Larry Lenke

A Multicenter Study of the Outcomes of the Surgical Treatment Of Adolescent Idiopathic Scoliosis Using the Scoliosis Research Society (SRS) Outcome Instrument

Study Design. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society Questionnaire (SRS 24). Objective. To evaluate the patient based outcome of the surgical treatment of adolescent idiopathic scoliosis. Summary of Background Data. A paucity of information exists with respect to patient measures of outcome regarding the surgical treatment of adolescent idiopathic scoliosis. To our knowledge, no prospective outcome study on this topic thus far exists. Methods. Using the SRS 24 questionnaire, seven scoliosis centers agreed to prospectively assess outcome for surgically treated patients with adolescent idiopathic scoliosis. Data were collected before surgery and at 24 months after surgery. Data were analyzed using paired and independent samples t test for all seven SRS 24 questionnaire domains (Pain, General Self-Image, Postoperative Self-Image, Postoperative Function, Function From Back Condition, General Level of Activity, and Satisfaction) using Statistical Package for Social Science. The domains were analyzed with respect to the total cohort, gender, curve magnitude, and type of surgery using independent-samples t tests. Results. A total of 242 patients were included in our analysis. A baseline preoperative pain level of 3.68 of 5 was found. This improved to 4.63 after surgery, representing an improvement of 0.95 points. Surgical intervention was associated with improving outcome when compared with preoperative status. Pain, General Self-Image, Function From Back Condition, and Level of Activity all demonstrated statistically significant improvement as compared with preoperative status (P < 0. 001). Overall, patients were highly satisfied with the results of surgery. Conclusion. Preoperative pain exists in our adolescent scoliosis population. Pain scores were improved in our study population at the 2-year postsurgical follow-up. Statistically significant improvements were likewise seen in the General Self-Image, Function From Back Condition, and Level of Activity domains. The present study demonstrates the ability of surgery to improve the outcome of patients afflicted with adolescent idiopathic scoliosis.

Do Radiographic Parameters Correlate With Clinical Outcomes in Adolescent Idiopathic Scoliosis

Study Design. A radiographic assessment has been developed to include coronal, sagittal, and axial parameters. Objective. To determine the correlation of postoperative radiographic results and percentage postoperative radiographic improvement with patient clinical self-assessment. Summary of Background Data. With the increasing interest in outcome studies, the authors wanted to determine whether Scoliosis Research Society clinical questionnaire results would correlate with objective radiographic improvement.— Methods. Inclusion criteria: adolescent idiopathic scoliosis treated with anterior or posterior instrumentation, a solid fusion, minimum 2-year follow-up, and a completed postoperative Scoliosis Research Society questionnaire. Seventy-eight patients met the criteria. Measurements included in the radiographic score: Cobb angles of the coronal curve, C7 to the center sacral vertical line, apical translation, apical vertebral rotation, T1 rib angle, end-instrumented vertebrae angulation, angulation of the disc below the end-instrumented vertebra, and curve type. Sagittal measurements included T2–T12, T5–T12, T2–T5, T12–L2, and L1–S1. Results. The preoperative radiographic score of these 78 patients was mean 60.1 ± 9.7 (range 41–88, maximum radiographic score, 100). The 2-year postoperative radiographic score was mean 83.8 ± 8.8 (range, 65–100). The median Scoliosis Research Society questionnaire score was 98 ± 12.3 (range, 58–116, maximum score, 125, showing that the patient is highly satisfied and asymptomatic). The postoperative radiographic score versus the questionnaire score showed a Spearman rank correlation of 0.04 (P = 0.68, little or no correlation throughout). Percentage improvement of the radiographic score versus the questionnaire score showed a Spearman rank correlation of 0.1 (P = 0.38, little or no correlation throughout). Conclusion. In this initial group of patients, the radiographic assessment shows a significant improvement between preoperative and 2-year postoperative scores. However, little correlation between the radiographic assessment and the questionnaire scores was found in this adolescent population, suggesting that separate analysesof radiographic and clinical outcome data are required when evaluating results of postoperative scoliosis surgery.

