Back Pain in Adolescents and Young Adults with Idiopathic Scoliosis-Identifying Factors Associated with Significant Pain-A Multivariate Logistic Regression Analysis.

(1) Background: Previous data show that patients with idiopathic scoliosis (IS) can be classified into two groups according to pain intensity. This paper aims to determine which factors can independently predict the likelihood of belonging to a high-level pain group. (2) Methods: The study used a prospective, multicenter, cross-sectional design. Two-hundred and seventy-two patients with IS (mean age 18.1 years) (females 83.5%) were included. The sample was divided into two groups. The PAIN group comprised 101 patients (37.1%) with an average NRS of 5.3. The NO-PAIN group consisted of 171 patients (62.9%) with an average NRS of 1.1. Data on various factors such as comorbidities, family history, curve magnitude, type of treatment, absenteeism, anxiety, depression, kinesiophobia, family environment, and social relationships were collected. Statistical analysis consisted of multivariate logistic regression analysis to identify independent predictors of high-level pain. (3) Results: In the final model, including modifiable and non-modifiable predictors, age (OR 1.07 (1.02-1.11)); Absenteeism (OR 3.87 (1.52-9.87)), HAD anxiety (OR 1.18 (1.09-1.29)) and an indication for surgery (OR 2.87 (1.28-6.43)) were associated with an increased risk of pain. The overall model is significant at p = 0.0001 level and correctly predicts 72.6% of the responses. (4) Conclusions: Age, an indication for surgery, anxiety, and work/school absenteeism are the variables that independently determine the risk of belonging to the high-level pain group (NRS > 3).

How back pain intensity relates to clinical and psychosocial factors in patients with idiopathic scoliosis.

OBJECTIVE: A pain intensity of 3 can reliably distinguish idiopathic scoliosis (IS) patients with acceptable pain or not. This research aims to analyze psychosocial, family and quality of life differences in patients according to their pain status. MATERIAL AND METHODS: Patients with IS, without previous surgery, Cobb ≥ 30° and age (12-40) were included in the study. They completed the questionnaires Numerical Rate Scale (NRS), Tampa Scale for Kinesiophobia (TSK)-11, SRS22r, Hospital Anxiety-Depression Scale (HADS), COMI item 7 (work/school absenteeism) and family APGAR. Comorbidities and family health history were collected. Analysis of covariance was performed to compare means between the PAIN (NRS > 3), (NRS < = 3) groups controlling for the effect of age and the magnitude of the curve. RESULTS: In total, 272 patients were included. 37.1% belonged to the PAIN group (PG). The PG showed a significantly higher Cobb grade and age than the NO-PAIN group. After controlling for these variables, the PG had worse pain, mental health and SRS22-subtotal values. However, they did not differ in function or self-image. PG showed higher levels of kinesiophobia, anxiety, depression, absenteeism from work/school and impact on social/family environment. PG patients reported a higher prevalence of comorbidities and family history of nonspecific spinal pain. CONCLUSIONS: Patients with IS and unacceptable pain constitute a group with a different incidence of psychological, social, family and comorbidities factors than those with acceptable pain. In contrast, the severity of IS was not substantially different between the groups. This profile is similar to that observed in patients with nonspecific spinal pain.

The Relationship of Kinesiophobia with Pain and Quality of Life in Idiopathic Scoliosis.

STUDY DESIGN: Prospective, multi-centric, cross-sectional study. OBJECTIVE: To analyze the construct validity of the Tampa Scale of Kinesiophobia (TSK) in a cohort of patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF THE BACKGROUND DATA: Back pain is not uncommon in AIS. The fear of movement (kinesiophobia) in response to pain is related to back pain. TSK psychometric properties in AIS patients have not been properly analyzed. METHODS: Patients with AIS and no prior spine surgery were prospectively included. They fulfilled the Spanish version of the TSK-11 questionnaire, a pain intensity numerical rating scale (NRS), refined SRS-22 (SRS-22r), the Hospital Anxiety and Depression Scale (HADS), and item 7 of the Core Outcome Measurement Index (COMI). The sample was split into two groups for the statistical analysis: adolescents and young adults. Cronbach alpha was used to assess internal consistency. Discriminant and concurrent validity were obtained by computing Pearson correlation coefficients between the TSK score and several criterion measures. RESULTS: A total of 275 patients were included-198 adolescents (mean age of 14.6 yrs) and 77 young adults (mean age of 26.9 yrs). The Cobb of largest curve means were 44.9° and 48.9°, respectively. In the adolescent group, the TSK mean (±SD) was 21.5 (±5.93), with a floor effect of 2.5%. In the adult group, the TSK mean was 24.2 (±6.63), with a floor effect of 3.9%. The ceiling effect was 0% in both groups. Cronbach alphas for the adolescent and adult groups were 0.76 and 0.79, respectively. No correlation was found in any group between the TSK score and the curve magnitude or pattern (Lenke classification). The TSK was significantly correlated with HAD depression and SRS-22r in both groups. However, these correlations were weaker in adolescents. In adults, the TSK also significantly correlates with NRS and work/school absenteeism. CONCLUSION: The Spanish version of TSK-11 is a reliable and valid instrument to analyze kinesiophobia in AIS. However, the weak correlation between kinesiophobia and pain intensity, disability, and emotional condition in adolescents requires further study.Level of Evidence: 4.

