Patient and parental perception of adolescent idiopathic scoliosis before and after surgery in comparison with surface and radiographic measurements

Anterior Spinal Fusion for Thoraco-Lumbar Idiopathic Scoliosis Comparing Less Invasive Concave versus Traditional Convex Approach: A Pilot Study

Background/Objectives: Anterior spinal fusion for primary thoracolumbar or lumbar (TL/L) adolescent idiopathic scoliosis, AIS, has advantages over posterior fusion, particularly in saving motion segments below the fusion construct. Traditionally, the approach is anterolaterally from the convexity. In adult degenerative scoliosis, the lateral or anterolateral approach may be performed from the traditional or from the concave approach which is less invasive and gives comparable outcomes. The purpose of the present pilot study was to assess the feasibility of the less invasive concave approach for younger AIS patients and compare it to the traditional convex approach over a 5-year follow-up period. Methods: The two cohorts were assessed by comparing pre- to postoperative radiographs, and clinical outcomes for pain, function, self-perception of appearance, and opinion of surgical success were prospectively obtained. Results: Radiographs found that primary TL/L scoliosis significantly improved from 53° to 18° (65%) for both the concave and convex cohorts. Sagittal alignments remained stable and there was no difference between cohorts. Coronal balance improved in both cohorts and sagittal balance was stable for both. Clinically, VAS back pain improved significantly for both cohorts initially and remained improved in the concave group. Leg pain, pain drawing, ODI disability, and VAS appearance scores improved and there was no difference between cohorts. The self-rating of success of the procedure was 100% at early and late follow-up periods. There were no neurological/surgical complications. Conclusions: The concave approach for anterior fusion for TL/L AIS is feasible with comparable radiographic and clinical outcomes to the traditional approach.

Determination of predictors associated with pain in non‑surgically treated adults with idiopathic scoliosis

BACKGROUND

It is recognized that pain related to adult individuals with idiopathic scoliosis (IS) substantially impacts individuals' daily activities and quality of life. The objective of this study was to identify the possible predictors of pain intensity in non‑surgically treated adults with IS.

METHODS

This cross-sectional study included 58 adults individuals with Lenke type 1 IS. Participants' sociodemographic characteristics were recorded, and pain severity, curvature severity, trunk rotation angle, disability, spinal mobility, cosmetic deformity perception, and quality of life were assessed. Regression analyses with various models were performed to determine the predictors of pain severity and the best model was selected based on performance criteria.

RESULTS

Strong associations were found between pain severity with curvature severity, spinal mobility, trunk rotation angle, perception of cosmetic deformity, disability, and quality of life (p < 0.05). It was observed that Lasso regression was the best model based on the performance criteria considered. According to this model, the primary predictors of pain intensity in adult IS were determined as curvature severity, spinal mobility, trunk rotation angle, cosmetic deformity perception, back-related disability and quality of life, in order of importance.

CONCLUSION

In accordance with the findings of this study, which examined for the first time the determinants of pain intensity in adult individuals with Lenke type 1 IS, we suggest that mentioned possible factors affecting and determining pain should be taken into consideration when establishing evaluation and treatment programs.

Changes in trunk appearance following surgical correction of adolescent idiopathic scoliosis

PURPOSE

To assess the postoperative appearance of the trunk in surgically treated scoliosis patients after a 2 year follow-up using reliable indices and compare the results with 6-month follow-up.

METHODS

Forty-six Adolescent Idiopathic Scoliosis (AIS) patients (female; preop mean age 14.4 ± 2.4 years) who underwent a posterior spinal fusion from 2009 to 2018 were included in this study. All had Lenke 1A thoracic curves, with surface topography taken preoperatively, 6 months and 2 years postoperatively. To assess spinal deformity, we measured the proximal thoracic, main thoracic and thoracolumbar/lumbar Cobb angles in the frontal plane from spinal X-rays and inclinometer angles in the thoracic and lumbar regions. To assess trunk deformity, Back Surface Rotation (BSR) and Trunk Lateral Shift (TLS) were computed along the trunk. We analysed the effect of age, height, weight, Cobb angle, length of follow-up, and surgical technique. We also compared correction rates (CRs) of the spinal and trunk measurements after 6 months and 2 years.

RESULTS

Good spinal correction was achieved, with Cobb angles decreasing in the whole cohort. CRs for TLS and BSR were positive (denoting improvement) for 76% and 48% of patients, respectively, after 2 years. Compared with 6 months, the mean TLS CR increased while there was no improvement for BSR on average. We found no significant association after 2 years between truncal index CRs and clinical variables (age, height, weight, preoperative Cobb angles) or surgical technique. However, there were significant correlations between the CRs of TLS and the main thoracic Cobb angle (r = 0.35), and between the CRs of BSR and thoracic inclinometer angle.

CONCLUSION

Although more than 55% of the TLS was corrected after 2 years of follow-up, the BSR remained stable over time and the persistence of rib hump on the back surface could be observed.

LEVEL OF EVIDENCE

III.

Automatic assessment of scoliosis surgery outcome on trunk shape using left-right trunk asymmetry

PURPOSE

To present a novel set of Left-Right Trunk Asymmetry (LRTA) indices and use them to assess the postoperative appearance of the trunk in Adolescent Idiopathic Scoliosis (AIS) patients.

METHODS

We hypothesize that LRTA measurements provide complementary information to existing trunk asymmetry indices when documenting the outcome of scoliosis surgery. Forty-nine AIS patients with thoracic curves who underwent posterior spinal fusion were included. All had surface topography scans taken preoperatively and at least 6 months postoperatively. We documented spinal curvature using Radiographic Cobb angles, scoliometer readings and coronal balance. To evaluate Global Trunk Asymmetry (GTA), we used the standard measures of Back Surface Rotation (BSR) and Trunk Lateral Shift (TLS). To measure LRTA, we identified asymmetry areas as regions of significant deviation between the left and right sides of the 3D back surface. New parameters called Deformation Rate (DR) and Maximum Asymmetry (MA) were measured in different regions based on the asymmetry areas. We compared the GTA and LRTA changes with those in spinal curvature before and after surgery.

RESULTS

The GTA indices, mainly TLS, showed improvement for more than 75% of patients. There was significant improvement of LRTA in the shoulder blades and waist regions (95% and 80% of patients respectively).

CONCLUSION

We report positive outcomes for LRTA in the majority of patients, specifically in the shoulder blades and waist, even when no reduction of BSR is observed. The proposed indices can evaluate local trunk asymmetries and the degree to which they are improved or worsened after scoliosis surgery.

Pedicle Dysplasia in Proximal Thoracic Adolescent Idiopathic Scoliosis Curves: What are We Missing and What are its Possible Surgical Implications? An Observational Retrospective Study on 104 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To assess if pedicle dysplasia is present in proximal thoracic (PT), both structural and nonstructural, compared to main thoracic (MT) curves; and to assess if it is predictive of radiographic outcomes at minimum 2 years of follow-up.

METHODS

A retrospective review of surgically-treated Adolescent Idiopathic Scoliosis (AIS) patients with Lenke 1-2-3-4 curves was performed. On preoperative CT-scan, at the apical vertebra, pedicle width on the concavity (PWc) and on the convexity (PWv) and Pedicle Dysplasia Index (PDI, defined as PWc/PWv) were measured. Preoperative and last follow-up (at least 2 years) x-rays were reviewed.

RESULTS

104 patients meeting the inclusion criteria were divided into Structural-PT (S-PT) and Nonstructural-PT (NS-PT) groups based on Lenke criteria. PWc (P < .001). And PDI (P < .001 for S-PT, P = .004 for NS-PT) were significantly smaller in the PT than in MT curves for both groups. PT-PWc significantly correlated with follow-up PT Cobb for both groups (P < .001 and P = .015 respectively). PT-PDI significantly correlated with follow-up PT-Cobb (P < .001), CA (P < .040) and T1 tilt (P < .002), only for NS-PT group. NS-PT patients with PWc PT <1 mm had higher RSHD (P = .021) and T1 tilt (P = .025) at follow-up. NS-PT patients with PDI PT <.3 had higher RSHD (P < .001), CA (P = .002) and T1 tilt (P = .003) at follow-up.

CONCLUSION

S-PT and NS-PT curves show significant pedicle dysplasia on the concavity. Pedicle dysplasia significantly correlated with shoulder balance at follow-up, for NS-PT patterns. Patients with a PWc <1 mm or PDI <.30 are at particular risk of postoperative shoulder imbalance.

Thoracic Cage Deformity Correction in Patients with Lenke Type 1 Adolescent Idiopathic Scoliosis

Whether the thoracic cage deformity in adolescent idiopathic scoliosis (AIS) can be sufficiently treated with vertebral derotation alone, has been quite controversial. Our aim is to control the hypothesis that the rib cage deformity (RCD) may be adequately corrected when only vertebral derotation is applied. We studied retrospectively patients treated for AIS with posterior spinal fusion without costoplasty. The RCD was assessed on lateral radiographs by rib index (RI). The correction of RI after surgery was calculated. Of the 103 patients that were finally included in our study, 29 patients (22 females and 7 males; mean age, 14.5 ± 2.1 years) represented Group A (Harrington rod instrumentation - no derotation), while 74 patients (61 females and 13 males; mean age, 14.1 ± 2.4 years) were operated with either a full pedicle screw system or a hybrid construct with hooks and pedicle screws (Group B-derotation). RI was significantly corrected after surgery in both groups. RI was significantly greater in Group A after surgery. Whatsoever, the correction of RI, thereby the RCD correction, did not significantly differ among groups. In conclusion, it cannot be suggested by the present study that vertebral derotation alone can offer an absolute correction of the deformity of the thoracic cage in patients with Lenke Type 1 AIS, and it seems also that the development of RCD may not exclusively result from the spinal deformity, thus questions can be further raised regarding scoliogeny per se.

