APSS-ASJ Best Clinical Research Award: Is There a Difference between Patients' and Parents' Perception of Physical Appearance in Adolescent Idiopathic Scoliosis?

Evaluation of the changes in waistline asymmetry using digital photography in adolescents with idiopathic thoracolumbar/lumbar scoliosis after corrective surgery

PURPOSE

Waist line asymmetry is a major cosmetic concern in patients with adolescent idiopathic scoliosis (AIS). The primary surgical goal in patients with AIS is to correct spinal deformities and prevent further progression while maintaining global alignment. Additionally, an important objective of surgical treatment is to address physical appearance by reducing asymmetry. This study aimed to evaluate changes in waistline asymmetry using digital photographs in adolescents with thoracolumbar/lumbar (TL/L) scoliosis who underwent corrective surgery.

METHODS

We retrospectively analyzed the data of patients with Lenke types 5C and 6C AIS who underwent posterior fusion surgery with at least 2 years of follow-up. Waist line asymmetry was assessed using digital photography. The waist angle ratio (WAR), waist height angle (WHA), and waistline depth ratio (WLDR) were measured pre- and postoperatively. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were also evaluated.

RESULTS

Forty-two patients (40 females and 2 males; 34 with type 5C and 8 with type 6C) were included in the study. The WAR, WHA, and WLDR significantly improved after surgery (0.873 → 0.977, - 2.0° → 1.4°, and 0.321 → 0.899, respectively). Every waistline parameter moderately correlated with the apical vertebral translation of the TL/L curve (WAR: r =  - 0.398, WHA: r =  - 0.442, and WLDR: r =  - 0.692), whereas no correlations were observed with the TL/L curve magnitude. No correlations were observed between the photographic parameters and SRS-22r scores.

CONCLUSION

Lateral displacement of the apical vertebra on the TL/L curve correlated with waistline asymmetry. Preoperative waistline asymmetry improved with scoliosis correction.

LEVEL OF EVIDENCE

Level 4.

Analyzing Factors Associated with Postoperative Shoulder Imbalance in Lenke2 Adolescent Idiopathic Scoliosis (Retrospective Cohort Study)

OBJECTIVE

To assess the incidence of postoperative shoulder imbalance (PSI) following posterior spinal fusion surgeries in adolescent idiopathic scoliosis (AIS) with Lenke2 and calculate the risk factors for PSI.

METHODS

Sixty patients who underwent surgery for Lenke2 AIS with more than 2-year follow-up were selected. Radiographic parameters were measured before and after surgery, and at the latest follow-up. The patients were divided into PSI and non-PSI groups, with PSI defined as a radiographic shoulder height >15 mm on postoperative radiography. The factors were compared between the PSI and non-PSI groups using the Mann-Whitney U test or chi-squared test. Finally, explanatory variables were chosen for multivariate analysis based on previous studies.

RESULTS

The PSI group comprised 17 patients. Most PSI cases spontaneously improved, and four patients (6.7%) showed PSI at the final follow-up. Univariate analysis indicated significant differences between postoperative T1 tilt (9.00 ± 5.17 vs. 5.67 ± 4.02, P = 0.029), UIV tilt (1.94 ± 4.49 vs. -1.00 ± 5.04, P = 0.039), and ΔT1 tilt (4.82 ± 3.99 vs. 2.12 ± 3.77, P = 0.026). Multivariate logistic regression analysis indicated that ΔT1 tilt had a significant positive relationship with PSI occurrence (coefficient = 0.2541, 95% confidence interval [CI]: 0.023 to 0.485, P = 0.0310). This study found no significant differences in the SRS-22 scores at the final follow-up.

CONCLUSIONS

The incidence of PSI for Lenke2 AIS was 28.3% at 1 week postoperatively and 6.7% at the final follow-up. ΔT1 tilt was a risk factor for PSI. Adjustment of the T1 tilt during surgery was considered useful for the prevention of PSI.

Patients' Perception and Satisfaction on Neck and Shoulder Imbalance in Adolescent Idiopathic Scoliosis

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To evaluate the perception and satisfaction among adolescent idiopathic scoliosis (AIS) patients on Neck Tilt with Medial Shoulder Imbalance and Lateral Shoulder Imbalance.

METHODS

Lenke 1 and 2 AIS patients were stratified into 6 groups of preoperative/ postoperative Balanced (B), Lateral Shoulder Imbalance (LSI) (>2 cm), and Neck Tilt with Medial Shoulder Imbalance (NT) (Grade 3). Patients were interviewed using Modified Neck and Shoulder Appearance and SRS-22r questionnaires. T1 tilt, Cervical Axis (CA), Clavicle Angle (Cla-A) and Radiographic Shoulder Height (RSH) were measured.