Clinical photography in severe idiopathic scoliosis candidate for surgery: is it a useful tool to differentiate among Lenke patterns?

PURPOSE: Clinical photography has proven to be reliable for posture assessment in adolescents and young adults with idiopathic scoliosis. This paper attempts to elucidate whether clinical photography is capable of distinguishing the distinctive characteristics in trunk deformity of the different Lenke patterns in patients with severe scoliosis candidate for surgery. METHODS: One hundred and seventy-three patients (82% women), average age of 20.8 years and average largest curve magnitude of 58.7° were included. PA standing full-spine X-rays and digital photographs from the back of the trunk were measured. RADIOLOGICAL MEASUREMENTS: It is used to measure magnitude of the proximal thoracic (PTC), main thoracic (MTC) and thoracolumbar/lumbar (TL/LC) curves, T1 tilt and the clavicle-rib intersection angle. PHOTOGRAPHIC MEASUREMENTS: It is used to measure shoulder height angle, axilla height angle, waist height angle (WHA), right and left waist angles and trunk areas. STATISTICAL ANALYSIS: One-way ANOVA to test mean differences among Lenke types for radiological and photographic measurements was performed. ROC curve analysis was conducted to find out cutoff values in photographic measurements to differentiate among curve patterns. RESULTS: Most radiological and photographic measurements differ among curve patterns. On ROC curve analysis, solid cutoff values were found for WHA (AUC = 0.8), left waist angle (AUC = 0.81), right waist angle (AUC = 0.81) and the difference between left and right waist angles (AUC = 0.86) to differentiate between types 1 and 2 and the other three types (3, 5 and 6). CONCLUSIONS: Clinical photography is a valid method for assessing trunk asymmetry in severe idiopathic scoliosis. Specifically, for waist area measurements, robust cutoff values can be determined to discriminate among different curve patterns according to Lenke classification. These slides can be retrieved under Electronic Supplementary Material.

Responsiveness of Image Perception Outcome Scales After Surgical Treatment of Idiopathic Scoliosis: A Comparison Between the Trunk Appearance Perception Scale (TAPS) and Scoliosis Research Society-22 (SRS-22) Questionnaire.

STUDY DESIGN: Retrospective study of prospectively collected longitudinal data. OBJECTIVES: To analyze the Trunk Appearance Perception Scale's (TAPS's) responsiveness to surgical treatment of idiopathic scoliosis (IS). SUMMARY OF BACKGROUND DATA: TAPS is a drawing-based instrument to assess trunk deformity in IS. It shows appropriate metric properties, such as internal consistency and discriminant validity. However, no data on responsiveness to surgical treatment is available. METHODS: A total of 109 patients (85.3% females) with IS were included (mean age at surgery 18 years). In all the cases, surgery consisted of posterior spine fusion and instrumentation. The magnitude of the largest curve (MLC) was 63.8° before surgery and 26.3° (correction 58.3%) at a mean follow-up of 20.8 months. Internal and external responsiveness were analyzed on the basis of effect size (ES), standardized response mean (SRM), minimum detectable change (MDC), and correlation between percentage of MLC correction and outcome measure change. Data for TAPS were compared to those of SRS-22 Image domain. RESULTS: TAPS showed somewhat larger internal responsiveness (ES 1.96, SRM 1.73, 86.2% of patients exceeding MDC) than SRS-22 Image scale (ES 1.44, SRM 1.29, 73.4% of patients exceeding MDC). No correlation was found between the percentage of MLC correction and baseline to follow-up change in TAPS or SRS-22 Image scores. CONCLUSION: The TAPS instrument shows adequate responsiveness to surgical treatment of idiopathic scoliosis and is somewhat larger than SRS-22 Image domain data. The lack of correlation between radiologic correction and clinical improvement indicates that the two outcomes must be independently collected. These data on responsiveness complete the TAPS validation process. TAPS is a valid, reliable, and responsive instrument to evaluate the outcome of surgical treatment of idiopathic scoliosis. LEVEL OF EVIDENCE: Level IV.

