Discriminative validity of the Scoliosis Research Society 22 questionnaire among five curve-severity subgroups of adolescents with idiopathic scoliosis

Self-image in spinal deformity: a state-of-the-art review

PURPOSE

To review the current literature surrounding the assessment of self-image in pediatric and adult spinal deformity.

METHODS

The literature were reviewed for studies examining patient-reported outcome measurements (PROM) and self-image in pediatric and adult spinal deformity. PROM performance metrics were collected and described. The relationships between self-image PROM and patient outcomes, including satisfaction, were described.

RESULTS

Several self-image PROM exist, including the Scoliosis Research Society-22r (SRS-22r) self-image domain, the Body Image Disturbance Questionnaire (BIDQ), and the Spinal Appearance Questionnaire (SAQ). The most commonly used is the self-image domain of the SRS-22r. It is validated in adult and pediatric spinal deformity and is correlated with patient desire for surgery and satisfaction after surgery. This domain is limited by floor and ceiling effects.

CONCLUSION

Self-image assessment is critical to both pediatric and adult spinal deformity surgeries. The SRS-22r self-image domain is the most frequently reported PROM for this health domain. While valid in both surgical cohorts, this PROM is affected by floor and ceiling effects which limits the ability to discriminate between health states. Given the overall importance of this domain to patients with spinal deformity further efforts are needed to improve discrimination without gross increases in PROM question burden, which may limit broad acceptance and use.

Prospectively Collected Comparison of Outcomes Between Surgically and Conservatively Treated Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective review of a prospectively collected multicenter registry.

OBJECTIVE

To evaluate health-related quality of life (HRQOL) measures in an operative cohort of patients (OP) and compare them with a matched nonoperative cohort (NON).

SUMMARY OF BACKGROUND DATA

Historically, the surgical outcomes of adolescent idiopathic scoliosis (AIS) have been radiographically evaluated. However, the importance of HRQOL measures and their impact on surgical outcomes are increasingly being understood.

MATERIALS AND METHODS

We identified 90 NON patients with curves in the operative range who were observed for at least two years. These patients were matched with an OP cohort of 689 patients. All patients completed the Scoliosis Research Society-22 (SRS-22) questionnaire at the initial evaluation and at a minimum of two-year follow-up. Subgroup comparisons were based on curve type: primary thoracic (Th), primary thoracolumbar/lumbar (TL/L), and double major (DM) curves.

RESULTS

The preoperative major curves in the Th, TL/L, and DM OP subgroups averaged 50.4°, 45.4°, and 51.5°, respectively, and 49.4°, 43.7°, and 48.9° in the NON cohort ( P >0.05). At two years postoperatively, the major curve in the Th, TL/L, and DM OP subgroups improved to 19.0°, 19.2°, and 19.3°, respectively, compared with the progression to 51.3°, 44.5°, and 49.7° in the NON group at two-year follow-up ( P <0.05). The SRS-22 self-image, mental health, satisfaction, and total scores at the two-year follow-up were significantly better in all OP subgroups ( P <0.001) but remained largely unchanged in the NON group. A significant percentage of patients ( P <0.001) in the OP cohort reported better SRS-22 scores at the two-year follow-up in the self-image, mental health, and satisfaction domains than the NON group at two years.

CONCLUSIONS

Surgically treated patients with AIS have improved HRQOL outcomes in several domains compared with age-matched and curve magnitude-matched nonoperatively treated patients at two-year follow-up.

An Analysis of Scoliosis in Autism Spectrum Disorder

BACKGROUND

Children with autism/Asperger are grouped into the diagnosis of autism spectrum disorder (ASD). It remains uncertain whether children with ASD and scoliosis have radiographic and clinical outcomes similar to idiopathic scoliosis (IS) patients.

METHODS

A single-center, retrospective review of a prospective scoliosis registry evaluated patients who had a posterior spinal fusion±Anterior Spinal Fusion and an underlying diagnosis of ASD between 1990 and 2021. A 2:1 match with AIS patients by age and sex was compared using demographic, radiographic, intraoperative, and SRS-22/30 variables.

