spinal fusion should be avoided with attempted access to the spinal canal but should not dictate a delivery plan. A multidisciplinary team consisting of obstetrician, anesthesiologist, and orthopaedic surgeon can provide the most comprehensive information to empower a patient to make her decisions regarding birth experience anesthesia based on maternal rather than provider preference.

LEVEL OF EVIDENCE

IV.

Adolescent Idiopathic Scoliosis and Pregnancy

Objective This study examined the interaction between adolescent idiopathic scoliosis (AIS) and pregnancy, focusing on pregnancy outcomes, changes in back pain, and anesthesia use. Methods A retrospective analysis was conducted on adult patients with AIS who gave birth at our institution between 2006 and 2022. Results A total of 163 AIS patients with 263 pregnancies were included. The median age at delivery was 33 (range 18 to 50) years. Among 157 patients with information on prior scoliosis treatment, 66.9% had not received treatment, 20.4% had undergone spinal fusion, and 12.7% had received bracing. Of the 260 pregnancies with available data, 90.4% were delivered at term and 8.5% were preterm. Of the 257 pregnancies with information on anesthesia type, 35.0% received epidural anesthesia, 17.9% received spinal anesthesia, 37.7% received combined spinal and epidural anesthesia, 8.2% received no anesthesia, and 1.2% received intravenous or general anesthesia. Difficulty administering neuraxial anesthesia was reported in 6.1% of cases, and these patients were less likely to receive combined spinal and epidural anesthesia (6.3% versus 39.8%, p = 0.0123). Among 116 cases with recorded back pain during pregnancy, 67.2% reported increased pain, 31.9% reported similar pain, and one patient reported decreased pain. Of the 16 patients with pre and postpartum radiographs, eight showed a Cobb angle increase ≥ 3°, with five patients having an increase ≥ 5°. Conclusions Pregnancy can exacerbate back pain and pose challenges for neuraxial anesthesia in some AIS patients. Further large-scale, multi-institutional studies with standardized data collection are needed to fully understand the impact of pregnancy on AIS.

The impact of pregnancy on women with adolescent idiopathic scoliosis: a scoping review

INTRODUCTION

Adolescent idiopathic scoliosis is the most common spinal deformity encountered in adolescents and larger curves are more prevalent in girls. For females with scoliosis, women's health issues are of particular concern, especially pregnancy. The aim of this review was to summarise the best available evidence to determine the influence of pregnancy on scoliosis-related outcomes in women with scoliosis and whether scoliosis affects maternal-health outcomes, differentiating between patients who have been managed conservatively and/or surgically.

EVIDENCE ACQUISITION

A search was conducted using CINAHL, Scopus, Cochrane Database, MEDLINE, and EMBASE from inception to May 2023 to identify relevant articles in any language. The scoping review followed the PRISMA-ScR guidelines. Studies were eligible if they included pregnant women (primiparous or multiparous) with a diagnosis of scoliosis of unknown aetiology. The results were summarized by outcomes, including pregnancy and scoliosis-related outcomes and type of management.

EVIDENCE SYNTHESIS

Our comprehensive search strategy identified 6872 articles, of which 50 articles were eligible for this review. Back pain appears to be more prevalent in this population during pregnancy and associated with the major curve and the decrease of lumbar lordosis. There have been reports of failed attempted spinal anaesthesia among patients with instrumented scoliosis correction and minor complications related to epidural anaesthesia at a higher rate compared to non-instrumented patients and healthy controls, however successful spinal analgesia can be achieved in patients with instrumented scoliosis correction. Overall, the caesarean section rate was similar in scoliosis patients compared to controls without scoliosis and to national averages. Curve progression occurs in some but not all patients during pregnancy, and this phenomenon occurs irrespective of the treatment received.

CONCLUSIONS

Higher-quality prospective longitudinal research is needed to understand the relationship between pregnancy and adolescent idiopathic scoliosis. Further, the patient's perspective, concerns and fears surrounding pregnancy with scoliosis are yet to be explored. Exploring the impact of pregnancy on women with adolescent idiopathic scoliosis would have clinically relevant outcomes and could help provide pertinent answers to patients and healthcare workers and help guide future research.