Evidence of causality of low body mass index on risk of adolescent idiopathic scoliosis: a Mendelian randomization study

Introduction

Adolescent idiopathic scoliosis (AIS) is a disorder with a three-dimensional spinal deformity and is a common disease affecting 1-5% of adolescents. AIS is also known as a complex disease involved in environmental and genetic factors. A relation between AIS and body mass index (BMI) has been epidemiologically and genetically suggested. However, the causal relationship between AIS and BMI remains to be elucidated.

Material and methods

Mendelian randomization (MR) analysis was performed using summary statistics from genome-wide association studies (GWASs) of AIS (Japanese cohort, 5,327 cases, 73,884 controls; US cohort: 1,468 cases, 20,158 controls) and BMI (Biobank Japan: 173430 individual; meta-analysis of genetic investigation of anthropometric traits and UK Biobank: 806334 individuals; European Children cohort: 39620 individuals; Population Architecture using Genomics and Epidemiology: 49335 individuals). In MR analyses evaluating the effect of BMI on AIS, the association between BMI and AIS summary statistics was evaluated using the inverse-variance weighted (IVW) method, weighted median method, and Egger regression (MR-Egger) methods in Japanese.

Results

Significant causality of genetically decreased BMI on risk of AIS was estimated: IVW method (Estimate (beta) [SE] = -0.56 [0.16], p = 1.8 × 10-3), weighted median method (beta = -0.56 [0.18], p = 8.5 × 10-3) and MR-Egger method (beta = -1.50 [0.43], p = 4.7 × 10-3), respectively. Consistent results were also observed when using the US AIS summary statistic in three MR methods; however, no significant causality was observed when evaluating the effect of AIS on BMI.

Conclusions

Our Mendelian randomization analysis using large studies of AIS and GWAS for BMI summary statistics revealed that genetic variants contributing to low BMI have a causal effect on the onset of AIS. This result was consistent with those of epidemiological studies and would contribute to the early detection of AIS.

Increased proximal vertebral rotation is associated with shoulder imbalance after posterior spinal fusion for severe adolescent idiopathic scoliosis

PURPOSE

Residual shoulder imbalance is associated with suboptimal outcomes following the surgical correction of adolescent idiopathic scoliosis (AIS) including poor patient satisfaction. In this retrospective study, we evaluate the radiographic parameters and the relationship between the global and local indices of spinal alignment with shoulder balance pre- and postoperatively utilizing EOS imaging and 3D reconstruction.

METHODS

A retrospective radiographic analysis was performed on patients with AIS, treated with posterior spinal fusion. Postoperative radiographs were obtained immediately following surgery, at 6 months and final follow-up over 2 years postoperatively. 3D Radiographic measurements included in the coronal plane radiographic shoulder height difference (RSHD), proximal thoracic Cobb angle (PT) and main thoracic Cobb (MT), in the sagittal plane T4-T12 kyphosis, T12-L5 lordosis, in the axial plane proximal thoracic (PT AVR) and main thoracic apical vertebral rotation (MT AVR).

RESULTS

Sixty-six patients were included (63 females) with an average main thoracic curvature of 76 degrees. RSHD averaged 14 mm ± 14 preoperatively, -15 mm ± 12 postoperatively, -8.5 mm ± 11 at 6 months, and -8.3 mm ± 8.7 at final follow-up, respectively. Statistical analysis revealed a significant correlation between RSHD and proximal thoracic Cobb angle, between RSHD and proximal thoracic apical vertebral rotation (PTAVR) (r > 0.20, p < 0.05).

CONCLUSION

The significant correlation presented in this study suggests that PT Cobb angle and PT AVR are involved in postoperative shoulder imbalance.

THE LEVEL OF EVIDENCE

Level 4.

A Novel Classification of 3D Rib Cage Deformity in Subjects With Adolescent Idiopathic Scoliosis

STUDY DESIGN

This was a multicentric cross-sectional descriptive study.

OBJECTIVE

To analyze patterns of 3D rib cage deformity in subjects with adolescent idiopathic scoliosis (AIS) and their relationship with the spinal deformity.

SUMMARY OF BACKGROUND DATA

Subjects with AIS present with rib cage deformity that can affect respiratory functions. The 3D rib cage deformities in AIS and their relationship to the spinal deformity are still unelucidated.

METHODS

A total of 200 AIS and 71 controls underwent low-dose biplanar x-rays and had their spine and rib cage reconstructed in 3-dimensional (D). Classic spinopelvic parameters were calculated in 3D and: rib cage gibbosity, thickness, width, volume and volumetric spinal penetration index (VSPI). Subjects with AIS were classified as: group I with mild rib cage deformity (n=88), group II with severe rib cage deformity (n=112) subgrouped into IIa (high gibbosity, n=48), IIb (high VSPI, n=48), and IIc (both high gibbosity and VSPI, n=16).

RESULTS

Groups IIa and IIb had a higher Cobb angle (33 vs. 54 degrees and 46 degrees, respectively) and torsion index (11 vs. 14 degrees and 13 degrees, respectively) than group I. Group IIb showed more severe hypokyphosis (IIb=21 degrees; IIa=33 degrees; I=36 degrees; control=42 degrees) with a reduced rib cage volume (IIb=4731 cm3; IIa=4985 cm3; I=5257 cm3; control=5254 cm3) and thickness (IIb=135 mm; IIa=148 mm; I=144 mm; control=144 mm). Group IIa showed an increasingly large local gibbosity descending from proximal to distal levels and did not follow the axial rotation of the spine. Group IIc showed characteristics of both groups IIa and IIb.

CONCLUSIONS

This new classification of 3D rib cage deformity in AIS shows that the management of cases with high VSPI (groups IIb and IIc) should focus on restoring as much kyphosis as possible to avoid respiratory repercussions. Treatment indications in groups I and IIa would follow the consensual basic principles reported in the literature regarding bracing and surgery.

Polygenic Risk Score of Adolescent Idiopathic Scoliosis for Potential Clinical Use

Adolescent idiopathic scoliosis (AIS) is a common disease causing three-dimensional spinal deformity in as many as 3% of adolescents. Development of a method that can accurately predict the onset and progression of AIS is an immediate need for clinical practice. Because the heritability of AIS is estimated as high as 87.5% in twin studies, prediction of its onset and progression based on genetic data is a promising option. We show the usefulness of polygenic risk score (PRS) for the prediction of onset and progression of AIS. We used AIS genomewide association study (GWAS) data comprising 79,211 subjects in three cohorts and constructed a PRS based on association statistics in a discovery set including 31,999 female subjects. After calibration using a validation data set, we applied the PRS to a test data set. By integrating functional annotations showing heritability enrichment in the selection of variants, the PRS demonstrated an association with AIS susceptibility (p = 3.5 × 10^-40 with area under the receiver-operating characteristic [AUROC] = 0.674, sensitivity = 0.644, and specificity = 0.622). The decile with the highest PRS showed an odds ratio of as high as 3.36 (p = 1.4 × 10^-10 ) to develop AIS compared with the fifth in decile. The addition of a predictive model with only a single clinical parameter (body mass index) improved predictive ability for development of AIS (AUROC = 0.722, net reclassification improvement [NRI] 0.505 ± 0.054, p = 1.6 × 10^-8 ), potentiating clinical use of the prediction model. Furthermore, we found the Cobb angle (CA), the severity measurement of AIS, to be a polygenic trait that showed a significant genetic correlation with AIS susceptibility (rg = 0.6, p = 3.0 × 10^-4 ). The AIS PRS demonstrated a significant association with CA. These results indicate a shared polygenic architecture between onset and progression of AIS and the potential usefulness of PRS in clinical settings as a predictor to promote early intervention of AIS and avoid invasive surgery. © 2021 American Society for Bone and Mineral Research (ASBMR).

Predicting Adolescent Idiopathic Scoliosis among Chinese Children and Adolescents

Objective

Adolescent idiopathic scoliosis (AIS) affects 1%-4% of adolescents in the early stages of puberty, but there is still no effective prediction method. This study aimed to establish a prediction model and validated the accuracy and efficacy of this model in predicting the occurrence of AIS.

Methods

Data was collected from a population-based school scoliosis screening program for AIS in China. A sample of 884 children and adolescents with the radiological lateral Cobb angle ≥ 10° was classified as an AIS case, and 895 non-AIS subjects with a Cobb angle < 10° were randomly selected from the screening system. All selected subjects were screened by visual inspection of clinical signs, the Adam's forward-bending test (FBT), and the measurement of angle of trunk rotation (ATR). LR and receiver operating characteristic (ROC) curves were used to preliminarily screen the influential factors, and LR models with different adjusted weights were established to predict the occurrence of AIS.

Results

Multivariate LR and ROC curves indicated that angle of thoracic rotation (adjusted odds ratios (AOR) = 5.18 − 10.06), angle of thoracolumbar rotation (AOR = 4.67 − 7.22), angle of lumbar rotation (AOR = 6.97 − 8.09), scapular tilt (area under the curve (AUC) = 0.77, 95% CI: 0.75-0.80), shoulder-height difference, lumbar concave, and pelvic tilt were the risk predictors for AIS. LR models with different adjusted weights (by AOR, AUC, and AOR+AUC) performed similarly in predicting the occurrence of AIS compared with multivariate LR. The sensitivity (82.55%-83.27%), specificity (82.59%-83.33%), Youden's index (0.65-0.67), positive predictive value (82.85%-83.58%), negative predictive value (82.29%-83.03%), and total accuracy (82.57%-83.30%) manifested that LR could accurately identify patients with AIS.

Conclusions

LR model is a relatively high accurate and feasible method for predicting AIS. Increased performance of LR models using clinically relevant variables offers the potential to early identify high-risk groups of AIS.

