Mohammad Diab

The minimum clinically important difference in Scoliosis Research Society-22 Appearance, Activity, And Pain domains after surgical correction of adolescent idiopathic scoliosis.

Study Design. Longitudinal cohort. Objective. To determine the minimum clinically important difference (MCID) of the Scoliosis Research Society (SRS)-22 Appearance, Activity, and Pain domains in patients with adolescent idiopathic scoliosis undergoing surgical correction of their spinal deformity. Summary of Background Data. The MCID, a threshold of improvement that is clinically relevant to the individual patient, is increasingly used to evaluate treatment effectiveness. MCID values for the SRS-22 domains have not been determined. Methods. Patients with adolescent idiopathic scoliosis who underwent surgical correction and had completed SRS-22 before operation and the SRS-30 and Scoliosis Appearance Questionnaire (SAQ) at 1 year after operation from a multicenter database for pediatric scoliosis were identified. The SAQ is a modification of the Walter Reed Visual Assessment Scale and is used to assess the patients perception of their spinal deformity. Paired sample t tests were used to compare preoperative and 1-year postoperative scores. Spearman correlations were used to evaluate associations between domain scores and summed responses to anchors for Appearance, Activity, and Pain. MCID values for the SRS-22 domains were determined using receiver operating characteristic curve analysis, with summed responses to anchor questions 23 to 30 of the SRS-30 and items 26 and 32 of the SAQ. Results. There were 735 women and 152 men with a mean age of 14.3 years and a mean Cobb angle of 53°. There was a statistically significant difference between paired preoperative and 1-year SRS domain scores. Analysis of variance showed a statistically significant difference between the summed responses to the anchors. The MCID was 0.20 for the Pain domain (area under the curve [AUC] = 0.723), 0.08 for Activity (AUC = 0.648), and 0.98 for Appearance (AUC = 0.629). The MCID for activity was less than the standard error of measurement. Conclusion. The MCID for the Pain domain was 0.20 and 0.98 for Appearance. Because these patients were generally in good health, a minimal though significant change in activity was observed, such that the calculated MCID was within the measurement error. As expected, the largest and most important change was in the Appearance domain. Future studies are needed to determine the MCID for the mental domain and the total SRS score and to further validate the MCID values in this study.

The Spinal Appearance Questionnaire: Results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis

Study Design. Prospective, sequential enrollment. Objective. We report the development and testing of the Spinal Appearance Questionnaire (SAQ) for reliability, validity, and responsiveness in patients with idiopathic scoliosis. Summary of Background Data. The SAQ was designed to measure patients’ and their parents’ perception of their spinal deformity’s appearance using standardized drawings and questions. This study was designed to test the instrument’s psychometric properties. Methods. The SAQ was administered as a test-retest to idiopathic scoliosis patients and parents for reliability and initial validity assessment (Group I). It was then administered to patients before surgery and 1 year after surgery (Group II) for responsiveness and further validity testing. Finally, both the SAQ and SRS instruments were administered to adolescent idiopathic patients before surgery and 1 year after surgery (Group III) for comparison of the 2 instruments. Results. Group I: The individual scale items had good to excellent reliability (Spearman’s rho, 0.57–0.99) and high internal scale consistency (Cronbach’s alpha >0.7). The mean scale scores differentiated between curves greater than 30° and lesser curves (P < 0.01). Surgery improved scores compared with those with “surgery recommended.” Group II: The domains correlated with clinical and radiographic aspects of the deformity before surgery. All of the domains showed significant difference after surgery (P < 0.0001) and large effect size for all domains except for the patient chest domain. Group III: Both the SAQ and the SRS instruments had significant improvement in all of their domains except for the SRS Activity scale. The relative efficiency of the SAQ domains to the SRS appearance domain (the most responsive SRS domain) was greater for 5 SAQ domains. Conclusion. The SAQ is reliable, responsive to curve improvement, and shows strong evidence of validity. It provides more detail than the SRS in the appearance domain, and provides explanation of spinal deformity’s concerns and improvements.

Patient satisfaction after surgical correction of adolescent idiopathic scoliosis.

