Do middle-aged patients with onset of idiopathic scoliosis before the age of 10 years who have reduced pulmonary function have a risk for rapid decline - a comparative study

BACK GROUND

Knowledge concerning pulmonary function in adult patients with onset of idiopathic scoliosis before age 10 is sparse. A long-term follow-up (FU, mean 26 years, > 12 years after treatment) of pulmonary function (PF) in patients treated with brace or surgery due to idiopathic scoliosis with onset before the age of 10 was earlier performed. To evaluate whether a more severe reduction in pulmonary function leads to more rapid deterioration within a four-year period, this study was performed.

METHODS

Twenty patients with the most reduced pulmonary function and 19 out of those with normal PF found at the long-term FU were reexamined 4 years later to evaluate further changes in pulmonary function. Patients underwent spirometry and arterial blood gas analysis and answered pulmonary symptom questionnaires.

RESULTS

70% of the reduced pulmonary function group had undergone surgery vs. 26% of the normal group. The mean age (47 vs. 43 years) at this FU and curve size (37° vs. 35°) at the 26-year FU were similar. The decline in forced vital capacity (FVC) % of predicted was similar in both groups over the four-year period, from 67 to 65% in the reduced PF group vs. 96 to 94% in the normal PF group. The total lung capacity (TLC) % of predicted did not change over time in either group. No patient reported worsening dyspnea symptoms. Only one patient in the reduced PF group showed low arterial oxygen tension, 8.4 kPa, not signifying respiratory insufficiency.

CONCLUSION

The age-related decline in FVC and TLC % of predicted did not differ between those with reduced and those with normal pulmonary function at the 26-year follow-up. Thus, these data do not infer increased rate of decline in the most deteriorated patients.

Health-related quality of life and function in middle-aged individuals with thalidomide embryopathy

OBJECTIVES

The aim of this study was to evaluate the effect of limb malformations on health-related quality of life (HRQL) and function of the extremities in middle-aged individuals with thalidomide embryopathy (TE). Between 1959 and 1962, approximately 150 children with multiple malformations were born in Sweden following the maternal intake of thalidomide during pregnancy, of whom 100 survived.

METHODS

Thirty-one individuals with TE underwent evaluations of musculoskeletal manifestations by clinical examination. Validated questionnaires were used for the assessment of general HRQL [the 36-Item Short Form Health Survey (SF-36) and the EuroQ Five Dimensions health questionnaire (EQ-5D)]. The function of the upper and lower extremities was evaluated using specific questionnaires (Disabilities of the Arm, Shoulder and Hand scale and Rheumatoid and Arthritis Outcome Score, respectively). The lower limbs were evaluated by computed tomography. The median age of the study group was 46 years, and 42% were females. Twenty-five individuals had malformations of the hand, but 27 had a grip function. Five individuals had severe lower limb malformations. Individuals with at least one extremity with major malformation(s) that affected function (n = 15) were compared with those without (n = 16).

RESULTS

The physical HRQL for the entire study group [mean 40.6, 95% confidence interval (CI) 35.4-45.8], as evaluated by the Physical Composite Score (PCS) of the SF-36, was significantly lower than the national norm value (population-based norm) of 50.0, and the physical HRQL of the subgroup with major limb malformations (15/31) was even lower (mean 34.6, 95% CI 25.9-43.4). The mental aspects of HRQL, based on SF-36 and EQ-5D scores, were not affected in the entire study group or in the subgroups.

CONCLUSION

The physical quality of life was significantly lower in individuals with TE compared with the general national population, while the mental aspects were not affected.

LEVEL OF EVIDENCE

IV.

The prevalence of disc aging and back pain after fusion extending into the lower lumbar Spine: A matched MR study twenty-five years after surgery for adolescent idiopathic scoliosis

Purpose: To determine the long-term outcome after fusion for adolescent idiopathic scoliosis in terms of degenerative disc findings diagnosed using MR imaging and to elucidate the clinical consequences.

