Adolescent idiopathic scoliosis: shoulder balance and SRS-22 patient-reported outcome

Retrospective study. To investigate the relationship between a +ve postoperative Upper Instrumented Vertebra (UIV) (≥0°) tilt angle and the risk of medial shoulder/neck and lateral shoulder imbalance among Lenke 1 and 2 Adolescent Idiopathic Scoliosis (AIS) patients following Posterior Spinal Fusion. Current UIV selection strategy has poor correlation with postoperative shoulder balance. The relationship between a +ve postoperative UIV tilt angle and the risk of postoperative shoulder and neck imbalance was unknown. One hundred thirty-six Lenke 1 and 2 AIS patients with minimum 2 years follow-up were recruited. For medial shoulder and neck balance, patients were categorized into positive (+ve) imbalance (≥+4°), balanced, or negative (-ve) imbalance (≤-4°) groups based on T1 tilt angle/Cervical Axis measurement. For lateral shoulder balance, patients were classified into +ve imbalance (≥+3°) balanced, and -ve imbalance (≤-3°) groups based on Clavicle Angle (Cla-A) measurement. Linear regression analysis identified the predictive factors for shoulder/neck imbalance. Logistic regression analysis calculated the odds ratio of shoulder/neck imbalance for patients with +ve postoperative UIV tilt angle. Postoperative UIV tilt angle and preoperative T1 tilt angle were predictive of +ve medial shoulder imbalance. Postoperative UIV tilt angle and postoperative PT correction were predictive of +ve neck imbalance. Approximately 51.6% of patients with +ve medial shoulder imbalance had +ve postoperative UIV tilt angle. Patients with +ve postoperative UIV tilt angle had 14.9 times increased odds of developing +ve medial shoulder imbalance and 3.3 times increased odds of developing +ve neck imbalance. Postoperative UIV tilt angle did not predict lateral shoulder imbalance. Patients with +ve postoperative UIV tilt angle had 14.9 times increased odds of developing +ve medial shoulder imbalance (T1 tilt angle ≥+4°) and 3.3 times increased odds of developing +ve neck imbalance (cervical axis ≥+4°). 4.

Retrospective clinical, radiographic, and patient outcome review of surgically treated adolescent idiopathic scoliosis. To correlate radiographic and clinical features of shoulder balance and the proximal thoracic curve with patient satisfaction outcomes at a minimum 2-year follow-up. Traditionally, radiographic features of a structural proximal thoracic curve have been T1 tilt, proximal thoracic Cobb angle, and proximal thoracic side-bending Cobb; however, these do not always correlate with clinical shoulder balance. A total of 112 patients (single surgeon) with adolescent idiopathic scoliosis and a proximal thoracic curve >or=20 degrees (average 32 degrees, range 20-78 degrees) were evaluated in terms of shoulder balance and curve flexibility/correction. Four groups were analyzed: Group 1, posterior spinal fusion to T2 (proximal thoracic curve included, n = 24); Group 2, posterior spinal fusion to T3 (proximal thoracic curve partially included, n = 23); Group 3, posterior spinal fusion to T4 or T5 (proximal thoracic curve not included, n = 21); and Group 4, anterior spinal fusion to T4 or below (proximal thoracic not included, n = 44). Proximal thoracic, main thoracic, and thoracolumbar-lumbar upright coronal, side-bending, and sagittal Cobb measurements were assessed before surgery, 1 week after surgery, and at a minimum 2-year postoperative follow-up (average 3.8 years, range 2.0-7.6 years). In addition to T1 tilt, clavicle angle (intersection of a horizontal line and the tangential line connecting the highest two points of each clavicle), coracoid height difference, trapezius length (horizontal distance of the T2 pedicle to second rib-clavicle intersection), first rib-clavicle height difference (vertical distance of first rib apex to superior clavicle), and proximal thoracic, main thoracic, and thoracolumbar-lumbar apical vertical translation were determined. Shoulder asymmetry as measured by the radiographic soft tissue shadow was graded as balanced (<1 cm), slight (1-2 cm), moderate (2-3 cm), or significant (>3 cm). A postoperative patient questionnaire addressed shoulder balance and overall appearance at most recent follow-up. The four groups were found to be statistically equivalent in terms of preoperative proximal thoracic curve (P = 0.4146), proximal thoracic side-bending Cobb (P = 0.2199), main thoracic curve (P = 0.6999), and main thoracic side-bending curves (P = 0.7307). Radiographic: Preoperative proximal thoracic measurements correlating with postoperative shoulder balance (P < 0.05) included the clavicle angle (three of four groups with a trend toward statistical significance in the fourth group, P = 0.07) and coracoid height (two of four groups). No other measurement, including T1 tilt and proximal thoracic side-bending Cobb, correlated in more than one group. Proximal thoracic curve correction was greatest in Group 1 (posterior spinal fusion to T2; average 12 degrees) and Group 4 (anterior spinal fusion to T4 or below; average 12 degrees). Clinical: Shoulder balance improved in all four groups (range 0.38-1.00 grades). There was no difference in shoulder balance between groups (P = 0.2723). Patient assessment: All four groups also reported improvement in self-perceived shoulder balance (63% up to one grade, 37% over two-grade improvement), whereas no patient reported worsening of shoulder balance. There was no significant difference in patient outcomes between the four groups (P = 0.3654). The clavicle angle, not T1 tilt, upright proximal thoracic, or side-bending proximal thoracic Cobb, provided the best preoperative radiographic prediction of postoperative shoulder balance. In each of the four groups, postoperative shoulder balance and clinical appearance also improved and correlated with patient postoperative assessments.

