eO
RIGINAL
ARTICLE
Evaluation of Quality of Life in Adolescent Idiopathic Scoliosis With Different Distal Fusion Level A Comparison of L3 Versus L4 Ran Ding, MD, Jinqian Liang, MD, Guixing Qiu, MD, Jianxiong Shen, MD, and Zheng Li, MD
Study Design: Retrospective case-control study. Objective: The aim of this study was to assess patients’ quality of life with different fusion levels in posterior pedicle screw correction of idiopathic scoliosis. Summary of Background Data: No previous study has demonstrated differences in health-related quality of life (HRQoL) between patients fused to L3 versus L4. Materials and Methods: A retrospective study was conducted on 30 scoliotic patients fused to L3 using complete pedicle screw instruments. Thirty age-matched and sex-matched scoliotic patients fused to L4 were in the control group. Radiologic parameters were assessed before surgery and at latest follow-up between the 2 groups. These 2 groups were compared for the Scoliosis Research Society 22 questionnaire (SRS-22), Oswestry Disability Index (ODI), visual analogue scale (VAS), and Short Form-36 (SF-36) questionnaires, which were administered preoperatively and at final follow-up. Results: There were no significant differences in sex, age, followup duration, the distribution of curve patterns, the postoperative residual Cobb angle of the main curve, complications, or surgical method between the L3 and L4 groups (P > 0.05). Preoperative scores were statistically similar in the L3 and L4 groups for all domains of all questionnaires. There was no difference between the L3 and L4 groups for ODI (P = 0.527) and VAS (P = 0.518). There were no significant differences in the scores on function/activity, self-image/appearance, pain, mental health, or satisfaction with treatment domains between the 2 groups. No significant differences between the 2 groups were Received for publication September 3, 2013; accepted December 3, 2013. From the Department of Orthropaedic Surgery, Peking Union Medical College Hospital, Chinese Academy Of Medical Sciences & Peking Union Medical College, Beijing, China. Supported by National Natural Science Foundation of China (Grant No. 81272053 and NO. 81301596). No Benefits in any form have been or will be received from any commercial party related directly and indirectly to the subject of this manuscript. The authors declare no conflict of interest. Reprints: Jianxiong Shen, MD, Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing 100730, China (e-mail: shenjian [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
J Spinal Disord Tech
Volume 27, Number 5, July 2014
found at the final follow-up in the SF-36 subscales/domain scores. Conclusions: This study attempted to elucidate the correlation between the length of fusion and functional outcome; however, it could not identify any difference between different fusion levels. On the basis of short-term results, there were no significant differences in the questionnaire scores between the 2 groups. Key Words: quality of life, adolescent idiopathic scoliosis, health-related quality of life questionnaire, lowest instrumented vertebra (J Spinal Disord Tech 2014;27:E155–E161)
S
urgical treatments for adolescent idiopathic scoliosis (AIS) attempt to be achieving a balanced spinal fusion. Although longer spinal fusions have been shown to result in improved deformity correction compared with shorter fusions, patients have experienced an increased potential for accelerated lumbar degeneration. A shorter fusion that saves the distal motion segment has usually been the aim of surgeons. However, the correlation between the length of fusion and functional outcome remains controversial. Several studies1–5 have shown that the lowest instrumented vertebra below the L3 in patients with scoliosis has resulted in a greater functional loss and a higher incidence of disk degeneration and low back pain (LBP). There are also few studies6,7 demonstrating that no differences could be found between patients fused to L3 or higher versus L4 or lower. Nevertheless, preserving lumbar motion segments is still an aim of surgeons. Besides traditional radiographic measurements and clinical outcomes, health-related quality of life (HRQoL) is an important measure in evaluating the treatment of AIS. With the development of outcome tools for measuring general HRQoL, such as the Short Form-36 (SF36) or visual analogue scale (VAS), and disease-specific questionnaires, such as the Scoliosis Research Society 22 questionnaire (SRS-22) and Oswestry Disability Index (ODI), a number of articles on HRQoL during or after treatment in patients with scoliosis have been published.8–11 www.jspinaldisorders.com |
E155
J Spinal Disord Tech
Ding et al
To the best of our knowledge, previous studies6,7 on the outcome of back pain and function have been presented by comparing general longer spinal fusions with shorter fusions. However, no previous study has demonstrated the differences in HRQoL with specific fusion levels, especially between L3 and L4. Moreover, whether patients fused to L4 have more back pain than those fused to L3is still unknown. The aim of this study was to determine patients’ preference between a longer fusion versus a shorter fusion by the administration of the 4 questionnaires listed above.
MATERIALS AND METHODS Patients and Determination of Fusion Levels Consecutive patients with AIS requiring surgical correction were studied during 2007–2011 in the Peking Union Medical College Hospital. We selected 30 patients fused to L3 using complete pedicle screw instruments. All patients were followed-up for at least 2 years. The mean age at the time of the surgery was 15.4 ± 1.78 years. We also reviewed our database of patients with AIS who received surgical treatment during the same period (ie, from 2007 to 2011). These scoliotic patients fused to L4 were chosen and best matched for sex, age, curve pattern, and then matched at a 1:1 ratio.
Surgical Procedure The surgical procedure consisted of a posterior approach with a complete pedicle screw system. Briefly, all-pedicle screws were inserted with a free-hand pedicle screw-placement technique. Curve correction was achieved with rod rotation, compression, and/or distraction. The rods were bent into designed spinal kyphosis and lordosis with placement. The spinous processes maybe removed during surgery and curetted, and alongside homogenous bone grafts be saved to perform bone graft fusion toward the end of the procedure. All surgeries were performed by the same senior surgeon (S.J.X).
Radiographic Measurements Radiologic parameters were assessed before surgery, about 1 week after surgery, and at the latest follow-up. Coronal plane measurements included Cobb angles (including preoperative convex bending Cobb angle). Trunk shift was determined by measuring the horizontal distance between C7 plumb line and the central sacral vertical line. Sagittal plane measurements included sagittal kyphosis (in degrees, T5–T12) and sagittal lordosis (in degrees, L1–S1). Radiographic measurements were taken by 2 independent physicians.
Questionnaire To capture the impact of the disease and its treatment, generic and scoliosis-specific questionnaires were all selected in this study. Patients were assessed preoperatively and at the latest follow-up by the prepared questionnaires. At follow-up, a standardized questionnaire was mailed to the patients and mailed back with a stamped return envelope.
E156 | www.jspinaldisorders.com
Volume 27, Number 5, July 2014
SRS-22 The SRS-22 Outcomes Instrument has been a widely used HRQL questionnaire to evaluate the perception of patients suffering from scoliosis.6,10–13 A simplified Chinese version was used in mainland China.14 The SRS-22 covers 5 domains (function/activity, pain, self-image, mental health, and satisfaction with treatment). Each item has 5 verbal response alternatives ranging from 1 (worst) to 5 (best). Results are expressed as the mean (total sum of the domain divided by the number of items answered) for each domain.
