Study Design. Review of a prospective database registry.

Objective. To compare the Scoliosis Research Society (SRS)-22 and SRS-24 outcomes instruments in terms of scores, rate of ceiling effects, and discriminant ability in patients with pre- and postoperative adolescent idiopathic scoliosis.

Summary of Background Data. Despite improvements noted with the SRS-22, the SRS-24 is still occasionally used prospectively and for comparisons with previous studies reporting SRS-24 scores. Previous work has demonstrated that postoperative scores from the 2 versions are not interchangeable.

Methods. A multicenter prospective registry of patients who underwent surgical correction of adolescent idiopathic scoliosis was queried for preoperative and 2-year postoperative SRS-22 and SRS-24 scores. Scores were compared between versions and ceiling effects were identified. Groups of deformity severity were created to evaluate discriminant ability.

Results. 829 patients were identified. The SRS-22 scores for pain and general function were significantly greater than SRS-24 scores (P < 0.001), whereas the SRS-22 scores were significantly lower than the SRS-24 for self-image (P < 0.001). Preoperative ceiling effect was only noted in 1 domain each. Both versions were able to discriminate between large (80°+) and small (<45°) preoperative curves in all domains and total scores (P < 0.05). Postoperatively, the SRS-22 scores for all shared domains and total score were significantly greater than SRS-24 scores (P < 0.001). Ceiling effects in 5 of 5 domain scores were noted postoperatively for SRS-22 and in 4 of 7 for SRS-24. With a smaller range of deformity postoperatively, only the SRS-22 self-image domain was able to discriminate between large (29°+) and small (≤11°) residual curves (P < 0.05).

Conclusion. Scores obtained by the SRS-22 and the SRS-24 are not translatable despite shared domains. Whereas both versions demonstrated preoperative discriminant ability, postoperative discrimination of residual deformity is lacking in both. Patient-reported outcomes of treatment are crucial in advancing treatment, and improvement in the ability to assess subjective outcomes is essential.

Study Design. A prospective multicenter database of operative patients with Scheuermann kyphosis (SK) with minimum 1-year follow-up was studied for major complications compared with contemporaneous operative patients with adolescent idiopathic scoliosis (AIS) from the database.

Objective. To evaluate complications associated with current surgical techniques in SK and AIS.

Summary of Background Data. There is a paucity of literature regarding complications associated with SK surgical treatment, but prior data suggest an elevated neurological risk.

Methods. Complication rates were compared using analysis of variance and Fisher exact test analyses. Major complications were those that were life-threatening, caused spinal cord, nerve root, or ocular injury or required reoperation including surgical site infections. A binary logistic regression determined the likelihood of complications based on diagnosis, levels fused, blood loss, operative time, and length of stay.

Results. Ninety-seven patients with SK (57 males; mean age, 16.5 yr; 75.3° mean kyphosis) and 800 patients with AIS (622 females; mean age, 14.9 yr; 55.6° mean curvature) met inclusion criteria. Patients with SK had significantly more major complications than those with AIS (16.3% vs. 2.3%; P < 0.001). The SK group had more infections (10.3% vs. 0.75%) and reoperations (14.4% vs. 1.4%) (P < 0.001). Operative time was longer and more levels were fused in the SK group (P < 0.001). Surgical site infection was the most common complication. There were no significant differences in length of stay or blood loss. Patients with SK were 3.9× more likely to have a major complication than those with AIS (odds ratio: 0.26, P = 0.003). The number of levels fused was an independent predictor of major complications: each additional level fused increased the odds of a complication by 36% in both groups (odds ratio: 1.36, P = 0.034).

Conclusion. Major complications are 3.9× more likely to occur in operative SK than in AIS. The number of levels fused is an independent risk factor for major complications. Patients with SK are at higher risk for infections and reoperation than those with AIS.

Study Design. Retrospective review of prospectively collected data.