The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications.

BACKGROUND CONTEXT: In 2008, Mirza et al. designed and validated the first and only index capable of quantifying the complexity of spine surgery. However, this index is not fully applicable to adult spinal deformity (ASD) surgery as it does not include the surgical techniques most commonly used and most strongly associated with perioperative complications in patients with ASD. PURPOSE: The objective of this study is to develop an "Adult Deformity Surgery Complexity Index" (ADSCI) to quantify objectively the complexity of the ASD posterior surgery. STUDY DESIGN/SETTING: This is an expert consensus (Delphi process) and retrospective analysis of prospectively collected data using multiple regression models. PATIENT SAMPLE: Patients were prospectively enrolled in two comparable multicenter ASD databases sharing the same inclusion criteria. OUTCOME MEASURES: The ADSCI was internally and externally validated using R2 for intraoperative bleeding and length of surgery. Receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to assess the sensitivity and specificity of ADSCI. METHODS: The development and validation of ADSCI was based on the construction and comparison of three different tools: ADSCI score was constructed by three rounds of expert consensus (ADSCI-Delphi) and two multiple regression models (ADSCI-RM-Simple and ADSCI-RM-Mixed). Their predictive capability was compared by means of R2 values in the same subrogated of surgical complexity as in the Mirza index validation: intraoperative bleeding and duration of surgery. Sensitivity and specificity were evaluated using ROC curves and AUC analysis. The external validity was also examined by evaluating its predictive capability in another multicenter ASD database of comparable patients in the United States. RESULTS: At the time of the study, the database included 1,325 patients. Four hundred seventy-five patients were eligible for the study, having been treated surgically using a posterior approach only (52.2 years standard deviation 20; 77.7% women; 85.4% American Society of Anesthesiologists I/II). Fifty-one international experts participated in the Delphi consensus process. The surgical variables selected by consensus and included in the equation were divided into actions and factors. Actions selected were number of fused segments, decompressions, interbody fusions, and cemented levels; number and type of posterior osteotomies; and use of pelvic fixation. The factors included were implant density, revision surgery, and team experience. ADSCI-RM-Mixed (regression model with Delphi formula interactions) provided the best estimates and predictive value, well above Mirza's invasiveness index. The ADSCI-RM-Mixed, with greater AUCs (>0.70), was also the most sensitive and specific for both of the dependent variables studied and for complication prediction. ADSCI-RM-Mixed obtained also the highest R2 value in the validation cohort in predicting blood loss (R2=0.34) and surgical time (R2=0.26) with effect sizes similar to those for the derivation cohort. CONCLUSIONS: The ADSCI is the first tool to be specifically developed for the preoperative assessment of the complexity of ASD surgery. This study confirms its validity, specificity, and sensitivity, and shows that it has greater predictive capability than the more generic Mirza invasiveness index. The ADSCI should be useful for quantitatively estimating the increased risk associated with more invasive surgery and adjusting for surgical case-mix when making safety comparisons in ASDS.

Impact of early unanticipated revision surgery on health-related quality of life after adult spinal deformity surgery.

BACKGROUND CONTEXT: Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes. PURPOSE: The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery. DESIGN: This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database. PATIENT SAMPLE: The present study included 280 patients from a multicenter international prospective database. OUTCOME MEASURE: Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work. METHODS: Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models. RESULTS: Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups. At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group. CONCLUSIONS: Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up.

Introversion, the prevalent trait of adolescents with idiopathic scoliosis: an observational study.