SF-36 The Chinese (mainland) version of the SF-36, quite similar to the original American population, was tested.15 The 36-item Short Form Health Survey is a brief selfadministered questionnaire that generates scores across 8 dimensions of health: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH).
VAS We added 1 question about GH (“How is your health status now?” on a scale from 0 to 100, wherein 100 indicates the best possible health status and 0 indicates the worst possible health status) using the visual analogue scale (VAS).16
ODI This score had 10 questions about pain and painrelated disability in activities of daily living and social participation. The sum was calculated and presented as a percentage, wherein 0% represents no pain and disability, and 100% represents the worst pain and disability.17 All questionnaires were checked for completeness to avoid missing answers by 2 independent physicians.
Statistical Analysis Normality test was conducted to examine the shape and distribution of the continuous variables. All continuous variables were presented as mean ± SD. Independent samples’ t test and the paired t test were conducted to compare the scoring and radiologic parameters. All statistical analyses were performed by using SPSS 17.0 statistical software (SPSS Inc., Chicago, IL). All the tests were 2-tailed and the significance level (P) was 0.05). A summary of radiographic findings was provided in Table 1. In addition, no patients in our groups experienced decompensation or revision surgery (Figs. 1, 2).
Quality of Life All patients completed the SF-36, SRS-22, VAS, and ODI questionnaires. Preoperative scores were statistically similar in the L3 and L4 groups for all domains of all questionnaires. The differences between the scores of the L3 and L4 groups on the 5 domains of the SRS-22 scale were summarized in Table 2. All domains of the SRS-22 scale showed that there was an improvement overall, but only the self-image domain had a statistically significant difference within itself over time. There were no significant differences in the scores on function/activity, self-image/ appearance, pain, MH, or satisfaction with treatment domains between the 2 groups. Although all subscales did not show a statistically significant difference (Table 2), for the SF-36, comparisons between the subscales of the L3 and L4 groups were made, as shown in Table 2. Except for RP and PF, both groups showed an improvement over 2 years of follow-up overall for other subscales. Surprisingly, the RP scores in the postoperative stage of the L3 group were significantly lower than that in the preoperative stage, and PF scores changed in the opposite trend. No significant differences between the 2 groups were found preoperatively or at any time point in the SF-36 subscales/domain scores.
Evaluation of Quality of Life in AIS
In our group, results revealed that there was no difference between the L3 and L4 groups for ODI (P = 0.527). The single-item GH measure (VAS) did not show significant differences between the L3 and L4 groups at the final follow-up.
DISCUSSION A shorter fusion that saves the distal motion segment has been the aim of this criterion. However, the correlation between the length of fusion and the longterm functional outcome remains controversial. Numerous studies18–20 have commented on the incidences of LBP, which may have been caused by increasing stress on caudal uninstrumented levels. Loss of motion may lead to accelerated progression of normal degenerative changes at adjacent unfused levels. Nevertheless, no differences in terms of pain and back function were also detected between those with a “high” fusion (down to L3 or above) versus a “low” fusion (down to L4 or below).6,7 However, preservation of as many motion segments in the lumbar spine as possible is the general goal of the surgical management for surgeon. To date, there were few studies that use the scoliosis-specific and scoliosis-nonspecific HRQoL questionnaires to measure patient-based outcome according to different distal fusion level, especially comparison of L3 versus L4 with all-pedicle screw instruments. We failed to correlate variables concerning the length of fusion with pain and back function as measured by SRS-22, SF-36, VAS, and ODI. In our study, patients scored around 4 points on a 5-point scale in all domains (SRS-22), which implies that these patients were satisfied. Results revealed that there was no difference between the L3 and L4 groups for ODI (P = 0.527) and VAS (P = 0.567). For the SF-36 and SRS-22, 8 subscales and 5 domains did not show a statistically significant difference between the L3 and L4 groups. Similar findings were also described by Danielsson and Nachemson6 and Helenius et al.7 In 2003,
TABLE 1. Comparisons of Patient Characteristics Between the L3 and L4 Groups Distal Fusion Level Characteristics
L3 (n = 30)
L4 (n = 30)
P
Age at the present follow-up (y) Follow-up (mo) Female [n (%)] MT Cobb angle (deg., Preop.) TL/L Cobb angle (deg., Preop.) MT Cobb angle (deg., Follow-up) TL/L Cobb angle (deg., Follow-up) T5–T12 kyphosis (deg., Preop.) L1–S1 lordosis (deg., Preop.) T5–T12 kyphosis (deg., Follow-up) L1–S1 lordosis (deg., Follow-up) Coronal C7 to CSVL deviation (mm, Preop.) Coronal C7 to CSVL deviation (mm, Follow-up)
15.4 ± 1.78 37.5 ± 116.0 26 (86.7) 42.75 ± 11.73 38.23 ± 10.88 10.9 ± 7.0 6.6 ± 5.4 21.8 ± 10.5 46.1 ± 11.6 28.6 ± 13.1 46.7 ± 9.0 13.0 ± 9.0 6.5 ± 5.5
16.7 ± 7.69 40.1 ± 11.3 27 (90.0) 46.23 ± 20.65 48.07 ± 8.07 16.7 ± 9.1 7.9 ± 6.1 25.4 ± 14.9 47.7 ± 14.7 25.5 ± 7.8 49.8 ± 8.9 21.1 ± 11.1 7.2 ± 6.8
0.457 0.347 0.986 0.572 0.009 0.067 0.538 0.411 0.715 0.435 0.319 0.030 0.781
CSVL indicates central sacral vertical line; Follow-up, final follow-up; MT, main thoracic; Preop., preoperation; PT, proximal thoracic; TL/L, thoracolumbar/lumbar.
r
2014 Lippincott Williams & Wilkins
www.jspinaldisorders.com |
E157
Ding et al
J Spinal Disord Tech
Volume 27, Number 5, July 2014
FIGURE 1. Determination of the lowest instrumented vertebra (LIV) for a 13-year-old female patient with double-curve scoliosis. A and B, Thoracic and lumbar curve magnitudes are 40 and 60 degrees, respectively. The rotation of L4 was less than II degree according to the Nash-Moe method, and kyphosis deformity of this zone was not measured in sagittal radiograph. C and D, Bending radiographs of the same patient. In concave bending, the L4 was intersected by the central sacral vertical line (CSVL) in concave side-bending radiographs (CSBR). Therefore, the L4 was chosen to be the LIV for this patient according to bending radiographs. E–H, Radiographs at 1 week (E and F) and 2.6 years (G and H) after surgery show satisfactory curve correction and trunk balance restoration.
