Scoliosis Research Society Scores Research Articles

SRS-7: A Valid, Responsive, Linear, and Unidimensional Functional Outcome Measure for Operatively Treated Patients With AIS.

Comparison of the Scoliosis Research Society-22 (SRS-22) questionnaire with a 7-item Rasch-derived questionnaire (SRS-7). To compare the construct and discriminant validity, internal consistency, responsiveness, and dimensionality of SRS-7 against SRS-22 in operatively treated children with adolescent idiopathic scoliosis. SRS-22 has not been shown to possess linearity or unidimensionality (internal validity). A multicenter database was queried for children with adolescent idiopathic scoliosis who underwent spinal fusion and answered all preoperative and 1-year postoperative SRS-22 questions. SRS-7 scores for the 685 patients were calculated from SRS-22 item responses. Traditional psychometric properties were assessed for both instruments (significance, P < 0.01). SRS-7 and SRS-22 scores correlated preoperatively and postoperatively (r = 0.78, P < 0.001, and r = 0.78, P < 0.001, respectively). Both instruments showed good discriminant validity in segregating 4 groups of patients with adolescent idiopathic scoliosis by curve magnitudes (F = 8.36, P < 0.001, and F = 8.38, P < 0.001, respectively). Pre- and postoperative SRS-7 and SRS-22 had internal consistency Cronbach α values of 0.64 and 0.67, and 0.85 and 0.85, respectively. With SRS-7, mean postsurgical improvement was 18.7 points (46.6-65.3, P < 0.001), with effect size measures of Cohen d = 1.57, Hedge g = 1.57, and r = 0.62. With SRS-22, mean improvement was 11.6 points (84.5-96.1, P < 0.01), with effect size measures of Cohen d = 1.25, Hedge g = 1.25, and r = 0.53. Iterative principal factor analysis of pre- and postoperative SRS-7 and SRS-22 showed the presence of 1 dominant latent factor (unidimensionality) and 4 latent factors (multidimensionality), respectively. SRS-7 shows good concurrent and discriminative validity, reasonable internal consistency, and excellent responsiveness. It has the advantages over SRS-22 of being short, unidimensional, and an interval scale. 4.

Randomized Clinical Study on Surgical Techniques with Different Pedicle Screw Densities in the Treatment of Adolescent Idiopathic Scoliosis Types Lenke 1A and 1B

Introduction Advances in surgical instrumentation for the correction of vertebral deformities have been followed by the use of an increased number of implants in the construct. These advances have allowed greater correction, especially in complex cases. The use of pedicle screws throughout all anatomical levels of the spine has provided satisfactory correction of spinal deformities of large curves (between 70 and 100) through a single posterior approach, thus avoiding thoracotomy for intervertebral disc release. Nonetheless, the impact of the screw density on clinical, functional, and radiographic results of adolescent idiopathic scoliosis (AIS) treatment is still controversial. To the authors' knowledge, there is no clinical randomized study to date correlating two different surgical techniques using different pedicle screws densities (defined as the proportion of screws and number of pedicles being fused) and costs in patients with AIS. Material and Methods Forty-six patients with Lenke 1A/1B AIS and main thoracic curves to the right, 45 to 70, were operated using a posterior approach and free-hand technique. Once included in the study, patients were randomly allocated to one of the two groups with different techniques for surgical correction of the thoracic deformities. A member of the nursing team who was not involved in the research made the randomization using 46 identical, opaque, sealed envelopes, each containing one of the two group allocations and mixed them up in a box before the beginning of patient recruitment for this study. Group 1 was treated with 10 screws in strategically determined vertebrae: 4 in the base, 3 in the central vertebrae, and 3 in the superior vertebrae. In Group 2, the principles of segmental instrumentation were followed, treating all pedicles on the concavity side, except for the apical vertebra, and alternate pedicles on the convexity side, using 10 to 14 screws. Screw density was calculated as the ratio between the number of screws and pedicles fused. Results Groups were homogeneous regarding preoperative clinical and functional variables, surgery time, and intraoperative bleeding volume. Group 2 had a higher number of screws, average density of pedicle screws, and cost of treatment ( p = 0.000). The number of fused levels was similar between the groups. Two years postoperatively, all radiographic variables were homogeneous between the groups (mean correction of main thoracic curve was 68.5% in Group 1 and 67.9% in Group 2), but Group 2 achieved better clinical correction of the thoracic hump ( p = 0.000). Both presented significant improvement in the five domains of Scoliosis Research Society Score 30. Conclusion In AIS patients with Lenke 1A/B curves of 45 to 70, treatment with a higher pedicle screw density construct was significantly more expensive but had statistically similar functional results and radiographic correction. The denser construct achieved better correction of the thoracic hump 2 years after surgery.

Optimal radiographical criteria after selective thoracic fusion for patients with adolescent idiopathic scoliosis with a C lumbar modifier: does adherence to current guidelines predict success?