BACKGROUND: A large number of studies about adolescents with idiopathic scoliosis focus on health-related quality of life (HRQOL). However, only a few articles aim at evaluating the personality of these patients. Therefore, the purpose of the present research is to assess the personality traits of adolescents with idiopathic scoliosis and their relationship with HRQOL.Our hypothesis is that adolescents with idiopathic scoliosis present the principal personality trait of introversion, defined as self-reliance and inhibition in social relationships. METHODS: This was a cross-sectional study. The examined group consisted of 43 patients (only 4 boys), mean age = 14.3 (SD = 2.23). On the day of the visit, HRQOL tools (Scoliosis Research Society-22 Questionnaire (SRS-22) and Trunk Appearance Perception Scale (TAPS)) and a personality test (16 Personality Factors-Adolescent Personality Questionnaire (16PF-APQ)) were completed; in addition, a posterior-anterior radiography was performed. Correlations among demographic and medical data and HRQOL and personality tests were assessed. RESULTS: Results for SRS-22 were as follows: Function 4.5 (SD = .4), Pain 4.3 (SD = .5), Self-image 3.6 (SD = .7), Mental Health 3.8. (SD = .7), and Subtotal 4.2 (SD = .7). Mean TAPS was 3.5 (SD = .6).In personality, the lowest values were assessed for Extroversion (M = 29.4, SD = 24.7) and Self-reliance (M = 71, SD = 25.3).Independence was negatively related to Self-image (r = -.51), Mental Health (r = -.54), and Subtotal SRS-22 (r = -.60) (p < .01). CONCLUSIONS: Adolescents with idiopathic scoliosis presented a common style of personality, characterized by social inhibition (introversion), preference for staying alone, and being self-sufficient (self-reliance).Specific programs in promoting social abilities may help adolescent patients with idiopathic scoliosis in finding a way to express themselves and to become more sociable. Correlational studies between personality and HRQOL need to be performed to better understand these issues.

Trunk appearance perception scale for physicians (TAPS-Phy) - a valid and reliable tool to rate trunk deformity in idiopathic scoliosis.

BACKGROUND: Evaluation of trunk deformity by physicians in patients with idiopathic scoliosis (IS) has been considered an important part of clinical practice. Different methods to quantify the severity of trunk deformity by external observation have been reported. A valid tool to evaluate patients' perception of trunk deformity, the Trunk Appearance Perception Scale (TAPS), is hereby validated for use by physicians (TAPS-Phy). METHODS: Cross-sectional study of patients with non-surgically treated IS. Patients were prospectively recruited. On the day of the visit, a posterior-anterior radiograph in standard position and clinical photographs in three different views (anterior, posterior and forward bending position) were obtained. Patients also completed a TAPS questionnaire (TAPS-Pat). Three different observers scored the TAPS questionnaire (TAPS-Phy), based on the digital photographs previously obtained, twice a week. The angle of trunk inclination (ATRI) was also measured on digital photographs. Inter and intra-rater reliability was calculated through weighted kappa coefficient. External validity was tested by the Spearman correlation coefficient between the TAPS-Phy score and the scoliosis magnitude determined using the magnitude of the largest curve (MLC), ATRI, and TAPS-Pat. RESULTS: Fifty two patients (46 women; mean age 16.6 years) were included. The average curve magnitude of the major curve was 44°. Mean scores of TAPS-Phy for the three evaluators ranged from 3.4 to 3.5. No differences between the three means were found. TAPS-Phy showed good internal consistency (Cronbach's alpha coefficient 0.84). Inter-observer reliability ranged from slight to substantial (0.14 to 0.63); intra-observer reliability ranged from 0.35 to 0.99. Correlation between TAPS-Phy and ATRI (r = -0.54 to -0.75), MLC (r = -0.47 to -0.6) and TAPS-Pat (r = 0.29 to 0.34) were statistically significant (p < 0.01). CONCLUSIONS: TAPS-Phy is a valid and reliable scale to rate a physician's impression of the severity of the deformity in patients with idiopathic scoliosis and can be useful in routine clinical records.

Validity and reliability of photographic measures to evaluate waistline asymmetry in idiopathic scoliosis.

OBJECTIVE: Evaluate the relationship between radiological, clinical and perceived waistline asymmetry (WLA) in a sample of idiopathic scoliosis (IS) patients. METHODS: 77 patients were included (mean age 20.3 years; 85 % women). We obtained a full X-ray of the spine and back clinical photography for all patients. On photographs, waist height angle (WHA), right/left waist angles (WA) and right/left waistline distance ratio were measured. SRS22, Trunk Appearance Perception Scale (TAPS) and Spinal Appearance Questinnaire (SAQ) questionnaires were also completed. The intra and inter-observer reliability of each photographic measure was assessed. A correlation analysis between all variables was done using Pearson Correlations Coefficient. RESULTS: All measures reported have excellent intra- and inter-observer (ICC ≥0.8) reliability. A significant correlation was found between WHA and Cobb angle, mainly with Main Thoracic (MT) (r = -0.56). Right and left waist angles, and especially the difference between them (RLWAD), is related to the thoracolumbar/lumbar (TLL) curve. We have found a significant correlation between RLWAD and TLL curve magnitude (r = -0.54) and with the inclination of the lower end vertebra (LEV) (r = 0.74). Only WHA has a significant, but poor correlation (r â‰… 0.3) with trunk perception scales (TAPS and SAQ). No other significant correlations were found between WLA measures and patient related outcome scores. CONCLUSION: WLA measures proposed in this article are reliable tools to assess WLA. We have found a significant correlation between clinical WLA and skeletal deformity (Cobb angle). WHA is related with MT curve while the RLWAD depends on the TLL curve magnitude and its LEV. We have also found a significant relation between WHA and the patient's perception of the deformity. It seems that WLA is a cosmetic concern to take into account in clinical evaluation of IS patients.