Introduction Surgical outcomes for adult patients with residual adolescent idiopathic scoliosis (AdIS) with a major thoracic curve are expected to be inferior to those of AIS but have not been well reported. This study aimed to evaluate surgical, radiographical, and clinical results in adult patients with AdIS and to characterize these patients by comparing their results with those of patients with adolescent idiopathic scoliosis (AIS). Methods Thirty-five patients with AdIS, who were diagnosed with AIS Lenke type 1 or 2 before the age of 19 years and underwent surgery after the age of 20 years, were included in the study. As a control group, 84 patients with AIS Lenke type 1 or 2 who underwent surgery before the age of 19 were included. Both groups were matched on the basis of the preoperative main thoracic (MT) and proximal thoracic (PT) Cobb angles, causing 30 patients to be selected in each group. Results The AdIS group exhibited a greater preoperative bending Cobb angle of the MT and PT curves (MT: 35.1° vs. 31.3°, PT: 17.8° vs. 13.8°) and a lower MT curve flexibility index than in the AIS group (36.6% vs. 42.2%). Postoperatively, the AdIS group had a higher number of fused intervertebral segments than did the AIS group (8.2 vs. 7.4), but the correction rate was comparable in the 2 groups. Moreover, the intraoperative time was longer and blood loss was larger in the AdIS group. In the Scoliosis Research Society (SRS)-22 score, self-image and mental health domains were significantly lower preoperatively in the AdIS group. Postoperative improvement of self-image domain was significantly greater in the AdIS group (Δ self-image: 1.6 vs. 0.9), and postoperative satisfaction was similar in the 2 groups. Conclusions Surgical invasiveness was increased in AdIS, and preoperative SRS-22 scores were lower in self-image and mental health domains than in AIS. However, postoperative SRS-22 scores were comparable, and postoperative self-image improvement was significantly greater in AdIS than in AIS.

Trunk imbalance in adolescent idiopathic scoliosis

Cosmetic appearance in adolescent idiopathic scoliosis: Predictive factors and evaluation of the TAPS and SRS-22 self-image subdomains before and after posterior spinal fusion.

