Aims

To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

Purpose of the study. To establish the relation between the magnitude of the deformity in scoliosis, measured by cobb angle on radiograph & Volumetric asymmetry with the ISIS2 surface topography, and the patient perception of self image and mental health, measured with SRS-22 scores. Methodology. A total of 89 untreated patients with scoliosis were included in the study. They had clinical assessment, cobb angle measurement of radiograph and surface topography performed on the same day along with SRS-22 questionnaires. The cobb angle was measured by single surgeon using a digital PACS system, who was unaware of the volumetric asymmetry score. Volumetric asymmetry was measured by ISIS2 surface topography performed by a research nurse who was unaware of the cobb angle. Volumetric asymmetry was calculated using standard ISIS2 software. A comparison correlation of SRS scores for function, pain, self image and mental health against cobb angle and volumetric asymmetry was undertaken by clinical scientist. Scores for patient satisfaction to treatment was excluded as these were untreated patients. Statistical analysis was performed using cor. test on software R. Results. Correlation of both cobb angle and volumetric asymmetry for function and pain were statistically not significant (p value > 0.05). However for self image, correlation was statistically significant with cobb angle (p value-0.0033) and volumetric asymmetry (p value-0.00031), but the correlation was not high. Cobb angle contributed only around 10% to self image, whilst volumetric asymmetry contributed only 14%. Similarly for mental health, correlation was statistically significant with cobb angle (p value-0.0194) and volumetric asymmetry (p value-0.00559), but the correlation was not high. Cobb angle contributed only around 6.2% to mental health, whilst volumetric asymmetry contributed only 8.6%. Conclusion. Volumetric asymmetry correlates better to both mental health and self image as compared to cobb angle, but the correlation is still poor. Neither cobb angle or volumetric asymmetry can be used to predict patients self image or mental health. We are pursuing this study further to look at other parameters which may affect SRS-22 such as gender, age, type of deformity, waist asymmetry and shoulder asymmetry. Ethics approval: None. Interest Statement: None

Introduction. Monitoring of scoliosis is traditionally done with radiographs, which can be associated with an increased risk of cancer secondary to multiple exposures over many years. This study investigated whether the findings from surface topography can be used to monitor scoliosis curves and how much this method affects outcome scores in patients with scoliosis. This study therefore had two subsets: (1) to investigate whether lateral asymmetry (LA) from ISIS2 surface topography can predict radiographic Cobb angle, providing an alternative non-invasive means of monitoring patients with scoliosis (LA and Cobb subset); and (2) to establish the relationships between the magnitude of the deformity in scoliosis, measured by Cobb angle on radiograph and volumetric asymmetry (VA) with the ISIS2 surface topography, and the patient perception of self-image and mental health, measured with SRS-22 scores (Cobb, VA, and SRS subset). Methods. In the LA and Cobb subset, 72 untreated patients with scoliosis (77 curves) with a Cobb angle of 55° or less were included in the study. They had clinical assessment, Cobb angle measurement taken from a standard radiograph, and surface topography done on the same day. A comparison of Cobb angle and LA was done. In the Cobb, VA, and SRS subset, 89 untreated patients with scoliosis were included in the study. They had clinical assessment, Cobb angle measurement of radiograph, and surface topography done on the same day along with SRS-22 questionnaires. A comparison correlation of SRS scores for function, pain, self-image, and mental health against Cobb angle and VA was undertaken. All statistical analysis was done with software R. Results. In the LA and Cobb subset, for Cobb angle less than 55° on radiograph, ISIS2 was able to predict the Cobb angle within 13°. In the VA, Cobb, and SRS subset, Cobb angle contributed only about 10% to self-image, whereas VA contributed 14%. Cobb angle contributed about 6·2% to mental health, whereas VA contributed 8·6%. Conclusions. Cobb angles display poor reliability, with estimates ranging from 3° to 10°. Even so, the 95% CIs on the prediction of Cobb angle from ISIS2 LA are too wide to use it alone to monitor spinal curvature. Whether or not LA is capable of monitoring change in curvature will be investigated as more longitudinal data are built up. VA correlates better with both mental health and self-image than does Cobb angle, but the correlation is still poor. Neither Cobb angle nor VA can be used to predict patient's self-image or mental health. We are pursuing this study further to look at other parameters that may affect SRS-22 such as sex, age, type of deformity, waist asymmetry, and shoulder asymmetry