Danielsson and colleagues reported results of 91% of initial 156 patients undergoing Harrington Instrumentation for AIS 23 years (mean) from the termination of treatment to the present follow-up. The results in terms of pain and back function did not show any differences between those with a fusion ending below L3 versus those with a more proximal ending of the fusion.
E158 | www.jspinaldisorders.com
Recently, Green et al21 could not show any difference for subpopulations of patients with lowest instrumented vertebra of T12 or L1 and L3 as measured by SRS-22R scores and ODI scores. No patients reported significant lower back pain and took analgesic medications for pain in this study. Several studies18–20,22 have demonstrated rates of LBP r
2014 Lippincott Williams & Wilkins
J Spinal Disord Tech
Volume 27, Number 5, July 2014
Evaluation of Quality of Life in AIS
FIGURE 2. Determination of the lowest instrumented vertebra (LIV) for a 11-year-old female patient with double-curve scoliosis. A and B, Anteroposterior (AP) standing radiographs showed that thoracic and lumbar curve magnitudes are 40 and 43 degrees, respectively. The rotation of L3 was less than II degree according to the Nash-Moe method, and kyphosis deformity of this zone was not measured in sagittal radiograph. C and D, Bending radiographs of the same patient. In concave bending, central sacral vertical line (CSVL) distinctly comes into contact with L3 and passes medial to its concave pedicle. Therefore, the L3 can be chosen as LIV according to bending radiographs. E–H, Radiographs at 1 week (E and F) and 2 years (G and H) after surgery show satisfactory curve correction and trunk balance restoration.
(15%–45%) after successful fusion for AIS at long-term follow-up. This decreased prevalence in our study may have occurred because of rather short-term follow-up. Although no significant differences between the 2 groups were found in the self-image domain scores, this item of SRS-22 after surgery in both the groups were significantly improved compared with that before surgery (P < 0.05). This finding was also consistent with the r
2014 Lippincott Williams & Wilkins
results of the previous studies, which have found selfimage to be the main factor improved by surgical treatment. Merola et al23 reported a multicenter study of the outcomes of the surgical treatment of AIS using the Scoliosis Research Society Questionnaire. Pain, General Self-Image, Function From Back Condition, and Level of Activity all demonstrated statistically significant improvement as compared with preoperative status. www.jspinaldisorders.com |
E159
J Spinal Disord Tech
Ding et al
Volume 27, Number 5, July 2014
TABLE 2. Comparison of Clinical Questionnaires Between Preoperative and Final Follow-up in the 2 Groups Fused to L3 ODI VAS SRS-22 Function/activity Pain Self-image Mental health Satisfaction SF-36 RP BP GH PF VT SF RE MH
Fused to L3
Fused to L4
Preop.
Follow-up
P
Preop.
Fused to L4 Follow-up
P
Follow-up
Follow-up
P
2.9 ± 3.2 90.3 ± 23.7
2.6 ± 2.7 88.9 ± 32.2
0.563 0.651
3.21 ± 3.51 89.2 ± 24.5
3.1 ± 2.7 91.4 ± 19.2
0.900 0.290
2.6 ± 2.7 88.9 ± 32.2
3.1 ± 2.7 91.4 ± 19.2
0.567 0.518
4.0 ± 0.5 4.4 ± 0.7 3.2 ± 0.8 3.8 ± 0.8 4.0 ± 0.9
3.9 ± 0.6 4.5 ± 0.7 4.2 ± 0.7 4.2 ± 0.7 4.3 ± 0.6
0.703 0.485 0.011 0.052 0.239
4.2 ± 0.6 4.5 ± 0.7 3.5 ± 1.1 3.8 ± 0.8 3.7 ± 1.0
4.1 ± 0.4 4.5 ± 0.7 4.2 ± 0.6 4.3 ± 0.5 4.4 ± 0.6
0.860 0.934 0.047 0.056 0.141
3.9 ± 0.6 4.5 ± 0.7 4.2 ± 0.7 4.2 ± 0.7 4.3 ± 0.6
4.1 ± 0.4 4.5 ± 0.7 4.2 ± 0.6 4.3 ± 0.5 4.4 ± 0.6
0.338 0.975 0.994 0.830 0.796
90.8 ± 23.9 90.8 ± 15.9 50.7 ± 9.2 98.2 ± 13.8 74.5 ± 15.1 90.1 ± 23.4 86.0 ± 27.9 71.4 ± 17.3
75.0 ± 36.3 86.0 ± 19.9 55.4 ± 10.3 97.4 ± 36.8 78.4 ± 14.5 98.7 ± 17.6 86.0 ± 27.9 74.5 ± 16.9
0.030 0.403 0.013 0.935 0.247 0.023 1.000 0.187
71.7 ± 42.1 86.4 ± 14.6 45.1 ± 12.4 91.3 ± 10.8 73.3 ± 13.5 90.0 ± 19.6 68.9 ± 38.9 67.2 ± 20.2
68.3 ± 35.9 87.5 ± 12.6 52.0 ± 9.3 85.0 ± 8.0 80.0 ± 8.2 93.3 ± 14.8 77.8 ± 34.9 76.3 ± 10.6
0.751 0.844 0.062 0.089 0.073 0.469 0.334 0.061
75.0 ± 36.3 86.0 ± 19.9 55.4 ± 10.3 97.4 ± 36.8 78.4 ± 14.5 98.7 ± 17.6 86.0 ± 27.9 74.5 ± 16.9
68.3 ± 35.9 87.5 ± 12.6 52.0 ± 9.3 85.0 ± 8.0 80.0 ± 8.2 93.3 ± 14.8 77.8 ± 34.9 76.3 ± 10.6
0.597 0.805 0.330 0.212 0.710 0.354 0.452 0.730
BP indicates bodily pain; GH, general health; MH, mental health; ODI, Oswestry Disability Index; PF, physical functioning; Preop., preoperative score; RE, role limitations due to emotional problems; RP, role limitations due to physical problems; SF, social functioning; SF-36, Short Form-36; SRS-22, Scoliosis Research Society 22 questionnaire; VT, vitality.