RESULTS

Thirty patients with ASD (63% male, mean age at surgery 14.6±2.5 y) met inclusion criteria, with a follow-up of 2.46±1.00 years. Despite no differences in curve magnitude preoperatively, patients with ASD had a higher percent correction at 2-year follow-up (66% vs. 57%, P =0.01) and improved mean curve magnitude (20±10 degrees) at 2-year follow-up compared with IS patients (27±11 degrees, P <0.01). ASD patients had less lumbar lordosis preoperatively (40±12 vs. 53±14, P <0.01), but there were no significant differences in sagittal parameters at 2-year follow-up. There were no significant differences in the rate of complications at 2-year follow-up between ASD and AIS cohorts.

CONCLUSIONS

Although patients with ASD exhibited decreased lordosis compared with IS patients preoperatively, their radiographic outcomes at 2-year follow-up were the same. In addition, ASD patients maintained greater curve correction than IS patients at 2 years follow-up.

LEVEL OF EVIDENCE

Prognostic retrospective study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Thoracic insufficiency syndrome: Approaches to assessment and management

Thoracic insufficiency syndrome (TIS) was described in 2003 as the inability of the thorax to support normal respiration or lung growth. TIS includes a broad and disparate group of typically degenerative thoracospinal conditions. Although TIS arises due to a heterogeneous group of disorders and thus its incidence is not well quantified, general approaches to management and treatment exist. Evolving imaging techniques and measurements of health-related quality of life augment tests of pulmonary function to quantify disease burden, longitudinally and pre- and post-intervention. Intervention is primarily via growth-sparing surgery, for which several device options exist, to preserve vertical growth prior to a definitive spinal fusion at skeletal maturity.

Benchmarking surgical indications for adolescent idiopathic scoliosis across time, region, and patient population: a study of 4229 cases

PURPOSE

There is no identified consensus for the curve magnitude at which an adolescent idiopathic scoliosis (AIS) patient is indicated for posterior spinal fusion (PSF). We aimed to identify a benchmark for curve magnitude at which fusion is indicated; we also aimed to evaluate which patients were being fused under 50°.

METHODS

A prospective multicenter AIS database was queried to identify patients who underwent PSF for AIS. Clinical outcome and demographic information was collected along with anatomic area of the primary curve. Benchmarking was assessed by median and IQR. Patients were stratified by fusion prior to 50° or at 50° or more, and statistical analysis was performed to assess risk factors for fusion < 50°.

RESULTS

4229 patients were included in the analysis. The median indication for PSF in the thoracic curve cohort was 55°, and in the lumbar curve cohort was 51°. Site-specific evaluation showed that two sites were more likely to fuse < 50° compared to all other sites (p < 0.05). Over time, the percentage of patients being fused < 50° has declined (p < 0.05). On univariate and multivariate analysis, lumbar curve location, increasing Risser score and female sex were all risk factors for fusion < 50° (p < 0.05). Low SRS-24 scores did not correlate to fusion below 50°.

CONCLUSION

There exist location-specific indications for posterior spinal fusion that vary throughout the country. Additionally, increasing maturity, female sex, and lumbar curve location are independent risk factors for fusion under 50°.

Evaluation of Self-Perceived Body Image in Adolescents with Mild Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is the most prevalent types of scoliosis, affecting up to 3% of children around the world. The progression of AIS can cause alteration in psychological components such as self-perceived body image and self-identity, which negatively affect the teenager quality of life (QoL). The mainly aim of this cross-sectional study is to investigate how mild AIS impacts self-perceived body image in young people. Fifteen participants (mean age = 14.47 ± 2.825) of both sexes (male = 5; female = 10) with a curve magnitude from 10° up to 25° completed the Scoliosis Research Society Patient Questionnaire (SRS-22), the Trunk Appearance Perception Scale (TAPS) and were subject to spinal analysis and photogrammetry. Results display statistical differences between self-perceived body image and other SRS-22 domains (Hotelling t2= 70.29; F(3,12) = 20.08; p < 0.001). Additionally, the regression model, which better explained the self-perceived variability, was fit by function/activity, pain, and mental health domains (F(4,10) = 4.39; p = 0.029; R2 = 0.545). Although AIS was not severe, it negatively affected participants self-perceived body image. More attention in AIS qualify of life is needed, and early treatments could be necessary to prevent psychological impairments self-perception related.