Use of Video-Assisted Thoracoscopic Surgery to Reduce Perioperative Morbidity in Scoliosis Surgery

Study Design. A case series of idiopathic scoliosis patients treated with thoracoscopic anterior instrumentation was compared to a similar group of patients treated by open anterior instrumentation. Objectives. To evaluate the morbidity associated with thoracoscopic instrumentation compared to the open approach for thoracic scoliosis. Methods. A consecutive group of thoracoscopically treated patients with Lenke 1 adolescent idiopathic scoliosis was compared to similar patients gathered from the DePuy-AcroMed Harms Study Group database. Perioperative outcome measures as well as early postoperative functional outcomes (pulmonary function, shoulder strength) were compared. Results. There were 38 thoracoscopic instrumentation cases with greater than 6 months’ follow-up that were compared to 68 anterior open instrumentation cases. The radiographic outcomes were similar (60% ± 11%vs. 59% ± 17% thoracic curve correction for the thoracoscopic and open groups, respectively). The reduction in forced vital capacity was significantly (P = 0.01) greater in the open group (0.6 ± 0.3 L) compared to the endoscopic group (0.4 ± 0.3 L). There was a trend towards greater return of shoulder girdle strength and range of motion 6 weeks after surgery in the thoracoscopic patients. Conclusion. The thoracoscopic approach for instrumentation of scoliosis has advantages of reduced chest wall morbidity compared with the open thoracotomy method but allows comparable curve correction.

Analysis of patient and parent assessment of deformity in idiopathic scoliosis using the Walter Reed Visual Assessment Scale.

Objectives. This study evaluates the Walter Reed Visual Assessment Scale (WRVAS) compared with clinical parameters and written descriptions of the deformity from idiopathic scoliosis patients and their parents. Summary of Background Data. The WRVAS demonstrates seven visible aspects of spinal deformity in an analogue scale. Higher scores reflect worsening deformity. Materials and Methods. The WRVAS was administered to 182 idiopathic scoliosis patients at four centers in conjunction with open-ended questions about patients’ and their parents’ perceptions of their spinal deformity. The open-ended responses were categorized as either “deformity noted” or “no deformity noted.” Results. WRVAS scores strongly correlate with curve magnitude (P = 0.01) and clearly differentiates curves of 30° or more from lesser curves. Among treatment groups, patients with surgery recommended had significantly higher scores than that of other patients. The instrument differentiated those noting no deformity from those noting a deformity. The correlation between patients’ and parents’ scores was high (Spearman’s rho = 0.8). When a deformity was noted, parents gave higher scores than did their children for rib prominence, shoulder level, scapular rotation, and the total score, but not for the other dimensions. Conclusions. Increasing scores of the WRVAS are strongly correlated with curve magnitude lending construct validity to this type of assessment tool. Patients with “surgery recommended” report more visible deformity on the scale than observed, braced, and postoperative patients, supporting the hypothesis that surgery improves the perceived appearance. Parents perceive more deformity of the ribs and shoulders more than did the patients, but other aspects of the deformity are identified equally. WRVAS scores correlate significantly with curve magnitude and treatment. Parents and patients have similar scores, but with parents perceiving more deformity of the ribs and shoulders than patients.

A multicenter Study analyzing the relationship of a standardized radiographic scoring system of adolescent idiopathic Scoliosis and the Scoliosis Research Society outcomes instrument