Does patient perception of shoulder balance correlate with clinical balance?

OBJECTIVE: To evaluate the relationship between radiological, clinical and perceived shoulder balance (ShB) in a sample of non-operated, moderate, idiopathic scoliosis (IS) patients. METHODS: 80 patients (85 % women) with a mean age of 20.3 years (SD 8.6, 12-40 years) were included. Mean Cobb angle was 45.9° (SD 12.9, 25.1°-77.2°). All patients had full spine X-ray and a digital photography from the front. To determine clinical ShB, shoulder height angle (SHA) and axilla height angle (AHA) were measured on clinical photographs. Radiological ShB was assessed with the clavicle-rib intersection angle and T1-tilt. Patients also completed different patient-reported outcomes (PRO) instruments: SRS-22, TAPS and Spinal Appearance Questionnaire (SAQ). SAQ included two questions concerning the shoulder area (SAQ-6 = perception and SAQ-13 = expectation) which were used to assess perceived ShB. Patients were divided into two groups: balanced (SHA <3.0°), and imbalanced (SHA ≥3.0°) according to minimal detectable change of SHA. The correlations between variables and mean differences between the two groups were analyzed. RESULTS: No statistically significant correlations were found between clinical (SHA and AHA) and perceived ShB (SAQ-6), or with PRO scores. 62.5 % of patients were in the "Balanced" group. 46.6 % (14/30) of patients in the clinically imbalanced group (≥3.0°) perceive themselves as totally balanced (score 1 and 2 in SAQ-6), while 10 % (5/50) of patients in the balanced group (SHA <3.0°) perceive themselves as totally imbalanced (score 4 and 5 in SAQ-13). No differences were found between both groups in terms of radiological and perceived ShB, or in PRO scores. CONCLUSION: We have not found a significant correlation between clinical/radiological ShB and perceived ShB in non-operated IS patients. It seems that ShB is not a key factor in patient trunk deformity perception. In addition, patient expectations regarding improvement with treatment are not directly related to actual clinical imbalance.

Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions.

PURPOSE: Medical and health policy providers should be aware of the impact of adult spinal deformity (ASD) on health-related quality of life (HRQL). The purpose of this study was to compare the relative burden of four chronic conditions with that of ASD. METHODS: The International Quality of Life Assessment project gathered data from 24,936 people and published the SF-36 scores of patients with self-reported arthritis, chronic lung disease, diabetes and congestive heart failure from 8 industrialized countries (3 continents) Alonso et al. (Qual Life Res Int J Qual Life Asp Treat Care Rehabil 13:283-298, 2004). We compared these with the SF-36 baseline data of consecutive patients with ASD enrolled in a prospective multicentre international database with the following inclusion criteria: age >18 years and scoliosis >20°, sagittal vertical axis >5 cm, pelvic tilt >25° or thoracic kyphosis >60°. Four ASD groups were considered: all ASD patients, surgical candidates (preop HRQL scores), and non-surgical candidates with and without previous surgery. Adjusted estimates of the impact of chronic disease were calculated using separate multivariate linear regression models. Individuals without chronic conditions were used as the reference group. Coefficients for each chronic condition and ASD represent the difference compared with this healthy group. RESULTS: 766 patients (mean age 45.8 years) met the inclusion criteria for ASD. The scores on all SF-36 domains were lower in ASD patients than in any other chronic condition. Differences between ASD and the other chronic conditions were always greater than the reported minimal clinically important differences. When compared with individuals reporting no medical conditions, SF-36 scores from the population with self-reported chronic conditions ranged from -2.5 to -14.1. Comparable scores for patients with ASD ranged from -10.9 to -45.0. Physical function, role physical and pain domains showed the worst scores. Surgical candidates with ASD displayed the worst HRQL scores (-17.4 to -45.0) and patients previously operated the best (-10.9 to -33.3); however, even the latter remained worse than any scores for the other self-reported chronic conditions. CONCLUSIONS: The global burden of ASD was huge compared with other self-reported chronic conditions in the general population of eight industrialized countries. The impact of ASD on HRQL warrants the same research and health policy attention as other important chronic diseases.

