Radiological Outcomes in Adolescent Idiopathic Scoliosis Patients More Than 22 Years After Treatment

doi:10.1016/j.jspd.2015.03.003

Spine Deformity

Volume 3, Issue 5, September 2015, Pages 436-439

https://doi.org/10.1016/j.jspd.2015.03.003 Get rights and content

Abstract

Study Design

Longitudinal cohort.

Objectives

To evaluate the long-term radiologic outcomes in adolescent idiopathic scoliosis (AIS) patients more than 22 years after treatment.

Summary of Background Data

Although treatment for AIS is prophylactic and is aimed at preventing curve progression, very few studies report long-term outcomes of treatment.

Methods

AIS patients treated with Boston brace or posterior spinal fusion (PSF) with Harrington–dorso-transverse traction (DTT) instrumentation from 1983 to 1990 were requested to return to clinic. Subsequently, 36-inch standing radiographs were obtained after patient consent. Cobb angles were compared with pretreatment and immediate posttreatment radiographs. Any evidence of adjacent-level disease or local kyphosis was also noted.

Results

One hundred fifty-nine (78%) of 219 patients were available for follow-up, 66 braced and 93 surgical. There were 85 females with an average age at surgery of 14.3 years and an average age at follow-up of 37.6 years. The mean length of follow-up was 24.5 years (range, 22–30 years). There was a statistically significant curve progression of 2.9° in the PSF group. There was a greater degree of curve progression in the braced group (5.5°), but this was not statistically significant. Proximal segment degeneration was seen in 8 (5%), 2 in the brace cohort and 6 in the PSF cohort. Distal segment degeneration was seen in 26 (16%) patients, 4 treated with brace and 22 treated with PSF. No patient developed proximal junction kyphosis. Three patients in the PSF cohort required additional surgery for distal adding-on. Four patients had a noncontiguous L5–S1 fusion, three from the PSF cohort and one from the braced cohort.

Conclusion

In this cohort with an average follow-up of 24.5 years, with 78% available for follow-up, both the braced and surgically treated patients had a very small degree of curve progression, with a small incidence of distal segment degeneration and reoperation.

Level of Evidence

III.

Introduction

Scoliosis affects 1% to 2% of the population, with adolescent idiopathic scoliosis (AIS) the most common subgroup [1], [2]. It affects teenagers, mostly females, and is diagnosed from age 11 to 14 years, where growth in the spine is rapid. Untreated, AIS can progress to severe deformation of the spine, pulmonary impairment, back pain, and poor self-image [3].

Brace treatment [4] and surgical correction [5] are the only two treatments that have been shown to alter the natural history and progression of AIS. At Copenhagen University Hospital, brace treatment with Boston brace was initiated in curves within 30° to 50° with documented curve progression and remaining skeletal growth. The patients were instructed to wear the brace for 23 hours a day and were examined twice a year including posteroanterior x-ray by an orthopedic surgeon. If the curve had not progressed on 2 successive visits and the patient was judged skeletally mature based on the Risser sign [6], [7], brace weaning over a 6-month period was initiated. In patients where the Cobb angle exceeded 50°, surgical correction, fusion with Harrington–dorso-transverse traction (DTT) instrumentation was recommended, which was the standard of care at that time. Postoperatively, the patients were placed in a cast for a 12-month period.

To our knowledge, only a few studies have been published with more than 20 years of follow-up after AIS treatment [3], [5], [8], [9], [10], [11], [12]. The purpose of this study was to evaluate the long-term radiologic outcomes, specifically curve progression and adjacent level degeneration, in AIS patients at a mean 25 years after treatment.