Study Design. A multicenter study examining the association between radiographic and outcomes measures in adolescent idiopathic scoliosis. Objectives. To evaluate the association between an objective radiographic scoring system and patient quality of life measures as determined by the Scoliosis Research Society outcomes instrument. Summary of Background Data. Although surgical correction of scoliosis has been reported to be positively correlated with patient outcomes, studies to date have been unable to demonstrate an association between radiographic measures of deformity and outcomes measures in patients with adolescent idiopathic scoliosis. Methods. A standardized radiographic deformity scoring system and the Scoliosis Research Society outcome tool were used prospectively in seven scoliosis centers to collect data on patients with adolescent idiopathic scoliosis. A total of 354 data points for 265 patients consisting of those with nonoperative or preoperative curves ≥10°, as well as those with surgically treated curves, were analyzed. Correlation analysis was performed to identify significant relationships between any of the radiographic measures, the Harms Study Group radiographic deformity scores (total, sagittal, coronal), and the seven Scoliosis Research Society outcome domains (Total Pain, General Self-Image, General Function, Activity, Postoperative Self-Image, Postoperative Function, and Satisfaction) as well as Scoliosis Research Society outcomes instrument total scores. Radiographic measures that were identified as significantly correlated with Scoliosis Research Society outcome scores were then entered into a stepwise regression analysis. Results. The coronal measures of thoracic curve and lumbar curve magnitude were found to be significantly correlated with the Total Pain, General Self-Image, and total Scoliosis Research Society scores (P < 0.0001). The thoracic and upper thoracic curve magnitudes were also correlated with General Function (P < 0.002). The “coronal” subscore as well as the “total” score of the Harms Study Group radiographic scoring system were also significantly correlated with these Scoliosis Research Society domain and total scores. No radiographic measures taken after surgery were significantly correlated with the postoperative domains of the Scoliosis Research Society outcomes instrument. Stepwise regression analysis of these radiographic measures as predictors of Scoliosis Research Society scores resulted in adjusted R2 values of 0.03–0.07 (P < 0.0001). Although these results show that a significant association exists between the radiographic Cobb angle measure of the scoliosis and the Scoliosis Research Society outcomes scores, the low R2 values indicate that variables other than the radiographic appearance of the deformity (e.g., psychosocial, functional) must also be affecting these scores. Conclusion. The Cobb angle measure of the major deformity has a small, but statistically significant, correlation with the reported Total Pain, General Self-Image, and General Function as measured by the Scoliosis Research Society outcomes instrument. None of the radiographic measures in this population correlated with postoperative domain scores of the Scoliosis Research Society outcomes tool.

Recognition and treatment of the proximal thoracic curve in adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation.

Study Design. A retrospective radiographic and clinical review of a consecutive series of patients with adolescent idiopathic scoliosis (AIS) instrumented/fused with Cotrel-Dubousset instrumentation (CDI) was undertaken. Objective. The authors determined criteria when the upper thoracic curve should be instrumented/fused in AIS treated with CDI and assessed the results of surgical treatment. Summary of Background Data. Failure to recognize and include the upper left thoracic curve in the instrumentation/fusion of a lower right thoracic idiopathic scoliosis may produce shoulder imbalance and coronal decompensation. Patients with an elevated left shoulder clinically or a positive T1 tilt radiographically usually require instrumentation/fusion of the proximal thoracic curve. However, the upper left thoracic curve may be structural and require inclusion in the instrumentation/fusion when the shoulders clinically are level or even if the right shoulder is elevated preoperatively when using CDI. Methods. The authors compared 27 patients with AIS with structural upper thoracic curves that were instrumented with CDI to T2 (Group I) to 27 patients with King Type III curves treated with CDI that did not have the upper thoracic curve instrumented/fused (Group II). Results. The distinguishing Group I preoperative criteria indicating a structural upper thoracic curve included a proximal thoracic curve greater than 30° that corrected to no better than 20° on sidebending; ≥ Grade I rotation or ≥ 1 cm translation present at the apex of this curve; any elevation of the left shoulder or tilt of T1 into the concavity of the upper thoracic curve; or when the transitional vertebra between the two curves is at T6 or below. Conclusions. When these aforementioned criteria are present and surgical correction with CDI is planned, we recommend extending the instrumentation up to T2 to produce level shoulders and maintain coronal balance.

Seeing the spine in 3D: how will it change what we do?