The Effect of Adolescent Idiopathic Scoliosis on Natural Delivery and Epidural Use in Pregnant Females: A Matched Cohort Study

STUDY DESIGN

Retrospective matched cohort study.

OBJECTIVE

The aim of this study was to determine whether females with idiopathic scoliosis (IS), both with and without spine fusion, experience different rates of cesarean section (CS) and epidural anesthesia (EA) than females without scoliosis.

SUMMARY OF BACKGROUND DATA

IS is a common spine condition with a higher prevalence in females. It is unclear whether females with scoliosis, treated nonoperatively or operatively, have different rates of cesarean delivery or EA.

MATERIALS AND METHODS

Patients with IS who delivered in our integrated health care system during a 6-year period were identified (N = 1810). They were matched with a group without scoliosis who delivered during the same period (N = 1810). Rates and relative risk (RR) of CS and EA between cohorts and subgroups were calculated.

RESULTS

The scoliosis cohort had significantly higher rates and RR of EA ( P = 0.002 and P = 0.004, respectively). Scoliosis patients treated nonoperatively had an 8% greater RR of EA ( P = 0.004) and had a significantly lower rate of CS (23.2% vs . 26%, P = 0.048) compared with the control group. Among only scoliosis patients, those treated with spine fusion had a 38% decreased RR of EA ( P < 0.001). Distal fusion level did not seem to influence the RR of EA or CS.

CONCLUSIONS

Females with scoliosis were significantly more likely to receive EA at delivery compared with females without scoliosis. Rates and RR of cesarean delivery were not significantly lower among women with scoliosis, but females treated nonoperatively for scoliosis had a significantly lower CS rate than those without scoliosis. Females treated with spine fusion for scoliosis were far less likely to receive EA than both females without scoliosis and females with scoliosis treated nonoperatively.

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

Long-term outcome of patients with adolescent idiopathic scoliosis seeking nonoperative treatment after a mean follow-up of 42 years

PURPOSE

Adolescent idiopathic scoliosis (AIS) affects up to 3% of otherwise healthy adolescents. The extreme long-term outcomes of nonoperative treatment are underreported. This study aimed to investigate the long-term outcome of nonoperative-treated AIS patients. Comparison between a bracing and an observation approach were performed.

METHODS

In a retrospective cohort study, 20 nonoperatively treated AIS patients were observed concerning patient-related outcome measures (PROM) (visual analog scale (VAS), Short Form Health Survey 36 item (SF 36), Scoliosis Research Society (SRS 24), Oswestry Low Back Pain Disability Index (ODI), Psychological General Well-Being Index (PGWBI)), radiological curve progression and health-related quality of life (HRQoL). Baseline characteristics and radiological imaging were collected. At follow-up, anteroposterior and lateral X-rays as well as questionnaires were analyzed.

RESULTS

Twenty patients (16 females, mean age: 14.6 ± 3.2 years) with a follow-up time of 42 ± 9 years were included. Nine patients (initial Cobb 35° ± 19°) were treated with bracing for a mean time of 26 ± 9 months, while the other 11 patients (initial Cobb 29° ± 11°) were observed. The primary curve progressed from 32° ± 15° to 52° ± 25° in average with no significant difference between the cohorts (p = 0.371). At final follow-up, a mean ODI score of 7 ± 7.9 points with no difference depending on the treatment (p = 0.668) was seen. No significant differences were observed for PROMs. Curve magnitude correlated neither at diagnosis (p = 0.617) nor at follow-up (p = 0.535) with the ODI score at final follow-up.

CONCLUSION

After a mean of 42 years, patients with nonoperative treatment of moderate AIS demonstrated a good clinical outcome despite progression of the deformity.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Scoliosis Management for Primary Care Practitioners

For many families, the possibility that their child may have scoliosis causes great anxiety because their child may be deformed for life, may need to wear a brace for years, or may need to undergo a large and dangerous operation. For most families, these fears are groundless. Up to 3% of the population has a spinal curvature, most of which are small curves that may not need referral or repeated imaging. Many adolescents with scoliosis do well and do not need to wear a brace or have surgery.