The reliability of sagittal pelvic parameters: the effect of lumbosacral instrumentation and measurement experience.

STUDY DESIGN: Sagittal pelvic parameters (SPPs) of a representative patient sample drawn from a consecutive adult spinal deformity database were measured using Surgimap Spine. Estimated coefficient of reliability intraclass coefficient (95% confidence interval), standard error of measurement, and mean absolute deviation were used for the analysis. OBJECTIVE: The primary objective of this study was to assess the reliability of SPP measurements using Surgimap Spine. The secondary objective was to evaluate the impact of pelvic instrumentation as well as the impact of user expertise. SUMMARY OF BACKGROUND DATA: The radiographical measurement of SPP is increasingly recognized as playing a critical role in establishing the surgical goals and surgical strategy of many spinal disorders. Although instrumented flatback is a common cause of sagittal malalignment, to our knowledge, SPP measurement reliability has never been assessed in instrumented spines. METHODS: Sixty-three adult full-spine standing lateral radiographs (31 with lumbosacral instrumentation) were measured twice by 13 observers using Surgimap Spine. Observers were stratified into 3 levels of experience: high (research coordinators, 4), mid (senior surgeons, 5), and low (junior surgeons, 4). Research coordinators trained all surgeons for less than 30 minutes. Parameters measured were pelvic incidence, pelvic tilt, and sacral slope. RESULTS: Thirteen observers and 63 radiographs generated 817 observations (2 misses). Overall inter- and intraobserver reliability of SPP measurement was excellent (intraclass coefficient > 0.85). Lumbosacral instrumentation did not modify intraobserver reliability but reduced significantly interobserver reliability of pelvic tilt (P = 0.006) and sacral slope (P = 0.007). Experience did not affect intraobserver reliability but interobserver reliability of highly experienced observers was significantly lower (P < 0.05) than among less experienced observers. CONCLUSION: Measurement of SPP using Surgimap Spine equals or improves previously reported reliability data. Lumbosacral instrumentation reduces interobserver reliability taking it from excellent to moderate in the sacral slope measurement. Inexperienced observers can measure SPP reliably after a short tutorial. LEVEL OF EVIDENCE: 4.

Reliability and validity study of measurements on digital photography to evaluate shoulder balance in idiopathic scoliosis.

OBJECTIVE: To determine the validity of digital photography as an evaluation method for shoulder balance (ShB) in patients with idiopathic scoliosis. MATERIAL AND METHODS: A total of 80 patients were included (mean age 20.3 years; 85% women). We obtained a full x-ray of the vertebral column and front and back clinical photography for all patients. For antero-posterior x-rays we measured the proximal thoracic curve angles (CPT). To evaluate radiological shoulder balance we calculated the clavicle-rib intersection angle (CRIA) and T1-tilt. For clinical photography we measured shoulder height angle (SHA), axilla height angle (AHA) and the left right trapezium angle (LRTA). We analyzed the reliability of the different photographic measurements and the correlation between these and the radiological parameters. RESULTS: The mean magnitude of PTC, CRIA and T1-tilt were 19°, -0.6° and 1.4° respectively. Mean SHA from the front was -1.7°. All photographic measurements revealed an excellent-near perfect intra and inter-observer reliability in both photographic projections. No correlation was found between the ShB and the magnitude of the PTC. A statistically significant correlation was found between clinical balance of the shoulders and radiological balance (r between 0.37 and 0.51). CONCLUSIONS: Digital clinical photography appears to be a reliable method for objective clinical measurement of ShB. The correlation between clinical and radiological balance is statistically significant although moderate/weak.

Is Routine Postoperative Radiologic Follow-up Justified in Adolescent Idiopathic Scoliosis?