The SRS-22 instrument was developed to assess quality of life in adolescent idiopathic scoliosis patients (AIS). The aim of our study was to evaluate the impact of surgical treatment on quality of life in neurologically normal patients with complex spinal deformity of a range of aetiologies using the SRS-22 questionnaire. We analysed prospectively collected SRS-22 data on 407 consecutive patients (315 females-92 males) treated from 2006–2012 under the care of the senior author. 97.6% of patients had a posterior (PSF), 1.3% an anterior (ASF) and 1.1% an anterior-posterior (A/PSF) spinal fusion. Questionnaires were completed at 4 stages of treatment: preoperatively, 6-months, 12-months and 24-months postoperatively. Other variables included age at surgery, gender, diagnosis and year of surgery. 9 diagnoses were included in the study: 271 patients had AIS; 39 Scheuermann's kyphosis; 31 spondylolisthesis; 16 congenital scoliosis; 13 JIS; 6 IIS; 13 scoliosis associated with intraspinal anomalies; 11 syndromic scoliosis; 7 scoliosis associated with congenital cardiac disease. Mean age at surgery was 15.14±2.07 years. Age at surgery was divided in 3 groups to compare outcomes against previous studies: 10–12, 13–15, and 15–19 years. Mean total SRS-22 scores for the whole group were: preoperative 3.62±0.66; 6-month 4.12±0.44; 12-month 4.39±0.40; and 24-month 4.52±0.37 (p<0.0001). Individual preoperative scores for the whole group were: function 3.77±0.75; pain 3.7±0.97; self-image 3.14±0.66; mental 3.86±0.77. Mean 24-month postoperative scores for the whole group were: function 4.39±0.42; pain 4.59±0.56; self-image 4.39±0.51; mental 4.43±0.56; satisfaction 4.81±0.40. All changes observed at 2-year follow-up were statistically significant (p<0.0001). Male preoperative total score (3.64±0.66) did not have a significant difference compared to female (3.62±0.66); however 24-month total score improvement was significant, with males (4.62±0.25) performing better than females (4.49±0.39) including satisfaction (p=0.004). Spondylolisthesis patients performed worse preoperatively (2.93±0.26) compared to other diagnoses (p<0.0001); AIS 3.67±0.64, congenital 3.81±0.57, syndromic 3.80±0.54, Scheuermann's 3.48±0.75, JIS 3.90±0.63, scoliosis with congenital cardiac disease 4.04±0.41 or intraspinal anomalies 3.71±0.66, and IIS 3.58±0.80. No change in total and individual scores was observed at 24-month review across diagnoses (p>0.05). There were no significant changes between each year of surgery in the study period and the total values at each stage (p>0.05). There were no significant changes between the 3 age ranges at each stage (p>0.05). Patients undergoing ASF performed significantly better at preoperative function (4.7±0.27) compared to PSF (3.76±0.74) and A/PSF (3.68±0.72), (p=0.19). All values at 2-years were not significant in comparison regarding type of operation (p>0.05). All individual domains and total SRS-22 scores improved after surgical correction of spinal deformity in our young patient cohort with an incremental change between preoperative, 6-month, 12-month and 24-month postoperative. Our 24-month postoperative outcomes in all diagnoses compare favourably to reported SRS-22 scores in healthy adolescents (function: 4.31±0.54; pain: 4.44±0.67; image: 4.41±0.64; mental health: 3.96±0.81; total 4.26±0.54). We are planning to continue this study with longer follow-up in order to allow comparison of our SRS-22 outcomes after surgical treatment to those obtained in patients treated with bracing or patients who were followed untreated (previous reports SRS-22 total scores: 4.2 for braced patients and 4.1 for observed patients)

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra.

A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17).

In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra.

Cite this article: Bone Joint J 2014;96-B:1082–9.