Outcomes of pregnancy in operative vs. nonoperative adolescent idiopathic scoliosis patients at mean 30-year follow-up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine whether patients who underwent surgical treatment of adolescent idiopathic scoliosis (AIS) in childhood would have an increased C-section risk in adulthood. Although the impact of scoliosis on future pregnancy and child delivery is a common question for patients and parents, there is limited data regarding pregnancy outcomes following childhood treatment of AIS.

METHODS

Between 1975 and 1992, 60 female patients underwent treatment for AIS with bracing, surgery, or observation and had data available regarding obstetrical history in the electronic medical record or in paper charts. In childhood, 28 had nonoperative treatment and 32 had fusion surgery. During the follow-up period, 2 nonoperative patients and 1 operative patient had fusion surgery in adulthood, but after childbearing years. Mean age at latest follow-up was 43 years (CI 38, 48). Meantime to follow-up since childhood treatment was 31 years (CI 26, 35).

RESULTS

29% of nonoperative patients had a C-section with at least one live birth compared to 38% of operative patients (p = 0.464). For surgical patients fused to L3 or lower, 46% required at least one C-section, compared to 32% of patients fused to L2 or higher (p = 0.40). Overall, 33% of the cohort of patients-including those with all scoliosis treatment methods-required at least one C-section, compared to the state weighted C-section rate of 20.5% (p = 0.014). The percentage of patients with operative treatment-including all levels of fusion-requiring at least one C-section was statistically different than the weighted state C-section rate (p = 0.020).

CONCLUSION

In this long-term cohort of 60 US scoliosis patients, childhood operative fusion treatment was associated with a statistically significant increased incidence of C-section compared to the state incidence at both the patient level and the delivery level.

LEVEL OF EVIDENCE

III, comparative cohort study.

Quality of Life During Pregnancy, Caesarean Section Rate, and Anesthesia in Women with a History of Anterior Correction Surgery for Lumbar Scoliosis: A Case-Control Study

Background

This study investigated the prevalence and severity of low back pain (LBP), caesarean section (C-section) rate, and the anesthesia approaches among lumbar scoliosis patients undergoing anterior correction surgery, and compared them with a healthy control cohort.

Material/Methods

The inclusion criteria for adolescent idiopathic scoliosis (AIS) patients were: presence of lumbar scoliosis, history of 1 or more pregnancies after surgery, and underwent anterior-only surgery. Healthy women with a history of 1 pregnancy were included as the control group. We recorded the type of delivery, neonatal birth weight, and perinatal complications. The quality of life was also evaluated.

Results

New-onset LBP was reported in 65.6% of AIS patients, significantly higher than in the control group (p<0.001). C-section was performed in 11 scoliosis patients (34.4%) and 25 healthy controls (31.25%), and the rates were not significantly different between groups (P=0.75). No serious perinatal complications were reported in either group. General anesthesia was used for all C-section AIS patients. The rate of successful neuraxial anesthesia in the control group was significantly higher (P<0.001).

Conclusions

Compared with the healthy control group, lumbar AIS patients did not experience a higher risk of perinatal complications or C-section rate after anterior surgical correction, but general anesthesia was more commonly used than neuraxial regional anesthesia. LBP was more frequently observed in the post-operative AIS patients.

Unusual cause of hemoptysis: A case report

Hemoptysis is defined as bleeding from the lower respiratory tract. It can be life-threatening and requires urgent investigation and intervention. Common causes of hemoptysis include bronchiectasis, tuberculosis, aspergilomas and malignancy. We present an unusual case of hemoptysis in a young woman with a history of surgery for scoliosis 18 years earlier.