Retrospective review of prospective data. To define optimal postoperative coronal parameters after selective thoracic fusions (STFs) and to test these parameters against recommended criteria for when to perform an STF. Previous studies have provided recommendations for when STF should be performed; however, clear parameters for target outcomes are lacking. Patients with Lenke 1C to 4C curves with adolescent idiopathic scoliosis from a multicenter database who underwent STF with minimum 2 years of follow-up were included. Postoperative parameters included lumbar Cobb angle, trunk shift, coronal balance, percent lumbar correction, and deformity-flexibility quotient. First, the upper 95% confidence interval for each parameter was calculated (queried data threshold) and set as the limit of "optimal" outcomes. Second, an independent surgeon survey was performed, and in patients with unanimous surgeon agreement of "success," the upper 95% confidence interval was determined (surgeon-derived threshold). Scoliosis Research Society-22 scores were compared between those above and below these 2 thresholds. Then, these outcomes were used to determine whether adherence to, or disregard for, previously published guidelines for STF were predictive of final outcome. A total of 106 patients were analyzed. Target postoperative parameters as determined by the queried data and surgeon-derived thresholds were similar and rounded to: deformity-flexibility quotient less than 4, lumbar Cobb angle less than 26°, lumbar correction more than 37%, coronal balance 2 cm or less, and trunk shift less than 1.5 cm. Patients within target parameters had significantly better Scoliosis Research Society-22 satisfaction scores. Neither preoperative apical vertebral translation ratio more than 1.2 nor Cobb angle ratio more than 1.2 predicted 2-year success. Preoperative lumbar curve less than 45° and lumbar bend less than 25° were associated with increased likelihood of optimal outcomes. Optimal postoperative outcomes for STF should include a lumbar Cobb angle less than 26°, coronal balance 2 cm or less, deformity-flexibility quotient less than 4, lumbar correction more than 37%, and trunk shift less than 1.5 cm. These findings suggest that performing an STF in patients with a preoperative lumbar Cobb angle less than 45° or a preoperative lumbar bend less than 25° will increase one's chances of success. 4.

Results of revision surgery after pedicle subtraction osteotomy for fixed sagittal imbalance with pseudarthrosis at the prior osteotomy site or elsewhere: minimum 5 years post-revision.

Retrospective review of pedicle subtraction osteotomy (PSO) cases. To report our results, radiographic and clinical outcomes at a minimum 5 years following revision surgery for pseudarthrosis after a PSO. To our knowledge, there is no report on the results of revision surgery for pseudarthrosis after a PSO. Eighteen consecutive patients with pseudarthrosis after PSO (16 females/2 males; average age at surgery, 49.8 yr) treated with revision surgery at one institution were analyzed (average follow-up, 6.5 yr; range, 5-12 yr). Radiographic and clinical outcomes analysis was performed. Sagittal vertical axis (SVA) and lumbar lordosis (LL) improved significantly after revision surgery (SVA, P = 0.000; LL, P = 0.024) and were maintained until ultimate post-revision follow-up (SVA, P = 0.170; LL, P = 0.729). Proximal junctional angle (P = 0.828), thoracic kyphosis (P = 0.828), and PSO angle (P = 0.717) achieved by the primary surgery were also maintained until ultimate post-revision. We increased the number of rods and/or changed them to 6.35-mm diameter in all patients. There were significant improvements post-revision in Oswestry Disability Index (45 vs. 37.9, P = 0.041) and Scoliosis Research Society pain subscale (2.6 vs. 3.1, P = 0.047) but not in Scoliosis Research Society total score or other subscales. Pelvic incidence greater than 60° demonstrated a trend toward poorer Oswestry Disability Index and Scoliosis Research Society scores (P > 0.05), but there were no significant differences between SVA greater or less than 11 cm. Revision surgery for pseudarthrosis after PSO can provide acceptable radiographic and clinical outcomes at a minimum 5 years post-revision. Successful surgical outcomes may be achieved by using an increased number or size of implants and ample bone graft for complete fusion after revision surgery. 4.

Revision Versus Primary Patients Undergoing Vertebral Column Resection for Severe Spinal Deformities

Study DesignRetrospective comparative study. ObjectivesTo compare correction rates and complications of revision versus primary patients undergoing vertebral column resection (VCR). Summary of Background DataAlthough an all-posterior VCR has obviated the need for a circumferential approach, it is technically demanding, especially in a revision setting. MethodsBetween 2002 and 2009, 55 revision patients underwent a posterior-only VCR. Diagnoses included severe scoliosis (n = 3), kyphoscoliosis (KS) (n = 29), global kyphosis (GK) (n = 13), and angular kyphosis (AK) (n = 10). Radiographic findings and complications were compared with 38 primary patients who underwent a VCR during the same period. All patients had a minimum 2-year follow-up (range, 2–6 years). ResultsThe mean number of VCR levels were 1.6 in revision versus 1.2 in primary cases (p = .005). In the severe scoliosis and KS groups, major coronal curve correction was 48% in revision versus 63% in primary cases (p = .001). In the KS, GK, and AK groups, the major sagittal curve correction was 52% in revision versus 57% in primary cases (p = .27). Preoperative (p = .015) and postoperative (p = .002) sagittal imbalance was significantly greater in the revision group. There were no spinal cord–related complications, but 7 revision (13%) and 3 primary (8%) patients temporarily lost neuromonitoring data or failed wakeup tests; however, none had a permanent neurological deficit. Six revision patients (11%) required further revision surgery due to implant failure (3), progressive sagittal or coronal imbalance (2), and delayed deep wound infection (1) versus only 1 primary patient (3%) due to increased coronal imbalance. Preoperative and postoperative Scoliosis Research Society scores were not significantly different between groups. ConclusionsVertebral column resections in revision patients may be more technically demanding than in primary patients but can be performed safely in conjunction with intraoperative spinal cord monitoring. Revision and primary patients undergoing a VCR showed improved clinical outcomes.