Study Design. Longitudinal cohort. Objective. The purpose of this study is to evaluate the relationship between change in SRS-22 domain scores and satisfaction with management in patients who underwent surgical correction for adolescent idiopathic scoliosis (AIS). Summary of Background Data. The Scoliosis Research Society-22 (SRS-22) is a widely used instrument to measure clinical outcomes in patients with scoliosis. The relationship between patient satisfaction and changes in domain scores in the SRS-22 has not been previously reported. Methods. This is a longitudinal cohort of 745 patients with AIS who underwent surgical correction and had completed SRS-22 preoperative and 2 years postoperative. Patients who had a previous spine surgery were excluded. Wilcoxon tests were used to compare preop and 2-year postop scores. Spearman correlations were used to evaluate associations between change in SRS-22 domain scores from preoperative to 2 years postoperative and the 2-year SRS Satisfaction score. Results. There were 622 females and 123 males with a mean age of 14.2 years and a mean Cobb angle of 54°. There was a statistically significant difference between paired preoperative and 2-year postoperative SRS domain scores. Spearman correlations between the change in SRS domain scores and the SRS Satisfaction score at 2 years postoperative were statistically significant but were low to moderate: Appearance = 0.284, Activity = 0.172, Pain = 0.260, Mental = 0.202, and Total = 0.398. Conclusion. Although there is a statistically significant change in all the SRS domain scores from preoperative to 2 years postsurgical correction of AIS, there was low to moderate associations between the change in any of the domain scores and patient satisfaction with treatment. This may be attributable to the prominent ceiling effect in the Satisfaction domain, or the lack of responsiveness of the SRS-22 to measure clinically relevant changes in activity, pain and mental health 2 years after correction of scoliosis in the adolescent population.

Comparison of observer variation in conventional and three digital radiographic methods used in the evaluation of patients with adolescent idiopathic scoliosis.

Study Design. This study is a reliability analysis of coronal Cobb angle measurements in adolescent idiopathic scoliosis obtained by multiple observers. Objective. We sought to quantify and compare the interobserver reliability of conventional radiographs and 3 methods of digital radiography. Summary of Background Data. The use of digital radiography for the evaluation of adolescent idiopathic scoliosis is being widely adopted. Previous studies comparing manual and computer-based measurements have found excellent intraobserver reliability for both techniques. Interobserver reliability of computer-based measurements on digital radiographs has not been compared with manual measurements on conventional radiographs. Other commonly used forms of output of digital radiography have not been studied. Methods. Preoperative standing posteroanterior full-length spine radiographs from 40 patients with adolescent idiopathic scoliosis were examined by 4 observers. Patients were divided into 2 groups of 20 patients. In 1 group, radiographs were obtained by conventional technique. In the other group, radiographs were obtained using a digital radiography system. Three types of output of the identical image obtained by a digital radiography system were examined, including computer-based image, printing of the image fitted onto a single film, or printing of the image onto 2 unstitched films. The Cobb angle, upper vertebra, and lower vertebra of the major curve were measured by each observer. Interobserver reliability for each technique was calculated by intraclass correlation coefficient and interobserver variance. Results. Interobserver reliability as described by intraclass correlation coefficient and interobserver variance was excellent (0.93–0.98) for measurements made on conventional, computer-based, and fitted printed radiographs. The intraclass correlation coefficient was good (0.87) in measurements obtained on radiographs printed on 2 unstitched films. Conclusion. Measurements made on conventional and digital radiographs using manual and computer-based techniques have similar good to excellent interobserver reliability. Interobserver reliability was lower for digital radiographs when printed onto 2 unstitched films. The results suggest that different observers will obtain similar measurements when viewing the same image, but care should be taken when interpreting images printed on 2 unstitched films.

The effect of age on motor evoked potentials in children under Propofol/Isoflurane Anesthesia

Intraoperative transcranial motor evoked potential (MEP) monitoring may help prevent neurologic injury during spine surgery. This type of monitoring may be difficult in the pediatric population under general anesthesia. We retrospectively reviewed data from 56 children, aged 2 to 18 yr, who were to undergo surgical correction of idiopathic scoliosis with MEP monitoring. Under combined isoflurane-propofol general anesthesia, before incision, we examined the minimum stimulating threshold voltage required to achieve a 50-microvolt or greater MEP response amplitude. Younger age was associated with an increase in the threshold voltage needed to elicit a sufficient MEP response. In addition, younger age was associated with longer stimulating pulse trains and greater need to adjust stimulating scalp electrodes. Body surface area, height, weight, and body mass index were also significant factors, but they were not independent predictors, after adjusting for age. Younger children received significantly lower levels of isoflurane and comparable doses of propofol, compared with older patients. Stronger stimulation needed to produce MEP responses in younger patients may reflect immaturity of their central nervous system, specifically conduction by the descending corticospinal motor tracts. Greater attention must be given to optimizing physiologic variables, limiting depressant anesthetics, and selecting the most favorable stimulating conditions in children, especially those <10 yr old.

Cost-Effectiveness Analysis of Periacetabular Osteotomy

BACKGROUND A lack of long-term outcomes data following periacetabular osteotomy makes it difficult for surgeons to recommend the most appropriate procedure to young patients who might be candidates for a joint-preserving procedure. In this study, we compared the cost-effectiveness of periacetabular osteotomy with total hip arthroplasty in terms of cost per quality-adjusted life year for the young adult. METHODS A decision model was constructed for a cost-utility analysis of periacetabular osteotomy compared with total hip arthroplasty. Outcome probabilities and effectiveness were derived from the literature. Effectiveness was expressed in quality-adjusted life years gained. Cost data were compiled and verified from our institution. Costs and utilities were discounted in accord with the United States Panel on Cost-Effectiveness in Health and Medicine. Principal outcome measures were average incremental costs, incremental effectiveness, incremental quality-adjusted life years, and net health benefits. Multivariate sensitivity analysis was used to assess the contribution of included variables in the models outcomes. RESULTS For Tönnis grade-1 coxarthrosis, periacetabular osteotomy dominates with an average incremental cost-effectiveness of

Intertrochanteric versus subcapital osteotomy in slipped capital femoral epiphysis.

