A century of spine surgery: what can patients expect?

Is there an indication for surgery in patients with spinal deformities? - A critical appraisal

Background

High-quality evidence exists to support physiotherapy and brace treatment for scoliosis and other spinal deformities. However, according to previous systematic reviews, it seems that no evidence exists for surgery. Nevertheless, the number of research articles focussing on spinal surgery highly exceeds the number of articles focussing on conservative treatment.

Objective

The purpose of this study is to conduct an updated search for systematic reviews providing high-quality evidence for spinal surgery in patients with spinal deformities.

Method

A narrative review including PubMed and the Cochrane database was conducted on April 12, 2020, with the following search terms: (1) spinal deformities, surgery, systematic review and outcome; (2) kyphosis, surgery, systematic review and outcome; (3) Scheuermann's disease, surgery, systematic review and outcome, and (4) scoliosis, surgery, systematic review and outcome.

Results

No reviews containing prospective controlled or randomised controlled studies were found providing evidence for surgery.

Conclusions

A general indication for spine surgery just based on the Cobb angle is not given. In view of the long-term unknown variables and the possible long-term complications of such treatment, a surgical indication for patients with spinal deformities must be reviewed on an individual basis and considered carefully. A current systematic review appears necessary in order to be able to draw final conclusions on the indication for surgery in patients with spinal deformities.

Clinical implications

In view of the increasing number of surgeons with an affiliation to industry, the indication for surgery needs to be given by independent conservative specialists for spinal deformities in order to provide an objective recommendation.

Clinical evaluation of the effectiveness of a new orthotic device for the non-operative treatment of scoliosis

BACKGROUND:

Bracing is one of the oldest non-operative treatments for patients with scoliosis. However, a wide variety of braces is used, and some show no effect, while others show conflicting results.

OBJECTIVE:

We aimed to evaluate the effectiveness of a new orthotic device for the treatment of adult scoliosis.

METHODS:

Twenty adult patients who were diagnosed with scoliosis and qualified for the study were selected and all participants were treated for 12 hours/day for 12 weeks using a new orthotic device. Various efficacy assessments (Cobb’s angle, spine length, pelvic angle, shoulder angle, thoracic angle, lumbar angle, pelvic sacral angle) were performed before and after the 12-week treatment. The values at each time point were compared.

RESULTS:

There were significant treatment effects in a time-dependent manner on every efficacy assessment (p< 0.05) after 12 weeks of bracing.

CONCLUSION:

In this clinical study, it was demonstrated that a new brace that is more comfortable for the wearer reduced scoliosis and may be a useful option for non-operative treatment of scoliosis.

Spinal manipulation after multiple fusions in an adult with scoliosis: a case report

BACKGROUND

Spinal fusion (SF)is a common surgical intervention for individuals with idiopathic scoliosis. However, individuals may experience continued pain and disability from suspected mechanical dysfunction.

CASE DESCRIPTION

The purpose of this case report was to describe how specific thrust manipulation (TM) was used to treat a patient with scoliosis after multilevel SF. The 25-year-old female patient presented with left-sided pain in the rib, thoracic, and lumbar and sacroiliac joint regions that had been aggravated by trail running. After clearance from her surgeon, physical therapy examination and subsequent diagnosis were consistent with mechanical dysfunction of the ribs, lumbar spine, and sacroiliac joint causing decreased ability to participate in high-level activities, such as running.

OUTCOMES

The patient was treated for eight visits her 4 months with specific TM, movement analysis, and physiotherapeutic scoliosis-specific exercises. Pain and function were assessed with the Trunk Appearance Perception scale (TAPS), Scoliosis Research Society questionnaire (SRS-22), Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), and spirometry. Pain and function improved during treatment, but outcomes for the ODI and spirometry remained the same.

DISCUSSION

The current case report suggests specific TM to areas outside of the fused spinal segments may be beneficial for decreasing pain and improving functional activities and participation levels. However, more research is needed to verify the efficacy of this treatment in clinical practice.