Section snippets

Methods

Patients diagnosed and treated with either a Boston brace or posterior spinal fusion (PSF) with Harrington-DTT instrumentation for AIS at Copenhagen University Hospital, Denmark, from 1983 to 1990 were identified. These patients were contacted and requested to return to the clinic for an interview and clinical examination, including assessment with health-related quality of life questionnaires. Two hundred nineteen patients were identified, among whom 104 were braced and 115 had a PSF. Of the

Results

One hundred fifty-nine patients participated in the radiologic follow-up (78%), 66 treated with Boston brace and 93 treated with PSF. Eleven patients refused x-ray examination because they were pregnant at the time of examination or because they had a history of breast or other cancers, and were thereby excluded from this study. Eight patients had emigrated out of Denmark and were not available for follow-up, two are deceased because of cardiac arrest and breast cancer and four patients were

Discussion

Although treatment for AIS is prophylactic, aimed at the prevention of curve progression and its associated consequences such as impaired pulmonary function and lumbar degeneration, there are very few studies looking at the long-term outcomes of AIS treatment [3], [5], [8], [9], [10], [11], [12]. In our cohort of AIS patients treated with a Boston brace, there was no clinically relevant progression of the curve from prebracing to completion of bracing. This is to be expected, as the goal of

Conclusion

In this cohort with an average follow-up of 25 years, with 78% available for follow-up, both the braced and surgically treated patients had a very small degree of curve progression, with a small incidence of PJK, distal segment degeneration, and reoperation. Although the criterion standard for AIS treatment has evolved in the past 25 years, it is our experience that AIS patients treated with either Boston brace or Harrington-DTT instrumentation will preserve the correction achieved for at least

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Cited by (12)

Minimum 20-Year Health-Related Quality of Life and Surgical Rates After the Treatment of Adolescent Idiopathic Scoliosis
2019, Spine Deformity
Citation Excerpt :
Because of the lack of nationalized health care linked to a common identification number, it is difficult to achieve high rates of follow-up in the US for pediatric orthopedic conditions. Although Simony et al.’s series from Denmark reports 78% follow-up at a mean of 24.5 years, no childhood radiographs were available for review, and childhood measurements were based on chart review [32,33]. Danielsson et al. achieved very high follow-up rates at minimum 20 years after scoliosis treatment in Sweden [19,20].
Longitudinal cohort.
To determine the patient-reported functional outcomes and need for related surgical procedures in a US cohort of adolescent idiopathic scoliosis (AIS) patients with minimum 20-year follow-up.
There is limited information regarding the long-term outcomes of scoliosis treatment in the US population.
A novel population of patients who underwent pediatric treatment for AIS with minimum 20-year follow-up was identified. Search of a single-center diagnostic registry generated 337 patients who fulfilled the inclusion criteria (AIS, curve magnitude >35°, and childhood treatment with bracing, surgery, or observation from 1975 to 1992). Any additional spine surgery as well as EQ5D, ODI, SRS 22, SAQ were determined. A total of 180 patients were included (mean of 30-year follow-up, range 20-37). Childhood treatment entailed bracing (41 patients), surgery (103 patients), and observation (36 patients).
During the study period, only 1 of the 41 bracing patients underwent additional scoliosis-related spine surgery, whereas 5 of the 36 patients in the observation cohort underwent scoliosis surgery as adults. Seven of 103 childhood surgical patients required additional revision surgery as adults. Fifteen patients (4 braced, 7 fusion, and 4 observed) underwent chest wall surgery as adults. SRS scores were around 10% worse compared to population-based controls, with the exception of SRS mental health scores, which were similar to controls. Overall, 5.6% of patients were on disability, with no difference between operative and nonoperative groups.
We found a low rate of adult scoliosis surgery in the braced population, and a low rate of revision surgery at the 30-year follow-up in patients undergoing spine fusion for AIS between 1975 and 1992. No detected differences in patient-reported outcomes were found between the braced, surgical, and observed populations at a mean of 30 years' follow-up.
Level III, therapeutic.
Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Long-Term Radiographic and Functional Outcomes*
2018, Spine Deformity
Citation Excerpt :
This principle was further discussed by Lenke in the new classification system of Lenke 1B and 1C curve patterns [2]. Spontaneous lumbar curve correction has been observed with an STF, and short-term results have shown curve correction maintenance [3-7], with long-term studies including STF cases in the review of the outcome of fusion for AIS [8,9]. There are three long-term studies of STF cases with a span of 7–20 years that report good outcomes [3,10,11].
Selective thoracic fusions (STFs) were introduced by Moe to treat the structural thoracic curve when a more flexible lumbar component existed. It is unknown how the curves behave and how the patients function beyond 20 years after surgery.
Of the 152 eligible patients with STF, 67 were traced and contacted and 40 completed outcome questionnaires (Oswestry Disability index [ODI], Scoliosis Research Society–30 [SRS-30]) and had follow-up standing radiographs. The preoperative, postoperative, 1-year, and follow-up films were compared, and the lumbar spine on follow-up assessed for signs of degeneration—disc space narrowing, osteophyte formation, rotatory subluxation, and lateral spondylolisthesis.
The average follow-up was 32.7 years. There were 27 Lenke 1C, 10 Lenke 2C, and 3 Lenke 1B curves. A posterior fusion was performed in 37, with a Harrington rod used in 28 and all-hook constructs in 12 with fusion to T10 (1), T11 (10), T12 (22), or L1 (7). The average preoperative right thoracic curves were 56.1°, 36.2° 1 year postoperation, and 38.6° at follow-up. The average preoperative lumbar curve was 44.6°, being 35.2° at 1 year postoperation, and 36.9° at follow-up. Five patients had additional surgery, 3 pseudarthrosis repairs (one with extension of the fusion to L4), 1 implant removal, and 1 microdiscectomy 35 years postoperatively. At follow-up, the average ODI was 8.7 (0–62) and the average SRS-30 3.8 (1.4–4.9). Nine patients took nonnarcotic medication, usually weekly or less, with only one taking daily narcotics. The most common lumbar radiographic finding was disc space narrowing at the apex of the lumbar curve, and osteophytes at L2–L3. There was no correlation of the lumbar changes to ODI, with a tendency to more medication use with longer follow-up (older subjects).
At an average 33-year follow-up, the lumbar curve in STF is unchanged, with patients functioning well and mild radiographic changes in the lumbar spine.
Long-term adjacent segment degeneration at average 21-year follow-up of posterior instrumented fusion for adolescent idiopathic scoliosis
2023, Spine Deformity
Predictors of Clinically Meaningful Results of Bracing in a Large Cohort of Adolescents with Idiopathic Scoliosis Reaching the End of Conservative Treatment
2023, Children
Defining “successful” treatment outcomes in adolescent idiopathic scoliosis: a scoping review
2023, European Spine Journal
Ultralong Follow-Up of Spinal Fusion for Adolescent Idiopathic Scoliosis: Harrington Instrumentation vs Uninstrumented Fusion
2022, International Journal of Spine Surgery