Physical Functioning in Adolescents with Idiopathic Scoliosis: A Systematic Review of Outcome Measures and Their Measurement Properties

STUDY DESIGN

A systematic review.

OBJECTIVE

To summarize evidence on measurement properties of Outcome Measures (OM) used to assess physical functioning in adolescents with idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

The AIS is a common spine deformity in those aged 10 to 18 years old. Associated health problems (e.g., back pain) significantly impact the quality of life (QoL). One important domain in QoL is physical functioning, which can be measured with patient-reported outcome measures (PROM), performance-based outcome measures (PBOM), and body structure and function OM. Adequate measurement properties of OM are important for precision in research and practice.

METHODS

A two-staged search strategy was performed on electronic databases up to December 2019. Search one revealed a list of OM was used for physical functioning assessment in AIS. Search two identified studies that evaluated the measurement properties of OM in AIS; using the list identified in search one. Two independent reviewers determined study eligibility, risk of bias assessment (COnsensus-based Standards for the selection of health Measurement INstruments [COSMIN] checklist), and performed data extraction. The level of evidence was established using a modified GRADE approach.

RESULTS

Search one yielded: 28 PROM, 20 PBOM, and 10 body structure and function OM. Search two revealed: 16 measurement properties studies for PROM, one for PBOM, and three for body structure and function measures. Construct validity, reliability, and responsiveness of most PROM has been established in AIS, but not content validity or internal consistency (moderate evidence). Construct validity was sufficient for the Timed Up and Go test and body structure and function measures (very low to low evidence).

CONCLUSION

Currently, physical functioning is evaluated with a variety of measures in AIS. The majority of measurement properties studies evaluated PROM with a paucity of information on measurement properties of PBOM and body structure and function OM. Based on COSMIN methodology, none of the OM identified in this review can be recommended with confidence in individuals with AIS.Level of Evidence: 2.

Associations between curve severity and revised Scoliosis Research Society-22 and scoliosis Japanese Questionnaire-27 scores in female patients with adolescent idiopathic scoliosis: a multicenter, cross-sectional study

Background

Patient-reported outcome measures are widely utilized to assess health-related quality of life (HRQOL) in patients with adolescent idiopathic scoliosis (AIS). However, the association between HRQOL and curve severity is mostly unknown. The aim of this study is to clarify the association between HRQOL and curve severity, and to determine the optimal cutoff values of patient-reported outcomes for major curve severity in female patients with AIS.

Methods

Female patients with AIS treated conservatively were recruited. The patients’ HRQOL outcomes were examined using the revised Scoliosis Research Society-22 (SRS-22r) and the Scoliosis Japanese Questionnaire-27 (SJ-27). The correlations of the SRS-22r and SJ-27 scores with the major Cobb angle were assessed using Spearman’s correlation coefficient analysis. The association between HRQOL issues in the SJ-27 and the major Cobb angle was evaluated by calculating Akaike’s Information Criterion (AIC). Furthermore, the optimal cutoff values of the SRS-22r and SJ-27 scores for the major Cobb angle were determined by AIC analysis.

Results

The study cohort comprised 306 female patients with AIS. The SRS-22r and SJ-27 scores were significantly correlated with the major Cobb angle. Questions in the SJ-27 regarding discomfort when wearing clothes showed a lower AIC value in patients with severe scoliosis. The optimal cutoff values were a SRS-22r score of 3.2 for the discrimination of severe scoliosis (Cobb angle ≥48°), and a SJ-27 score of 32 for the discrimination of moderate scoliosis (Cobb angle ≥33°).