Scoliosis in adulthood-a case with untreated early onset scoliosis presenting at the age of 76 years

[Purpose] Untreated early-onset scoliosis may eventually progress to more than 90° after growth, cause severe health problems, and increase chance of mortality. Therefore, surgical intervention is often indicated prior to the development of a life-threatening deformity. This case report aims to reveal how a 76-year-old male patient with curves exceeding 110° is functioning with minimal difficulty. [Subject and Methods] The patient, who has never had surgical intervention for scoliosis, can perform his everyday activities. His curves were 111° thoracic and 118° lumbar when he presented at the author’s office in January 2015. [Results] The patient reported that he rarely needs a physician and participates in endurance sports like jogging. Despite this, the patient recognizes his restrictive ventilation disorder (shortness of breath) when he is inactive. The patient complained of shortness of breath and cosmetic concerns. [Conclusion] The current guidelines indicate that early-onset scoliosis should be operated at a young age; however, this protocol is not supported by high-quality evidence. Notably, patients with curvatures exceeding 100° after puberty may have a reasonable quality of life when they lead an active life with regular participation in endurance sports and physical rehabilitation.

Long-Term Effects of Untreated Adolescent Idiopathic Scoliosis: A Review of the Literature

Currently, adolescent idiopathic scoliosis (AIS) is principally regarded as benign, but some researchers have cited serious or extreme effects, including severe pain, cardiopulmonary compromise, social isolation, and even early death. Therefore, exploration of the long-term effects of AIS, the most common type of idiopathic scoliosis, is warranted. The purpose of this review was to examine the long-term studies on the natural history of AIS and/or reviews concerning the long-term effects of untreated AIS. A PubMed search was conducted using the key words idiopathic scoliosis, long-term effects and idiopathic scoliosis, natural history. For further analysis, references cited in those studies were reviewed for additional, related evidence not retrieved in the initial PubMed search. A review of the pertinent bibliography showed that older natural history studies did not distinguish between late-onset scoliosis (referred to in this paper as AIS) and early-onset scoliosis (EOS). The more recent studies offer such important distinction and reach to the general conclusion that untreated AIS does not lead to severe consequences with respect to signs and symptoms of scoliosis. It is possible that earlier studies may have included patient populations with EOS, leading to the perception of untreated scoliosis as having an unusually high morbidity rate. Studies on the long-term effects of AIS that specifically excluded EOS patients conclude that AIS is a benign disorder. This indicates that for research and reporting purposes, it is important to distinguishing between AIS and EOS. This will allow the practitioner and patient and their families to decide on an optimal treatment plan based on the most appropriate prognosis.

Adolescent idiopathic scoliosis and back pain

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

[Perceived self-image in adolescent idiopathic scoliosis: an integrative review of the literature]

OBJECTIVE

To learn about the experiences of adolescents diagnosed with idiopathic scoliosis.

METHOD

Integrative review of the literature published within a specified time frame.

RESULTS

For both sexes, the predominant clinical symptom of this condition appears to be the negative effect that the deformity exerts on perceived self-image. Quantitative studies used numerical scores to assess perceptions of body image but did not analyse emotional aspects. Patients treated surgically were found to have a better self-image than patients treated with a brace. Quality of life was improved by a reduction in the magnitude of the curve.

CONCLUSION

Spinal deformity exerts a psychological effect on adolescent girls.

Comparison of the Combined Anterior-Posterior Approach versus Posterior-Only Approach in Scoliosis Treatment

Study Design

This is descriptive analytical study.

Purpose

The present study aims at comparing treatment results found between the two groups comprising of patients who underwent posterior spinal fusion using thoracic pedicle screws and the ones who underwent combined anterior-posterior method, respectively.

Overview of Literature

There was controversy about surgical techniques including anterior, posterior, or a combined anterior-posterior approaches are applied to treat non-congenital scoliosis with surgical indications.

Methods

Medical records of 50 patients suffering from thoracic non-congenital scoliosis with curves exceeding 70° were reviewed. In this study, 25 patients who underwent posterior spinal fusion using thoracic pedicle screws were compared with 25 patients who underwent combined anterior-posterior method.