A 30-years-old woman was admitted to our institution for recurring hemoptysis since one year. She had a history of scoliosis and had undergone antero-lateral Th7 through Th12 spinal fusion surgery 18 years earlier. The hemoptysis was slight and resolved spontaneously or after empirical antibiotic therapy, and was attributed to bronchitis. Computed tomography revealed spinal rod penetration into the lung resulting in injury, while the caudal edge of the rod migrated into the liver and the joining screws had entered the mediastinum. Hemoptysis was due to penetration of the rod into the lung. The patient underwent extensive surgery, which was successful.

The case highlights the need for thorough evaluation of patients with hemoptysis. Every incident of hemoptysis, even if minor, should be promptly investigated, because it can be life-threatening.

•

This case demonstrates a rare cause of hemoptysis due to penetration of the rod inserted during surgery for scoliosis into the lung 18 years after surgery; this condition was accompanied by migration the caudal edge of the rod into the liver and displacement of the joining screws into the mediastinum threatening to damage the aorta.

•

It highlights the need promptly and thoroughly evaluate patients with even slight hemoptysis because it can be life-threatening.

•

It indicates the need for periodic follow-up of patients after scoliosis surgery to prevent or minimize its complications.

Health-related quality of life, including marital and reproductive status, of middle-aged Japanese women with posterior spinal fusion using Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis: Longer than 22-year follow-up

BACKGROUND

Few studies have examined long-term outcomes after posterior spinal fusion using Cotrel-Dubousset instrumentation (CDI) for adolescent idiopathic scoliosis (AIS). Most patients with AIS are female, and their main concern is how spinal fusion will affect their future life. This study aimed to investigate the long-term health-related quality of life (HRQOL), including marital and reproductive status, of middle-aged Japanese women who underwent posterior spinal fusion using CDI for AIS in its earliest days in Japan.

METHODS

Japanese women who were younger than 20 years of age at the time of surgery using CDI, between 1985 and 1995, were targeted. Roland-Morris Disability Questionnaire, Oswestry Disability Index, Scoliosis Research Society-22 questionnaire, and 36-Item Short-Form Survey (SF-36) were used to evaluate HRQOL. Marital and reproductive status were also investigated. These results were compared to those of healthy women controls and Japanese national data for 2015.

RESULTS

Of 87 female patients, 29 (33.3%) were included, with 71 healthy women as controls. The average age of the patient group was 42.7 years (range 37-48 years), and the average follow-up period was 27.5 years (range 22-32 years). HRQOL scores in the patient group were generally lower than that in the healthy control group, although there was no significant difference between the two groups in the role component summary score (RCS) of SF-36. Marital and reproductive status were not significantly different between patient and control groups, and results for the patient group were similar to Japanese national data.

CONCLUSIONS

This is the first study of HRQOL in middle-aged patients who underwent posterior spinal fusion using CDI for AIS in Japan. Although HRQOL scores expect RCS of the patient group were lower than those of the healthy control group, the effects of posterior spinal fusion using CDI on women's social life and marital and reproductive statuses were minimal.

Impact of Pregnancy on Loss of Deformity Correction After Pedicle Screw Instrumentation for Adolescent Idiopathic Scoliosis

OBJECTIVE

A retrospective multicenter comparative study was carried out to evaluate whether pregnancy leads to the loss of deformity correction (LOC) in female patients surgically treated for idiopathic scoliosis.

METHODS

A total of 128 female patients who underwent segmental spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS) between 1999 and 2014 were reviewed. Of these patients, 62 became pregnant (surgery-pregnancy group [SPG]), whereas 66 did not (surgery-nonpregnancy [SNP] group). Radiographic parameters were analyzed before surgery, after surgery, before pregnancy, up to 1 year after delivery, and at final follow-up (FFU). Health-related quality of life was analyzed using the Scoliosis Research Society outcome questionnaire (SRS-22r).