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: This study was approved by the Ethical Committee of Southern Denmark, Datatilsynet and was conducted at the Section for Spine Surgery and Research, Lillebaelt Hospital, Ostre Hougvej 55, 5000 Middelfart, Denmark.

: This study was funded by the Danish Rheumatism Association, Fonden af 17-12-1981, Erik Birger Christensen Fund and AP Møllers Fund.

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Long-Term Follow-Up Case SeriesRadiological Outcomes in Adolescent Idiopathic Scoliosis Patients More Than 22 Years After Treatment

Abstract

Study Design

Objectives

Summary of Background Data

Methods

Results

Conclusion

Level of Evidence

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Voluntary school screening for scoliosis in Minnesota

J Bone Joint Surg Am

Adolescent idiopathic scoliosis in twins, a population based survey

Spine

Natural history of adolescent idiopathic scoliosis: a tool for guidance in decision of surgery of curves above 50°

J Child Orthop

Effect of bracing in adolescent with idiopathic scoliosis

N Engl J Med

Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study—part I

Spine (Phila Pa 1976)

The iliac apophysis; an invaluable sign in the management of scoliosis

Clin Orthop

Risser sign inter-rater and intra-rater agreement: is the Risser sign reliable?

Skeletal Radiol

Long-Term Follow-Up Case Series
Radiological Outcomes in Adolescent Idiopathic Scoliosis Patients More Than 22 Years After Treatment