However, with regard to the level of activity, we found mild decrease in Function/Activity (SRS-22) and PF (SF-36) domain scores at the final follow-up, although the difference was not statistically significant (P > 0.05). Moreover, there was no difference between the L3 and L4 groups for Function/Activity (SRS-22) and PF. Research showed that postoperative scores could also change over time. Newton et al24 and Pellegrino and Avanzi25 found significant reductions in Function/Activity scores at 3-month follow-up. However, at 12-month follow-up, thesescores had increased significantly. During follow-up, we have found that patients were not participating in vigorous activities because they were afraid of hard exercise after surgery. Moreover, the patients were short of health education and possessed varying levels of cognitive ability at different ages. All the patients in our study had posterior instrumentation and fusion using all-pedicle screws. Lubicky et al26 had contrasted SRS outcome scores for patients receiving different types of spinal instrumentation. There were no statistically significant baseline differences among the 3 instrumentation construct groups. However, our study still does have some limitations. First, we have a relatively small number of included patients. Indeed, there are confounding variables and selection bias because of small sample size and retrospective study. Moreover, there is clearly a need for prospective, multicenter, large-scale trials to aid surgical decision making in the future regarding the length of spinal fusions. Second, the follow-up time was still relatively short. The indication for surgery of AIS is to prevent future deterioration of the curve and ensuing impairment of quality of life, not an immediate improvement in the quality of life. Therefore, maybe, there is no significant change in the quality of life in the relative short-term outcome. A continued follow-up of our patients is under way.
E160 | www.jspinaldisorders.com
Nevertheless, the sample was small, and the time of follow-up was relatively short. Our preliminarily study, to some extent, could still indicate that a shorter fusion does not show significant superiority compared with a longer fusion as far as functional outcome is concerned. In addition, perhaps those questionnaires above are not sensitive enough in certain domains to reflect early change. Is it necessary to save the L3–L4 motion segment for a simple “fuse short” that may increase the risk of postoperative trunk imbalance? Meanwhile, when does it not seem to matter much to the patients? The answer needs to be further explored.
CONCLUSIONS In summary, there were no significant differences in the Questionnaire scores between the 2 groups. On the basis of short-term results, it is not clear whether function and LBP improved in patients with increased numbers of mobile motion segments, despite surgeons always aiming to save motion segment as much as possible. REFERENCES 1. Ilharreborde B, Morel E, Mazda K, et al. Adjacent segment disease after instrumented fusion for idiopathic scoliosis: review of current trends and controversies. J Spinal Disord Tech. 2009;22:530–539. 2. Danielsson A, Cederlund C, Elkholm S, et al. 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. Acta Radiol. 2001;42:187–197. 3. Wilk B, Karol LA, Johnston CE, et al. The effect of scoliosis fusion on spinal motion: a comparison of fused and nonfused patients with idiopathic scoliosis. Spine (Phila Pa 1976). 2006;31:309–314. 4. Michel CR, Lalain JJ. Late results of Harrington’s operation. Longterm evolution of the lumbar spine below the fused segments. Spine (Phila Pa 1976). 1985;10:414–420. 5. Ginsburg HH, Goldstein LA, Robinson SC. Back pain in post operative idiopathic scoliosis: long term follow-up study. Spine. 1979;4:518. r
2014 Lippincott Williams & Wilkins
J Spinal Disord Tech
Volume 27, Number 5, July 2014
6. Danielsson A, Nachemson A. Back pain and function 23 years after fusion for adolescent idiopathic scoliosis: a case-control studypart II. Spine (Phila Pa 1976). 2003;28:E373–E383. 7. Helenius I, Remes V, Yrjonen T, et al. Comparison of long-term functional and radiologic outcomes after Harrington instrumentation and spondylodesis in adolescent idiopathic scoliosis: a review of 78 patients. Spine (Phila Pa 1976). 2002;27:176–218. 8. Gotze C, Liljenqvist UR, Slomka A, et al. Quality of life and back pain: outcome 16.7 years after Harrington instrumentation. Spine (Phila Pa 1976). 2002;27:1456–1463; discussion 63–4. 9. Danielsson AJ, Wiklund I, Pehrsson K, et al. 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. Eur Spine J. 2001;10:278–288. 10. Newton PO, Parent S, Marks M, et al. Prospective evaluation of 50 consecutive scoliosis patients surgically treated with thoracoscopic anterior instrumentation. Spine (Phila Pa 1976). 2005;30:S100–S109. 11. Sweet FA, Lenke LG, Bridwell KH, et al. Prospective radiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2001;26:1956–1965. 12. Asher M, Min Lai S, Burton D, et al. The reliability and concurrent validity of the Scoliosis Research Society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976). 2003;28:63–69. 13. Asher M, Min Lai S, Burton D, et al. Discrimination validity of the Scoliosis Research Society-22 patient questionnaire: relationship to idiopathic scoliosis curve pattern and curve size. Spine (Phila Pa 1976). 2003;28:74–78. 14. Li M, Wang CF, Gu SX, et al. Adapted simplified Chinese (mainland) version of Scoliosis Research Society-22 questionnaire. Spine (Phila Pa 1976). 2009;34:1321–1324. 15. Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalization. J Epidemiol Community Health. 2003;57:259–263. 16. Bunge EM, Juttmann RE, de Kleuver M, et al. Health-related quality of life in patients with adolescent idiopathic scoliosis after
r
2014 Lippincott Williams & Wilkins
Evaluation of Quality of Life in AIS
17. 18. 19. 20. 21.
22. 23.
24. 25. 26.
treatment: short-term effects after brace or surgical treatment. Eur Spine J. 2007;16:83–89. Lue YJ, Hsieh CL, Huang MH, et al. Development of a Chinese version of the Oswestry Disability Index version 2.1. Spine (Phila Pa 1976). 2008;33:2354–60. Lenke LG, Bridwell KH, Baldus C, et al. Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1992;74:1056–1067. Bjerkreim I, Steen H, Brox JI. Idiopathic scoliosis treated with Cotrel-Dubousset instrumentation: evaluation 10 years after surgery. Spine (Phila Pa 1976). 2007;32:2103–2110. Benli IT, Ates B, Akalin S, et al. Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation. Eur Spine J. 2007;16:381–391. Green DW, Lawhorne TW III, Widmann RF. Long-term magnetic resonance imaging follow-up demonstrates minimal transitional level lumbar disc degeneration after posterior spine fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36: 1948–1954. Takayama K, Nakamura H, Matsuda H. Low back pain in patients treated surgically for scoliosis: longer than sixteen-year follow-up. Spine (Phila Pa 1976). 2009;34:2198–2204. Merola A, Haher T, Brkaric M. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument. Spine (Phila Pa 1976). 2002;27:2046–2051. Asher M, Min Lai S, Burton D, et al. Scoliosis research society-22 patient questionnaire: responsiveness to change associated with surgical treatment. Spine (Phila Pa 1976). 2003;28:70–73. Pellegrino LA, Avanzi O. Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery. J Spinal Disord Tech. November 8, 2013. DOI: 10.1097/BSD.0b013e3182797a5e. Lubicky JP, Hanson JE, Riley EH. Instrumentation constructs in pediatric patients undergoing deformity correction correlated with Scoliosis Research Society Scores. Spine (Phila Pa 1976). 2011;36:1692–1700.