Conclusion

Discomfort when wearing clothes was the most important HRQOL problem caused by severe scoliosis. The SRS-22r and SJ-27 scores are useful for the discrimination of clinical status in female patients with severe scoliosis or moderate scoliosis.

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

STUDY DESIGN

Retrospective study.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II, prognostic.

Major Complications at Two Years After Surgery Impact SRS Scores for Adolescent Idiopathic Scoliosis Patients

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores.

SUMMARY OF BACKGROUND DATA

There is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients.

METHODS

Surgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated.

RESULTS

1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p < .05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p < .05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p < .001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10).

CONCLUSIONS

When timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score.

LEVEL OF EVIDENCE

Level III.

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

STUDY DESIGN

Case control comparative series.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3.

Comparison of Functional Outcome and Quality of Life in Patients With Idiopathic Scoliosis Treated by Spinal Fusion

Longer spinal fusions have been shown to result in improved deformity correction; however, loss of normal flexibility in the fusion area should not be ignored. Current consensus was to achieve a shorter fusion in primary surgery, with the goal of preserving as much of the distal motion segment as possible. However, the correlation between the length of fusion and functional outcome remains controversial. To the best of our knowledge, a previous study has demonstrated the function outcomes and the differences in HRQoL with specific fusion levels.In this cross-sectional study, 172 patients (mean age, 17.8 y) with idiopathic scoliosis treated by spinal fusion (mean time since surgery, 29.7 mo) were included to measure lumbar spine mobility and quality of life using validated outcome instruments in the study population. Patients were assigned to 5 groups according to the lower instrumented vertebra (LIV) level: group A (fusion above L2) 26 patients; group B (fusion to L2) 21 patients; group C (fusion to L3) 46 patients; group D (fusion to L4) 53 patients; and group E (fusion to L5) 26 patients. At each follow-up, patients were asked to complete the Scoliosis Research Society 22 (SRS-22) Questionnaire. Lumbar mobility was assessed using a dual digital inclinometer.Average spinal range of motion (ROM) was 41.4 degrees (SD, 20.7), forward flexion was 29.2 degrees (SD, 15.0), and backward extension was 12.2 degrees (SD, 9.5). The total spinal range of motion and forward flexion dropped noticeably as the LIV got more distal. Statistically significant between-group differences (1-way ANOVA) were found for ROM (P < 0.001), forward flexion (P < 0.001), or backward extension (P < 0.001). The motion segments preserved significantly correlated with ROM (r = 0.76, P < 0.001), ROMF (r = 0.76, P < 0.001), and ROME (r = 0.39, P < 0.001). However, no significant between-group differences was found for each domain of SRS-22 questionnaire.The motion segments preserved strongly correlated with lumbar mobility. Less fusion levels can preserve better lumbar flexibility by keeping more motion segments.

Postoperative Perfection: Ceiling Effects and Lack of Discrimination With Both SRS-22 and -24 Outcomes Instruments in Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Review of a prospective database registry.

OBJECTIVE

To compare the Scoliosis Research Society (SRS)-22 and SRS-24 outcomes instruments in terms of scores, rate of ceiling effects, and discriminant ability in patients with pre- and postoperative adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Despite improvements noted with the SRS-22, the SRS-24 is still occasionally used prospectively and for comparisons with previous studies reporting SRS-24 scores. Previous work has demonstrated that postoperative scores from the 2 versions are not interchangeable.

METHODS

A multicenter prospective registry of patients who underwent surgical correction of adolescent idiopathic scoliosis was queried for preoperative and 2-year postoperative SRS-22 and SRS-24 scores. Scores were compared between versions and ceiling effects were identified. Groups of deformity severity were created to evaluate discriminant ability.

RESULTS

829 patients were identified. The SRS-22 scores for pain and general function were significantly greater than SRS-24 scores (P < 0.001), whereas the SRS-22 scores were significantly lower than the SRS-24 for self-image (P < 0.001). Preoperative ceiling effect was only noted in 1 domain each. Both versions were able to discriminate between large (80°+) and small (<45°) preoperative curves in all domains and total scores (P < 0.05). Postoperatively, the SRS-22 scores for all shared domains and total score were significantly greater than SRS-24 scores (P < 0.001). Ceiling effects in 5 of 5 domain scores were noted postoperatively for SRS-22 and in 4 of 7 for SRS-24. With a smaller range of deformity postoperatively, only the SRS-22 self-image domain was able to discriminate between large (29°+) and small (≤11°) residual curves (P < 0.05).