Self-Experienced Trunk Appearance in Individuals With and Without Idiopathic Scoliosis

STUDY DESIGN

Cross-sectional.

OBJECTIVE

The aim of this study was to describe the self-experienced trunk appearance in individuals with and without idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Idiopathic scoliosis is the most common spinal deformity. A large scoliotic deformity increases the risk of back pain and pulmonary dysfunction. The deformity has also a psychological impact.

METHODS

The pictorial part of the spinal appearance questionnaire (pSAQ) was administered to 1416 individuals with idiopathic scoliosis (386 untreated, 529 brace treated, 501 surgically treated) and 272 individuals without scoliosis from the general population. Comparisons were made between individuals with and without scoliosis, between treatment groups and sex in the scoliosis group.

RESULTS

Mean (95% confidence interval) age of the individuals with scoliosis was 36.2 (35.5-36.9) years and for the individuals without scoliosis 40.2 (37.9-42.4). pSAQ total was 12.3 (12.1-12.5) for individuals with scoliosis and 7.4 (7.3-7.6) for individuals without scoliosis (P < 0.001, adjusted for age and sex). pSAQ total was 11.5 (11.1-11.9) for untreated, 13.0 (12.6-13.3) for brace treated, and 12.3 (11.9-12.6) for surgically treated individuals (P < 0.001, adjusted for sex and curve size). The pSAQ total between males and females with idiopathic scoliosis did not differ (P = 0.22 adjusted for age and curve size).

CONCLUSION

This study shows that individuals with idiopathic scoliosis have more concern about their body appearance than individuals without scoliosis. Untreated individuals are not as bothered of their spinal appearance as treated individuals. Males and females with scoliosis do not differ significantly in the perception of their spinal appearance.

LEVEL OF EVIDENCE

3.

Association Between Incorrect Posture and Adolescent Idiopathic Scoliosis Among Chinese Adolescents: Findings From a Large-Scale Population-Based Study

Objectives: Adolescent idiopathic scoliosis (AIS) affects between 1 and 4% of adolescents, and severe curvature may be related to their adverse long-term outcomes. However, whether the change in body appearance is related to AIS remains largely unclear. We aimed to explore the association between incorrect posture and AIS among Chinese adolescents. Methods: Data were collected from a population-based (595,057) school scoliosis screening program in China. A sample of 3,871 adolescents was classified as cases with a diagnosed radiological lateral Cobb angle ≥10°, and 3,987 control subjects with a Cobb angle <10° were randomly selected from the screening system. Adolescents were accessed with demographic information and incorrect posture measured by visual inspection of physical signs, Adam's forward bending test (FBT), and the angle of trunk rotation (ATR). Logistic regression (LR) models were used to examine the associations. Results: Multivariate LR showed that shoulder-height difference, scapula tilt, lumbar concave, and pelvic tilt were associated with AIS. Adolescents with angle of thoracic rotation ≥5° [adjusted odds ratio (AOR) = 5.33-14.67, P < 0.001], thoracolumbar rotation ≥5° (AOR = 4.61-5.79, P < 0.001), or lumbar rotation ≥5° (AOR = 7.49-7.85, P < 0.001) were at especially higher risk for AIS than those with ATR <5°. Conclusions: Incorrect posture may be the potential risk factor for developing AIS, and ATR ≥5° was an important indicator for predicting the occurrence of scoliosis. Early monitoring of incorrect posture for school adolescents should be considered as a routine intervention to effectively identify the progress of scoliosis.

How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the most common spine deformity in adolescent patients. Although structural deformity may affect spinal biomechanics of patients with AIS, little is known regarding various period prevalence proportions of back pain and chronic back pain and factors associated with back pain in such patients.

QUESTIONS/PURPOSES

(1) What are the period prevalence rates of back pain among teenagers with AIS? (2) Is back pain in patients with AIS associated with curve severity?

METHODS

A total of 987 patients with AIS who were treated without surgery were recruited from a single center's scoliosis clinic. Between December 2016 and July 2017, this center treated 1116 patients with suspected AIS. During that time, patients were offered surgery when their Cobb angle was at least 50° and had evidence of curve progression between two visits, and most of the patients who were offered surgery underwent it; other patients with AIS were managed nonsurgically with regular observation, brace prescription, posture training, and reassurance. To be included in this prospective, cross-sectional study, a patient needed to be aged between 10 and 18 years with a Cobb angle > 10°. No followup data were required. A total of 1097 patients with AIS were managed nonsurgically (98.3% of the group seen during the period in question). After obtaining parental consent, patients provided data related to their demographics; physical activity levels; lifetime, 12-month, 30-day, 7-day, and current thoracic pain and low back pain (LBP); chronic back pain (thoracic pain/LBP); brace use; and treatments for scoliosis/back pain. Pain was rated on a 10-point numeric rating scale for pain. The Insomnia Severity Index, Epworth Sleepiness Scale, and Depression Anxiety Stress Scales were also assessed. These features and radiologic study parameters between patients with and without back pain were also compared. Factors associated with current and 12-month back pain as well as chronic back pain were analyzed by multivariate analyses.

RESULTS

Depending on the types of period prevalence, the prevalence of thoracic pain ranged from 6% (55 of 987) within 12 months to 14% (139 of 987) within 7 days, whereas that of LBP ranged from 6% (54 of 987) to 29% (289 of 987). Specifically, chronic thoracic pain or LBP had the lowest prevalence. Compared with the no pain group, patients with current back pain had more severe insomnia (odds ratio [OR], 1.80; p = 0.02; 95% confidence interval [CI], 1.10-2.93) and daytime sleepiness (OR, 2.41; p < 0.001, 95% CI, 1.43-4.07). Those with chronic back pain had the same problems along with moderate depression (OR, 2.49; p = 0.03; 95% CI, 1.08-5.71). Older age (OR range, 1.17-1.42; all p values ≤ 0.030) and Cobb angle > 40° (OR range, 2.38-3.74; all p values ≤ 0.015), daytime sleepiness (OR range, 2.39-2.41; all p values ≤ 0.011), and insomnia (OR range, 1.76-2.31; all p values ≤ 0.001) were associated with episodic and/or chronic back pain. Females were more likely to experience back pain in the last 12 months than males. Moderate depression (OR, 3.29; 1.45-7.47; p = 0.004) and wearing a brace (OR, 3.00; 1.47-6.15; p = 0.003) were independently associated with chronic back pain.

CONCLUSIONS

Biopsychosocial factors are associated with the presence and severity of back pain in the AIS population. Our results highlight the importance of considering back pain screening/management for patients with AIS with their psychosocial profile in addition to curve magnitude monitoring. In particular, sleep quality should be routinely assessed. Longitudinal changes and effects of psychotherapy should be determined in future studies.

LEVEL OF EVIDENCE

Level II, prognostic study.

The Relationship Between Apical Vertebral Rotation and Truncal Rotation in Adolescent Idiopathic Scoliosis Using 3D Reconstructions

STUDY DESIGN

Retrospective review of prospective data.

OBJECTIVES

To evaluate the relationship between absolute apical vertebral rotation (AVR) evaluated with upright 3D imaging and angle of trunk rotation (ATR) before and after surgery for thoracic and lumbar curves in adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

New imaging technology allows for improved radiographic assessment of the degree of AVR pre- and postoperatively through 3D spine models created from biplanar, simultaneous spine radiographs.

METHODS

A prospective registry was queried and identified 55 AIS patients with major thoracic or major thoracolumbar/lumbar curves who underwent posterior spinal fusion. All patients had biplanar upright imaging of their spine and ATR measurements assessed via scoliometer pre- and postoperatively.

RESULTS

There were 33 major thoracic and 22 major lumbar curves. The mean Cobb angles for thoracic and thoracolumbar/lumbar curves were 54° ± 10° and 47° ± 8° preoperatively, and 11 ± 6° and 12 ± 7° postoperatively. The differences in the mean preoperative ATR measurements for both major curve types was not statistically significant; however, the difference in AVR between thoracic curves (13 ± 6°) and lumbar curves (22 ± 7°) was significant (p < .001). There was a significant decrease in the ATR and AVR for both thoracic and thoracolumbar/lumbar curves (p < .001) postoperatively. A significant correlation between ATR and AVR was found only for the major thoracolumbar/lumbar curves (p < .001). The relationship between ATR and AVR changes for both curves was not statistically significant.

CONCLUSION

ATR measured via scoliometer strongly correlates with 3D measurements of AVR in both thoracic and lumbar curves before and after surgery for AIS. No significant relationship was found between the changes in ATR and AVR due to surgery. Postoperatively, greater clinical rotational deformity remains in the thoracic spine compared to the lumbar spine, despite greater apical vertebra axial plane correction in thoracic curves.

LEVEL OF EVIDENCE

Level II, diagnostic.

A Detailed Comparative Analysis of Anterior Versus Posterior Approach to Lenke 5C Curves

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To prospectively compare radiographic, perioperative, and functional outcomes between anterior spinal instrumentation and fusion (ASIF) and posterior spinal instrumentation and fusion (PSIF) in Lenke 5C curves.

SUMMARY OF BACKGROUND DATA

Historically, ASIF has been the treatment of choice for treatment of thoracolumbar adolescent idiopathic scoliosis. More recently, PSIF has gained popularity for its ease, versatility, and amount of correction achieved. Current literature lacks a prospective comparative analysis between these two approaches to better aid treating surgeons in decision making when treating Lenke 5C curves.

METHODS

A prospective, longitudinal multicenter adolescent idiopathic scoliosis database was used to identify 161 consecutive patients with Lenke 5C curves treated by ASIF with a dual rod system, or PSIF with a pedicle screw-rod construct. Pre- and 2-year postoperative radiographic data, Scoliosis Research Society outcome scores, and perioperative comparisons were made between the two approaches.