7856 per quality-adjusted life year and an average incremental effectiveness of 0.15. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy is, on the average, more cost-effective than total hip arthroplasty with an incremental cost-effectiveness of

Scapulothoracic Fusion for Facioscapulohumeral Muscular Dystrophy

824 per quality-adjusted life year, but it is less effective than total hip arthroplasty, on the average, with an incremental effectiveness of -1.4 quality-adjusted life years. Periacetabular osteotomy becomes more cost-effective at a longevity of 5.5 years for Tönnis grade-1 coxarthrosis and 18.25 years for Tönnis grade-2 coxarthrosis. In Tönnis grade-3 coxarthrosis, total hip replacement becomes the dominant treatment strategy. CONCLUSIONS Periacetabular osteotomy is, on the average, more cost-effective in Tönnis grade-1 and grade-2 coxarthrosis, while it is both more costly and less effective in Tönnis grade-3 coxarthrosis. These findings can inform clinical decision-making in the absence of long-term data. On the basis of this model, periacetabular osteotomy is preferable to total hip arthroplasty in Tönnis grade-1 and grade-2 coxarthrosis when the patient is sufficiently young and when functionality in sports is important.

Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis.

We reviewed 15 flexion intertrochanteric osteotomies and 11 subcapital osteotomies done for chronic, severe, stable slipped capital femoral epiphysis at one institution with a minimum 2 years followup. The goal was to determine which procedure achieved better deformity correction and which procedure was safer. Radiographically, the two groups were equivalent in compensating for epiphyseal slip. Flexion intertrochanteric osteotomy was more effective in restoring proximal femoral anatomy, as determined by articulotrochanteric distance and trochanter-center of head distance. The incidence of complications, including osteonecrosis and chondrolysis, was low for both groups, but the reoperation rate was greater in the subcapital osteotomy group than in the flexion intertrochanteric group. Flexion intertrochanteric osteotomy seems to be an effective, safe, and reproducible realignment osteotomy for treatment of chronic, severe, stable slipped capital femoral epiphysis.

A biomechanical analysis of sublaminar and subtransverse process fixation using metal wires and polyethylene cables.

BACKGROUND Facioscapulohumeral muscular dystrophy causes winging of the scapula and weakness and discomfort of the shoulder. Surgical stabilization of the scapula to the posterior part of the chest wall permits shoulder abduction and flexion by the deltoid muscle. In the present retrospective study, we describe our experience with eleven scapulothoracic fusion procedures that were performed for the treatment of the infantile and adolescent forms of the disease. METHODS Eleven procedures were performed in eight patients, including four male patients (one of whom had bilateral involvement and three of whom had unilateral involvement) and four female patients (two of whom had bilateral involvement and two of whom had unilateral involvement). One of the female patients had the infantile variant, whereas all other patients had the adolescent form of the disease. The mean age at the time of the eleven operations was seventeen years. The scapula was fused to the thorax in 25 degrees of abduction with use of 16-gauge wires, a plate or washers on the posteromedial scapular surface to prevent wire pull-out, and iliac crest autograft. After a mean duration of follow-up of 6.3 years, all patients were assessed clinically and radiographically. RESULTS In all cases, scapular winging and shoulder fatigue and pain were initially eliminated. In the first year after the operation, active abduction and flexion of the shoulder improved to a mean of 145 degrees (range, 110 degrees to 160 degrees ) and 144 degrees (range, 130 degrees to 160 degrees ), respectively, from a preoperative mean of 75 degrees (range, 70 degrees to 90 degrees ). At the time of the final assessment (mean, 6.3 years postoperatively), abduction and flexion were maintained at a mean of 139 degrees and 134 degrees , respectively, in seven shoulders; however, in the remaining four shoulders, both of these motions had decreased to a mean of 48 degrees because of progressive loss of deltoid muscle strength. In two cases, prominent subcutaneous wires required trimming. There were no other complications. CONCLUSIONS Scapulothoracic fusion relieves shoulder fatigue and pain, allows for smooth functional abduction and flexion of the upper extremity, and improves the appearance of the neck and shoulder in patients who have symptomatic scapular winging due to facioscapulohumeral muscular dystrophy. The procedure is associated with a low risk of complications. Progression of the disease affecting the deltoid muscle can cause loss of abduction, but the other benefits of stabilization persist. LEVEL OF EVIDENCE Therapeutic Level IV.