BackgroundIdiopathic scoliosis (IS), a three-dimensional spinal deformity common in adolescents, can be treated with numerous approaches, including Schroth, Spiral stabilization (SPS), and core exercises, to improve spinal alignment and health. However, few studies have shown the superiority of one treatment over another.ObjectiveThis retrospective cohort study was designed to evaluate the efficacy of three distinct physical therapy protocols in managing IS among adolescents aged 6–18 years with Cobb angles ≤40°.MethodsA total of 61 patients were allocated to one of three therapeutic groups. Each group received interventions twice weekly for 10 sessions. Primary outcomes were assessed by measuring changes in the Cobb angle, whereas secondary outcomes included evaluations of pain (visual analog scale, VAS), the angle of trunk rotation (ATR), trunk aesthetic clinical evaluation (TRACE), radiographic parameters (Alignment of the C7 plumbline (C7PL), clavicle angle, and pelvic obliquity), and quality of life (the Scoliosis Research Society-22 questionnaire,SRS-22).ResultsThe findings revealed significant within-group improvements in the Cobb angle, pain, and trunk rotation for all interventions (p < 0.05). Notably, between-group comparisons indicated that both the Schroth and SPS modalities resulted in greater reductions in the Cobb angle and trunk rotation than core stabilization exercises did (p < 0.05). Moreover, SPS resulted in superior enhancements in the clavicle angle and dynamic postural control, whereas Schroth yielded significant improvements in C7PL alignment.ConclusionThis short-term study underscores the relative effectiveness of the Schroth and SPS interventions in managing three-dimensional spinal deformities and enhancing dynamic postural control while recognizing the limitations of core stabilization exercises for scoliosis.Clinical trial registrationThis retrospective analysis of a clinical trial has been registered in the Chinese Clinical Trial Registry (ChiCTR2500096077) https://www.google.com/search?client=firefox-b-d&q=ChiCTR2500096077.

Review of a prospective database registry of surgical patients with adolescent idiopathic scoliosis (AIS). The purpose of this study was to examine the prevalence of postoperative pain and its impact on patient-reported postoperative outcomes using the Scoliosis Research Society (SRS)-22 outcomes questionnaire. Although reportedly rare, postoperative pain can be a devastating situation for the patient with AIS. Most recent studies examining outcomes in AIS surgical treatment use the SRS Pain domain score to assess pain in this population. A prospectively enrolled multicenter database was queried. Patients with minimum 2-year follow-up and 2-year SRS scores were included. Postoperative pain after the acute phase of recovery when reported by the patient to the treating surgeon/clinical team in follow-up is recorded as a complication in the database. Patients included in this series were grouped as either reporting pain or not to the surgeon/clinical team postoperatively. Pre- and postoperative SRS scores were then compared between these 2 groups using analysis of variance (P < 0.05). Five hundred and eighty-four patients meeting the inclusion criteria were identified. Sixty-one (11%) reported pain at sometime between 2 weeks and 2 years postoperatively. Thirteen were within the 6-month postoperative period. Of the remaining 48 reporting pain between 6 and 24 months postoperatively, 41 (7% of the total cohort) had no obvious cause for their pain. More than half of these patients (26/41) were referred for further treatment (physical therapy, referral to pain specialist, further imaging). These 41 patients had significantly decreased 2-year SRS scores in the domains of Pain, Self-image, Mental health, and Total score (P < 0.05). The patients with postoperative pain were found to have significantly lower preoperative Pain domain scores (P < 0.001), indicative of greater pain preoperatively, yet there were no other domains effected preoperatively. For this group the pre- to postoperative SRS pain scores did not show significant change (P > 0.05). Unexplained pain after the 6-month postoperative period occurred in 7% of the cohort. The results indicate that patients reporting pain to their surgeons/clinical team postoperatively have lower pain scores on a subjective outcome instrument thus further validating the SRS-22 outcome tool. This reported pain seems to be associated with decreases in other SRS-22 domains. Interestingly, these patients also have lower preoperative pain scores than those without postoperative pain. Study into causes of pain in AIS and whether preoperative education and expectations targeted at this population would positively impact outcomes is warranted, especially because on average patients after AIS surgery have less pain. 3.