Material and Methods: Thirty-two patients with adolescent idiopathic scoliosis, who had undergone spinal fusion using Harrington rods to the lower lumbar spine with one or two unfused discs below the fusion, were re-examined 25 years after the fusion. The re-examinations included validated questionnaires, clinical examination, full standing frontal and lateral radiographs and MR examination of the lower lumbar region. Curve size and degenerative findings on MR images were evaluated by two unbiased radiologists, blinded to the clinical findings. A matched control group of 32 persons without scoliosis was subjected to the same examinations.

Results and Conclusion: There were significantly more degenerative disc changes ( p<0.0001), disc height reduction ( p=0.0010) and end-plate changes ( p<0.0001 for both upper and lower end-plates) in the lowest unfused disc in the patient group compared with the control group. The MR findings in the lowest unfused disc, but not the one above, in the patient group correlated to lumbar pain intensity as well as to the diminished lumbar lordosis.

Adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) is the most common form of structural spinal deformities that have a radiological lateral Cobb angle - a measure of spinal curvature - of ≥10(°). AIS affects between 1% and 4% of adolescents in the early stages of puberty and is more common in young women than in young men. The condition occurs in otherwise healthy individuals and currently has no recognizable cause. In the past few decades, considerable progress has been made towards understanding the clinical patterns and the three-dimensional pathoanatomy of AIS. Advances in biomechanics and technology and their clinical application, supported by limited evidence-based research, have led to improvements in the safety and outcomes of surgical and non-surgical treatments. However, the definite aetiology and aetiopathogenetic mechanisms that underlie AIS are still unclear. Thus, at present, both the prevention of AIS and the treatment of its direct underlying cause are not possible.

Pulmonary Function in Middle-Aged Patients With Idiopathic Scoliosis With Onset Before the Age of 10 Years

STUDY DESIGN

Consecutive patients with idiopathic scoliosis diagnosed before age 10 attended a clinical follow-up at least 10 years after treatment.

OBJECTIVES

To evaluate the pulmonary function in adulthood after treatment with brace or surgery before maturity.

SUMMARY OF BACKGROUND DATA

Long-term studies of these patients have not been published.

METHODS

One hundred twenty-four patients (69% of the original group) underwent radiography, spirometry, and answered symptom questionnaires. A total of 73 patients had spirometries before treatment enabling longitudinal evaluation. Overall, 68 braced only (BT) and 56 surgically treated (ST) were analyzed in detail. A population-based control group was used.

RESULTS

At follow-up, the mean age was 41.5 years and the mean curve size 36 degrees (26% of the curves >45 degrees). The full patient group had a significantly reduced pulmonary function (as measured by the forced vital capacity [FVC], percentage of predicted) compared with the control group, mean 85% versus 102% (p < .0001). Both subgroups of BT and ST patients showed a significant reduction, more in the ST than the BT group (means 79% and 90%, respectively, p = .0003). The most important risk factor for a low lung function at follow-up was a low initial FVC value. Initial curve size correlated with pulmonary function both before treatment and at follow-up. Most surgically treated patients, who had larger curves before treatment, did not improve their pulmonary function after surgery.

CONCLUSIONS

Both braced and surgically treated patients had reduced pulmonary function at the age of around 40 years. The pulmonary function did not worsen over time in most patients. There was no difference in terms of symptoms between patient groups and controls. Initial curve size was found to be of great importance for pulmonary function. Initial spirometry and follow-up in selected patients is important.

LEVEL OF EVIDENCE

III.

Long-term follow-up of thalidomide embryopathy: malformations and development of osteoarthritis in the lower extremities and evaluation of upper extremity function

BACKGROUND

Between 1959 and 1962, several children with multiple malformations were born after maternal intake of thalidomide during pregnancy, known as thalidomide embryopathy (TE).

OBJECTIVES

The aim of this study was to evaluate the malformations, their long-term effect on the function of the extremities and the development of degenerative osteoarthritis (OA) in the lower extremities.