RESULTS

A total of 120 Lenke 1 and 2 AIS patients were recruited. NT patients were aware and unhappy with their abnormal neck with medial shoulder appearances (P < .001). Similarly, LSI patients were aware and unhappy with their abnormal lateral shoulder appearances (P < .001). NT group had larger preoperative/ postoperative T1 tilt (9.2 ± 5.0°; 9.5 ± 5.3°) and CA (4.6 ± 3.1°; 7.0 ± 2.0°) (P < .01). LSI group had larger preoperative/ postoperative Cla-A (4.8 ± 2.8°; 4.0 ± 1.3°) and RSH (20.1 ± 9.4 mm; 17.0 ± 6.6 mm) (P < .001). Postoperative B group scored higher in overall SRS-22r scores, self-image and satisfaction domains (4.2 ± 0.3; 4.0 ± 0.5; 4.4 ± 0.5) while preoperative LSI scored the lowest comparatively (3.5 ± 0.4; 2.4 ± 0.5; 3.3 ± 0.5) (P < .001).

CONCLUSION

NT and LSI were major concerns among AIS patients. Both NT and LSI groups were unhappy with their appearances. NT group had larger T1 tilt/ CA whereas LSI group had larger Cla-A/ RSH. Postoperative B group scored higher in overall SRS-22r scores, self-image and satisfaction domains.

Clinical outcomes of selective fusion for the thoracolumbar-lumbar curve in patients with Lenke type 6C adolescent idiopathic scoliosis: a preliminary study

Limited evidence is available in the literature regarding the fate of the unfused structural thoracic curve following selective thoracolumbar-lumbar curve fusion (SLF) in Lenke 6C adolescent idiopathic scoliosis (AIS) patients. Therefore, we compared the outcomes of SLF between Lenke 6C and 5C AIS patients. We retrospectively reviewed 31 patients Lenke 5C (n = 18) and Lenke 6C (n = 13) AIS patients who underwent SLF at a single institution. Multiple radiological parameters were measured using whole-spine radiographs taken before and after surgery and at the last follow-up visit. SRS-22 at the final follow-up was obtained for clinical assessment. A total of 31 patients with a mean age of 14.6 years at operation who were followed for a mean of 6.4 years were included in this study. The Cobb angle of the unfused thoracic curve was spontaneously corrected immediately following SLF and increased slightly but not significantly at the final follow-up in both groups (Lenke 5C: pre 33.0°, post 14.4°, final 19.4°, Lenke 6C: pre 46.1°, post 31.7°, final 34.2°). At every time point, the thoracic Cobb angle was significantly larger in the Lenke 6C. SRS-22 score at the final follow-up, including the self-image domain, did not differ between the two groups. In this study, SLF for Lenke 6C AIS achieved a significant spontaneous correction of the unfused thoracic curve and yielded a comparable SRS-22 result at the final follow-up to that of Lenke 5C. Our findings suggest that SLF is a viable treatment option for Lenke 6C AIS.

What Constitutes Shoulder Imbalance in Adolescent Idiopathic Scoliosis? Aesthetic Threshold for Surgical Correction

OBJECTIVE

To determine what constitutes clinical shoulder imbalance and the aesthetic unsightliness of the torso region in patients with scoliosis. How can it be measured? Shoulder imbalance is one of the most perplexing problems in scoliosis. There are no standard clinical or radiologic criteria for diagnosing shoulder imbalance, and hence its impact and prevention are poorly understood. This prospective cohort study aims to determine the clinical parameters in the torso region that are most aesthetically disfiguring in scoliosis, and the measures with their threshold values that can define shoulder imbalance.

METHODS

Twenty-six consecutive patients with adolescent idiopathic scoliosis formed the patient cohort. Only preoperative clinical photographs (not x-rays) of these patients were used for the study. Forty random observers were asked to rate the shoulder disfigurement in these patients as acceptable or unacceptable. An independent researcher plotted and measured 10 different deformity markers on these photographs. Three regions of the torso, the neck, shoulder, and axillary region, were studied separately. Receiver operating characteristic analysis was used to determine significance of each measure.

RESULTS

The patients with unacceptable deformation had statistically significant values in each of the 3 regions. The patients with acceptable appearance also had several measures that proved significant. Threshold values for each of these parameters were established from the analysis.

CONCLUSIONS

Shoulder imbalance in scoliosis is defined based on 3 regions: the neck, shoulder, and axillary region. Each has a specific threshold for producing cosmetically unacceptable deformation and they can be measured on clinical photographs. Measurement of the shoulder level alone is less representative.