STUDY DESIGN: Retrospective review. OBJECTIVES: To determine whether routine periodic radiographic examination is worthwhile in adolescent idiopathic scoliosis (AIS) patients undergoing instrumented fusion with third-generation implants. SUMMARY OF BACKGROUND DATA: In common practice, patients who have undergone surgery for idiopathic scoliosis are followed up for a minimum of 2 years by clinical assessment and routine radiographic study at 3, 6, 12, and 24 months. The radiation related to these examinations is not negligible. To our knowledge, the use of routine radiographic follow-up after posterior spinal fusion for adolescent idiopathic scoliosis has not been evaluated. METHODS: We retrospectively analyzed full-spine X-rays and clinical records from the first 2 postoperative years of 43 patients. We sought any clinical feature (eg, pain, deformity progression, material protrusion) justifying X-ray, and any relevant radiologic finding (eg, loss of correction, instrumentation loosening, junctional kyphosis). RESULTS: Excluding the immediate postoperative films, 14.8% of X-rays were clinically justified, 8.3% were associated with a relevant finding, and 4.3% led to a therapy change. All patients with clinical deformity progression had a relevant X-ray finding. Pain was associated with a relevant finding in 23.5% of cases (positive predictive value, 0.1); 7.4% of films with no clinical justification showed a relevant finding (negative predictive value, 0.86). Lower Risser sign increased the risk of having a relevant radiographic finding (p < .05). CONCLUSIONS: With the current use of third-generation implants, routine biplanar postoperative X-rays at 3, 6, 12, and 24 months do not seem to be justified in AIS and should be avoided in mature, asymptomatic patients.

Outcome instruments to assess scoliosis surgery.

PURPOSE: To review and summarize the current knowledge regarding the outcome measures used to evaluate scoliosis surgery. METHODS: Literature review. RESULTS: Outcome instruments should be tested to ensure that they have adequate metric characteristics: content and construct validity, reliability, and responsiveness. In the evaluation of scoliosis, generic instruments to assess health-related quality of life (HRQL) have been used, such as the SF-36 questionnaire and the EuroQol5D instrument. Nonetheless, it is preferable to use disease-specific instruments for this purpose, such as the SRS-22 Patient Questionnaire and the quality of life profile for spinal deformities (QLPSD). More recently, these generic and disease-specific instruments have been complemented with the use of super-specific instruments; i.e., those assessing a single aspect of the condition or specific populations with the condition. The patients' perception of their trunk deformity and body image has received particular attention, and several instruments are available to evaluate these aspects, such as the Walter-Reed Visual Assessment Scale (WRVAS), the Spinal Appearance Questionnaire (SAQ), and the Trunk Appearance Perception Scale (TAPS). The impacts of brace use can also be measured with specific scales, including the Bad Sobernheim Stress Questionnaire (BSSQ) and the Brace Questionnaire (BrQ). The available instruments to evaluate the treatment for non-idiopathic scoliosis have not been sufficiently validated and analyzed. CONCLUSIONS: Evaluation of scoliosis treatment should include the patient's perspective, which can be obtained with the use of patient-reported outcome measures.

Does the lower instrumented vertebra have an effect on lumbar mobility, subjective perception of trunk flexibility, and quality of life in patients with idiopathic scoliosis treated by spinal fusion?

STUDY DESIGN: Cross-sectional study in patients with idiopathic scoliosis treated with spinal fusion. OBJECTIVES: To measure lumbar spine mobility in the study population; determine low back pain intensity (LBPi), subjective perception of trunk flexibility (TF), and quality of life using validated outcome instruments; and investigate correlations of the lower instrumented vertebra (LIV) with TF, LBPi, and quality of life. SUMMARY OF BACKGROUND DATA: The loss of range of motion resulting from spinal fusion might lead to low back pain, trunk rigidity, and a negative impact on quality of life. Nonetheless, these outcomes have not been conclusively demonstrated because lumbar mobility and LIV have not been correlated with validated outcome instruments. METHODS: Forty-one patients (mean age, 27 y) with idiopathic scoliosis treated by spinal fusion (mean time since surgery, 135 mo) were included. Patients were assigned to 3 groups according to LIV level: group 1 (fusion to T12, L1, or L2) 14 patients; group 2 (fusion to L3) 13 patients, and group 3 (fusion to L4, L5, or S1) 14 patients. At midterm follow-up, patients completed the Scoliosis Research Society (SRS)-22 Questionnaire and Quality of Life Profile for Spine Deformities to evaluate perceived TF, and rated LBPi with a numerical scale. Lumbar mobility was assessed using a dual digital inclinometer. RESULTS: Group 3 (fusion to L4, L5, or S1) showed statistically significant differences relative to the other groups, with less lumbar mobility and poorer scores for the SRS subtotal (P = 0.003) and SRS pain scale (P = 0.01). Nevertheless, LBPi and TF were similar in the 3 groups. TF correlated with SRS-22 subtotal (r = -0.38, P = 0.01) and pain scale (r = -0.42, P = 0.007) scores, and with LBPi (r = 0.43, P = 0.005). CONCLUSIONS: LIV correlated moderately with lumbar mobility, health-related quality of life (SRS-22), and spinal pain (SRS-22 pain subscale), but not with intensity of pain in the lumbar area or perceived TF.