www.jspinaldisorders.com |
E161
RIGINAL
ARTICLE
Evaluation of Quality of Life in Adolescent Idiopathic Scoliosis With Different Distal Fusion Level A Comparison of L3 Versus L4 Ran Ding, MD, Jinqian Liang, MD, Guixing Qiu, MD, Jianxiong Shen, MD, and Zheng Li, MD
Study Design: Retrospective case-control study. Objective: The aim of this study was to assess patients’ quality of life with different fusion levels in posterior pedicle screw correction of idiopathic scoliosis. Summary of Background Data: No previous study has demonstrated differences in health-related quality of life (HRQoL) between patients fused to L3 versus L4. Materials and Methods: A retrospective study was conducted on 30 scoliotic patients fused to L3 using complete pedicle screw instruments. Thirty age-matched and sex-matched scoliotic patients fused to L4 were in the control group. Radiologic parameters were assessed before surgery and at latest follow-up between the 2 groups. These 2 groups were compared for the Scoliosis Research Society 22 questionnaire (SRS-22), Oswestry Disability Index (ODI), visual analogue scale (VAS), and Short Form-36 (SF-36) questionnaires, which were administered preoperatively and at final follow-up. Results: There were no significant differences in sex, age, followup duration, the distribution of curve patterns, the postoperative residual Cobb angle of the main curve, complications, or surgical method between the L3 and L4 groups (P > 0.05). Preoperative scores were statistically similar in the L3 and L4 groups for all domains of all questionnaires. There was no difference between the L3 and L4 groups for ODI (P = 0.527) and VAS (P = 0.518). There were no significant differences in the scores on function/activity, self-image/appearance, pain, mental health, or satisfaction with treatment domains between the 2 groups. No significant differences between the 2 groups were Received for publication September 3, 2013; accepted December 3, 2013. From the Department of Orthropaedic Surgery, Peking Union Medical College Hospital, Chinese Academy Of Medical Sciences & Peking Union Medical College, Beijing, China. Supported by National Natural Science Foundation of China (Grant No. 81272053 and NO. 81301596). No Benefits in any form have been or will be received from any commercial party related directly and indirectly to the subject of this manuscript. The authors declare no conflict of interest. Reprints: Jianxiong Shen, MD, Department of Orthorpaedic Surgery, Peking Union Medical College Hospital, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing 100730, China (e-mail: shenjian [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
J Spinal Disord Tech
Volume 27, Number 5, July 2014
found at the final follow-up in the SF-36 subscales/domain scores. Conclusions: This study attempted to elucidate the correlation between the length of fusion and functional outcome; however, it could not identify any difference between different fusion levels. On the basis of short-term results, there were no significant differences in the questionnaire scores between the 2 groups. Key Words: quality of life, adolescent idiopathic scoliosis, health-related quality of life questionnaire, lowest instrumented vertebra (J Spinal Disord Tech 2014;27:E155–E161)
S
urgical treatments for adolescent idiopathic scoliosis (AIS) attempt to be achieving a balanced spinal fusion. Although longer spinal fusions have been shown to result in improved deformity correction compared with shorter fusions, patients have experienced an increased potential for accelerated lumbar degeneration. A shorter fusion that saves the distal motion segment has usually been the aim of surgeons. However, the correlation between the length of fusion and functional outcome remains controversial. Several studies1–5 have shown that the lowest instrumented vertebra below the L3 in patients with scoliosis has resulted in a greater functional loss and a higher incidence of disk degeneration and low back pain (LBP). There are also few studies6,7 demonstrating that no differences could be found between patients fused to L3 or higher versus L4 or lower. Nevertheless, preserving lumbar motion segments is still an aim of surgeons. Besides traditional radiographic measurements and clinical outcomes, health-related quality of life (HRQoL) is an important measure in evaluating the treatment of AIS. With the development of outcome tools for measuring general HRQoL, such as the Short Form-36 (SF36) or visual analogue scale (VAS), and disease-specific questionnaires, such as the Scoliosis Research Society 22 questionnaire (SRS-22) and Oswestry Disability Index (ODI), a number of articles on HRQoL during or after treatment in patients with scoliosis have been published.8–11 www.jspinaldisorders.com |
E155
J Spinal Disord Tech
Ding et al
To the best of our knowledge, previous studies6,7 on the outcome of back pain and function have been presented by comparing general longer spinal fusions with shorter fusions. However, no previous study has demonstrated the differences in HRQoL with specific fusion levels, especially between L3 and L4. Moreover, whether patients fused to L4 have more back pain than those fused to L3is still unknown. The aim of this study was to determine patients’ preference between a longer fusion versus a shorter fusion by the administration of the 4 questionnaires listed above.
MATERIALS AND METHODS Patients and Determination of Fusion Levels Consecutive patients with AIS requiring surgical correction were studied during 2007–2011 in the Peking Union Medical College Hospital. We selected 30 patients fused to L3 using complete pedicle screw instruments. All patients were followed-up for at least 2 years. The mean age at the time of the surgery was 15.4 ± 1.78 years. We also reviewed our database of patients with AIS who received surgical treatment during the same period (ie, from 2007 to 2011). These scoliotic patients fused to L4 were chosen and best matched for sex, age, curve pattern, and then matched at a 1:1 ratio.
Surgical Procedure The surgical procedure consisted of a posterior approach with a complete pedicle screw system. Briefly, all-pedicle screws were inserted with a free-hand pedicle screw-placement technique. Curve correction was achieved with rod rotation, compression, and/or distraction. The rods were bent into designed spinal kyphosis and lordosis with placement. The spinous processes maybe removed during surgery and curetted, and alongside homogenous bone grafts be saved to perform bone graft fusion toward the end of the procedure. All surgeries were performed by the same senior surgeon (S.J.X).
Radiographic Measurements Radiologic parameters were assessed before surgery, about 1 week after surgery, and at the latest follow-up. Coronal plane measurements included Cobb angles (including preoperative convex bending Cobb angle). Trunk shift was determined by measuring the horizontal distance between C7 plumb line and the central sacral vertical line. Sagittal plane measurements included sagittal kyphosis (in degrees, T5–T12) and sagittal lordosis (in degrees, L1–S1). Radiographic measurements were taken by 2 independent physicians.
Questionnaire To capture the impact of the disease and its treatment, generic and scoliosis-specific questionnaires were all selected in this study. Patients were assessed preoperatively and at the latest follow-up by the prepared questionnaires. At follow-up, a standardized questionnaire was mailed to the patients and mailed back with a stamped return envelope.
E156 | www.jspinaldisorders.com
Volume 27, Number 5, July 2014
SRS-22 The SRS-22 Outcomes Instrument has been a widely used HRQL questionnaire to evaluate the perception of patients suffering from scoliosis.6,10–13 A simplified Chinese version was used in mainland China.14 The SRS-22 covers 5 domains (function/activity, pain, self-image, mental health, and satisfaction with treatment). Each item has 5 verbal response alternatives ranging from 1 (worst) to 5 (best). Results are expressed as the mean (total sum of the domain divided by the number of items answered) for each domain.