This is an analysis of a prospective 2-year study on nonoperative patients enrolled in the Adult Symptomatic Lumbar Scoliosis (ASLS) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) trial. The purpose was to evaluate the impact of serious adverse events (SAEs) on patient-reported outcomes (PROs) in nonoperative management of ASLS as measured by Scoliosis Research Society-22 (SRS-22), Oswestry Disability Index (ODI), and Short Form-12 (SF-12) at 2-year follow-up. Little is known about PROs in the nonoperative management of ASLS or the prevalence and impact of SAEs on PROs. The ASLS trial dataset was analyzed to identify adult lumbar scoliosis patients electively choosing or randomly assigned to nonoperative treatment with minimum 2-year follow-up. Patient data were collected prospectively from 2010 to 2015 as part of NIAMS R01-AR055176-01A2 "A Multi-Centered Prospective Study of Quality of Life in Adult Scoliosis." SAEs were defined as life-threatening medical events, new significant or permanent disability, new or prolonged hospitalization, or death. One hundred five nonoperative patients were studied to 2-year follow-up. Twenty-seven patients (25.7%) had 42 SAEs; 15 (14.3%) had a SAE during the first year. The SAE group had higher body mass index (29.4 vs. 25.2; P = 0.008) and reported worse SRS-22 Function scores than the non-SAE group at baseline (3.3 vs. 3.6; P = 0.024). At 2-year follow-up, SAE patients experienced less improvement (change) in SRS-22 Self-Image (-0.07 vs. 0.26; P = 0.018) and Mental Health domains (-0.19 vs. 0.25; P = 0.002) than non-SAE patients and had lower SRS-22 Function, Self-Image, Subscore, and SF-12 Mental and Physical component scores (MCS/PCS). Fewer SAE patients reached minimal clinically important difference (MCID) threshold in SRS-22 Mental Health (14.8% vs. 43.6%; P = 0.01). A high percentage (25.7%) of ASLS patients managed nonoperatively experienced SAEs. Those patients who sustained a SAE had less improvement in reported outcomes. 2.

OBJECTIVE Postoperative shoulder imbalance (PSI) is a critical consideration after corrective surgery for a double thoracic curve (Lenke Type 2); however, the radiographic factors related to PSI remain unclear. The purpose of this study was to identify the radiographic factors related to PSI after corrective surgery for adolescent idiopathic scoliosis (AIS) in patients with a double thoracic curve. METHODS This study included 80 patients with Lenke Type 2 AIS who underwent corrective surgery. Patients were grouped according to the presence [PSI(+)] or absence [PSI(-)] of shoulder imbalance at the final follow-up examination (differences of 20, 15, and 10 mm were used). Various radiographic parameters, including the Cobb angle of the proximal and middle thoracic curves (PTC and MTC), radiographic shoulder height (RSH), clavicle angle, T-1 tilt, trunk shift, and proximal and distal wedge angles (PWA and DWA), were assessed before and after surgery and compared between groups. RESULTS Overall, postoperative RSH decreased with time in the PSI(-) group but not in the PSI(+) group. Statistical analyses revealed that the preoperative Risser grade (p = 0.048), postoperative PWA (p = 0.028), and postoperative PTC/MTC ratio (p = 0.011) correlated with PSI. Presence of the adding-on phenomenon was also correlated with PSI, although this result was not statistically significant (p = 0.089). CONCLUSIONS Postoperative shoulder imbalance is common after corrective surgery for Lenke Type 2 AIS and correlates with a higher Risser grade, a larger postoperative PWA, and a higher postoperative PTC/MTC ratio. Presence of the distal adding-on phenomenon is associated with an increased PSI trend, although this result was not statistically significant. However, preoperative factors other than the Risser grade that affect the development of PSI were not identified by the study. Additional studies are required to reveal the risk factors for the development of PSI.