RESULTS

A total of 69 patients were treated with ASIF and 92 patients with PSIF. Curve extent, magnitude, stable, and end vertebrae distribution before surgery were similar between the two groups. At 2-year follow-up, there were no significant differences in percentage correction of the main curve (ASIF: 59.1%, PSIF: 59.6%), C7 decompensation (ASIF: -0.6 ± 1.2, PSIF: -0.3 ± 1.4 cm), length of hospital stay (ASIF: 5.6 days, PSIF: 5.7 days), postoperative day conversion to oral pain medication (ASIF: 3.2 days, PSIF: 3.2 days), and SRS outcome scores (P = 0.560) between the two groups. The number of levels fused was significantly lower in ASIF group (ASIF: 4.7, PSIF: 6.3; P < 0.001), but PSIF resulted in significantly less disc angulation below lowest instrumented vertebrae (ASIF: 3.4°, PSIF: 1.7°; P = 0.011), greater lumbar lordosis (P < 0.001), and greater % correction of lumbar prominence (P = 0.017).

CONCLUSION

The amount of correction achieved was similar between ASIF and PSIF. ASIF resulted in shorter fusions (average 1.6 levels) compared with PSIF. This was at the expense of increased disc angulation below the lowest instrumented vertebrae, less lumbar lordosis, and a lower % correction of the lumbar prominence than PSIF.

LEVEL OF EVIDENCE

2.

Three-dimensional EOS Analysis of Apical Vertebral Rotation in Adolescent Idiopathic Scoliosis

BACKGROUND

Apical vertebral rotation (AVR) is increasingly recognized as one of the important radiographic parameters in adolescent idiopathic scoliosis (AIS). EOS enables us to precisely measure AVR by 3-dimensional reconstruction. The objective of the present study was to describe the postoperative correction and the long-term follow-up of AVR in posterior spinal fusion with direct vertebral rotation and elucidate the factors that affected the correction.

METHODS

We retrospectively reviewed 153 consecutive posterior spinal fusion surgeries for AIS performed between 2009 and 2012. Among them, 55 patients who fulfilled the study inclusion criteria with complete preoperative, immediate postoperative, and last follow-up (>1 y) EOS images were included in the present study. EOS 3-dimentional reconstructions were undertaken for each patient. Postoperative AVR correction and the loss of correction were calculated.

RESULTS

Preoperative AVR of the major curve averaged 19 degrees (SD=7 degrees), and AVR on immediate postoperative images averaged 9 degrees (SD=6 degrees, P<0.001). AVR at final follow-up averaged 11 degrees (SD=6 degrees, P=0.06). Postoperative correction was larger in all-screw construct than in hybrid construct (55% vs. 36%, P=0.03).

CONCLUSIONS

The present study is the first study to measure AVR in a large population of AIS patients using EOS 3-dimensional reconstruction. We report the correction magnitude was significantly affected by the construct.

LEVEL OF EVIDENCE

Level IV-therapeutic study (case series).

Back Pain Prevalence Is Associated With Curve-type and Severity in Adolescents With Idiopathic Scoliosis: A Cross-sectional Study

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

The aim of this study was to investigate spinal pain prevalence in adolescents with idiopathic scoliosis (AIS) and to explore associations between pain intensity and pain-related disability with scoliosis site, severity, and spinal bracing.

SUMMARY OF BACKGROUND DATA

The causal link between spinal pain and AIS remains unclear. Spinal asymmetry has been recognized as a back pain risk factor, which is a known cause of care-seeking in adolescents.

METHODS

Participants were recruited from an outpatient tertiary-care scoliosis clinic. Pain intensity and pain-related disability were measured by the Brief Pain Inventory questionnaire and the Roland-Morris Disability Questionnaire. Scoliosis severity estimation was performed using Cobb angles. Associations were explored using multiple linear regressions and reported with unstandardized beta coefficients (β) adjusted for age and sex.

RESULTS

We recruited 500 patients (85% female) with mean (SD) age of 14.2 (1.8) years. Means (SD) of thoracic and lumbar Cobb angle were 24.54(9.77) and 24.13 (12.40), respectively. Spinal pain prevalence was 68% [95% confidence interval (95% CI): 64.5-72.4] with a mean intensity of 1.63 (SD, 1.89). Spinal pain intensity was positively associated with scoliosis severity in the main thoracic (P = 0.003) and lumbar (P = 0.001) regions. The mean (SD) disability score was 1.73 (2.98). Disability was positively associated with scoliosis severity in the proximal thoracic (P = 0.035), main thoracic (P = 0.000), and lumbar (P = 0.000) regions.Spinal bracing was associated with lower spinal pain intensity in the thoracic (P = 0.000) and lumbar regions (P = 0.009). Bracing was also related with lower disability for all spinal areas (P < 0.045).

CONCLUSION

Spinal pain is common among patients with AIS, and greater spinal deformity was associated with higher pain intensity. These findings should inform clinical decision-making when caring for patients with AIS.

LEVEL OF EVIDENCE

3.

The effect of Kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: A randomized controlled trial

Purpose

This study investigated the short-term effects of KT on back pain (BP) in patients with Lenke Type 1 adolescent idiopathic scoliosis (AIS).

Methods

We chosen Lenke Type 1 scoliosis who have had only back pain (the localization of the pain: the only in the apical convex edge). Forty patients suffering from BP with Lenke Type 1 AIS were randomly separated into two groups, Group 1 (20 patients) and Group 2 (20 patients). Group 1 was given KT with tension and home exercises and Group 2 was given KT without tension and home exercises. KT and home exercises was applied to the thoracic area of the patients in both groups for four weeks. Pain intensity was measured using a visual analog scale (VAS) and SRS-22 (subtotal SRS-20) before and after treatment.

Results

Mean age of both groups was 16.1 years. Mean Cobb angle of the thoracic scoliosis was 31.8° (range: 17°–44°) in Group 1 and 32.8° (range: 19°–43°) in Group 2 before the treatment. The decrease in VAS score of Group 1 after taping was higher than that of Group 2. The difference between the pre- and post-treatment VAS scores of both groups was statistically significant (p < 0.05). The increase in mean SRS-20 score of Group 1 following taping application was significantly higher than the increase in the control group (p < 0.05).

Conclusion

Results demonstrated that KT application with tension effectively leads to back pain relief shortly after application. In addition, KT has a positive impact on quality of life. Thus, KT may be a suitable intervention in treating back pain of patients with AIS.

Level of Evidence

Level 1, Therapeutic study

Influence of Sequential Ponte Osteotomies on the Human Thoracic Spine With a Rib Cage

STUDY DESIGN

Biomechanical cadaveric study.

OBJECTIVES

The purpose of this study was to determine the change in range of motion (ROM) of the human thoracic spine and rib cage due to sequential Ponte osteotomies (POs).

SUMMARY OF BACKGROUND DATA

POs are often performed in deformity correction surgeries to provide flexibility in the sagittal plane at an estimated correction potential of 5° per PO, but no studies have evaluated the biomechanical impact of the procedure on a cadaveric model with an intact rib cage.

METHODS

Seven human thoracic cadavers with intact rib cages were loaded with pure moments in flexion, extension, axial rotation, and lateral bending for five conditions: intact, PO at T9-T10, PO at T8-T9, PO at T7-T8, and PO at T6-T7. Motion of T1, T6, and T10 were measured, and overall (T1-T12) and regional (T6-T10) ROMs were reported for each mode of bending at each condition.

RESULTS

POs increased ROM in flexion both overall (T1-T12) and regionally (T6-T10), although the magnitude of the increase was marginal (<1°/PO). No significant differences were found in axial rotation or lateral bending.

CONCLUSIONS

POs may increase sagittal correction potential before fusion in patients with hyperkyphosis, though more work should be done to determine the magnitude of the changes.

LEVEL OF EVIDENCE

Level V.

Commentary on development and assessment of a digital X-ray software tool to determine vertebral rotation in adolescent idiopathic scoliosis

Eijgenraam SM, Boselie TF, Sieben JM, Bastiaenen CH, Willems PC, Arts JJ, Lataster A. Spine J 2015;September 26. pii: S1529-9430(15)01449-7.

The impact of direct vertebral rotation (DVR) on radiographic outcome in surgical correction of idiopathic scoliosis

INTRODUCTION

Recent developments of spinal instruments allow to address nearly all components of idiopathic scoliosis. Direct vertebral rotation (DVR) maneuver was introduced to correct apical axial vertebral rotation. It is however still not well established how efficiently DVR affects results of scoliosis correction. The object of the study was to evaluate en bloc apical vertebral rotation (DVR) and its impact on coronal and sagittal correction of the spine in patients undergoing surgical scoliosis treatment.

MATERIALS AND METHODS

Thirty-six consecutive patients who underwent posterior spinal fusion with pedicle screws only constructs for idiopathic scoliosis. Fifteen patients (20 curves) were corrected by rod derotation only and 21 patients (26 curves) had both rod derotation and DVR. Curve measurements were performed on x-rays obtained before and postoperatively-coronal curves, kyphosis (T2-T12, T5-T12). Spine flexibility was assessed on prone bending x-rays. Apical axial rotation was determined on CT scans obtained intraoperatively and postoperatively. Rotation angle (RAsag) was measured according to Aaro and Dahlborn.

RESULTS

We observed reduction of RAsag in all patients; however, in DVR group, decrease was greater, by 31.8% comparing to non-DVR group, by 8.6% (p = 0.0003). Mean coronal correction in DVR group was 68.8% and in rod derotation group without DVR 55% (p = 0.002). No significant correlation was found between degree of derotation obtained and coronal correction. In DVR group T2-T12 kyphosis has increased in 28 (65%) patients whereas in non-DVR group in 31 (69%) cases. Mean value of T2-T12 kyphosis growth was 16.7% in DVR and 22.1% in non-DVR group. These differences however did not occur statistically significant.