SF-36 The Chinese (mainland) version of the SF-36, quite similar to the original American population, was tested.15 The 36-item Short Form Health Survey is a brief selfadministered questionnaire that generates scores across 8 dimensions of health: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH).
VAS We added 1 question about GH (“How is your health status now?” on a scale from 0 to 100, wherein 100 indicates the best possible health status and 0 indicates the worst possible health status) using the visual analogue scale (VAS).16
ODI This score had 10 questions about pain and painrelated disability in activities of daily living and social participation. The sum was calculated and presented as a percentage, wherein 0% represents no pain and disability, and 100% represents the worst pain and disability.17 All questionnaires were checked for completeness to avoid missing answers by 2 independent physicians.
Statistical Analysis Normality test was conducted to examine the shape and distribution of the continuous variables. All continuous variables were presented as mean ± SD. Independent samples’ t test and the paired t test were conducted to compare the scoring and radiologic parameters. All statistical analyses were performed by using SPSS 17.0 statistical software (SPSS Inc., Chicago, IL). All the tests were 2-tailed and the significance level (P) was 0.05). A summary of radiographic findings was provided in Table 1. In addition, no patients in our groups experienced decompensation or revision surgery (Figs. 1, 2).
Quality of Life All patients completed the SF-36, SRS-22, VAS, and ODI questionnaires. Preoperative scores were statistically similar in the L3 and L4 groups for all domains of all questionnaires. The differences between the scores of the L3 and L4 groups on the 5 domains of the SRS-22 scale were summarized in Table 2. All domains of the SRS-22 scale showed that there was an improvement overall, but only the self-image domain had a statistically significant difference within itself over time. There were no significant differences in the scores on function/activity, self-image/ appearance, pain, MH, or satisfaction with treatment domains between the 2 groups. Although all subscales did not show a statistically significant difference (Table 2), for the SF-36, comparisons between the subscales of the L3 and L4 groups were made, as shown in Table 2. Except for RP and PF, both groups showed an improvement over 2 years of follow-up overall for other subscales. Surprisingly, the RP scores in the postoperative stage of the L3 group were significantly lower than that in the preoperative stage, and PF scores changed in the opposite trend. No significant differences between the 2 groups were found preoperatively or at any time point in the SF-36 subscales/domain scores.
Evaluation of Quality of Life in AIS
In our group, results revealed that there was no difference between the L3 and L4 groups for ODI (P = 0.527). The single-item GH measure (VAS) did not show significant differences between the L3 and L4 groups at the final follow-up.
DISCUSSION A shorter fusion that saves the distal motion segment has been the aim of this criterion. However, the correlation between the length of fusion and the longterm functional outcome remains controversial. Numerous studies18–20 have commented on the incidences of LBP, which may have been caused by increasing stress on caudal uninstrumented levels. Loss of motion may lead to accelerated progression of normal degenerative changes at adjacent unfused levels. Nevertheless, no differences in terms of pain and back function were also detected between those with a “high” fusion (down to L3 or above) versus a “low” fusion (down to L4 or below).6,7 However, preservation of as many motion segments in the lumbar spine as possible is the general goal of the surgical management for surgeon. To date, there were few studies that use the scoliosis-specific and scoliosis-nonspecific HRQoL questionnaires to measure patient-based outcome according to different distal fusion level, especially comparison of L3 versus L4 with all-pedicle screw instruments. We failed to correlate variables concerning the length of fusion with pain and back function as measured by SRS-22, SF-36, VAS, and ODI. In our study, patients scored around 4 points on a 5-point scale in all domains (SRS-22), which implies that these patients were satisfied. Results revealed that there was no difference between the L3 and L4 groups for ODI (P = 0.527) and VAS (P = 0.567). For the SF-36 and SRS-22, 8 subscales and 5 domains did not show a statistically significant difference between the L3 and L4 groups. Similar findings were also described by Danielsson and Nachemson6 and Helenius et al.7 In 2003,
TABLE 1. Comparisons of Patient Characteristics Between the L3 and L4 Groups Distal Fusion Level Characteristics
L3 (n = 30)
L4 (n = 30)
P
Age at the present follow-up (y) Follow-up (mo) Female [n (%)] MT Cobb angle (deg., Preop.) TL/L Cobb angle (deg., Preop.) MT Cobb angle (deg., Follow-up) TL/L Cobb angle (deg., Follow-up) T5–T12 kyphosis (deg., Preop.) L1–S1 lordosis (deg., Preop.) T5–T12 kyphosis (deg., Follow-up) L1–S1 lordosis (deg., Follow-up) Coronal C7 to CSVL deviation (mm, Preop.) Coronal C7 to CSVL deviation (mm, Follow-up)
15.4 ± 1.78 37.5 ± 116.0 26 (86.7) 42.75 ± 11.73 38.23 ± 10.88 10.9 ± 7.0 6.6 ± 5.4 21.8 ± 10.5 46.1 ± 11.6 28.6 ± 13.1 46.7 ± 9.0 13.0 ± 9.0 6.5 ± 5.5
16.7 ± 7.69 40.1 ± 11.3 27 (90.0) 46.23 ± 20.65 48.07 ± 8.07 16.7 ± 9.1 7.9 ± 6.1 25.4 ± 14.9 47.7 ± 14.7 25.5 ± 7.8 49.8 ± 8.9 21.1 ± 11.1 7.2 ± 6.8
0.457 0.347 0.986 0.572 0.009 0.067 0.538 0.411 0.715 0.435 0.319 0.030 0.781
CSVL indicates central sacral vertical line; Follow-up, final follow-up; MT, main thoracic; Preop., preoperation; PT, proximal thoracic; TL/L, thoracolumbar/lumbar.
r
2014 Lippincott Williams & Wilkins
www.jspinaldisorders.com |
E157
Ding et al
J Spinal Disord Tech
Volume 27, Number 5, July 2014
FIGURE 1. Determination of the lowest instrumented vertebra (LIV) for a 13-year-old female patient with double-curve scoliosis. A and B, Thoracic and lumbar curve magnitudes are 40 and 60 degrees, respectively. The rotation of L4 was less than II degree according to the Nash-Moe method, and kyphosis deformity of this zone was not measured in sagittal radiograph. C and D, Bending radiographs of the same patient. In concave bending, the L4 was intersected by the central sacral vertical line (CSVL) in concave side-bending radiographs (CSBR). Therefore, the L4 was chosen to be the LIV for this patient according to bending radiographs. E–H, Radiographs at 1 week (E and F) and 2.6 years (G and H) after surgery show satisfactory curve correction and trunk balance restoration.