The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis.

Single-surgeon series investigating the learning curve involved in surgery for spinal deformity may be confounded by changes in technology and techniques. Our objective with this multicenter, prospective study was to present a cross-sectional analysis of the impact of surgeon experience on surgery for adolescent idiopathic scoliosis. All posterior-only surgical procedures for adolescent idiopathic scoliosis performed in the 2007 to 2008 academic year, with a minimum of two years of patient follow-up, were included. Two groups were created on the basis of surgeon experience: a young surgeons' group, which included patients of surgeons with less than five years of experience, and an experienced surgeons' group, which included patients of surgeons with five or more years of experience. Nine surgeons (four young and five experienced) operated on a total of one hundred and sixty-five patients with adolescent idiopathic scoliosis. The surgeons' experience ranged from less than one year to thirty-six years in practice. The two groups had similar preoperative curve-magnitude measurements, SRS-22 (Scoliosis Research Society-22) scores, and distribution by Lenke curve type. There were significant operative and postoperative differences. The young surgeons fused an average of 1.2 levels more than the experienced surgeons (p = 0.045). The mean intraoperative estimated blood loss (EBL) of the young surgeons' group was more than twice that of the experienced surgeons' group (2042 mL compared with 1013 mL; p < 0.001). The duration of surgery was 458 minutes for the young surgeons compared with 265 minutes for the experienced surgeons (p < 0.001). The overall SRS-22 scores were significantly worse in the young surgeons' group (a mean of 4.1 compared with 4.5; p = 0.001). The difference between groups was also significant for the domains of pain (p = 0.016), self-image (p = 0.008), and function (p < 0.001). Complication rates did not differ significantly between the groups. Operative results and health-related quality of life following surgery for adolescent idiopathic scoliosis were significantly and positively correlated with surgeon experience. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of novel corrective spinal technique on adolescent idiopathic scoliosis as assessed by radiographic imaging

To compare the therapeutic effects of a 3-dimensional corrective spinal technique (CST) and a conventional exercise program (CE) on altered spinal curvature and health related quality-of-life in patients with adolescent idiopathic scoliosis (AIS). Adolescents with idiopathic scoliosis (N=32, 6 males and 26 females) between 10 and 19 years of age (14.34 ± 2.60 years) were recruited and underwent the CST or CE for 60 minutes/day, 2-3 times a week, and an average of total 30 sessions. Diagnostic X-ray imaging technique was used to determine intervention-related changes in the Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, sacral slope, pelvic tilt, pelvic incidence, and vertebral rotation (Nash-Moe method). The Scoliosis Research Society-22 (SRS-22) health related quality-of-life questionnaire was used. Data were analysed using independent t-test, paired t-test, and non-parametric Mann-Whitney U-test at p < 0.05. CST showed greater improvements in Cobb angle (p=0.003), vertebral rotation (p=0.000), and SRS-22 scores (self-image and treatment satisfaction subscale scores and total score, p=0.026, p=0.039, and p=0.041, respectively) as compared to the controls. There were no significant changes in the other measures between the two groups. This is the first clinical trial to investigate the effects of the 3-dimensional CST on spinal curvatures and health related quality-of-life in AIS, providing the important clinical rationale and compelling evidence for the effective management of AIS.

Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity.