CONCLUSION

Scores obtained by the SRS-22 and the SRS-24 are not translatable despite shared domains. Whereas both versions demonstrated preoperative discriminant ability, postoperative discrimination of residual deformity is lacking in both. Patient-reported outcomes of treatment are crucial in advancing treatment, and improvement in the ability to assess subjective outcomes is essential.

LEVEL OF EVIDENCE

3.

Quality of life in normal and idiopathic scoliosis adolescents before diagnosis: reference values and discriminative validity of the SRS-22. A cross-sectional study of 1,205 pupils

BACKGROUND CONTEXT

The Scoliosis Research Society 22 Questionnaire (SRS-22) has shown to worsen with increasing deformity in adolescents with idiopathic scoliosis (AIS). However, all the studies have been performed on patients who have already been diagnosed and in relatively small samples.

PURPOSE

The purposes of this study were to evaluate a large sample of consecutive patients before diagnosis to develop reference values and check the discriminative validity and correlation with deformity of the SRS-22.

STUDY DESIGN/SETTING

This is a cross-sectional study, with patients referred to a specialized outpatient scoliosis rehabilitation institute.

PATIENT SAMPLE

The recruited subjects were 1,205 consecutive adolescents, 75% females (13.7±1.9 years), before their first scoliosis evaluation. Five subgroups were 0°-10° Cobb (normal) and 11° to 20°, 21° to 30°, 31° to 40°, and greater than 40° (AIS).

OUTCOME MEASURES

The outcome measure is based on the SRS-22.

METHODS

The SRS-22 was used to examine the differences between the domains of the five subgroups and total scores, and it was correlated with Cobb degrees and curve location. We used one-way analysis of variance and Spearman rho test.

RESULTS

Apart from the self-image domain in both genders and all subgroups, all other scores were greater than 4 points with small standard deviations. Females showed significant differences among groups for all domains and total score (p<.05). In males, function, pain, and mental health did not show statistically significant differences among groups (p>.1). All differences found were less than the minimally clinically significant change (0.5 points). The correlations with the severity of deformity measures were very low (rs<0.289).

CONCLUSIONS

According to our results, deformity is apparently not a real issue for AIS before diagnosis made, treatment planned, and/or specialists interfere with their everyday life. Scoliosis Research Society 22 Questionnaire demonstrated some discriminative validity between small and large curves, but the differences found were small.

Results of selective thoracic versus nonselective fusion in Lenke type 3 curves

STUDY DESIGN

A retrospective analysis of a prospectively collected multicenter database.

OBJECTIVE

To identify the radiographical and clinical outcomes in Lenke 3 curves fused selectively (S) versus nonselectively (NS).

SUMMARY OF BACKGROUND DATA

Surgical treatment options for Lenke 3 curves include fusion of both curves (NS) or selective thoracic curve fusion (S). Selective fusion of the thoracic curve spares lumbar motion segments; however, it may result in marked residual deformity.

METHODS

A prospectively collected multicenter database was retrospectively reviewed for adolescent idiopathic scoliosis Lenke 3 curves treated with posterior spinal fusion with a minimum of 2 years of follow-up. Patients were divided into 2 groups: NS (nonselective fusion) and S (selective thoracic fusion). Radiographical and clinical data were compared between the groups using the unpaired Student t test and analysis of variance.