Danielsson and colleagues reported results of 91% of initial 156 patients undergoing Harrington Instrumentation for AIS 23 years (mean) from the termination of treatment to the present follow-up. The results in terms of pain and back function did not show any differences between those with a fusion ending below L3 versus those with a more proximal ending of the fusion.
E158 | www.jspinaldisorders.com
Recently, Green et al21 could not show any difference for subpopulations of patients with lowest instrumented vertebra of T12 or L1 and L3 as measured by SRS-22R scores and ODI scores. No patients reported significant lower back pain and took analgesic medications for pain in this study. Several studies18–20,22 have demonstrated rates of LBP r
2014 Lippincott Williams & Wilkins
J Spinal Disord Tech
Volume 27, Number 5, July 2014
Evaluation of Quality of Life in AIS
FIGURE 2. Determination of the lowest instrumented vertebra (LIV) for a 11-year-old female patient with double-curve scoliosis. A and B, Anteroposterior (AP) standing radiographs showed that thoracic and lumbar curve magnitudes are 40 and 43 degrees, respectively. The rotation of L3 was less than II degree according to the Nash-Moe method, and kyphosis deformity of this zone was not measured in sagittal radiograph. C and D, Bending radiographs of the same patient. In concave bending, central sacral vertical line (CSVL) distinctly comes into contact with L3 and passes medial to its concave pedicle. Therefore, the L3 can be chosen as LIV according to bending radiographs. E–H, Radiographs at 1 week (E and F) and 2 years (G and H) after surgery show satisfactory curve correction and trunk balance restoration.
(15%–45%) after successful fusion for AIS at long-term follow-up. This decreased prevalence in our study may have occurred because of rather short-term follow-up. Although no significant differences between the 2 groups were found in the self-image domain scores, this item of SRS-22 after surgery in both the groups were significantly improved compared with that before surgery (P < 0.05). This finding was also consistent with the r
2014 Lippincott Williams & Wilkins
results of the previous studies, which have found selfimage to be the main factor improved by surgical treatment. Merola et al23 reported a multicenter study of the outcomes of the surgical treatment of AIS using the Scoliosis Research Society Questionnaire. Pain, General Self-Image, Function From Back Condition, and Level of Activity all demonstrated statistically significant improvement as compared with preoperative status. www.jspinaldisorders.com |
E159
J Spinal Disord Tech
Ding et al
Volume 27, Number 5, July 2014
TABLE 2. Comparison of Clinical Questionnaires Between Preoperative and Final Follow-up in the 2 Groups Fused to L3 ODI VAS SRS-22 Function/activity Pain Self-image Mental health Satisfaction SF-36 RP BP GH PF VT SF RE MH
Fused to L3
Fused to L4
Preop.
Follow-up
P
Preop.
Fused to L4 Follow-up
P
Follow-up
Follow-up
P
2.9 ± 3.2 90.3 ± 23.7
2.6 ± 2.7 88.9 ± 32.2
0.563 0.651
3.21 ± 3.51 89.2 ± 24.5
3.1 ± 2.7 91.4 ± 19.2
0.900 0.290
2.6 ± 2.7 88.9 ± 32.2
3.1 ± 2.7 91.4 ± 19.2
0.567 0.518
4.0 ± 0.5 4.4 ± 0.7 3.2 ± 0.8 3.8 ± 0.8 4.0 ± 0.9
3.9 ± 0.6 4.5 ± 0.7 4.2 ± 0.7 4.2 ± 0.7 4.3 ± 0.6
0.703 0.485 0.011 0.052 0.239
4.2 ± 0.6 4.5 ± 0.7 3.5 ± 1.1 3.8 ± 0.8 3.7 ± 1.0
4.1 ± 0.4 4.5 ± 0.7 4.2 ± 0.6 4.3 ± 0.5 4.4 ± 0.6
0.860 0.934 0.047 0.056 0.141
3.9 ± 0.6 4.5 ± 0.7 4.2 ± 0.7 4.2 ± 0.7 4.3 ± 0.6
4.1 ± 0.4 4.5 ± 0.7 4.2 ± 0.6 4.3 ± 0.5 4.4 ± 0.6
0.338 0.975 0.994 0.830 0.796
90.8 ± 23.9 90.8 ± 15.9 50.7 ± 9.2 98.2 ± 13.8 74.5 ± 15.1 90.1 ± 23.4 86.0 ± 27.9 71.4 ± 17.3
75.0 ± 36.3 86.0 ± 19.9 55.4 ± 10.3 97.4 ± 36.8 78.4 ± 14.5 98.7 ± 17.6 86.0 ± 27.9 74.5 ± 16.9
0.030 0.403 0.013 0.935 0.247 0.023 1.000 0.187
71.7 ± 42.1 86.4 ± 14.6 45.1 ± 12.4 91.3 ± 10.8 73.3 ± 13.5 90.0 ± 19.6 68.9 ± 38.9 67.2 ± 20.2
68.3 ± 35.9 87.5 ± 12.6 52.0 ± 9.3 85.0 ± 8.0 80.0 ± 8.2 93.3 ± 14.8 77.8 ± 34.9 76.3 ± 10.6
0.751 0.844 0.062 0.089 0.073 0.469 0.334 0.061
75.0 ± 36.3 86.0 ± 19.9 55.4 ± 10.3 97.4 ± 36.8 78.4 ± 14.5 98.7 ± 17.6 86.0 ± 27.9 74.5 ± 16.9
68.3 ± 35.9 87.5 ± 12.6 52.0 ± 9.3 85.0 ± 8.0 80.0 ± 8.2 93.3 ± 14.8 77.8 ± 34.9 76.3 ± 10.6
0.597 0.805 0.330 0.212 0.710 0.354 0.452 0.730
BP indicates bodily pain; GH, general health; MH, mental health; ODI, Oswestry Disability Index; PF, physical functioning; Preop., preoperative score; RE, role limitations due to emotional problems; RP, role limitations due to physical problems; SF, social functioning; SF-36, Short Form-36; SRS-22, Scoliosis Research Society 22 questionnaire; VT, vitality.