Retrospective review of prospectively collected data. To assess the prevalence, risk factors, and clinical outcomes for pseudarthrosis after a lumbar pedicle subtraction osteotomy (PSO). There exists no large series that examines pseudarthrosis rates of PSOs. Data of 171 consecutive patients with adult deformity who underwent a lumbar PSO by 2 surgeons at a single institution with a minimum 2-year follow-up were analyzed. Pseudarthrosis diagnosed through sagittal malalignment and instrumentation failure noted on radiograph was confirmed intraoperatively. Eighteen (10.5%) of 171 patients developed pseudarthrosis after a PSO. Eleven of the 18 patients (6.4% of all patients, 61.1% of the 18 patients with pseudarthrosis) had pseudarthrosis at the PSO site, L3 being the most common; other locations included the lumbosacral junction (4/18), thoracolumbar junction (2/18), and upper thoracic spine (1/18). Preoperative pseudarthrosis level was a predictor of the postoperative level of pseudarthrosis (93%). Fifteen of the 18 patients (83%) had no interbody fusion directly above or below the PSO site, 16 (88%) had a history of pseudarthrosis at the time of PSO surgery and 2 of 3 patients who had prior radiation to the lumbar region developed pseudarthrosis. Most pseudarthroses occurred within the first 2 years (n = 13/18), between 2 and 5 years (n = 3/18), and more than 5 years (n = 2/18) postoperatively. Prior pseudarthrosis (P < 0.0001), pseudarthrosis at the PSO site (P < 0.0001), prior decompression in the lumbar region (P = 0.0037), prior radiation to the lumbar region (P < 0.0001), and presence of inflammatory/neurological disorders (P < 0.0036) were identified as risk factors. All 18 patients with pseudarthroses required revision surgery (posterior-only surgery, n = 12; anteroposterior surgery, n = 6) due to loss of sagittal alignment and pain. The mean pre-revision Scoliosis Research Society score was 85, post-revision score was 95 (P = 0.0166), and the mean pre-revision Oswestry Disability Index score was 42.5, post-revision score was 34.5 (P = 0.0203). The overall prevalence of pseudarthrosis was 10.5% of which 61% occurred at the actual PSO site and Scoliosis Research Society and Oswestry Disability Index scores improved significantly after pseudarthrosis repair. 4.

Upper thoracic versus lower thoracic upper instrumented vertebrae endpoints have similar outcomes and complications in adult scoliosis.

Retrospective review-multicenter database. The purpose of this study was to compare the upper thoracic (UT) and lower thoracic (LT) upper instrumented vertebrae (UIV) in long fusions to the sacrum for adult scoliosis. The optimal UIV for stopping long fusions to the sacrum/pelvis are controversial. Although a UT endpoint may lead to greater operative times, blood loss, and higher rates of pseudarthrosis, the risk for the development of proximal junctional kyphosis and need for revision surgery is likely lower. Retrospective analysis of a prospective database of patients with adult spinal deformity, Patients were selected on the basis of fusions to the sacrum/pelvis with UIV of T1-T6 (UT group) and those with a UIV of T9-L1 (LT group). Demographic data, operative details, and radiographical outcomes with Scoliosis Research Society scores, and Oswestry Disability Index outcomes were collected, as well as complication data were compared. The Fisher exact T tests were used for statistical analysis. A total of 198 patients (UT = 91, LT = 107) with a mean age of 61.6 were followed for an average of 2.5 years. Demographic variables were similar between the groups except for larger numbers of females in the UT group and a slightly higher body mass index in the LT group. Preoperatively, the UT group demonstrated significantly more lumbar scoliosis, thoracic scoliosis, and thoracolumbar kyphosis. The UT group demonstrated a larger number of fused segments length of stay and longer operative times. There was slightly larger volume of blood loss in the UT group.The total number of complications and number of revision surgical procedures were similar between the groups. The UT group had a higher percentage of patients with 2 or more complications. Both groups had similar proximal junctional kyphosis angles and number of cases requiring revision for proximal junctional kyphosis. Scoliosis Research Society and Oswestry Disability Index outcomes were similar between the groups. The UT and LT groups had similar outcomes. The UT group may have a higher rate of total complications, but major complications requiring return to the operative room were similar. The length of stay and operative times were higher in the UT group but may have been necessarily evidenced by the significantly higher coronal deformity and greater thoracolumbar kyphosis in the UT group. 4.

Two-level spinal osteotomy for severe thoracolumbar kyphosis in ankylosing spondylitis. Experience with 48 patients.

A retrospective study. To report surgical results for severe thoracolumbar kyphosis secondary to ankylosing spondylitis (AS) corrected with 2-level spinal osteotomy. Transpedicular osteotomy in the lumbar spine is the major approach to correct kyphosis in AS. Most surgical procedures were performed at 1 level and only few literature report 2-level osteotomy in 1 patient. From January 2003 to June 2011, we reviewed 48 patients experiencing AS with severe thoracolumbar kyphosis who underwent stage 2-level spinal osteotomy in our hospital. The osteotomies were performed at T12 and L2 or L1 and L3, according to the apex of kyphosis. Preoperative and postoperative height, chin-brow vertical angle, sagittal balance, and the sagittal Cobb angle of the vertebral osteotomy segment were documented. Intraoperative, postoperative, and general complications were recorded. The chin-brow vertical angle improved from 65.0° ± 28.0° to 5.0°± 10.0° (P = 0.000) and the sagittal imbalance distance improved from 26.9 ± 10.4 cm to 10.6 ± 5.6 cm (P = 0.000). The mean amount of correction was 24.9° at the superior site of the osteotomy and 38.1° at the inferior site of the osteotomy. Postoperatively, all patients could walk with horizontal vision and lie on their backs. No major acute complications such as death or complete paralysis occurred. Five patients experienced complications such as infections (n = 1) and cerebrospinal fluid leaks (n = 4). Both Oswestry Disability Index and Scoliosis Research Society scores improved largely. Fusion at the osteotomy site was achieved in each patient, and no implant failures were noted. Single-stage 2-level osteotomy can effectively and safely correct kyphotic deformities of the thoracolumbar spine caused by AS. 3.