RESULTS

A total of 74 patients met our inclusion criteria, with 49 (66.2%) in the NS group and 25 (33.8%) in the S group. Overall, both groups were similar preoperatively except for lumbar Cobb (NS = 56.3°, S = 47.2°, P < 0.001), lumbar lordosis (NS = 56.9°, S = 67.2°, P = 0.001), lumbar rotational prominence (NS = 11.2°, S = 8.2°, P < 0.05), and lumbar apical translation (NS = 3.2 cm, S = 1.9 cm, P < 0.05). Postoperatively, NS fusion demonstrated significantly less coronal imbalance of 2 cm or less (NS = 10.2%, S = 56.0%, P < 0.001), better lumbar curve correction (NS = 68.2%, S = 51.9%, P < 0.001), better lumbar apical translation correction (NS = 1.2 cm, S = 2.1 cm, P < 0.01), and better percent correction of the lumbar prominence (NS = 66.5%, S = 40.4%, P < 0.05). Scoliosis Research Society Questionnaire 22 scores at 2 years were similar between the groups.

CONCLUSION

Despite preoperatively smaller lumbar curves with less apical translation and lumbar prominence, most patients with selective fusions were out of balance postoperatively and had inferior radiographical outcomes as compared with their nonselective comparison cohort with similar patient-reported outcomes. Long-term follow-up is required to determine whether the trade-off of sparing motion segments at the expense of somewhat lessened radiographical outcomes is worthwhile.

Congenital scoliosis SRS-22 outcomes in children treated with observation, surgery, and VEPTR

STUDY DESIGN

Prospective, nonrandomized study of children with congenital scoliosis.

OBJECTIVE

To determine the outcomes of children with congenital scoliosis using SRS-22.

SUMMARY OF BACKGROUND DATA

Outcome measures in children with congenital scoliosis are unreported. Novel treatments such as VEPTR (vertical expandable prosthetic titanium rib) must show positive patient-reported outcomes during treatment because improvement in pulmonary function has not been demonstrated.

METHODS

Patients with congenital scoliosis were prospectively enrolled and divided into 3 groups: children under observation (OBSERVATION), children who had surgery (SURGICAL), and children treated with VEPTR (VEPTR). The SRS-22 questionnaire reports 6 domains: Total, Function, Mental Health, Image, Satisfaction, and Pain. SRS-22 questionnaires were prospectively collected from 184 OBSERVATION patients, 27 SURGICAL patients, and 22 VEPTR patients. Because of repeated measurement on each patient, the observations cannot be assumed to be independent. To account for this dependence, linear mixed models were used.

RESULTS

OBSERVATION scores were near normal in all domains. Initial postoperative scores for Function and Pain decreased for the SURGICAL group and subsequently Total, Function, Image, and Satisfaction scores increased. Initial postoperative VEPTR scores in Mental Health and Pain decreased and Total, Function, and Image scores increased during subsequent visits.

CONCLUSION

Children with congenital scoliosis had SRS-22 scores that compare favorably with scores reported in the literature for adolescent idiopathic scoliosis. For SURGICAL and VEPTR patients with congenital scoliosis, SRS-22 Total, Function, and Image scores increased over time. Function, Image, and Pain require focus in children with congenital scoliosis. This is the first study that documents improvement in outcomes of VEPTR patients while in treatment.

LEVEL OF EVIDENCE

2.

Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease

Pulmonary rehabilitation (PR) is an important therapeutic intervention that should no longer be considered suitable only for patients with chronic obstructive pulmonary disease (COPD). A strong rationale exists for providing PR to persons with a broad range of respiratory disorders other than COPD. Evidence shows that PR for these patients is feasible, safe and effective. A disease-relevant approach should be undertaken, based on individual patients' needs. Further research is needed to better understand the optimal program content, duration and outcomes measures, to enable diverse patients to achieve maximal benefits of PR.

Body image in idiopathic scoliosis: a comparison study of psychometric properties between four patient-reported outcome instruments

BACKGROUND

Four patient-reported outcome (PRO) instruments are commonly used to assess body image in idiopathic scoliosis (IS): the Quality of Life Profile for Spinal Deformities (QLPSD), SRS-22 Self-Image scale, Spinal Appearance Questionnaire (SAQ), and Trunk Appearance Perception Scale (TAPS). The aim of this study is to compare the psychometric properties of these instruments in patients with IS and report the translational/cultural adaptation of the SAQ to Spanish.