Results

Patients treated through posterior-only and combined approaches were respectively hospitalized for 11.84±5.18 and 26.5±5.2 days (p=0.001). There was a significant difference between these two groups considering intensive care unit admission duration (p=0.001), correction in sagittal view of X-ray (p=0.01), and number of days the patients underwent traction (0.001). Finally, coronal view was corrected without any significant difference (p=0.2).

Conclusions

According to our findings, it is hypothesized that posterior-only method is associated with some significant advantages and is an advisable method in patients with severe scoliosis over than 70°.

Perioperative concerns in pediatric patients u10/1/2013ndergoing different types of scoliosis correction surgery: A retrospective observational study

Background:

Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction.

Objectives:

To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery.

Patients and Methods:

After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution.

Results:

Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobb's angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care.

Conclusions:

Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients.

An FE investigation simulating intra-operative corrective forces applied to correct scoliosis deformity

Background

Adolescent idiopathic scoliosis (AIS) is a deformity of the spine, which may require surgical correction by attaching a rod to the patient’s spine using screws implanted in the vertebral bodies. Surgeons achieve an intra-operative reduction in the deformity by applying compressive forces across the intervertebral disc spaces while they secure the rod to the vertebra. We were interested to understand how the deformity correction is influenced by increasing magnitudes of surgical corrective forces and what tissue level stresses are predicted at the vertebral endplates due to the surgical correction.

Methods

Patient-specific finite element models of the osseoligamentous spine and ribcage of eight AIS patients who underwent single rod anterior scoliosis surgery were created using pre-operative computed tomography (CT) scans. The surgically altered spine, including titanium rod and vertebral screws, was simulated. The models were analysed using data for intra-operatively measured compressive forces – three load profiles representing the mean and upper and lower standard deviation of this data were analysed. Data for the clinically observed deformity correction (Cobb angle) were compared with the model-predicted correction and the model results investigated to better understand the influence of increased compressive forces on the biomechanics of the instrumented joints.

Results

The predicted corrected Cobb angle for seven of the eight FE models were within the 5° clinical Cobb measurement variability for at least one of the force profiles. The largest portion of overall correction was predicted at or near the apical intervertebral disc for all load profiles. Model predictions for four of the eight patients showed endplate-to-endplate contact was occurring on adjacent endplates of one or more intervertebral disc spaces in the instrumented curve following the surgical loading steps.

Conclusion

This study demonstrated there is a direct relationship between intra-operative joint compressive forces and the degree of deformity correction achieved. The majority of the deformity correction will occur at or in adjacent spinal levels to the apex of the deformity. This study highlighted the importance of the intervertebral disc space anatomy in governing the coronal plane deformity correction and the limit of this correction will be when bone-to-bone contact of the opposing vertebral endplates occurs.

Postoperative pain management after spinal fusion surgery: an analysis of the efficacy of continuous infusion of local anesthetics

Spinal fusion surgery is a major surgery that results in severe postoperative pain, therefore pain reduction is a primary concern. New strategies for pain management are currently under investigation and include multimodal treatment. A 3-year retrospective analysis of patients with idiopathic scoliosis undergoing spinal fusion surgery was performed at our hospital, assessing patient pain scores, opioid use, and recovery. We evaluated the effect of adding continuous infusion of local anesthetics (CILA) to a postoperative pain management protocol that includes intraoperative intrathecal morphine, as well as postoperative patient-controlled analgesia and oral opioid/acetaminophen combination. The study compared 25 patients treated according to the standard protocol, with 62 patients treated with CILA in addition to the pain management protocol. Patients in the CILA group used nearly 0.5 mg/kg less opioid analgesics during the first 24 hours after surgery.

Scoliosis short-term rehabilitation (SSTR) according to 'Best Practice' standards-are the results repeatable?

Claims have been made in a pilot study that a new form of short-term rehabilitation according to 'Best Practice' standards would change signs and symptoms of patients with scoliosis in the short-term. Aim of this study is to repeat the study published 2010 with a larger sample of patients using the same protocol. Both authors have undergone training in this special approach to scoliosis rehabilitation in 2010.