METHODS

All living persons with TE in Sweden were invited to participate in the study. Thirty-one patients were examined clinically as a part of a multi-disciplinary follow-up programme. Evaluation of upper and lower limb function was performed by validated questionnaires [Disabilities of the Arm, Shoulder and Hand (DASH) and Rheumatoid and Arthritis Outcome Score (RAOS), respectively] and radiographic appearance of lower limbs by the use of spiral computed tomography.

RESULTS

Five individuals had severe malformations of the lower limbs and proximal femoral focal deficiency (PFFD), with significantly reduced function as found on the RAOS values. Twenty-seven patients had two fully functional arms and hands, despite the fact that 8% of shoulders, 26% of elbows/forearms and 70% of hands were malformed. Loss of gripping function did not significantly affect the upper extremity function, as measured by the DASH score. Ten patients without major deformities had OA in the hips and 15 in the knees, mostly mild and with no effect on the RAOS value.

CONCLUSION

A wide variety of malformations in the upper and lower limbs was found in the study group. Degenerative changes were found in the hips and the knees but were mostly mild and without major clinical significance. Despite upper limb anomalies that affected the fine motor skills, upper extremity function was not significantly reduced for most individuals. Individuals with PFFD along with major deformities of upper limbs had a reduced function of upper as well as lower limbs.

Associations between orthopaedic findings, ambulation and health-related quality of life in children with myelomeningocele

PURPOSE

Modern principles for treatment of patients with myelomeningocele include early closure of the neural tube defect, neurosurgical treatment of hydrocephalus and treatment aimed at minimizing contractures and joint dislocations. The aim is to achieve a better survival rate and a better quality of life (QOL). Better ambulatory function is thought to improve the management of activities of daily living. This study focused on evaluating which factors might affect ambulation, function and health-related QOL in children with myelomeningocele.

METHODS

Thirty-eight patients with neurological deficit from myelomeningocele were examined in an unbiased follow-up. This included a physical examination using validated methods for ambulatory function and neuromuscular status, chart reviews and evaluation of radiographs in terms of hip dislocation and spine deformity. The Pediatric Evaluation of Disability Inventory (PEDI) was used to measure mobility, self-care and social function, and the Child Health Questionnaire (CHQ-PF50) was used to measure QOL.

RESULTS

Muscle function class, quadriceps strength, spasticity in hip and/or knee joint muscles and hip flexion contracture as well as the ambulatory level all affected functional mobility as well as self-care/PEDI. Patients with hip dislocation, spinal deformity or those who were mentally retarded also had significantly worse functional mobility. Besides being affected by the severity of the neurological lesion, self-care/PEDI was significantly impaired by hip flexion contracture and absence of functional ambulation. General health-related QOL was significantly lower in this patient group than for US norms. Nonambulatory and mentally retarded patients had a significantly lower physical function of their QOL (CHQ).

CONCLUSIONS

The severity of the disease, i.e. reduced muscle strength and occurrence of spasticity around hip/knee, affected ambulation, functional mobility and self-care. Acquired deformities (hip dislocation and spine deformity) affected functional ambulation only. Patients with reduced functional mobility and self-care experienced lower physical QOL. Children with myelomeningocele had significantly reduced QOL compared to healthy individuals.

A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity

STUDY DESIGN

The Swedish patients included in the previous SRS brace study were invited to take part in a long-term follow-up.

OBJECTIVE

To investigate the rate of scoliosis surgery and progression of curves from baseline as well as after maturity.

SUMMARY OF BACKGROUND DATA

Brace treatment was shown to be superior to electrical muscle stimulation, as well as observation alone, in the original SRS brace study. Few other studies have shown that brace treatment is effective in the treatment of scoliosis.

METHODS

Of 106 patients, 41 in Malmö (all Boston brace treatment) and 65 in Göteborg (observation alone as the intention to treat), 87% attended the follow-up, including radiography and chart review. All radiographs were (re)measured for curve size (Cobb method) by an unbiased examiner. Searching in the mandatory national database for performed surgery identified patients who had undergone surgery after maturity.