Six-year follow-up study on the effect of combined anterior and posterior spinal fusion on lung function and quality of life in young people with adolescent idiopathic scoliosis.

The effects of spinal surgery on lung function and quality of life (QoL) are important patient outcomes. Long-term follow-up of lung function and QoL in those undergoing combined anterior and posterior spinal fusion (A/PSF) for adolescent idiopathic scoliosis (AIS) is poorly documented with only one study extending beyond 2 years, though available evidence points to a decrement in lung function. Our study evaluated long-term change in lung function and QoL following A/PSF for AIS. Prospective cohort study. Patients with AIS. Tertiary paediatric respiratory centre and national spinal service. Spirometry was performed along with QoL (Scoliosis Research Society-22 (SRS-22) questionnaire). Paired t test and one-way analysis of variance were used to compare pre-A/PSF and post-A/PSF data. Data were available for 12 patients (9 female) who underwent A/PSF at mean 13.8 (range 11.8-15) years. Mean follow-up was undertaken 5.8 (range 4.1-6.8) years postoperatively. Height increased from mean (SD) 169 (9) cm preoperatively to 175 (5) cm at follow-up (p<0.01). Scoliosis corrected from 100 (15)° to 29 (11)° (p<0.001). Mean (SD) forced expiratory volume in 1 s was -3.4 (1.4) z scores preoperatively versus -3.3 (1) z scores postoperatively (p=0.85); and forced vital capacity was -3.4 (1.7) ) z scores pre-A/PSF and -3.4 (1.1) z scores post-A/PSF (p=0.83). SRS-22 scores improved mean (SD) of 3.6 (0.3) preoperatively to 4.2 (0.3) at 2 years postoperatively, and 4.4 (0.4) at 6 year follow-up (p<0.001, analysis of variance). High patient satisfaction rates (4.8 (0.3)) were recorded. No correlation was noted between changes in forced expiratory volume in 1 s (r=-0.15, p=0.63) or forced vital capacity (r=-0.12, p=0.71) and change in long-term SRS-22 score. Long-term follow-up of patients with AIS suggests no deficit in pulmonary function, while QoL shows incremental improvement and patient satisfaction is high over 6 years after A/PSF.

Scoliosis Research Society-22 Results in 3052 Healthy Adolescents Aged 10 to 19 Years

Cross-sectional survey. The purpose of our study was to evaluate a large population of adolescents from a broad mix of racial/ethnic backgrounds and age groups to better establish baseline normative values for the Scoliosis Research Society-22 (SRS-22). The SRS-22 instrument was developed to assess treatment outcomes in patients with adolescent idiopathic scoliosis. To accurately assess real changes in outcome measures, the SRS-22 must be able to differentiate patients with and without adolescent idiopathic scoliosis. The SRS-22 was administered to 3052 healthy adolescents, 51% female and 49% male, with a mean age of 14.6 years (range, 10-19 yr). We grouped the children into 3 age groups for analysis: 10 to 12 years (362), 13 to 15 years (1487), and 16 to 19 years (1203). Racial/ethnic groups included: Caucasian, 62%; African American, 14%; Hispanic, 9%; Asian, 6%; Native American, 5%; and Pacific Islander, 4%. SRS-22 scores were analyzed to establish normative values for each group. Mean SRS-22 scores were: activity, (4.31 ± 0.54); pain, (4.44 ± 0.67); image, (4.41 ± 0.64); mental, (3.96 ± 0.81); and total, (4.26 ± 0.54). Females had lower scores in the mental domain (3.90) than males (4.04) (P < 0.001). The scores of children aged 10 through 12 years were higher in the domains of activity (P = 0.000), pain (P < 0.001), and mental (P < 0.001) than those of children aged 13 through 15 years and 16 through 19 years. The 13- to 15-year group had significantly higher scores than the 16- to 19-year group (P < 0.001) in each of the same categories. Regarding race/ethnicity, Caucasians tended to report higher scores in most domains than other race/ethnic groups. Hispanics scored lower in all domains than the non-Hispanic group. Age, sex, and race had a significant impact on SRS-22 scores in a large group of healthy adolescents. In general, scores lowered as age increased from 10 to 19 years, Caucasians scored higher in function, pain, and image than other racial groups, and Hispanics scored lower than non-Hispanics in all domains. These factors should be considered when evaluating SRS-22 scores.