Surgical and conservative treatment of patients with congenital scoliosis: α search for long-term results

Background

In view of the limited data available on the conservative treatment of patients with congenital scoliosis (CS), early surgery is suggested in mild cases with formation failures. Patients with segmentation failures will not benefit from conservative treatment. The purpose of this review is to identify the mid- or long-term results of spinal fusion surgery in patients with congenital scoliosis.

Methods

Retrospective and prospective studies were included, reporting on the outcome of surgery in patients with congenital scoliosis. Studies concerning a small numbers of cases treated conservatively were included too. We analyzed mid-term (5 to 7 years) and long-term results (7 years or more), both as regards the maintenance of the correction of scoliosis and the safety of instrumentation, the early and late complications of surgery and their effect on quality of life.

Results

A small number of studies of surgically treated patients were found, contained follow-up periods of 4-6 years that in the most cases, skeletal maturity was not yet reached, and few with follow-up of 36-44 years. The results of bracing in children with congenital scoliosis, mainly in cases with failure of formation, were also studied.

Discussion

Spinal surgery in patients with congenital scoliosis is regarded in short as a safe procedure and should be performed. On the other hand, early and late complications are also described, concerning not only intraoperative and immediate postoperative problems, but also the safety and efficacy of the spinal instrumentation and the possibility of developing neurological disorders and the long-term effect these may have on both lung function and the quality of life of children.

Conclusions

Few cases indicate the long-term results of surgical techniques, in the natural progression of scoliosis. Similarly, few cases have been reported on the influence of conservative treatment.

In conclusion, patients with segmentation failures should be treated surgically early, according to the rate of deformity formation and certainly before the pubertal growth spurt to try to avoid cor- pulmonale, even though there is lack of evidence for that in the long-term. Furthermore, in patients with formation failures, further investigation is needed to document where a conservative approach would be necessary.

Idiopathic scoliosis patients with curves more than 45 Cobb degrees refusing surgery can be effectively treated through bracing with curve improvements

BACKGROUND CONTEXT

It is a broad consensus today that scoliosis curves cannot be improved through bracing, and the Scoliosis Research Society (SRS) methodological criteria for bracing have the avoidance of progression as their only objective. Consequently, in curves more than 45°, fusion is considered as basically the only possible treatment.

PURPOSE

The purpose of the study was to verify in a series of patients who utterly refused surgery if it was possible to achieve improvements of scoliosis of more than 45° through a complete conservative treatment (bracing and exercises).

STUDY DESIGN/SETTING

Retrospective cohort from a prospective database.

PATIENT SAMPLE

Out of 1,148 idiopathic scoliosis (IS) patients at the end of treatment, the sample comprised 28 subjects older than 10 years, still growing, with at least one curve above 45°, who had continually refused fusion. The group comprised 24 females and four males, including 14 in which previous brace treatments had failed; at the start of treatment, the age was 14.2±1.8 years and Cobb degrees in the curve were 49.4° (range, 45°-58°). Subgroups considered were gender, bone age, type of scoliosis, treatment used, and previous failed treatment.

OUTCOME MEASURES

Self-report measurement: SRS-22; physiological measures: Cobb degrees, Bunnell angle of trunk rotation (ATR), aesthetic index (AI), and sagittal plumb line distances.

METHODS

The methods comprised full-time treatment (23 or 24 hours per day) for 1 year with Risser cast, Lyon, or Sforzesco brace; weaning of 1 to 2 hours every 6 months; with strategies to maximize compliance through the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) management criteria applied and specific scientific exercises approach to scoliosis exercises (SEAS) performed.

RESULTS

Reported compliance in the 4.10±1.2 treatment years was 94%, with satisfaction regarding treatment and excellent results at the SRS-22. Two patients (7%) remained above 50° Cobb but six patients (21%) finished between 30° and 35° Cobb and 12 patients (43%) finished between 36° and 40° Cobb. Improvements have been found in 71% of patients and a 5° Cobb progression in one patient. Statistically, we found highly significant reductions of the main (-9.25°), average (-6.6°), thoracic (-7.8°), and lumbar (-15.9°) curves. Statistically significant improvements have been found for the AI and ATR, with a general decrease in plumb line distances.