RESULTS

The mean follow-up time was 16 years and the mean age at follow-up was 32 years The 2 treatment groups had equal curve size at inclusion. The curve size of patients who were treated with a brace from the start was reduced by 6 degrees during treatment, but the curve size returned to the same level during the follow-up period. No patients who were primarily braced went on to undergo surgery. In patients with observation alone as the intention to treat, 20% were braced during adolescence due to progression and another 10% underwent surgery. Seventy percent were only observed and increased by 6 degrees from inclusion until now. No patients underwent surgery after maturity. Progression was related to premenarchal status.

CONCLUSION

The curves of patients with adolescent idiopathic scoliosis with a moderate or smaller size at maturity did not deteriorate beyond their original curve size at the 16-year follow-up. No patients treated primarily with a brace went on to undergo surgery, whereas 6 patients (10%) in the observation group required surgery during adolescence compared with none after maturity. Curve progression was related to immaturity.

What impact does spinal deformity correction for adolescent idiopathic scoliosis make on quality of life?

STUDY DESIGN

: Literature review.

OBJECTIVE

: To identify scientifically sound studies that have reported changes in quality of life (QOL) after spinal deformity correction in patients with adolescent idiopathic scoliosis (AIS) and to discuss these findings.

SUMMARY OF BACKGROUND DATA

: Few studies have been published. Most are retrospective cohort studies and lack both preoperative and postoperative data for the outcome in terms of QOL.

METHODS

: A review of existing literature with the emphasis on spinal fusion for AIS and outcome as measured by health-related QOL was performed.

RESULTS

: Thirteen studies of various quality were found after reviewing the papers. Only 3 of them contained both preoperative and postoperative data on QOL, using the SRS-22/-24. They all reported a statistically significant improvement in some of the domain scores. The clinical implications of these findings are unclear, as the minimal clinically important differences for SRS-22/-24 have not yet been established.

CONCLUSION

: Weak evidence (Level IV) exists in the literature that spinal deformity correction for AIS does not significantly impact QOL in short-term or mid-term. The interpretation of this must be that there were no serious adverse events after surgery.

Spinal range of motion, muscle endurance, and back pain and function at least 20 years after fusion or brace treatment for adolescent idiopathic scoliosis: a case-control study

STUDY DESIGN

A consecutive series of patients with adolescent idiopathic scoliosis (AIS), treated between 1968 and 1977 before 21 years of age with either distraction and fusion using Harrington rods (ST, n = 156; 145 females and 11 males) or with brace (BT, n = 127; 122 females and 5 males), were followed at least 20 years after completion of the treatment.

OBJECTIVES

To determine the long-term outcome in terms of spinal mobility and muscle strength and its possible correlations to present back pain and function in patients surgically or brace treated for AIS.

SUMMARY OF BACKGROUND DATA

Few reports on long-term outcome on these variables have previously been presented for this group of patients.

METHODS

A total of 135 (87%) of ST and 102 (80%) of BT patients underwent a complete examination by two unbiased observers incl. evaluation of lumbar muscle endurance and spinal mobility, curve size (Cobb method), validated questionnaires in terms of general and disease-specific quality of life aspects, as well as present back function and pain. An age- and sex-matched control group of 100 persons was randomly selected and subjected to the same examinations.

RESULTS

For both ST and BT groups, lumbar spinal motion as well as muscle endurance were significantly decreased compared with controls. For ST patients, better lumbar extensor and flexor muscle endurance or lumbar spinal mobility correlated with a better physical function. The length of fusion into the lumbar spine correlated inversely with lumbar range of motion, but the finger-floor distance was not affected. BT patients with reduced lumbar spinal mobility experienced lumbar back pain more often than controls.

CONCLUSIONS

For both brace treated and surgically treated AIS patients, spinal mobility and muscle endurance were reduced more than 20 years after completed treatment. The physical function was not severely restricted.

Back pain and function 23 years after fusion for adolescent idiopathic scoliosis: a case-control study-part II

STUDY DESIGN

A consecutive series of patients with adolescent idiopathic scoliosis, treated between 1968 and 1977 before age 21 years with distraction and fusion using Harrington rods (surgically treated: n = 156; 145 females and 11 males) were followed-up at least 20 years after completion of the treatment.