Extension of Spine Fusion to the Sacrum Following Long Fusions for Deformity Correction

Retrospective review of prospective database. To investigate the long-term results after extension of previous long spine fusions to the sacrum. Long spine fusions not involving the sacrum may be complicated by distal degeneration and require subsequent extension to the sacrum. The clinical and radiographical outcomes after such revision remain unknown. Patients who had extension of a long fusion (≥5 levels with a thoracic level at the cranial end) to the sacrum between 2002 and 2007 at a single institution were analyzed. Oswestry Disability Index and Scoliosis Research Society scores and/or radiographical parameters were assessed at baseline, 6 weeks and 1 year, 2, 3, and/or 5 years postoperatively (PO) and complications were recorded. There were 74 patients with an average age of 49 years (range, 19-76 yr) and average clinical follow-up of 4.5 years (range, 3 mo-10 yr, 82% >2 yr PO). All had degeneration distal to prior fusions and 72% (n = 53) had fixed sagittal imbalance. Sagittal alignment improved at all PO time points from baseline (mean, 78 mm), but worsened between 1 year (mean, 21 mm) and 5 years PO (mean, 44 mm, P = 0.01). Major surgical complications occurred in 30% (n = 22) and there were 17 major reoperations in 15 patients (20%). Significant improvements (P < 0.05) in Oswestry Disability Index and all Scoliosis Research Society domain scores were found at each PO time point with no deterioration from 1 to 5 years PO. Mean outcome scores at 5 years PO were similar in groups with major surgical complications versus without and with major reoperation versus without. Extension of long fusions to the sacrum resulted in significant and sustained improvements in Oswestry Disability Index and Scoliosis Research Society scores and alignment during 5 years PO compared with baseline. Major surgical complications occurred in 30% and reoperations were performed in 20%, but outcome scores after treatment were similar to those without complications or reoperations.

Increased Body Mass Index Negatively Affects Patient Satisfaction After a Posterior Fusion and Instrumentation for Adolescent Idiopathic Scoliosis

Study DesignRetrospective. Summary of Background DataPrevious studies have reported the correlation of body mass index (BMI) with non-spine surgical outcomes; however, only a few reviewed the correlation of BMI to outcomes after spine surgery. ObjectivesTo review the influence of preoperative BMI on the follow-up clinical and functional outcomes after posterior-only fusion (PSF) and instrumentation for adolescent idiopathic scoliosis in a larger patient cohort. MethodsRetrospective review of a consecutive series of patients treated with PSF for adolescent idiopathic scoliosis from 2002 to 2009 at a single institution. There were 3 categories: underweight (UW), normal weight (NML), and overweight (OW). Percent correction of the major curve was collected at 2 years postoperatively and patient outcome scores were analyzed preoperatively and at 2 years postoperatively. Differences between groups were analyzed using analysis of variance, with p < .05. ResultsA total of 459 patients at an average age of 15.0 years (range, 10.0–21.3 years) treated with PSF instrumentation were included. At 2 years, all groups achieved and maintained equal percent correction with no differences between groups. Regarding preoperative Scoliosis Research Society (SRS) outcome scores, OW patients reported more pain than NML (p = .002) and UW patients (p < .001) despite less reported activity than for the NML (p = .033) and UW groups (p = .005). The total SRS score was also lower in the OW patients compared with NML (p = .009) and UW patients (p = .002). At 2 years, the OW group reported more pain than the UW (p = .031) and NML groups (p = .018), lower mental scores (p = .011) and lower SRS total scores (p = .005) than the NML group. ConclusionsAt follow-up, preoperative overweight adolescents reported more pain and lower mental, activity, and appearance domain scores after surgery than UW and NML patients despite equal percent curve correction. This information may help the surgeon with preoperative counseling of OW patients by stressing that their own assessment of outcome is influenced by BMI, which may help promote a healthy weight management program in this patient group.

Clinical improvement through nonoperative treatment of adult spinal deformity: who is likely to benefit?

The goal of this study was to determine the outcome and risk factors in patients with adult spinal deformity (ASD) who elected to receive nonoperative care. In this retrospective study the authors reviewed a nonoperative branch of the International Spine Study Group database, derived from 10 sites across the US. Specific inclusion criteria included nonoperative treatment for ASD and the availability of Scoliosis Research Society (SRS)-22 scores and radiographic data at baseline (BL) and at 1-year (1Y) follow-up. Health-related quality of life measures were assessed using the SRS-22 and radiographic data. Changes in SRS-22 scores were evaluated by domain and expressed in number of minimum clinically important differences (MCIDs) gained or lost; BL and 1Y scores were also compared with age- and sex-matched normative references. One hundred eighty-nine patients (mean age 53 years, 86% female) met inclusion criteria. Pain was the domain with the largest offset for 43% of patients, followed by the Appearance (23%), Activity (18%), and Mental (15%) domains. On average, patients improved 0.3 MCID in Pain over 1Y, without changes in Activity or Appearance. Baseline scores significantly impacted 1Y outcomes, with up to 85% of patients in the mildest category of deformity being classified as < 1 MCID of normative reference at 1Y, versus 0% of patients with the most severe initial deformity. Baseline radiographic parameters did not correlate with outcome. Patients who received nonoperative care are significantly more disabled than age- and sex-matched normative references. The likelihood for a patient to reach SRS scores similar to the normative reference at 1Y decreases with increased BL disability. Nonoperative treatment is a viable option for certain patients with ASD, and up to 24% of patients demonstrated significant improvement over 1Y with nonoperative care.