CONCLUSIONS

Direct vertebral rotation (DVR) maneuver reduces significantly apical rotation of the spine, enhances ability of coronal correction, and it does not reduce thoracic kyphosis.

Validity and reliability of photographic measures to evaluate waistline asymmetry in idiopathic scoliosis

OBJECTIVE

Evaluate the relationship between radiological, clinical and perceived waistline asymmetry (WLA) in a sample of idiopathic scoliosis (IS) patients.

METHODS

77 patients were included (mean age 20.3 years; 85 % women). We obtained a full X-ray of the spine and back clinical photography for all patients. On photographs, waist height angle (WHA), right/left waist angles (WA) and right/left waistline distance ratio were measured. SRS22, Trunk Appearance Perception Scale (TAPS) and Spinal Appearance Questinnaire (SAQ) questionnaires were also completed. The intra and inter-observer reliability of each photographic measure was assessed. A correlation analysis between all variables was done using Pearson Correlations Coefficient.

RESULTS

All measures reported have excellent intra- and inter-observer (ICC ≥0.8) reliability. A significant correlation was found between WHA and Cobb angle, mainly with Main Thoracic (MT) (r = -0.56). Right and left waist angles, and especially the difference between them (RLWAD), is related to the thoracolumbar/lumbar (TLL) curve. We have found a significant correlation between RLWAD and TLL curve magnitude (r = -0.54) and with the inclination of the lower end vertebra (LEV) (r = 0.74). Only WHA has a significant, but poor correlation (r ≅ 0.3) with trunk perception scales (TAPS and SAQ). No other significant correlations were found between WLA measures and patient related outcome scores.

CONCLUSION

WLA measures proposed in this article are reliable tools to assess WLA. We have found a significant correlation between clinical WLA and skeletal deformity (Cobb angle). WHA is related with MT curve while the RLWAD depends on the TLL curve magnitude and its LEV. We have also found a significant relation between WHA and the patient's perception of the deformity. It seems that WLA is a cosmetic concern to take into account in clinical evaluation of IS patients.

Usefulness of Simple Rod Rotation to Correct Curve of Adolescent Idiopathic Scoliosis

Objective

To correct apical vertebral rotation for adolescent idiopathic scoliosis (AIS), direct vertebral derotation (DVD) or simple rod rotation (SRR) might be considered. The aim of the present study is to introduce the surgical experiences of AIS by a Korean neurosurgeon and to evaluate the effectiveness of SRR for apical vertebral rotation.

Methods

A total of 9 patients (1 male and 8 females) underwent scoliosis surgery by a neurosurgeon of our hospital. The Lenke classifications of the patients were 1 of 1B, 2 of 1C, 1 of 2A, 1 of 2C, 3 of 5C and 1 of 6C. Surgery was done by manner of simple rod rotation on the concave side and in situ coronal bending. Coronal Cobb's angles, vertebral rotation angles and SRS-22 were measured on a plain standing X-ray and CT before and after surgery.

Results

The mean follow up period was 25.7 months (range : 5–52). The mean number of screw positioning level was nine (6–12). The mean age was 16.4 years (range : 13–25) at surgery. The mean Risser grade was 3.7±0.9. The apical vertebral rotation measured from the CT scans was 25.8±8.5° vs. 9.3±6.7° (p<0.001) and the Coronal Cobb's angle was 53.7±10.4° vs. 15.4±6.5° (p<0.001) preoperatively and postoperative, respectively. The SRS-22 improved from 71.9 preoperatively to 90.3 postoperatively. There were no complications related with the operations.

Conclusion

SRR with pedicle screw instrumentation could be corrected successfully by axial rotation without complications. SRR might serve as a good option to correct AIS deformed curves of AIS.

Changes in Trunk Appearance After Scoliosis Spinal Surgery and Their Relation to Changes in Spinal Measurements

STUDY DESIGN

Retrospective study of surgical outcome.

OBJECTIVES

To evaluate quantitatively the changes in trunk surface deformities after scoliosis spinal surgery in Lenke 1A adolescent idiopathic scoliosis (AIS) patients and to compare it with changes in spinal measurements.

SUMMARY OF BACKGROUND DATA

Most studies documenting scoliosis surgical outcome used either radiographs to evaluate changes in the spinal curve or questionnaires to assess patients health-related quality of life. Because improving trunk appearance is a major reason for patients and their parents to seek treatment, this study focuses on postoperative changes in trunk surface deformities. Recently, a novel approach to quantify trunk deformities in a reliable, automatic, and noninvasive way has been proposed.

METHODS

Forty-nine adolescents with Lenke 1A idiopathic scoliosis treated surgically were included. The back surface rotation and trunk lateral shift were computed on trunk surface acquisitions before and at least 6 months after surgery. We analyzed the effect of age, height, weight, curve severity, and flexibility before surgery, length of follow-up, and the surgical technique. For 25 patients with available three-dimensional (3D) spinal reconstructions, we compared changes in trunk deformities with changes in two-dimensional (2D) and 3D spinal measurements.

RESULTS

The mean correction rates for the back surface rotation and the trunk lateral shift are 18% and 50%, respectively. Only the surgical technique had a significant effect on the correction rate of the back surface rotation. Direct vertebral derotation and reduction by spine translation provide a better correction of the rib hump (22% and 31% respectively) than the classic rod rotation technique (8%). The reductions of the lumbar Cobb angle and the apical vertebrae transverse rotation explain, respectively, up to 17% and 16% the reduction of the back surface rotation.

CONCLUSIONS

Current surgical techniques perform well in realigning the trunk; however, the correction of the deformity in the transverse plane proves to be more challenging. More analysis on the positive effect of vertebral derotation on the rib hump correction is needed.

LEVEL OF EVIDENCE

III.

Correlation Between a Novel Surface Topography Asymmetry Analysis and Radiographic Data in Scoliosis

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To investigate the correlation between parameters extracted from a three-dimensional (3D) asymmetry analysis of the torso and the internal deformities of the spine presented on radiographs, including 1) curve number, direction and location; 2) location of the apical vertebra; and 3) curve severity.

SUMMARY OF BACKGROUND DATA

Surface topography (ST) is used to assess external torso deformities and may predict important characteristics of the underlying spinal curves. ST does not expose patients to radiation and could safely be used clinically for scoliosis patients. Most ST indices rely on anatomical landmarks on the torso and 2D measurements.

METHODS

The ability of a 3D markerless asymmetry technique to predict radiographic characteristics was assessed for 100 scoliosis patients with full torso ST scans. Twenty-four additional patients were used for validation. The number, direction, and location of curves were determined by three examiners using ST deviation color maps. The inter-method percentage of agreement and Kappa coefficient were estimated for each measure. Linear regression predicted the vertical location of the apical vertebra from ST. Curve severity (mild, moderate, severe) was predicted with a decision tree analysis using ST parameters.

RESULTS

The average percentage of agreement was 62%, 66%, and 23% for single, double, and triple curves, respectively. Curve direction was always correctly identified. The average percentages of agreement for curve location were 63%, 92%, and 62% for proximal thoracic, thoracic/thoracolumbar (T-TL), and lumbar (L) curves, respectively. Apical vertebra location was predicted with R² = 0.89 for T-TL and R² = 0.58 for L curves. ST parameters classified curve severity for T-TL and L curves with 73% and 59% accuracy, respectively.

CONCLUSIONS

The method presented here improves upon current ST techniques by using the entire torso surface and both a visual and quantitative representation of the asymmetry to better capture the torso deformity.

Prevalence and management of back pain in adolescent idiopathic scoliosis patients: A retrospective study

BACKGROUND

Back pain (BP) has often been associated with adolescent idiopathic scoliosis (AIS), which is a three-dimensional deviation of the vertebral column. In adolescents, chronic pain appears to be a predictor of health care utilization and has a negative impact on physical, psychological and family well-being. In this population, BP tends to be persistent and may be a predictor of BP in adulthood.

OBJECTIVE

To document the prevalence and management of BP in AIS patients.

METHODS

A retrospective chart review of AIS patients who were referred to Sainte-Justine University Teaching Hospital (Montreal, Quebec) from 2006 to 2011 was conducted.

RESULTS

A total of 310 randomly selected charts were reviewed. Nearly one-half of the patients (47.3%) mentioned that they experienced BP, most commonly in the lumbar (19.7%) and thoracic regions (7.7%). The type of BP was documented in only 36% (n=112) of the charts. Pain intensity was specified in only 21% (n=65) of the charts. In approximately 80% (n=248) of the charts, no pain management treatment plan was documented.

CONCLUSIONS

The prevalence of BP was moderately high among the present sample of adolescents with AIS. An improved system for documenting BP assessment, type, treatment plan and treatment effectiveness would improve pain management for these patients.

Do postoperative radiographically verified technical success, improved cosmesis, and trunk shift corroborate with patient-reported outcomes in Lenke 1C adolescent idiopathic scoliosis?

PURPOSE

To examine correlation between postoperative radiographic and cosmetic improvements in Lenke 1C adolescent idiopathic scoliosis (AIS) with patients' self-rated outcomes of health and disability at follow-up as determined by the Scoliosis Research Society questionnaire (SRS-30), Oswestry Disability Index score (ODI) and measure of overall health quality Euroqol-5d (EQ-5D).

METHODS

24 Lenke 1C scoliosis patients, mean age 16.5 (12.8-38.1) years, treated with posterior pedicle screw-only construct, were included. The coronal profile indices (radiographic and cosmetic) regarding magnitude of spinal deformity and truncal balance were measured preoperatively, postoperatively and at final follow-up. A comprehensive index of overall back symmetry was also measured by means of the Posterior Trunk Symmetry Index (POTSI). Pearson's correlation analysis determined the association between the radiographic-cosmetic indices and patient-rated outcomes.