However, with regard to the level of activity, we found mild decrease in Function/Activity (SRS-22) and PF (SF-36) domain scores at the final follow-up, although the difference was not statistically significant (P > 0.05). Moreover, there was no difference between the L3 and L4 groups for Function/Activity (SRS-22) and PF. Research showed that postoperative scores could also change over time. Newton et al24 and Pellegrino and Avanzi25 found significant reductions in Function/Activity scores at 3-month follow-up. However, at 12-month follow-up, thesescores had increased significantly. During follow-up, we have found that patients were not participating in vigorous activities because they were afraid of hard exercise after surgery. Moreover, the patients were short of health education and possessed varying levels of cognitive ability at different ages. All the patients in our study had posterior instrumentation and fusion using all-pedicle screws. Lubicky et al26 had contrasted SRS outcome scores for patients receiving different types of spinal instrumentation. There were no statistically significant baseline differences among the 3 instrumentation construct groups. However, our study still does have some limitations. First, we have a relatively small number of included patients. Indeed, there are confounding variables and selection bias because of small sample size and retrospective study. Moreover, there is clearly a need for prospective, multicenter, large-scale trials to aid surgical decision making in the future regarding the length of spinal fusions. Second, the follow-up time was still relatively short. The indication for surgery of AIS is to prevent future deterioration of the curve and ensuing impairment of quality of life, not an immediate improvement in the quality of life. Therefore, maybe, there is no significant change in the quality of life in the relative short-term outcome. A continued follow-up of our patients is under way.
E160 | www.jspinaldisorders.com
Nevertheless, the sample was small, and the time of follow-up was relatively short. Our preliminarily study, to some extent, could still indicate that a shorter fusion does not show significant superiority compared with a longer fusion as far as functional outcome is concerned. In addition, perhaps those questionnaires above are not sensitive enough in certain domains to reflect early change. Is it necessary to save the L3–L4 motion segment for a simple “fuse short” that may increase the risk of postoperative trunk imbalance? Meanwhile, when does it not seem to matter much to the patients? The answer needs to be further explored.
CONCLUSIONS In summary, there were no significant differences in the Questionnaire scores between the 2 groups. On the basis of short-term results, it is not clear whether function and LBP improved in patients with increased numbers of mobile motion segments, despite surgeons always aiming to save motion segment as much as possible. REFERENCES 1. Ilharreborde B, Morel E, Mazda K, et al. Adjacent segment disease after instrumented fusion for idiopathic scoliosis: review of current trends and controversies. J Spinal Disord Tech. 2009;22:530–539. 2. Danielsson A, Cederlund C, Elkholm S, et al. 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. Acta Radiol. 2001;42:187–197. 3. Wilk B, Karol LA, Johnston CE, et al. The effect of scoliosis fusion on spinal motion: a comparison of fused and nonfused patients with idiopathic scoliosis. Spine (Phila Pa 1976). 2006;31:309–314. 4. Michel CR, Lalain JJ. Late results of Harrington’s operation. Longterm evolution of the lumbar spine below the fused segments. Spine (Phila Pa 1976). 1985;10:414–420. 5. Ginsburg HH, Goldstein LA, Robinson SC. Back pain in post operative idiopathic scoliosis: long term follow-up study. Spine. 1979;4:518. r
2014 Lippincott Williams & Wilkins
J Spinal Disord Tech
Volume 27, Number 5, July 2014
6. Danielsson A, Nachemson A. Back pain and function 23 years after fusion for adolescent idiopathic scoliosis: a case-control studypart II. Spine (Phila Pa 1976). 2003;28:E373–E383. 7. Helenius I, Remes V, Yrjonen T, et al. Comparison of long-term functional and radiologic outcomes after Harrington instrumentation and spondylodesis in adolescent idiopathic scoliosis: a review of 78 patients. Spine (Phila Pa 1976). 2002;27:176–218. 8. Gotze C, Liljenqvist UR, Slomka A, et al. Quality of life and back pain: outcome 16.7 years after Harrington instrumentation. Spine (Phila Pa 1976). 2002;27:1456–1463; discussion 63–4. 9. Danielsson AJ, Wiklund I, Pehrsson K, et al. 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. Eur Spine J. 2001;10:278–288. 10. Newton PO, Parent S, Marks M, et al. Prospective evaluation of 50 consecutive scoliosis patients surgically treated with thoracoscopic anterior instrumentation. Spine (Phila Pa 1976). 2005;30:S100–S109. 11. Sweet FA, Lenke LG, Bridwell KH, et al. Prospective radiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2001;26:1956–1965. 12. Asher M, Min Lai S, Burton D, et al. The reliability and concurrent validity of the Scoliosis Research Society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976). 2003;28:63–69. 13. Asher M, Min Lai S, Burton D, et al. Discrimination validity of the Scoliosis Research Society-22 patient questionnaire: relationship to idiopathic scoliosis curve pattern and curve size. Spine (Phila Pa 1976). 2003;28:74–78. 14. Li M, Wang CF, Gu SX, et al. Adapted simplified Chinese (mainland) version of Scoliosis Research Society-22 questionnaire. Spine (Phila Pa 1976). 2009;34:1321–1324. 15. Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalization. J Epidemiol Community Health. 2003;57:259–263. 16. Bunge EM, Juttmann RE, de Kleuver M, et al. Health-related quality of life in patients with adolescent idiopathic scoliosis after
r
2014 Lippincott Williams & Wilkins
Evaluation of Quality of Life in AIS
17. 18. 19. 20. 21.
22. 23.
24. 25. 26.
treatment: short-term effects after brace or surgical treatment. Eur Spine J. 2007;16:83–89. Lue YJ, Hsieh CL, Huang MH, et al. Development of a Chinese version of the Oswestry Disability Index version 2.1. Spine (Phila Pa 1976). 2008;33:2354–60. Lenke LG, Bridwell KH, Baldus C, et al. Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1992;74:1056–1067. Bjerkreim I, Steen H, Brox JI. Idiopathic scoliosis treated with Cotrel-Dubousset instrumentation: evaluation 10 years after surgery. Spine (Phila Pa 1976). 2007;32:2103–2110. Benli IT, Ates B, Akalin S, et al. Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation. Eur Spine J. 2007;16:381–391. Green DW, Lawhorne TW III, Widmann RF. Long-term magnetic resonance imaging follow-up demonstrates minimal transitional level lumbar disc degeneration after posterior spine fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36: 1948–1954. Takayama K, Nakamura H, Matsuda H. Low back pain in patients treated surgically for scoliosis: longer than sixteen-year follow-up. Spine (Phila Pa 1976). 2009;34:2198–2204. Merola A, Haher T, Brkaric M. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument. Spine (Phila Pa 1976). 2002;27:2046–2051. Asher M, Min Lai S, Burton D, et al. Scoliosis research society-22 patient questionnaire: responsiveness to change associated with surgical treatment. Spine (Phila Pa 1976). 2003;28:70–73. Pellegrino LA, Avanzi O. Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery. J Spinal Disord Tech. November 8, 2013. DOI: 10.1097/BSD.0b013e3182797a5e. Lubicky JP, Hanson JE, Riley EH. Instrumentation constructs in pediatric patients undergoing deformity correction correlated with Scoliosis Research Society Scores. Spine (Phila Pa 1976). 2011;36:1692–1700.
www.jspinaldisorders.com |
E161