Objective. To compare patients with operative cerebral palsy with and without an intrathecal baclofen pump (ITB) to determine whether an ITB increases the complexity of scoliosis surgery and/or increases the risk of wound complications.

Summary of Background Data. Options for baclofen pump placement include before, during, or after scoliosis surgery. There is some concern that prior placement of an ITB and catheter can further complicate cerebral palsy scoliosis surgery and increase the risk for wound complications.

Methods. Prospectively collected cases from a multicenter cerebral palsy scoliosis database were reviewed for patients who underwent posterior spinal instrumentation and fusion for a major coronal deformity. These patients were then divided on the basis of whether they had ITB at the time of initial scoliosis surgery. The 2 groups were compared to determine differences in demographics, operative parameters, radiographical outcomes, and rates of wound complications.

Results. Of 187 patients identified, 32 had an ITB previously placed (ITB group) and 155 did not (non-ITB group). Both groups were similar in regard to age, sex, Gross Motor Function Classification Scale score, and preoperative Cobb magnitude. When comparing operative parameters, there were no differences in the total operating room time (ITB = 375 ± 127 min, non-ITB = 423 ± 178 min; P = 0.149) or total estimated blood loss (ITB = 2323 ± 1489 mL, non-ITB = 2081 ± 1572 mL; P = 0.424). Postoperatively, the 2 groups had similar correction rates (71% vs. 67%, P = 0.303). As for perioperative wound complications, there were no differences in rates (P = 0.546) between the ITB (16%) and non-ITB group (15%).

Conclusion. Although it may be inconvenient for the surgeon, ITBs do not increase the complexity of surgery or the risk for wound complications. When counseling patients and their caregivers on the timing of pump placement, it does not seem to compromise the care of the patient if the baclofen pump is placed first. Further study is needed to evaluate the safety of pump placement during or after scoliosis surgery.

Study Design. Comparison of the Scoliosis Research Society-22 (SRS-22) questionnaire with a 7-item Rasch-derived questionnaire (SRS-7).

Objective. 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.

Summary of Background Data. SRS-22 has not been shown to possess linearity or unidimensionality (internal validity).

Methods. 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).

Results. 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.

Conclusion. 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.

Study Design. Survey.

Objective. The aim of this study was to evaluate the surgeon’s perspective on the potential impact of prolonged surgical waitlists on the surgical care and perioperative management of patients with scoliosis.

Summary of Background Data. The long waits for surgical treatment of scoliosis found in some countries may have serious implications for the complexity of surgery and perioperative care required if the curve progresses while waiting. The surgeon’s perspective on this problem provides important information that needs to be taken into account during resource allocation.

Methods. Radiographs from 13 patients who had waited more than 6 months for scoliosis surgery were selected. Each patient had radiographs from the time of surgical booking and immediately preoperatively. The radiographs and a questionnaire were sent to 3 surgeons to canvass their surgical and postoperative plan. The surgeons were blinded to the fact that the radiographs were of the same patients at 2 time points. The patients’ actual course of treatment was documented.

Results. Data for 11 patients were available for analysis. The average wait for surgery was 24 months (range, 17–30 mo). The mean curve progression was 25.3° while on the waitlist, from an average of 52° to 77°. By the time the patients had to undergo surgery, more anterior releases were added to posterior instrumentation alone in the surgical plan. Mean estimated operative time increased by 2.2 hours, mean estimated length of hospital stay increased by 1 day, and the estimated level of difficulty of surgery increased 2.33 grades. The predicted estimated blood loss also increased.

Conclusion. From the surgeon’s perspective, lengthy waitlists have a significant negative impact on the perioperative and postoperative care of patients with scoliosis by increasing the complexity of surgery. The actual course of treatment corresponded to the responses from these different surgeons.

Study Design. Retrospective review of prospective data.

Objective. 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.

Summary of Background Data. Previous studies have provided recommendations for when STF should be performed; however, clear parameters for target outcomes are lacking.

Methods. 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.

Results. 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.

Conclusion. 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.