Surgical treatment of pathological loss of lumbar lordosis (flatback) in patients with normal sagittal vertical axis achieves similar clinical improvement as surgical treatment of elevated sagittal vertical axis: clinical article.

Increased sagittal vertical axis (SVA) correlates strongly with pain and disability for adults with spinal deformity. A subset of patients with sagittal spinopelvic malalignment (SSM) have flatback deformity (pelvic incidence-lumbar lordosis [PI-LL] mismatch > 10°) but remain sagittally compensated with normal SVA. Few data exist for SSM patients with flatback deformity and normal SVA. The authors' objective was to compare baseline disability and treatment outcomes for patients with compensated (SVA < 5 cm and PI-LL mismatch > 10°) and decompensated (SVA > 5 cm) SSM. The study was a multicenter, prospective analysis of adults with spinal deformity who consecutively underwent surgical treatment for SSM. Inclusion criteria included age older than 18 years, presence of adult spinal deformity with SSM, plan for surgical treatment, and minimum 1-year follow-up data. Patients with SSM were divided into 2 groups: those with compensated SSM (SVA < 5 cm and PI-LL mismatch > 10°) and those with decompensated SSM (SVA ≥ 5 cm). Baseline and 1-year follow-up radiographic and health-related quality of life (HRQOL) outcomes included Oswestry Disability Index, Short Form-36 scores, and Scoliosis Research Society-22 scores. Percentages of patients achieving minimal clinically important difference (MCID) were also assessed. A total of 125 patients (27 compensated and 98 decompensated) met inclusion criteria. Compared with patients in the compensated group, patients in the decompensated group were older (62.9 vs. 55.1 years; p = 0.004) and had less scoliosis (43° vs 54°; p = 0.002), greater SVA (12.0 cm vs. 1.7 cm; p < 0.001), greater PI-LL mismatch (26° vs. 20°; p = 0.013), and poorer HRQOL scores (Oswestry Disability Index, Short Form-36 physical component score, Scoliosis Research Society-22 total; p ≤ 0.016). Although these baseline HRQOL differences between the groups reached statistical significance, only the mean difference in Short Form-36 physical component score reached threshold for MCID. Compared with baseline assessment, at 1 year after surgery improvement was noted for patients in both groups for mean SVA (compensated -1.1 cm, decompensated +4.8 cm; p ≤ 0.009), mean PI-LL mismatch (compensated 6°, decompensated 5°; p < 0.001), and all HRQOL measures assessed (p ≤ 0.005). No significant differences were found between the compensated and decompensated groups in the magnitude of HRQOL score improvement or in the percentages of patients achieving MCID for each of the outcome measures assessed. Decompensated SSM patients with elevated SVA experience significant disability; however, the amount of disability in compensated SSM patients with flatback deformity caused by PI-LL mismatch but normal SVA is underappreciated. Surgical correction of SSM demonstrated similar radiographic and HRQOL score improvements for patients in both groups. Evaluation of SSM should extend beyond measuring SVA. Among patients with concordant pain and disability, PI-LL mismatch must be evaluated for SSM patients and can be considered a primary indication for surgery.

Does preoperative narcotic use adversely affect outcomes and complications after spinal deformity surgery? A comparison of nonnarcotic- with narcotic-using groups

Background contextThe role of preoperative (preop) narcotic use and its influence on outcomes after spinal deformity surgery are unknown. It is important to determine which patient factors and comorbidities can affect the success of spinal deformity surgery, a challenging surgery with high rates of complications at baseline. PurposeTo evaluate if preop narcotic use persists after spinal deformity surgery and whether the outcomes are adversely affected by preop narcotic use. Study design/settingRetrospective evaluation of prospectively collected data. Patient sampleTwo hundred fifty-three adult patients (230 females/23 males) undergoing primary spinal deformity surgery were enrolled from 2000 to 2009. Outcome measuresPreoperative and postoperative (postop) narcotic use and changes in Oswestry Disability Index (ODI), Scoliosis Research Society (SRS) pain, and SRS total scores. MethodsPreoperative, 2-year postop, and latest follow-up pain medication use were collected along with ODI, SRS pain, and SRS scores. Preoperative insurance status, surgical and hospitalization demographics, and complications were collected. All patients had a minimum 2-year follow-up (average 47.4 months). ResultsOne hundred sixty-eight nonnarcotic (NoNarc) patients were taking no pain meds or only nonsteroidal anti-inflammatories preoperatively. Eighty-five patients were taking mild/moderate/heavy narcotics before surgery. The average age was 48.2 years for the NoNarc group versus 53.6 years for the Narc group (p<.005). There were significantly more patients with degenerative than adult scoliosis in the Narc group (47 vs. 28, p<.001; mild 19 vs. 24, p<.02; moderate 6 vs. 14, p<.0003; heavy 3 vs. 10, p<.0002). Insurance status (private/Medicare/Medicaid) was similar between the groups (p=.39). At latest follow-up, 137/156 (88%) prior NoNarc patients were still not taking narcotics whereas 48/79 (61%) prior narcotic patients were now off narcotics (p<.001). Significant postop improvements were seen in Narc versus NoNarc groups with regard to ODI (26–15 vs. 44–30.3, p<.001), SRS pain (3.36–3.9 vs. 2.3–3.38, p<.001), and overall SRS outcome (3.36–4 vs. 2.78–3.68, p<.001) scores. A comparison of change in outcome scores between the two groups showed a higher improvement in SRS pain scores for the Narc versus NoNarc group (p<.001). ConclusionsIn adults with degenerative scoliosis taking narcotics a significant decrease in pain medication use was noted after surgery. All outcome scores significantly improved postop in both groups. However, the Narc group had significantly greater improvements in SRS pain scores versus the NoNarc group.