METHODS

The four instruments in a Spanish version were administered to 80 patients with IS aged 10 to 40 years old. The sample was stratified according to scoliosis magnitude (less and more than 45º). Analysis was also conducted for age groups. The psychometric properties studied included convergent and divergent construct validity, as well as internal consistency. Convergent validity was evaluated by correlation analysis between the self-image instruments and Cobb angle. Divergent validity was assessed with correlation analysis between PRO scores and SRS-22 dimensions scores such as Function, Pain and Mental Health.

RESULTS

In the overall sample, each of the PRO instruments demonstrated high internal consistency (QLPSD Body Image, α = 0.80; SRS-22 Self Image, α = 0.78; SAQ, α = 0.89; TAPS, α = 0.87), also both for younger and adult patients subgroups. Correlation with curve magnitude was significant for each of the four scales. However, the correlation was higher for the pictorial scales (SAQ Appearance r = 0.61, TAPS r = -0.62) than for the textual scales (QLPSD-bi r = 0.36, SRS-22 Self-Image scale r = -0.41). In the younger group, correlation between Cobb angle and textual scales (QLPSD-bi and SRS-22 Self-Image Scale) was not significant. Body Image scales showed significant correlations with SRS-22 Pain, Function and Mental Health dimensions.

CONCLUSIONS

All four instruments tested have good psychometric properties. Pictorial scales (SAQ Appearance and TAPS) correlated better with the radiological magnitude of the curve and this correlation is independent of age. Unexpectedly, all four scales demonstrated significant correlations with non-body image dimensions and the divergent hypothesis was not confirmed. Globally, pictorial scales showed slightly better construct validity to test body image perception than textual scales.

Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire--Scoliosis Version

BACKGROUND

Appearance concerns in individuals with adolescent idiopathic scoliosis can result in impairment in daily functioning, or body image disturbance. The Body Image Disturbance Questionnaire (BIDQ) is a self-reported, seven-question instrument that measures body image disturbance in general populations; no studies have specifically examined body image disturbance in those with adolescent idiopathic scoliosis. This study aimed to validate a modified version of the BIDQ in a population with adolescent idiopathic scoliosis and to establish discriminant validity by comparing responses of operatively and nonoperatively treated patients with those of normal controls.

METHODS

In the first phase, a multicenter study of forty-nine patients (mean age, fourteen years; thirty-seven female) with adolescent idiopathic scoliosis was performed to validate the BIDQ-Scoliosis version (BIDQ-S). Participants completed the BIDQ-S, Scoliosis Research Society (SRS)-22, Children's Depression Index (CDI), and Body Esteem Scale for Adolescents and Adults (BESAA) questionnaires. Descriptive statistics and Pearson correlation coefficients were calculated. In the second phase, ninety-eight patients with adolescent idiopathic scoliosis (mean age, 15.7 years; seventy-five female) matched by age and sex with ninety-eight healthy adolescents were enrolled into a single-center study to evaluate the discriminant validity of the BIDQ-S. Subjects completed the BIDQ-S and a demographic form before treatment. Independent-sample t tests and Pearson correlation coefficients were calculated.

RESULTS

The BIDQ-S was internally consistent (Cronbach alpha = 0.82), and corrected item total correlations ranged from 0.47 to 0.67. The BIDQ-S was significantly correlated with each domain of the SRS-22 and the total score (r = -0.50 to -0.72, p ≤ 0.001), with the CDI (r = 0.31, p = 0.03), and with the BESAA (r = 0.60, p < 0.001). BIDQ-S scores differed significantly between patients (1.50) and controls (1.06, p < 0.005), establishing discriminant validity.

CONCLUSIONS

The BIDQ-S is an internally consistent outcomes instrument that correlated with the SRS-22, CDI, and BESAA outcomes instruments in a scoliosis population. The scores of the patients with scoliosis indicated greater back-related body image disturbance compared with healthy controls. To our knowledge, this user-friendly instrument is the first to examine body image disturbance in adolescent idiopathic scoliosis, and it provides a comprehensive evaluation of how scoliosis-related appearance concerns impact psychosocial and daily functioning.