RESULTS

Mean follow-up for the cohort was 4.4 (±1.86) years. The thoracic apical vertebra-first thoracic vertebra horizontal distance (AV-TI) correction had significant correlation with function, self-image, and mental health SRS-30 scores (0.55, 0.54, 0.66). Similarly, thoracic apical vertebra horizontal translation from central sacral vertical line (AV-CSVL) correction at follow-up had significant correlation with self-image and management domains (0.57, 0.50). Follow-up POTSI correlated well with SRS-30 and EQ-5D scores (r = -0.64, -0.54). Postoperative leftward trunk shift/spinal imbalance did not influence overall cosmesis and outcomes; significant spinal realignment was evident in follow-up resulting in physiological balance and acceptable cosmesis and outcomes.

CONCLUSION

Significant, but less than "perfect" correlations were observed between the radiographic, cosmetic measures and patient-rated outcomes. Thoracic AV-CSVL, AV-T1 correction and POTSI associated significantly with SRS-30 scores. Whereas, thoracic Cobb angle, Cobb correction, and coronal balance did not correlate with any patient-rated outcome measure. It is, therefore, inferred that the patients-rated subjective outcomes are only poorly reflected by the objectively measured radiographic and cosmetic measures of deformity correction.

Effect of Lowest Instrumented Vertebra on Trunk Mobility in Patients With Adolescent Idiopathic Scoliosis Undergoing a Posterior Spinal Fusion

STUDY DESIGN

Prospective.

OBJECTIVES

The goal of this study was to evaluate the effect of posterior spinal fusion surgery terminating at different lowest instrumented vertebrae (LIV) on trunk mobility in individuals with adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Posterior spinal fusion with instrumentation is the standard surgical technique employed in AIS for correcting spine deformities with Cobb angles exceeding 50°. Surgical correction of curve deformity reduces trunk mobility and range of motion. However, conflicting findings from previous studies investigating the impact of different LIV levels on the reduction in trunk mobility after surgery have been reported.

METHODS

The study was designed as a prospective study with 47 patients (7 males and 40 females) with AIS who underwent posterior spinal fusion. Patients were classified into 5 groups based on their surgical LIV level (ie, T12, L1, L2, L3, and L4). Trunk flexion-extension (sagittal plane), lateral bending (coronal plane), and axial rotation (transverse plane) kinematics were assessed during preoperative, 1 year postoperative, and 2 years postoperative evaluation visits.

RESULTS

There were postoperative reductions of 41%, 51%, and 59% in trunk range of motion in the sagittal, coronal, and transverse planes, respectively (p < .0001). A trend toward greater postoperative reductions in peak forward flexion at more distal LIVs was observed (p = .04).

CONCLUSIONS

Fusion reduces trunk mobility in the sagittal, coronal, and transverse planes. More distal LIV fusions limit peak forward flexion to a greater extent which is considered clinically significant. After fusion, the reductions seen in axial rotation, lateral bending, and backward extension do not differ significantly at more distal LIVs.

Analysis of the Scoliosis Research Society-22 Questionnaire Scores: Is There a Difference Between a Child and Parent and Does Physician Review Change That?

STUDY DESIGN

Prospective sequential patient series.

OBJECTIVES

To investigate whether at initial assessment information imparted by a physician changed the Scoliosis Research Society (SRS) score for a patient or a parent scoring independently of the child; to investigate whether the SRS score should be assessed before or after consultation to achieve the most accurate representation of the patient; and to investigate the differences between the patient and parent assessment of the scoliosis using the SRS questionnaire.

METHODS

A total of 52 children with adolescent idiopathic scoliosis and their parents were given the SRS-22 questionnaire at first consultation before and after meeting the physician. Parents and patients completed the questionnaires in isolation.

RESULTS

Assessment and discussion with a physician made no statistical difference for the SRS-22 scores for both the patients and the parents when comparing SRS-22 scores before and after consultation in most domains. Significant differences were found in a few cases. This was the case for the patient group before and after consultation for the function domain (p = .023), the patient and parent groups before and after consultation for the pain domain (p = .025 and .022 for patient and parent groups respectively), the patient and parent groups after consultation for self-image domain (p = .024), and the parent group before and after consultation for mental health domain (p = .018). However, the differences in all these cases were low and not considered clinically important.

CONCLUSIONS

The SRS-22 questionnaire is robust and a true reflection of patients' assessment of their symptoms not influenced by meeting a physician. Assessment of the child by the parent is not statistically different from the child's self-assessment using the SRS-22 instrument. It makes no difference to the total SRS-22 score as to when it is measured in the initial clinic visit.

Prospective Assessment of Scoliosis-Related Anxiety and Impression of Trunk Deformity in Female Adolescents Under Brace Treatment

The aim of this study is to make a prospective analysis of changes in anxiety levels and determining their associations with a longitudinal subjective assessment of trunk deformity in adolescent females with scoliosis, in relation to clinical, radiological and brace-related data. The study design was comprised of three questionnaire assessments, with the second and third evaluations taking place 6 and 12 months after the beginning of the study, respectively. 36 AIS females treated conservatively were asked to fill in the Polish versions of the Spinal Appearance Questionnaire (SAQ-pl) and the trait version of the Spielberger's Anxiety Inventory for Children (STAIC-trait). High anxiety was indicated in 16.6, 8.3 and 8.3% during the 1st, 2nd and 3rd evaluations. Patients' results differ in regards to the Curve domain; the discrepancies concern the 2nd and 3rd and the 1st and 3rd evaluations (p = 0.028 and p = 0.003, respectively). The only association between STAIC-trait and SAQ-pl regards Trunk shift in the 1st evaluation (rs = 0.48). The logistic regression revealed that the duration of brace-wearing in months has a statistically significant (p = 0.021) influence on the probability of diagnosing patients' low anxiety levels in the 2nd assessment. Special attention should be paid to patients' emotional reactions later on as brace-wearing continues as well as to the results which support the point that patients' perceptions of spinal deformity do not deteriorate with treatment time. Clinicians need to be aware how patients' appearance-specific cognitions might be associated with levels of emotional distress and relate to clinical and radiological, scoliosis-related data.

Female patients' and parents' assessment of deformity- and brace-related stress in the conservative treatment of adolescent idiopathic scoliosis

STUDY DESIGN

A cross-sectional analysis of parents' and patients' perceptions of deformity- and brace-related stress regarding conservative treatment of adolescent idiopathic scoliosis.

OBJECTIVE

The purpose of this study was to determine the agreement between patients' and parents' assessments of emotional stress and to compare these assessments with radiographical measurements of spinal deformity.

SUMMARY OF BACKGROUND DATA

Conservative treatment in patients with scoliosis may cause emotional stress. To our knowledge, no group has ever reported patient and parental estimation of stress related to wearing a brace and spinal deformity in girls with adolescent idiopathic scoliosis.

METHODS

Sixty-three pairs of parents and girls with adolescent idiopathic scoliosis treated with a Cheneau brace were separately asked to complete the Bad Sobberheim Stress Questionnaire-Deformity and the Bad Sobberheim Stress Questionnaire-Brace. The age range of the patients was from 10 to 17 years. Patients were assessed at a mean of 14.12 (SD, 10.99) months after the start of the conservative treatment.

RESULTS

Patients thought that a moderate level of stress was connected with conservative treatment; however, the stress level, related to perceived trunk deformation, was low. From the parents' perspective, patients experienced a moderate level of stress during conservative treatment and related to spinal deformity. The study groups differ in their perception of stress levels due to body disfigurement but not during the conservative treatment. Parent-patient stress-level disparities were not related to body mass index, age of the patient, brace application, and radiographical measurements of spinal deformity.

CONCLUSION

Patients and parents perceive the emotional stress related to brace treatment in the same way; however, parents overestimate the assessment of stress levels related to body deformity. From the perspective of patients and parents, brace wearing increased the level of stress induced by the deformity alone. Complete assessment of conservative treatment should include evaluation of emotional stress from the perspective of patients and parents.

Parents' experiences of caring for a child with a cleft lip and/or palate: a review of the literature

This review brings together for the first time the existing quantitative and qualitative research evidence about the experiences of parents caring for a child with a cleft. It summarizes salient themes on the emotional, social and service-related experiences of parents and critiques the literature to date, comparing it with wider, selected literature from the field of children's long-term conditions, including disability. The review suggests that there are similarities and differences between the literatures, in terms of research focus and approach. Similarities are found across children's conditions in the perspectives of parents on emotional, social and service-related aspects, although much of the cleft literature is focused on the early stages of children's lives. However, the quality of cleft research to date about parents' experiences has also been variable, with a narrow emphasis on cross-sectional, deficit-orientated psychological approaches focused mainly on mothers. Despite a substantial literature, little qualitative research has examined parents' perspectives in-depth, particularly about their child's treatment journey. This contrasts with the wider children's literature, which has traditionally drawn not only on psychological approaches but also on the broader perspectives of sociology, social policy, nursing and health services research, using both qualitative and quantitative methods, often in integrated ways. Such approaches have been able to highlight a greater range of experiences from both mothers and fathers, about caring for a child with a long-term condition and views about treatment. The review identifies a lack of comparable research in the cleft field to examine parents' experiences and needs at different stages of their children's lives. Above all, research is needed to investigate how both mothers and fathers might experience the long-term and complex treatment journey as children become older and to elicit their views about decision making for cleft treatments, particularly elective surgeries.

Assessment of spinal appearance in female patients with adolescent idiopathic scoliosis treated operatively

BACKGROUND

Body deformities in patients with scoliosis significantly affect appearance perception. The majority of studies on this topic have analyzed the relation between radiological and clinical assessment performed by doctors, and patients' perception of deformity. The object of this study was to adapt the Spinal Appearance Questionnaire (SAQ) to Polish conditions and to explore the perception of trunk deformity by female patients with adolescent idiopathic scoliosis.