OBJECTIVES

To determine the long-term outcome in terms of back pain and function in patients surgically treated for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Few reports on long-term outcome of back pain and function have previously been presented for this group of patients. Results presented are not conclusive regarding effects on back pain and its correlation to a fusion extending into the lower lumbar spine.

MATERIALS AND METHODS

One hundred forty-two (91%) of the patients were reexamined as part of an unbiased personal follow-up. This included a clinical examination and evaluation of curve size (Cobb method) and degenerative findings in full standing frontal and lateral radiographs. Validated questionnaires in terms of general and disease-specific quality of life aspects as well as present back and pain symptoms were used. One hundred thirty-nine had complete follow-up. An age- and sex-matched control group of 100 individuals was randomly selected and subjected to the same examinations.

RESULTS

The deterioration of the curves was 3.5 degrees for all curves and eight (5.1%) of the patients treated with fusion had undergone some additional curve-related surgical procedure. The patients had significantly more degenerative disc changes than the controls. Lumbar pain, although mild (2.4 on visual analogue scale), was significantly more frequent among the patients than the controls (65 vs. 47%, P = 0.0079). Only 25% of the patients admitted daily pain, and analgesics were sparsely used. No major differences of back function and general health-related quality of life were noted between the patients or the controls. Except for having been on sick-leave ever because of the back (45% vs. 19%, P = 0.0040) no differences could be seen in sociodemographic variables between the groups. Furthermore, no differences could be found between patients fused to L3 or higher (n = 102) versus L4 or lower (n = 37). No correlation could be found between pain and its localization and various variables on the scoliotic curve, body mass index, or smoking. Persisting discomfort and/or sensory loss were noted significantly more often among the patients who had the autologous bone harvesting performed through a separate incision over the iliac crest (24.3%) than among those in whom this was performed through an elongated midline incision (4.6%, P = 0.0015).

CONCLUSIONS

Minimal pain and no dysfunction occurred (mean) 23 years after fusion for adolescent idiopathic scoliosis compared with normal straight controls. Significantly more pain in the scar region occurred when bone graft from an incision over the posterior iliac crest was used for harvesting bone to the fusion compared with an incision performed as an elongation of the midline incision used for the scoliosis surgery.

Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study-part I

STUDY DESIGN

A consecutive series of patients with adolescent idiopathic scoliosis and brace-treated (BT) between 1968 and 1977 before age 21 years (BT: n = 127; 122 females and 5 males) were followed-up at least 20 years after completion of the treatment.

OBJECTIVES

To determine the long-term outcome in terms of back pain and function in patients BT for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Few reports on long-term outcome of back pain and function have previously been presented for consecutive groups of these patients.

MATERIALS AND METHODS

One hundred ten (87%) BT patients were reexamined as part of an unbiased personal follow-up. This included a clinical examination, evaluation of curve size (Cobb method), and degenerative findings in full standing frontal and lateral radiographs. Validated questionnaires in terms of general and disease-specific quality-of-life aspects as well as present back and pain symptoms were used. One hundred nine had complete follow-up. An age- and sex-matched control group of 100 persons was randomly selected and subjected to the same examinations.

RESULTS

The deterioration of the curves was a mean of 7.9 degrees for all curves, excluding the only patient who underwent operation after 4 years (increase = 27 degrees). The patients had significantly more degenerative disc changes than the controls. Lumbar and thoracic back pain, although mild (2.7 on visual analogue scale), was significantly more frequent among the patients than the controls (75 vs. 47%, P = 0.0050 and 35.8 vs. 22.0%, P = 0.033, respectively). Only 24% of the patients admitted daily pain and analgesics were sparsely used. The patients had a slightly, but significantly, worse back function as measured by the Oswestry Disability Index (9.2 vs. 4.8, P = 0.0012) and general function score (7.7 vs. 4.2, P = 0.0006), but general health-related quality of life was not affected. No differences could be seen in sociodemographic variables between the groups, except for having ever been on sick leave because of the back (38% vs. 19%, P = 0.0036). Furthermore, no differences could be found between patients with different curve types (single thoracic, n = 50; lumbar, n = 19; double curves, n = 40). No correlation could be found between pain and its localization and curve size, an increase of at least 10 degrees since end of treatment, curve type, degenerative changes on any of the two lowest lumbar disc levels, body mass index, or smoking.