Ponte osteotomies in a matched series of large AIS curves increase surgical risk without improving outcomes.

The Scoliosis Research Society-30 (SRS-30) is a questionnaire originally developed from the SRS-22r questionnaire and is used to evaluate adolescent idiopathic scoliosis (AIS). It comprised questions on five domains: function, pain, self-image, mental health, and satisfaction, with seven additional questions related to postoperative aspects. In addition to the original English version, translations in multiple languages have been effectively applied. Herein, we evaluated the internal consistency and external validity of the Japanese version of the SRS-30 for AIS patients. Among the 30 questions in SRS-30, the eight additional questions from SRS-22r were translated and back-translated to create a Japanese version of the SRS-30. This translated questionnaire was then used to survey patients with AIS who underwent corrective fusion surgery one year postoperatively. The internal consistency of the responses was evaluated using the Cronbach α coefficient. Additionally, the Spearman correlation analyses were conducted to assess the correlation between the scores obtained from the SRS-30 Japanese version and SRS-22r and the Oswestry Disability Index (ODI) for the overall scale and the five domains. A total of 81 cases (eight males and 73 females; mean age at surgery 14.4 years) were enrolled. The mean preoperative Cobb angle was 51.0°. The Cronbach α coefficient for the overall SRS-30 was 0.861, indicating high internal consistency, while the coefficients for each domain were as follows: function/activity, 0.697; pain, 0.405; self-image/appearance, 0.776; mental health, 0.845; and satisfaction, 0.559. The SRS-30 total score significantly correlated with the SRS-22r total (r=0.945, P<0.001) and the ODI (r=-0.511, P<0.001). The SRS-30 domains highly correlated with the corresponding SRS-22r domains, with correlations ranging from r=0.826 to 0.901 (all P<0.001). The Japanese version of the SRS-30 demonstrated good internal and external validity. The SRS-30 can be used as an assessment tool for health-related quality of life in AIS patients.

Prospective cross-sectional measurement study. To determine the ability of the Scoliosis Research Society (SRS)-22 questionnaire to discriminate among management and scoliosis severity subgroups and to correlate with internal and external measures of curve severity. In earlier studies of the SRS-22 discriminative ability, age was not a controlled factor. The ability of the SRS-22 to predict curve severity has not been thoroughly examined. The SRS-22 was completed by 227 females with adolescent idiopathic scoliosis. Using Analysis of covariance analyses controlling for age, the SRS-22 scores were compared among management subgroups (observation, brace, presurgery, and postsurgery) and curve-severity subgroups (in nonoperated subjects: Cobb angles of <30 degrees, 30 degrees -50 degrees, and >50 degrees). A stepwise discriminant analysis was used to identify the SRS-22 domains most discriminative for curve-severity categories. Correlation between SRS-22 scores and radiographic or surface topography measurements was used to determine the predictive ability of the questionnaire. Pain was better for subjects treated with braces than for those planning surgery. Self-image was better for subjects under observation or postsurgery than for those planning surgery. Satisfaction was better for the brace and postsurgery subgroups than for the observation or presurgery subgroups. Statistically significant mean differences between subgroups were all larger than 0.5, which is within the range of minimal clinically important differences recommended for each of the 5-point SRS-22 domain scoring scales. Pain and mental health were worse for those with Cobb angles of >50 degrees than with Cobb angles of 30 degrees to 50 degrees. Self-image and total scores were worse for those with Cobb angles of >50 degrees than both other subgroups. Using discriminant analysis, self-image was the only SRS-22 domain score selected to classify subjects within curve severity subgroups. The percentage of patients accurately classified was 54% when trying to classify within 3 curve severity subgroups. The percentage of patients accurately classified was 73% when classifying simply as those with curves larger or smaller than 50 degrees . Pain, self-image, and satisfaction scores could discriminate among management subgroups, but function, mental health and total scores could not. The total score and all domain scores except satisfaction discriminated among curve-severity subgroups. Using discriminant analysis, self-image was the only domain retained in a model predicting curve-severity categories.