Improving the measurement of health-related quality of life in adolescent with idiopathic scoliosis: the SRS-7, a Rasch-developed short form of the SRS-22 questionnaire

Scoliosis Research Society-22 (SRS-22) questionnaire was developed to evaluate health-related quality of life (HRQL) in adolescent idiopathic scoliosis (AIS) patients. Rasch analysis (RA) is a statistical procedure which turns questionnaire ordinal scores into interval measures. Measures from Rasch-compatible questionnaires can be used, similar to body temperature or blood pressure, to quantify disease severity progression and treatment efficacy. Purpose of the current work is to present Rasch analysis (RA) of the SRS-22 questionnaire and to develop an SRS-22 Rasch-approved short form. 300 SRS-22 were randomly collected from 2447 consecutive IS adolescents at their first evaluation (229 females; 13.9 ± 1.9 years; 26.9 ± 14.7 Cobb°) in a scoliosis outpatient clinic. RA showed both disordered thresholds and overall misfit of the SRS-22. Sixteen items were re-scored and two misfitting items (6 and 14) removed to obtain a Rasch-compatible questionnaire. Participants HRQL measured too high with the rearranged questionnaire, indicating a severe SRS-22 ceiling effect. RA also highlighted SRS-22 multidimensionality, with pain/function not merging with self-image/mental health items. Item 3 showed differential item functioning (DIF) for both curve and hump amplitude. A 7-item questionnaire (SRS-7) was prepared by selecting single items from the original SRS-22. SRS-7 showed fit to the model, unidimensionality and no DIF. Compared with the SRS-22, the short form scale shows better targeting of the participants' population. RA shows that SRS-22 has poor clinimetric properties; moreover, when used with AIS at first evaluation, SRS-22 is affected by a severe ceiling effect. SRS-7, an SRS-22 7-item short form questionnaire, provides an HRQL interval measure better tailored to these participants.

Effect of spinal deformity on adolescent quality of life: comparison of operative scheuermann kyphosis, adolescent idiopathic scoliosis, and normal controls

STUDY DESIGN

A prospective multicenter study and retrospective chart review.

OBJECTIVE

To compare health-related quality of life (HRQOL) measures and sagittal deformity in operative Scheuermann kyphosis (SK), operative adolescent idiopathic scoliosis (AIS), and normal populations.

SUMMARY OF BACKGROUND DATA

No study to date has evaluated patient reported HRQOL measures before surgery in operative patients with SK.

METHODS

HRQOL data were prospectively collected pretreatment for operative patients with SK using the SRS-22 outcomes instrument and visual analogue scale (VAS). Comparison was made with the SRS-22 from operative AIS and normal populations. Eighty-six patients with SK enrolled in the prospective study were compared with 184 patients with AIS from a prospective database and 31 normal controls. To study the correlation between T5-T12 kyphosis magnitude and SRS-22 score, patients with AIS and SK were pooled together to create a larger continuum of kyphosis. Analysis of covariance, Pearson correlation analysis, and Bonferroni pairwise comparisons were used to determine statistical differences between group demographics, HRQOL indicators, and radiographical variables.

RESULTS

Patients with SK had significantly lower scores in all domains of the SRS-22 than patients with AIS. Patients with SK with a thoracolumbar apex reported significantly lower mean scores in the pain domain than those with a thoracic apex. Significant negative correlations were found between all domains of the SRS-22 and T5-T12 kyphosis-the self-image domain demonstrated the highest correlation (r = 0.37). VAS score in the SK population correlated negatively to the pain, self-image, and mental health domains.

CONCLUSION

Increasing sagittal plane deformity as a result of SK has a significant impact on HRQOL as determined by the SRS-22 outcome instrument. In this study, patients with SK reported significantly decreased (worse) scores in all subdomains of the SRS-22 compared with patients with AIS.

LEVEL OF EVIDENCE

1.