CONCLUSIONS

Bracing can be successfully used in patients who do not want to undergo operations for IS with curves ranging between 45° and 60° Cobb, given sufficient clinical expertise to apply good braces and achieve great compliance. Future studies could demonstrate the percentages at which this result can be achieved.

Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review

BACKGROUND

Some patients with mild or moderate thoracic scoliosis (Cobb angle <50-60 degrees) suffer disproportionate impairment of pulmonary function associated with deformities in the sagittal plane and reduced flexibility of the spine and chest cage. Long-term improvement in the clinical signs and symptoms of childhood onset scoliosis in an adult, without surgical intervention, has not been documented previously.

CASE PRESENTATION

A diagnosis of thoracic scoliosis (Cobb angle 45 degrees) with pectus excavatum and thoracic hypokyphosis in a female patient (DOB 9/17/52) was made in June 1964. Immediate spinal fusion was strongly recommended, but the patient elected a daily home exercise program taught during a 6-week period of training by a physical therapist. This regime was carried out through 1992, with daily aerobic exercise added in 1974. The Cobb angle of the primary thoracic curvature remained unchanged. Ongoing clinical symptoms included dyspnea at rest and recurrent respiratory infections. A period of multimodal treatment with clinical monitoring and treatment by an osteopathic physician was initiated when the patient was 40 years old. This included deep tissue massage (1992-1996); outpatient psychological therapy (1992-1993); a daily home exercise program focused on mobilization of the chest wall (1992-2005); and manipulative medicine (1994-1995, 1999-2000). Progressive improvement in chest wall excursion, increased thoracic kyphosis, and resolution of long-standing respiratory symptoms occurred concomitant with a >10 degree decrease in Cobb angle magnitude of the primary thoracic curvature.

CONCLUSION

This report documents improved chest wall function and resolution of respiratory symptoms in response to nonsurgical approaches in an adult female, diagnosed at age eleven years with idiopathic scoliosis.

How to improve aesthetics in patients with Adolescent Idiopathic Scoliosis (AIS): a SPoRT brace treatment according to SOSORT management criteria

BACKGROUND

Aesthetics is a main goal of both conservative and surgical treatments in adolescent idiopathic scoliosis (AIS). Previously, we developed and validated a clinical scale - the Aesthetic Index (AI)--in order to measure aesthetic impairment and changes during treatment.

AIM

To verify the efficacy of bracing on aesthetics in AIS.

STUDY DESIGN

Prospective Cohort Study.

POPULATION

Thirty-four consecutive patients, age 13.2 +/- 3.7, initial Cobb Angle 32 +/- 12 degrees , ATR 10 +/- 4 degrees Bunnel, 11 males.

METHODS

Patients with AI scores of at least 5/6 were included. Each of them had a brace prescription (18 to 23 hours per day), according to the SPoRT concept. AI was measured again after six months and at the end of treatment, and then the pre- and post-treatment scores compared. The Wilcoxon test was performed.

RESULTS

Twenty-nine patients out of the 34 included completed the treatment and had six-month and final results; four patients were lost during the treatment, and one was fused. At baseline, median AI was 6 (95% IC 5-6) but the score decreased to 3 (95% IC 0-5; p < 0.05) after six months with brace, and this value was maintained in the 29 who completed the treatment (95% IC 1-6; p < 0.05 with respect to the baseline).

CONCLUSION

Aesthetics can be improved in a clinically significant way when the brace treatment is performed according to the SPoRT concept and by following the SOSORT management criteria. This is a relevant result for patients and a major goal of scoliosis treatment, be it conservative or surgical. The use of a more sensitive tool like TRACE could more easily detect the clinical changes; nevertheless, AI proved sensible enough that its use in everyday clinical practice can be suggested.