RESULTS

The mean age at the time of surgery was 16 years in both groups. The mean preoperative major curves were 65° (standard deviation [SD], 12°) versus 67° (SD, 11°), 18° (SD, 9°) versus 17° (SD, 9°) immediately after surgery, and 20° (SD, 8°) versus 20° (SD, 8°) at FFU in the SPG and SNP groups, respectively (P > 0.10 for all comparisons). The mean loss of correction was 3.5° (SD, 3°) in the SPG and 4.5 (SD, 3°) for SNP groups, respectively (P = 0.379). The mean preoperative thoracic kyphosis (T5-T12) was 26.5° (SD, 11.9°) for SPG and 24.7° (SD, 14.5°) for SNP, after surgery 19.2° (SD, 9.5°) for SPG, 18.8 (SD, 8.9°) for SNP and at FFU, 20.3° (SD, 9°) for SPG and 21.3° (SD, 8.5°) for SNP.

CONCLUSIONS

Women who have undergone pedicle screw instrumentation and fusion who have had ≥1 pregnancies do not have curve progression or deterioration in the longer-term outcomes compared with patients who have not become pregnant.

High risk twin pregnancy complicated with severe rachiterata and huge dorsal mass suffering from refractory infection: A case report

RATIONALE

Severe rachiterata is rarely described as a complication of pregnancy, and it was assumed as a contraindication to pregnancy. We first report a case of severe spinal deformity associated both with scoliosis and kyphosis in pregnancy.

PATIENT CONCERNS

A 38-year-old pregnant woman [28+1 weeks of twin pregnancy, gravida 3, para 2 (G3P2)] was admitted to the emergency department with complaints of persistent productive cough, with increased expectoration, dyspnea, dizziness, fatigue, and irregular abdominal pain. She had obvious spinal protrusion of lateral bending deformity and kyphosis with "S" type distortion, and had a huge dorsal mass with refractory infection. In the third trimester of pregnancy, the anatomical changes resulted in thoracic cavity deformation, unmanageable pulmonary infections, and serious skin infections on the surface of the dorsal mass.

DIAGNOSIS

Single chorionic twin pregnancy with severe rachiterata and a huge dorsal mass.

INTERVENTIONS

Management was focused on treating pulmonary and skin infections and promoting fetal lung maturation. Appropriate timing of pregnancy termination and manner of delivery were decided through a multidisciplinary discussion. The patient was placed in a special position and assisted by a professional midwife during delivery.

OUTCOMES

The patient and her children survived after careful care and treatment.

LESSONS

Severe spinal deformities are not contraindications for pregnancy, but the changes in the thoracic cavity caused by these deformities can result in respiratory function decline, which becomes more apparent in the third trimester, which could likely cause pulmonary infection that is difficult to treat. In the future, studies investigating prenatal care procedures, timing of pregnancy termination, and appropriate delivery method are warranted.

Adolescent idiopathic scoliosis for the primary care physician: frequently asked questions

PURPOSE OF REVIEW

Provide primary care physicians with the best available evidence to support answers to frequently asked questions by caregivers of patients with adolescent idiopathic scoliosis (AIS).

RECENT FINDINGS

A review of best available evidence shows that schoolbag design and weight are not associated with higher odds of developing AIS. However, patients with AIS are more prone to balance problems with asymmetric backpack carrying and with rising weights. In patients with AIS, the backpack should be worn in a symmetric way and should never exceed 10% of the child's body weight. Although no relationship was found between systematic exercising in general and development of AIS, classical ballet and professional swimming in skeletally immature adolescents were associated to higher odds of having AIS. Since AIS affects adolescent girls mainly, women health issues are of paramount importance in this disease. Except for limited sexual activity and higher need for infertility treatment, patients with AIS perform similar to controls in marriage rates, age at first pregnancy, gestational age, offspring, labor and delivery. Best available evidence shows that adults with AIS diagnosed during adolescence have similar physical activity level compared with controls. In patients with AIS, adults with surgically treated idiopathic scoliosis have slightly lower physical activity level than previously braced and untreated patients.

SUMMARY

Although schoolbag weight isn't associated with higher odds of developing AIS, classical ballet and professional swimming in adolescents are. Except for limited sexual activity, patients with AIS perform similar to controls in remaining women health issues. Adults with AIS diagnosed during adolescence have similar physical activity level compared with controls.