MATERIAL/METHODS

Forty female patients who underwent surgical treatment for adolescent idiopathic scoliosis using the Cotrel-Dubousset method were asked to complete a Polish version of the Spinal Appearance Questionnaire. The mean preoperative Cobb angle of the thoracic curve in the study group was 55.3 degrees (SD 9.7). In the final postoperative examination the Cobb angle was 29.1 degrees (SD 10.1).

RESULTS

The general results of the SAQ demonstrated that the patients achieved a median of 34.48 points, showing a positive assessment of their appearance. Patients rated themselves most critically in the general, chest, surgical scar, symmetry of shoulders and waist domains. The logistic regression model revealed that only the size of the thoracic apical translation, with a model coefficient of -0.9138 (SE=0.350; p=0.013), has a statistically significant (p=0.002) influence on a good general result in the SAQ.

CONCLUSIONS

Patients assessed their appearance positively after surgical treatment. A higher thoracic apical translation value is related to a lower probability of achieving a good general result in the Spinal Appearance Questionnaire.

Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan

There have been a few studies regarding detail of back pain in adolescents with idiopathic scoliosis (IS) as prevalence, location, and severity. The condition of back pain in adolescents with IS was clarified based on a cross-sectional study using a questionnaire survey, targeting a total of 43,630 pupils, including all elementary school pupils from the fourth to sixth grade (21,893 pupils) and all junior high pupils from the first to third year (21,737 pupils) in Niigata City (population of 785,067), Japan. 32,134 pupils were determined to have valid responses (valid response rate: 73.7%). In Niigata City, pupils from the fourth grade of elementary school to the third year of junior high school are screened for scoliosis every year. This screening system involves a three-step survey, and the third step of the survey is an imaging and medical examination at the Niigata University Hospital. In this study, the pupils who answered in the questionnaire that they had been advised to visit Niigata University Hospital after the school screening were defined as Scoliosis group (51 pupils; 0.159%) and the others were defined as No scoliosis group (32,083 pupils). The point and lifetime prevalence of back pain, the duration, the recurrence, the severity and the location of back pain were compared between these groups. The severity of back pain was divided into three levels (level 1 no limitation in any activity; level 2 necessary to refrain from participating in sports and physical activities, and level 3 necessary to be absent from school). The point prevalence was 11.4% in No scoliosis group, and 27.5% in Scoliosis group. The lifetime prevalence was 32.9% in No scoliosis group, and 58.8% in Scoliosis group. According to the gender- and school-grade-adjusted odds ratios (OR), Scoliosis group showed a more than twofold elevated odds of back pain compared to No scoliosis group irrespective of the point or lifetime prevalence of back pain (OR, 2.29; P = 0.009 and OR, 2.10; P = 0.012, respectively). Scoliosis group experienced significantly more severe pain, and of a significantly longer duration with more frequent recurrences in comparison to No scoliosis group. Scoliosis group showed significantly more back pain in the upper and middle right back in comparison to No scoliosis group. These findings suggest that there is a relationship between pain around the right scapula in Scoliosis group and the right rib hump that is common in IS.

Biomechanical analysis of derotation of the thoracic spine using pedicle screws

STUDY DESIGN

Biomechanical analysis of derotational load-to-failure of pedicle screw (PS) instrumentation in cadaveric thoracic spinal segments.

OBJECTIVE

To investigate the derotational torque that can be applied to the thoracic spine through different linked constructs and evaluate the modes of failure.

SUMMARY OF BACKGROUND DATA

Thoracic derotation with PSs has been shown to provide better 3 plane correction than other methods but the effects of linked PS constructs has not been studied.

METHODS

Four groups of thoracic segments with different PS constructs were loaded to failure with a rotational torque applied to the construct to simulate the left to right derotational force applied to a typical idiopathic dextrorotary thoracic scoliosis curve. Single screw T4 segments instrumented on the medial (group 1M) and lateral (group 1L) sides, bilaterally-linked T5 segments (group 2), unilaterally-linked T6-T9 segments on the medial (group 3M) and lateral (group 3L) sides, and quadrangularly-linked T6-T9 segments (group 4) were loaded with MTS machine in a simulated thoracic derotation model.

RESULTS

Single T4 PSs on the medial and lateral sides failed at 4.0 +/- 1.4 Nm (group 1M) and 6.1 +/- 2.5 Nm (group 1L), respectively. Bilaterally-linked T5 screws failed at 11.9 +/- 3.1 Nm (group 2). Unilaterally linked T6-T9 PS constructs on the medial and lateral sides failed at 21.2 +/- 7.5 Nm (group 3M) and 17.9 +/- 11.1 Nm (group 3L), respectively. Quadrangularly-linked PSs failed at 42.5 +/- 14.5 Nm (group 4). CONCLUSION.: A near linear increase in relative torque applied before failure was found with each additional PS linked. Linked constructs allow for significantly greater torque with less risk of PS breach of the spinal canal.

Adolescent idiopathic scoliosis (AIS) - an indication for surgery? A systematic review of the literature

PURPOSE

Historically, the treatment options for AIS, the most common form of scoliosis are: Exercises, in-patient rehabilitation, braces and surgery. While there is evidence in the form of prospective controlled studies that Scoliosis Intensive Rehabilitation (SIR) and braces can alter the natural history of the condition, there is no review on prospective controlled trials for surgical treatment. The aim of this review was to perform a systematic search of the Pub Med literature to reveal the evidence on scoliosis surgery.

METHODS

A systematic review has been performed using the Pub Med database. Literature has been searched for the outcome parameter; 'rate of progression' and only prospective controlled studies that have considered the treatment versus the natural history have been included.

RESULTS

No controlled study, not in the short, mid or long term, searched within the review, has been found to reveal evidence to support the hypothesis that the effects of surgery as a treatment option for AIS is superior to natural history.

CONCLUSIONS

No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this.

Rate of complications in scoliosis surgery - a systematic review of the Pub Med literature

Background

Spinal fusion surgery is currently recommended when curve magnitude exceeds 40–45 degrees. Early attempts at spinal fusion surgery which were aimed to leave the patients with a mild residual deformity, failed to meet such expectations. These aims have since been revised to the more modest goals of preventing progression, restoring 'acceptability' of the clinical deformity and reducing curvature.

In view of the fact that there is no evidence that health related signs and symptoms of scoliosis can be altered by spinal fusion in the long-term, a clear medical indication for this treatment cannot be derived. Knowledge concerning the rate of complications of scoliosis surgery may enable us to establish a cost/benefit relation of this intervention and to improve the standard of the information and advice given to patients. It is also hoped that this study will help to answer questions in relation to the limiting choice between the risks of surgery and the "wait and see – observation only until surgery might be recommended", strategy widely used. The purpose of this review is to present the actual data available on the rate of complications in scoliosis surgery.

Materials and methods

Search strategy for identification of studies; Pub Med and the SOSORT scoliosis library, limited to English language and bibliographies of all reviewed articles. The search strategy included the terms; 'scoliosis'; 'rate of complications'; 'spine surgery'; 'scoliosis surgery'; 'spondylodesis'; 'spinal instrumentation' and 'spine fusion'.

Results

The electronic search carried out on the 1^st February 2008 with the key words "scoliosis", "surgery", "complications" revealed 2590 titles, which not necessarily attributed to our quest for the term "rate of complications". 287 titles were found when the term "rate of complications" was used as a key word. Rates of complication varied between 0 and 89% depending on the aetiology of the entity investigated. Long-term rates of complications have not yet been reported upon.

Conclusion

Scoliosis surgery has a varying but high rate of complications. A medical indication for this treatment cannot be established in view of the lack of evidence. The rate of complications may even be higher than reported. Long-term risks of scoliosis surgery have not yet been reported upon in research. Mandatory reporting for all spinal implants in a standardized way using a spreadsheet list of all recognised complications to reveal a 2-year, 5-year, 10-year and 20-year rate of complications should be established. Trials with untreated control groups in the field of scoliosis raise ethical issues, as the control group could be exposed to the risks of undergoing such surgery.

Pain and disability correlated with disc degeneration via magnetic resonance imaging in scoliosis patients

Prior imaging studies of scoliosis patients attempted to demonstrate a relationship between plain radiographic curve patterns and curve progression and pain, or used magnetic resonance imaging (MRI) to focus on spinal cord abnormalities. Pain in scoliosis patients may differ from nondeformity patients, yet may still be discogenic. The purpose of this study was to assess the possible relationship of degenerative disc findings on MRI to scoliosis patients' pain. This prospective study enrolled scoliosis and control patients, all of whom had assessment for back pain (visual analog scale) and disability (Oswestry Index) and spinal MRI to identify prevalence and distribution of degenerative disc findings. Specifically, we assessed 60 consecutive pediatric and adult idiopathic scoliosis patients who had progressed to surgical treatment, 60 age- and gender-matched asymptomatic controls, and 172 nondeformity symptomatic degenerative disc disease patients who had progressed to surgical treatment. All subjects had independent analysis of their preoperative MRI for disc degeneration, disc herniation, Schmorl's nodes, and inflammatory end plate changes. Imaging findings of the scoliosis patients were compared to those from asymptomatic and symptomatic control groups. Our results found that both pediatric and adult scoliosis patients had significantly more pain and disability than did asymptomatic controls (P < 0.001). The adult idiopathic scoliosis patients had pain and disability similar to those of surgical degenerative disc disease control groups. Disc degeneration and herniation (contained) were not related to pain. However, in the pediatric scoliosis patients, those with Schmorl's nodes often had greater pain than those without (P = 0.01). Adults with painful scoliosis, typically occurring at the apex of the scoliosis or at the lumbosacral junction, had a significantly higher frequency of inflammatory end plate changes on MRI than did controls (P < 0.001). Prior studies have demonstrated a correlation of inflammatory end plate changes to lumbar discogenic pain. In conclusions, scoliosis patients who have progressed to surgical intervention, pediatric patients have varying degrees of pain, and those with Schmorl's nodes may be at greater risk for pain. Adult scoliosis patients have multifactorial pain of which one component may be related to degeneration of the lower lumbar discs similar to that in nondeformity patients. Additionally, adult scoliosis patients may have MRI findings consistent with discogenic pain at the apex of their curvature, most commonly at the proximal lumbar levels.