The Trunk Appearance Perception Scale (TAPS): a new tool to evaluate subjective impression of trunk deformity in patients with idiopathic scoliosis.

BACKGROUND: Outcome assessment in idiopathic scoliosis should probably include patients' perception of their trunk deformity in addition to self-image. This can be accomplished with the Walter Reed Visual Assessment Scale (WRVAS). Nevertheless, this instrument has some shortcomings: the drawings are abstract and some figures do not relate to the corresponding radiological deformity. These considerations prompted us to design the Trunk Appearance Perception Scale (TAPS). METHODS: Patients with idiopathic scoliosis and no prior surgical treatment were included. Each patient completed the TAPS and SRS-22 questionnaire and underwent a complete radiographic study of the spine. The magnitude of the upper thoracic, main thoracic, and thoracolumbar/lumbar structural curves were recorded. The TAPS includes 3 sets of figures that depict the trunk from 3 viewpoints: looking toward the back, looking toward the head with the patient bending over and looking toward the front. Drawings are scored from 1 (greatest deformity) to 5 (smallest deformity), and a mean score is obtained. RESULTS: A total of 186 patients (86% females), with a mean age of 17.8 years participated. The mean of the largest curve (CMAX) was 40.2 degrees . The median of TAPS sum score was 3.6. The floor effect was 1.6% and ceiling effect 3.8%. Cronbach's alpha coefficient was 0.89; the ICC for the mean sum score was 0.92. Correlation coefficient of the TAPS mean sum and CMAX was -0.55 (P < 0.01). Correlation coefficients between TAPS mean sum score and SRS-22 scales were all statistically significant, ranging from 0.45 to 0.52 (P < 0.05). CONCLUSIONS: The TAPS is a valid instrument for evaluating the perception patients have of their trunk deformity. It shows excellent distribution of scores, internal consistency, and test-retest reliability, and has good capacity to differentiate the severity of the disease. It is simple and easy to complete and score, the figures are natural, and a new frontal view is included.

Minimal important differences of the SRS-22 Patient Questionnaire following surgical treatment of idiopathic scoliosis.

The responsiveness of an instrument measuring health-related quality of life is an important indication of its construct validity. The SRS-22 Patient Questionnaire has become the most widely used patient-reported outcome instrument in the clinical evaluation of patients with idiopathic scoliosis. The responsiveness of the SRS-22 following surgical treatment in patients with idiopathic scoliosis has not been fully assessed. The aim of this study is to evaluate this factor by calculating the minimal important differences (MIDs) of the SRS-22 Questionnaire. The study included 91 patients with idiopathic scoliosis (77 females and 14 males), who underwent surgical treatment; mean age at the time of surgery was 18.1 years. Patients completed the SRS-22 questionnaire before surgery and at a follow-up visit (mean follow-up, 45.6 months). At follow-up, patients rated their overall situation as related to before surgery with a four-point Likert scale: 1-Worse, 2-Same, 3-Better, 4-Much Better. This evaluation represented the global perceived effect (GPE) and served as the anchor criterion for calculating the MID. MIDs were calculated using two approaches. The anchor-based MID (MID-A) was defined as the mean preoperative/follow-up difference in SRS-22 scores in the group of patients who stated they were much better than before surgery (GPE = 4). Using the same anchor criterion, the optimal cut-off value able to identify patients that had clearly improved was determined on a receiver operating characteristic (ROC) curve. In addition, the distribution-based MID (MID-D) was calculated by the standard error of measurement method. The MID-As found for the different subscales and the sum score were: pain 0.6, function 0.3, image 1.3, mental health 0.3, average sum score 0.6, and raw sum score 13.1. The cut-off values on the ROC curve were: pain 0.2, function 0.0, image 1.6, mental health 0.4, average sum score 0.4, and raw sum score 10. The MID-Ds were: pain 0.6, function 0.8, image 0.5, mental health 0.4, average sum score 0.5, and raw sum score 6.8. As was expected, the MID values differed according to the calculation method used. In light of the fact that the MID-As for the function and mental health subscales are below the measurement error of the instrument, it seems preferable to use the MID-D values for determining subscale changes. If the purpose is to analyze sum score changes (either the raw or average values), the MID-A is preferable because it includes the patient's evaluation of the results of surgery.