Study Design. A multicenter, prospective evaluation of pulmonary function testing (PFT) and radiographical measures in patients surgically treated for adolescent idiopathic scoliosis (AIS).

Objective. The objective of this study was to evaluate pulmonary function to determine whether a more proximal upper instrumented vertebra (UIV) negatively impacts pulmonary function in patients surgically treated for AIS.

Summary of Background Data. There seems to be increasing concern that a more proximal extent of posterior thoracic spinal instrumentation and fusion reduces postoperative pulmonary function. However, there are few reports that analyze the relation between the selection of UIV and pulmonary function in AIS.

Methods. PFT and radiographical examination of 154 patients with major thoracic AIS (Lenke type 1–4) undergoing posterior thoracic spinal instrumentation and fusion without thoracoplasty were completed prospectively. Patients were divided into groups based on UIV (T1–T3 vs. T4–T5) and Lenke curve type (2 and 4 vs. 1 and 3) and analyzed respectively. Demographic, radiographical measurements, and PFT data from preoperative and 2-year time points were analyzed.

Results. Patients with a structural upper thoracic curve (Lenke 2 and 4) had significantly lower preoperative PFT values than those without a structural upper thoracic curve (Lenke 1 and 3). Lenke 2 and 4 patients were also more likely to be fused proximally (82%, T1–T3) than those in the Lenke 1 and 3 groups (42%, T1–T3, P< 0.05). Preoperatively, those with UIV from T1 to T3 tended to have lower PFT values than those with UIV from T4–T5; however, only percent total lung capacity was statistically different (P< 0.05). Both UIV groups showed significant increases in all absolute values (forced vital capacity, forced expiratory volume in 1s, total lung capacity) at 2-year follow-up (P< 0.05) as expected with growth, and the percent predicted values (% forced vital capacity, % forced expiratory volume in 1s, % total lung capacity) remained stable.

Conclusion. Although patients with UIV: T1–T3 showed slightly lower PFT values than UIV: T4–T5, the presence of a double thoracic curve was the primary cause of PFT reduction in these patients. Including the upper thoracic spine in the fusion had no significant effect on pulmonary function 2 years after surgical correction of AIS.

Study Design. Review of a prospective database registry of surgical patients with adolescent idiopathic scoliosis (AIS).

Objective. 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.

Summary of Background Data. 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.

Methods. 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).

Results. 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).

Conclusion. 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.

Study Design. Prospective, longitudinal cohort.

Objective. To evaluate the incidence, timing, and risk factors for reoperation in patients with adolescent idiopathic scoliosis (AIS) treated with pedicle screws (PSs) compared with hybrid (Hb) constructs.

Summary of Background Data. Rates of return to the operating room (OR) after definitive fusion for AIS vary, with a paucity of data on PS constructs.

Methods. A prospective multicenter database was retrospectively queried to identify consecutive patients with AIS who underwent posterior spinal fusion with either PS or Hb constructs with a minimum 2-year follow-up. All reoperations were stratified into an early group (<60 d) or a late group (>60 d). Univariate and multivariate logistical analyses were performed to identify potential risk factors related to reoperation.

Results. A total of 627 patients met the inclusion criteria (PS = 540, Hb = 87). There was a statistically significant difference in the rate of reoperations between the PS (3.5%) and Hb groups (12.6%), P < 0.001. Early return to the OR occurred in 2.0% of the patients with PS compared with 3.4% in the Hb group, P = 0.43. Late returns to the OR occurred in 1.5% of PS group versus 9.2% of the Hb group, P < 0.001. Multivariate analysis revealed longer operating time as an independent risk factor for an unplanned return to the OR in patients treated with PSs (P < 0.05).

Conclusion. Our results suggest that patients with AIS treated with PS have decreased rates of unplanned return to the OR when compared with patients with Hb constructs. The majority of returns to the OR were early (<60 d) for the PS group compared with late (>60 d) for the Hb group. Longer operative times increased the risk of unplanned reoperation for the PS group.