Reliability of trunk shape measurements based on 3-D surface reconstructions

This study aimed to estimate the reliability of 3-D trunk surface measurements for the characterization of external asymmetry associated with scoliosis. Repeated trunk surface acquisitions using the Inspeck system (Inspeck Inc., Montreal, Canada), with two different postures A (anatomical position) and B (''clavicle'' position), were obtained from patients attending a scoliosis clinic. For each acquisition, a 3-D model of the patient's trunk was built and a series of measurements was computed. For each measure and posture, intraclass correlation coefficients (ICC) were obtained using a bivariate analysis of variance, and the smallest detectable difference was calculated. For posture A, reliability was fair to excellent with ICC from 0.91 to 0.99 (0.85 to 0.99 for the lower bound of the 95% confidence interval). For posture B, the ICC was 0.85 to 0.98 (0.74 to 0.99 for the lower bound of the 95% confidence interval). The smallest statistically significant differences for the maximal back surface rotation was 2.5 and 1.5 degrees for the maximal trunk rotation. Apparent global asymmetry and axial trunk rotation indices were relatively robust to changes in arm posture, both in terms of mean values and within-subject variations, and also showed a good reliability. Computing measurements from cross-sectional analysis enabled a reduction in errors compared to the measurements based on markers' position. Although not yet sensitive enough to detect small changes for monitoring of curve natural progression, trunk surface analysis can help to document the external asymmetry associated with different types of spinal curves as well as the cosmetic improvement obtained after surgical interventions. The anatomical posture is slightly more reliable as it allows a better coverage of the trunk surface by the digitizing system.

Impact of spine surgery on signs and symptoms of spinal deformity

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

A review of quality of life and psychosocial issues in scoliosis

STUDY DESIGN

Recent literature regarding the psychological impact of scoliosis was reviewed.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Validity of the Walter Reed Visual Assessment Scale to measure subjective perception of spine deformity in patients with idiopathic scoliosis

Background

The Walter Reed Visual Assessment Scale (WRVAS) was designed to allow idiopathic scoliosis patients to describe their perception of their deformity. In a previous stduy, the scale has shown good correlation with magnitude of the curve

Methods

The study included 70 patients (60 women and 10 men), mean age 19.4 years (range 12–40), with idiopathic scoliosis. Each patient filled out the WRVAS and the SRS-22 questionnaire. Thoracic and lumbar curve angles were determined in standing X-rays and the largest was named Cobbmax. WRVAS internal consistency was assessed with Cronbach's alpha. Correlation coefficients were calculated between Cobbmax and the various WRVAS questions, and Cobbmax and the SRS-22 scales. The correlation between the WRVAS and SRS-22 was also determined

Results

Mean magnitudes were thoracic curve, 36.6° and lumbar curve, 33.2°; average Cobbmax was 37.9°. The mean total WRVAS score was 15.6. Mean scores for the various SRS-22 scales were function 4.6, pain 4.3, self-image 3.7, mental health 4.2, and total score 84.1. Internal consistency for the WRVAS was excellent (Cronbach's alpha, 0.9), and there were no signs of collinearity among the seven questions (tolerance range 0.2–0.5). All the items on the WRVAS correlated significantly with Cobbmax (correlation coefficients, 0.4 to 0.7). The correlation between the total WRVAS and total SRS-22 score was -0.54 (P = .0001) and between WRVAS total score and SRS-22 image domain score was -0.57 (p = 0.0001)

Conclusion

The WRVAS showed excellent internal consistency and absence of collinearity. There was a highly significant correlation between the results of the test and the magnitude of the deformity. The WRVAS correlated significantly with the SRS-22 image scale. The WRVAS is a valid instrument to assess scoliosis patients perception of their deformity

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

Background

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

Aim of the study

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Low back pain after spinal fusion and Harrington instrumentation for idiopathic scoliosis

We reviewed 41 patients with adolescent idiopathic scoliosis treated with spinal fusion and Harrington instrumentation between 1973 and 1992. The mean follow-up was 23 (11-30) years. All patients completed self-administered questionnaires, Oswestry Low Back Pain Disability Score (ODS), Roland Morris score (RLS), and Visual Analog Pain Intensity Scale (VAS). We found a high degree of satisfaction with more than three quarters of the patients in work. The outcome of ODS, RLS, and VAS showed low scores. We found a significant correlation between the scores and the Cobb angle preoperatively as well as at follow-up. The patient-oriented outcome did not correlate with the type of curve, extension of vertebral fusion, tilt angle of the lowest instrumented vertebra, postoperative Cobb angle, loss of correction, or lumbar lordosis. This long-term follow-up of Harrington rod fusion for adolescent idiopathic scoliosis showed no important impairment of health-related quality of life.

Cotrel-Dubousset (CD) or Universal Spine System (USS) instrumentation in adolescent idiopathic scoliosis (AIS): comparison of midterm clinical, functional, and radiologic outcomes

STUDY DESIGN

A retrospective comparison of the clinical, radiologic, and functional results of Cotrell-Dubousset (CD) and Universal Spine System (USS) instrumentation for adolescent idiopathic scoliosis (AIS).

OBJECTIVES

To establish whether there are any differences in outcome between the 2 instrumentation systems.

SUMMARY OF BACKGROUND DATA

CD is the first complex posterior double rod instrumentation system to provide multiple hook fixation. USS instrumentation permits the use of rod translation instead of rod rotation, the option to secure pedicle hooks with fixation screws, and the option to use transpedicular screws in the lower thoracic and lumbar spine. Midterm and long-term results of USS instrumentation are lacking.

METHODS

Fifty-seven (mean age, 28 years at follow up) patients treated with CD instrumentation and 55 (mean age, 23 years at follow up) patients treated with USS instrumentation for AIS participated in the study. The average follow-up rate was 80% and time 13.0 years for the CD group, and 95% and 7.8 years for the USS group. Radiographs were obtained before surgery, at 2-year follow up, and at final follow up. Additionally, a physical examination was performed by 2 independent observers, and the Scoliosis Research Society (SRS) questionnaire was completed; spinal mobility and nondynamometric trunk strength were measured at the final follow-up visit. RESULTS.: The mean Cobb angle of the instrumented thoracic curve was before surgery 55 degrees (range, 36-83 degrees for the CD and 52 degrees (range, 35-85 degrees) for the USS group. The mean number of instrumented vertebrae was 9.9 (range, 7-12) in the CD and 9.8 (range, 6-12) in the USS group. At final follow up, the mean angles were 32 degrees (range, 13-63 degrees) for the CD group and 29 degrees (range, 9-63 degrees) for the USS group (not significant). No significant difference was observed in thoracic kyphosis or lumbar lordosis between the study groups at final follow up. In the SRS questionnaire, the total score averaged 97 for the CD and 101 for the USS groups, respectively. In the questionnaire, 6 (11%) patients in the CD group, but none in the USS group, reported having low back pain often or very often at rest. No correlation was found between the Cobb angle of the thoracic or lumbar curves at follow up and the total score or back pain indexes of this questionnaire. Nondynamometric trunk strength measurements corresponded with age- and sex-adjusted reference values, on average, but patients in the CD group performed significantly better in the squatting test (P = 0.021) and patients in the USS group performed better in trunk side bending (P = 0.004). Complications were recorded in 15 (26%) patients in the CD and in 13 (24%) patients in the USS group (not significant).

CONCLUSIONS

The midterm radiologic and functional outcomes were quite similar in both groups as were the SRS scores. The patients performed, on average, as well as did the reference population in nondynamometric trunk strength measurements. Intraoperative and late complications were similar in both groups.

Risk factors for pain in children with severe cognitive impairments

Diagnosing cause of pain in children with severe cognitive impairments is difficult due to their problems with communication. Identification of risk factors for specific pain etiologies might help professionals in this task. The aim of this study was to determine whether child-related characteristics increase risk for specific types of pain. Participants were the caregivers of 41 females and 53 males with moderate to profound mental retardation, who were aged 3 to 18 years 8 months (mean 10:1, SD 4:4) but who communicated at the level of a typical child of 13.8 months (SD 10 months): 44 of the children had cerebral palsy (CP) and 59 a seizure disorder. Caregivers reported the cause of children's episodes of pain for four 1-week periods over 1 year. Logistic regression analyses were used to predict occurrence of specific types of pain using children's demographic, medical, and physical characteristics. Children had 406 episodes of pain due to accident, gastrointestinal conditions, musculoskeletal problems, infection, recurrent conditions, and common childhood causes. Results indicated that a unique set of risk factors predicted each pain type in this sample. Significant risk factors for pain included: lack of visual impairment and leg impairment (accidental pain); seizures, leg impairment, and greater number of medications (non-accidental pain); being male and tube fed (musculoskeletal pain); age <7 years, absence of CP, visual impairment, and less frequent medical monitoring (infection pain); being female and with arm impairment (gastrointestinal pain); and being tube fed and taking fewer medications (common childhood pains). In most cases, models were more specific than sensitive, indicating that the significant predictors are more useful for eliminating potential pain causes. These results suggest that population risk factors may be helpful in structuring diagnostic investigations for individual children with severe cognitive impairments.