CONCLUSIONS

More than 20 years after brace treatment for AIS, minimal pain and no dysfunction occurred compared with normal controls. Compared with surgically treated patients with a mean end result similar to this group, no significant differences were found except that BT patients experience more affective components of their pain.

Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery

No results on long-term outcome in terms of health-related quality of life (HRQL) have previously been presented for patients treated for adolescent idiopathic scoliosis. A consecutive series of patients with adolescent idiopathic scoliosis, treated between 1968 and 1977 before the age of 21, either with distraction and fusion using Harrington rods [surgical treatment group (ST), n=156; 145 females and 11 males] or with a brace [brace treatment group (BT), n=127; 122 females and 5 males] were followed at least 20 years after completion of the treatment. Ninety-four percent of ST and 91% of BT patients filled in a questionnaire comprising the SF-36, Psychological General Well-Being Index (PGWB), Oswestry Disability Back Pain Questionnaire, parts of SRS/MODEM'S questionnaire and study-specific questions concerning the treatment, as a part of an unbiased personal follow-up examination including radiography and clinical examination. An age- and sex-matched control group of 100 persons was randomly selected and subjected to the same examinations. The results showed no differences in terms of sociodemographic data between the groups. Both ST and BT patients had a slightly, but significantly, reduced physical function using the SF-36 subscales, SF-36/Physical Component Summary (PCS) score as well as the Oswestry Disability Back Pain Questionnaire compared to the controls. Neither the mental subscales and the Mental Component Summary (MCS) score of SF-36 nor the PGWB index showed any significant difference between the groups. Forty-nine percent of ST, 34% of BT and 15% of controls admitted limitation of social activities due to their back [P<0.001 ST vs controls, P=0.0010 BT vs controls, and n.s. (P=0.024) ST vs BT], mostly due to difficulties with physical participation in activities or self-consciousness about appearance. Pain was a minor reason for limitation. No correlation was found between the outcome scores and curve size after treatment, curve type, total treatment time or age at completed treatment. Patients treated for adolescent idiopathic scoliosis were found to have approximately the same HRQL as the general population. A minority of the patients (4%) had a severely decreased psychological well-being, and a few (1.5%) were severely physically disabled due to the back.

Childbearing, curve progression, and sexual function in women 22 years after treatment for adolescent idiopathic scoliosis: a case-control study

STUDY DESIGN

A consecutive series of female patients with adolescent idiopathic scoliosis treated between 1968 and 1977, either with distraction and fusion using Harrington rods (n = 145) or with a brace (n = 122), were followed for at least 20 years after completion of the treatment.

OBJECTIVES

To determine the long-term outcomes of childbearing and sexual life in women treated for adolescent idiopathic scoliosis, as compared with matched control subjects who did not have scoliosis.

SUMMARY OF BACKGROUND DATA

The effect of pregnancy on curve progression is not established, and results are contradictory. Few reports exist on the social life (marriage, childbearing, and sexual function) of formerly treated individuals with scoliosis.

METHODS

In this study, 136 surgically treated women (94%) and 111 brace-treated women (91%) completed the Scoliosis Research Society (SRS)/MODEM's questionnaire concerning childbearing and sexual life as a part of an unbiased personal follow-up examination. Of these, 129 surgically treated and 105 brace-treated women also underwent a radiographic examination. The Cobb method was used to measure curve size in present and earlier examinations. An age-matched control group of 90 women was randomly selected and subjected to the same examinations.