A retrospective review of a prospectively collected multicenter database. To assess the effect of proximal hooks versus screws on proximal junctional kyphosis (PJK) as well as shoulder balance in otherwise all pedicle screw (>80%) posterior spinal fusion (PSF) constructs in adolescent idiopathic scoliosis (AIS). Less rigid forms of fixation at the top of constructs in degenerative lumbar PSF have been postulated to decrease the risk of PJK. A multicenter AIS surgical database was reviewed to identify all patients who underwent PSF with all pedicle screw (>80%) constructs and minimum 2-year follow-up. Patients in the "hook" group had two hooks used at the top of the construct, whereas the "screw" group used only pedicle screws at all levels. A total of 354 patients were identified, 274 (77%) in the screw group, and 80 (23%) in the hook group. There were no significant preoperative differences with regards to curve type, coronal/sagittal Cobb angle, or curve flexibility for either group. At 2 years post-op, the coronal Cobb correction was similar for both groups (60%). There was no difference in correction of shoulder asymmetry and T1 rib angle, including when the groups were matched for preoperative shoulder balance. PJK, defined as the sagittal Cobb angle between the uppermost instrumented and uninstrumented vertebrae, was similar for the screw versus hook group as well (7.1° vs. 6.2°, P = 0.2). The use of different anchors (pedicle screws vs. hooks) at the top of an otherwise all pedicle screw PSF construct for AIS did not have any significant bearing on the correction of shoulder asymmetry and coronal Cobb angle at 2 years postoperative. There was also no significant difference in the magnitude of PJK or incidence of marked PJK (>15°) between either group at 2 years. 3.

BackgroundAs far as we know, no study has investigated spontaneous postoperative shoulder imbalance (PSI) correction in adolescent idiopathic scoliosis (AIS) patients. The objective is to assess the incidence of and associated factors for spontaneous PSI correction in AIS patients.MethodsThe study evaluated 144 postoperative AIS patients with PSI aged 10–20 years between 2010 and 2018. An analysis included demographic data and radiographic measurements (Risser grading, Lenke type, upper instrumented vertebra [UIV], and lowest instrumented vertebra [LIV]). Preoperative, postoperative, and follow-up radiographs were evaluated for shoulder parameters: radiologic shoulder height (RSH); T1 tilt angle; clavicle angle (CA); proximal thoracic curve (PTC), main thoracic curve (MTC), and lumbar curve (LC) Cobb measurements; and apical vertebral translation (AVT) of the PTC, MTC, and LC.ResultsSpontaneous PSI correction was observed in 99 (68.75%) patients. The spontaneous correction and nonspontaneous correction groups differed significantly in terms of Lenke-type preoperative LC (23° vs 26°; P = 0.091), postoperative LC (11° vs 8°; P = 0.013), LC at follow-up (13.5° vs 9°; P = 0.028), postoperative AVT of LC (− 0.8° vs − 0.4°; P = 0.033), AVT of LC at follow-up (− 0.7° vs − 0.1°; P = 0.091), PTC at follow-up (16° vs 20°; P = 0.019), and AVT of PTC at follow-up (0° vs -0.3°; P = 0.029). Multivariate analysis identified postoperative T1 tilt and postoperative LC as significantly associated with PSI correction.ConclusionsThe incidence of spontaneous PSI correction is high. Postoperative T1 tilt and postoperative LC are significantly associated with spontaneous PSI correction.

Development of National Research and Clinical Agendas for Patient-Reported Outcomes in IR: Proceedings from a Multidisciplinary Consensus Panel