Is There a “July Effect” in Surgery for Adolescent Idiopathic Scoliosis?

Prior studies in various medical and surgical specialties have suggested that the changeover of medical trainees in the United States at the end of the academic year, or so-called "July effect," negatively impacts the quality of patient care, including increasing morbidity and decreasing efficiency. We analyzed whether the outcomes of surgery for adolescent idiopathic scoliosis involving physicians-in-training as first assistants were affected by the time of year the surgery was performed. We performed a multicenter retrospective study with use of a prospectively collected database to examine outcomes following instrumented posterior spinal fusion in patients with adolescent idiopathic scoliosis. The minimum duration of follow-up was two years. The outcomes of procedures performed by twelve surgeons whose first assistants were all surgeons-in-training were analyzed on the basis of the month of year that the surgery was performed. Variables assessed included blood loss, operative time, length of hospitalization, radiographic outcomes, Scoliosis Research Society (SRS-22) scores, and complications. Five hundred and seventy-five surgical procedures for adolescent idiopathic scoliosis were performed, most in June (14%) and July (13%) (p ≤ 0.001). Preoperative radiographic characteristics were similar across all months as were postoperative radiographic outcomes. Preoperative and two-year SRS-22 scores were also similar across all months, with the exception of scores in the preoperative pain domain, which showed worse pain for patients who underwent surgery in February. No significant differences in blood loss, operative time, or length of hospital stay were observed when these variables were analyzed on the basis of the month in which the surgery was performed. The rate of patients experiencing any complication (23.5% overall) was not associated with the month of surgery, nor were the rates for the specific subcategories of neurologic, pulmonary, gastrointestinal, instrumentation, or surgical site-related complications. With the exception of three gastrointestinal complications that were observed in July, the odds of a patient having a complication from surgery in July/August were unchanged from other months. Overall, the data did not provide evidence to support a July effect. Our results suggest that surgery for adolescent idiopathic scoliosis during July and August yields safety and outcomes equal to that of other months.

Clinical and Radiographic Outcomes After 3-Column Osteotomies With 5-Year Follow-up

Retrospective review of prospective database. To investigate long-term results after 3-column osteotomies (3-CO). Short-term studies have noted improved outcomes and alignment after 3-CO, but there is a paucity of long-term studies with a large group of patients. An analysis of 126 patients who underwent a 3-CO (pedicle subtraction osteotomy [N = 101]/vertebral column resection [N = 25]) with minimum 5-year follow-up was performed at a single institution. The mean age was 48 years (range, 8-79 yr) and average follow-up was for 7 years (range, 5-14 yr). Oswestry Disability Index and Scoliosis Research Society (SRS) scores and radiographical parameters were assessed at baseline, 6 weeks, and 1, 2, 3, and/or 5 years postoperatively and complications were recorded. Sagittal alignment improved at all postoperative time points from baseline (mean, 117 mm), but diminished from 6 weeks (mean, 24 mm) to 5 years (mean, 41 mm; P = 0.03). Average coronal alignment was improved from baseline (27 mm) at 6 weeks (18 mm; P = 0.003) and 5 years postoperatively (19 mm; P = 0.007), with no deterioration between 6 weeks and 5 years postoperatively (P = 0.9). Major surgical complications occurred in 36% (n = 45) and major repeat surgery was performed in 28% (n = 35). Significant improvements (P < 0.05) in Oswestry Disability Index and all SRS domain scores were found at each time point. All mean outcome scores at 5 years postoperatively exceeded minimal clinically important difference thresholds except the SRS function domain. Improvement in outcomes at 5 years postoperatively was similar in groups with major surgical complications versus those without and in those with reoperation versus those without. This study of 126 patients undergoing 3-CO found significant and sustained improvements in Oswestry Disability Index and SRS scores and sagittal alignment at a minimum 5 years postoperatively. This demonstrates the durability of these complex spinal reconstructions, even surprisingly in those patients having a major complication and/or revision surgery. 4.

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 DesignProspective sequential patient series. ObjectivesTo 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. MethodsA 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. ResultsAssessment 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. ConclusionsThe 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.