RESULTS

The mean age for all the groups was 40 years. Of the surgically treated and brace-treated women, 85% were or had been married, as compared with 82% of the control women. In the total cohort, 628 pregnancies had occurred. No significant mean difference existed between the groups in the number of children born (1.8 for the surgically treated, 1.9 for the brace-treated, and 2 for the control women) (P = 0.25). The patients in the brace-treated group had a significantly higher mean age at first pregnancy (28 years) than the control subjects (25.9 years) (P = 0.011), whereas the age for the surgically treated women (26.6 years) did not differ significantly from that for the brace-treated women. There were no significant differences between the groups in rates for low back pain (35% for the surgically treated, 43% for the brace-treated, and 28% for the control group) or for cesarean section (19% for the surgically treated, 14% for the brace-treated, and 18% for the control group) during the first pregnancy. The rate of vacuum extractions was higher in the surgically treated group (16%) than in the control group (5%) (P = 0.036) or the brace-treated group(8%). Limitation of sexual function from the back was admitted by 33% of the surgically treated, 28% of the brace-treated, and 15% of the control women: surgically treated vs control subjects (P = 0.0042), brace-treated vs control subjects (P = 0.026), and brace-treated vs surgically treated subjects (P = 0.57, a nonsignificant difference). These limitations were largely because of difficulties participating physically in activities or self-consciousness about appearance. Pain was a minor reason for limitation. There was no correlation between progression of the major or lumbar curve and number of pregnancies, or between curve progression and age at first pregnancy.

CONCLUSIONS

Patients treated for adolescent idiopathic scoliosis appeared to function well with regard to marital status and number of children. The scoliotic curve did not seem to increase as a result of childbearing. Minor problems occurred during pregnancy and delivery. Some patients, however, experienced a slight negative effect in their sexual life.

Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals

STUDY DESIGN

This study is a follow-up investigation for a consecutive series of patients with adolescent idiopathic scoliosis treated between 1968 and 1977. In this series, 156 patients underwent surgery with distraction and fusion using Harrington rods, and 127 were treated with brace.

OBJECTIVES

To determine the long-term outcome in terms of radiologic findings and curve progression at least 20 years after completion of the treatment.

SUMMARY OF BACKGROUND DATA

Radiologic appearance is important in comparing the outcome of different treatment options and in evaluating clinical results. Earlier studies have shown a slight increase of the Cobb angle in brace-treated patients with time, but not in fused patients.

METHODS

Of 283 patients, 252 attended a clinical and radiologic follow-up assessment by an unbiased observer (91% of the surgically treated and 87% of the brace-treated patients). This evaluation included chart reviews, validated questionnaires, clinical examination, and full-length standing frontal and lateral roentgenographs. Curve size was measured by the Cobb method on anteroposterior roentgenograms as well as by sagittal contour and balance on lateral films. The occurrence of any degenerative changes or other complications was noted. An age- and gender-matched control group of 100 individuals was randomly selected and subjected to the same examinations.

RESULTS

The mean follow-up times were 23 years for surgically treated group and 22 years for brace-treated group. The deterioration of the curves was 3.5 degrees for all the surgically treated curves and 7.9 degrees for all the brace-treated curves (P < 0.001). Five patients, all brace-treated, had a curve increase of 20 degrees or more. The overall complication rate after surgery was low: Pseudarthrosis occurred in three patients, and flat back syndrome developed in four patients. Eight of the patients treated with fusion (5.1%) had undergone some additional curve-related surgical procedure. The lumbar lordosis was less in the surgically treated than in the brace-treated patients or the control group (mean, 33 degrees vs 45 degrees and 44 degrees, respectively). Both surgically treated and brace-treated patients had more degenerative disc changes than the control participants (P < 0.001), but no significant differences were found between the scoliosis groups. No statistically significant difference in terms of radiographically detectable degenerative changes in the unfused lumbar discs was found between patients fused below L3 or those fused to L3 and above (P = 0.22). A study on intra- and interobserver measurements of kyphosis, lordosis, and sagittal vertical axis on two films for each patient demonstrated that the repeatability of measuring sagittal plumbline on two different lateral radiographs, with patients moving between radiograms, was unreliable for comparison.

CONCLUSIONS

Although more than 20 years had passed since completion of the treatment, most of the curves did not increase. The surgical complication rate was low. Degenerative disc changes were more common in both patient groups than in the control group.