Towards an understanding of the information and support needs of surgical adolescent idiopathic scoliosis patients: a qualitative analysis

Background

Informed decision making for adolescents and families considering surgery for scoliosis requires essential information, including expected outcomes with or without treatment and the associated risks and benefits of treatment. Ideally families should also receive support in response to their individual concerns. The aim of this study was to identify health-specific needs for online information and support for patients with adolescent idiopathic scoliosis who have had or anticipate having spinal surgery.

Methods

Focus group methodology was chosen as the primary method of data collection to encourage shared understandings, as well as permit expression of specific, individual views. Participants were considered eligible to participate if they had either experienced or were anticipating surgery for adolescent idiopathic scoliosis within 12 months, were between the ages of 10 and 18 years of age, and were English-speaking.

Results

Two focus groups consisting of 8 adolescents (1 male, 7 female) and subsequent individual interviews with 3 adolescents (1 male, 2 female) yielded a range of participant concerns, in order of prominence: (1) recovery at home; (2) recovery in hospital; (3) post-surgical appearance; (4) emotional impact of surgery and coping; (5) intrusion of surgery and recovery of daily activities; (6) impact of surgery on school, peer relationships and other social interactions; (7) decision-making about surgery; (8) being in the operating room and; (9) future worries.

Conclusion

In conclusion, adolescents welcomed the possibility of an accessible, youth-focused website with comprehensive and accurate information that would include the opportunity for health professional-moderated, online peer support.

Scoliosis in patients with Prader Willi Syndrome - comparisons of conservative and surgical treatment

In children with Prader Willi syndrome (PWS), besides growth hormone (GH) therapy, control of the food environment and regular exercise, surgical treatment of scoliosis deformities seems the treatment of choice, even though the risks of spinal surgery in this specific population is very high. Therefore the question arises as to whether the risks of spinal surgery outweigh the benefits in a condition, which bears significant risks per se. The purpose of this systematic review of the Pub Med literature was to find mid or long-term results of spinal fusion surgery in patients with PWS, and to present the conservative treatment in a case study of nine patients with this condition.

METHODS

Types of studies included; all kinds of studies; retrospective and prospective ones, which reported upon the outcome of scoliosis surgery in patients with PWS.Types of participants included: patients with scoliosis and PWS.Type of intervention: surgery.Search strategy for identification of the studies; Pub Med; limited to English language and bibliographies of all reviewed articles.Nine patients with PWS from our data-base treated conservatively have been found, being 19 years or over at the time this study has been performed. The results of conservative management are described and related to the natural history and treatment results found in the Pub Med review.

RESULTS

From 2210 titles displayed in the Pub Med database with the key word being "Prader Willi syndrome", 5 different papers were displayed at the date of the search containing some information on the outcome of surgery and none appeared to contain a mid or long-term follow-up. The PWS patients treated conservatively from our series all stayed below 70 degrees and some of which improved.

DISCUSSION

If the curve of scoliosis patients with PWS can be kept within certain limits (usually below 70 degrees) conservatively, this treatment seems to have fewer complications than surgical treatments. The results of our retrospective study of nine patients demonstrate that scoliosis in this entity plays only a minor role and surgery is unnecessary when high quality conservative management exists.

CONCLUSION

There is lack of the long follow-up studies in post-surgical cases in patients with PWS and scoliosis. The rate of complications of spinal fusion in patients with PWS and scoliosis is very high and the death rates have been found to be higher than in patients with Adolescent Idiopathic Scoliosis (AIS). The long-term side-effects of the intervention are detrimental, so that the risk-benefit ratio favours the conservative approaches over spinal fusion surgery.

Adolescent idiopathic scoliosis - to operate or not? A debate article

Adolescent idiopathic scoliosis (AIS) represents a rare condition with a potentially detrimental impact on young patients. Despite vast clinical research and published treatment guidelines and algorithms, the optimal therapeutic choice for these patients remains highly controversial. While advocates of early surgery emphasize the benefits of surgical deformity correction with regard to physical and psychological outcome, the opponents base their arguments on the high risk of complications and a lack of documented subjective long-term outcome. In the present paper, the authors were invited to debate the opposite positions of "pro" versus "contra" surgical treatment of AIS, based on the currently available evidence and published guidelines.