BackgroundThe Scoliosis Research Society (SRS) has appointed a committee to evaluate the clinical relevance and impact of 3D analysis on scoliotic deformities and to develop a 3D classification of adolescent idiopathic scoliosis (AIS). The goal of this article is to summarize and present the work done in recent years within this committee and show how 3D analysis of AIS has the potential to change our current methods to analyse and treat scoliosis. MethodsA database of 600 3D reconstructions of the spine of patients with AIS has been established using calibrated PA and lateral radiographs obtained from either digital radiographs orthe EOS system. The 3D reconstructions were done using dedicated software and analyzed with the “da Vinci” view, a schematic top view representation of the 3D reconstructions, which summarizes the position of the End-Apex-End vertebrae planes (planes of maximum curvature). ResultsPreliminary work was done using 3D reconstructions in 409 patients with AIS. Fuzzy clustering techniques were used toshow that the cohort could be segmented in 5 easily differentiated curve patterns similar to those of the Lenke and King classifications. Two subsequent articles have shown that 3D reconstructions can be divided in different groups based on the location of the plane of maximum curvature of their curves. One study of 66 cases has shown a consistent loss of kyphosis within the 5 thoracic apical vertebrae. Finally, a study of 172 Lenke 1 curves analyzed by ISOData cluster analysis has confirmed the presence of 2 statistically different subtypes according to the planes passing through the End-Apex-End vertebrae of the main thoracic curve. ConclusionsThe study presented suggests that a valid and clinically useful 3D classification of AIS is within reach. 3D analysis has the potential to improve our comprehension of AIS curve types and automatic 3D classification may help decrease the known variability of current 2D classifications. Level of EvidenceLevel III, systematic review of retrospective comparative studies.

Outcomes of surgical treatment in male versus female adolescent idiopathic scoliosis patients.

Study Design. This research was part of a multicenter study of the surgical treatment of adolescent idiopathic scoliosis (AIS). Objective. To compare the radiographic and perioperative surgical treatment outcomes of male AIS patients with female AIS patients. Summary of Background Data. The results of treatment in male patients with idiopathic scoliosis have not been widely reported. Only 1 study has evaluated the differences in operative treatment outcomes between male and female patients with AIS. Methods. Data were collected for patients who met the indications for surgical intervention at 8 separate institutions. Radiographic, perioperative, and pulmonary function variables for male and female AIS patients treated surgically were analyzed. A univariate analysis of variance with the &agr; level adjusted to P ≤ 0.01 was used. Results. The data for 547 (449 females and 98 males) patients were included in this analysis. Posterior instrumentation (vs. anterior instrumentation) was performed slightly more often in males than females (51% vs. 44%, respectively). The preoperative primary curve magnitude was similar for both genders, but flexibility was less in males (44% vs. 49%; P = 0.01). Postoperative percent correction and the ratio of percent correction to preoperative flexibility were both similar in males versus females. Analysis of the perioperative variables yielded that estimated blood loss was higher in males than females (1342 vs. 898 cc, respectively; P = 0.001). Males reported greater pain on postoperative day 1 (6.1 vs. 5.4; P = 0.01), however, conversion to oral pain medication was similar for both. Preoperative and postoperative pulmonary function was similar for both genders. Conclusion. Male AIS patients had slightly more rigid primary curves compared to females but a similar degree of postoperative scoliosis correction. Differences in the preoperative status and perioperative course did not compromise the outcomes of surgical treatment as in all other measures; the results were comparable between the genders.

Preoperative spinal canal investigation in adolescent idiopathic scoliosis curves > or = 70 degrees.

STUDY DESIGNnThis is a prospective evaluation of a consecutive series of patients with adolescent idiopathic scoliosis (AIS) with curves > or = 70 degrees.nnnOBJECTIVEnThe authors investigated the possibility that large curve size may constitute an atypical presentation of idiopathic scoliosis suggestive of underlying neurologic pathology, which would warrant preoperative investigation.nnnSUMMARY OF BACKGROUND DATAnThe potential for intraspinal pathology to cause scoliosis is well accepted. The incidence of spinal canal abnormalities in congenital or atypical scoliosis may be as high as 30-60%. Identification of clinical neurologic deficits, congenital abnormalities, or atypical features of scoliosis are often helpful in identifying the subpopulation of scoliosis patients at risk for spinal canal pathology.nnnMETHODSnThirty-three consecutive patients with large (> or = 70 degrees) adolescent idiopathic scoliosis (AIS) and without evidence of neurologic or congenital abnormalities, were evaluated with either computed tomography/myelogram (n = 3) or magnetic resonance imaging (n = 30) to assess the entire spinal canal.nnnRESULTSnNone of the studies revealed any pathology of the neuraxis, and all 33 patients were treated with surgery without any neurologic sequelae.nnnCONCLUSIONSnPreoperative investigation of the central neuraxis is not mandatory in large (> or = 70 degrees) but otherwise typical AIS curves. These large curves do not appear to suggest associated spinal canal anomalies.