Study design This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. Objectives The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. Summary of background data Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. Methods The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. Results The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. Conclusions This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

Correlation of radiographic parameters and clinical symptoms in adult scoliosis

https://www.ipd.gu.se/digitalAssets/1252/1252566_Artikel_sept_Aina_Lancet_2_.pdf

Adolescent idiopathic scoliosis.

Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 degrees in the coronal plain. Adult scoliosis can be separated into four major groups: Type 1: Primary degenerative scoliosis, mostly on the basis of a disc and/or facet joint arthritis, affecting those structures asymmetrically with predominantly back pain symptoms, often accompanied either by signs of spinal stenosis (central as well as lateral stenosis) or without. These curves are often classified as "de novo" scoliosis. Type 2: Idiopathic adolescent scoliosis of the thoracic and/or lumbar spine which progresses in adult life and is usually combined with secondary degeneration and/or imbalance. Some patients had either no surgical treatment or a surgical correction and fusion in adolescence in either the thoracic or thoracolumbar spine. Those patients may develop secondary degeneration and progression of the adjacent curve; in this case those curves belong to the type 3a. Type 3: Secondary adult curves: (a) In the context of an oblique pelvis, for instance, due to a leg length discrepancy or hip pathology or as a secondary curve in idiopathic, neuromuscular and congenital scoliosis, or asymmetrical anomalies at the lumbosacral junction; (b) In the context of a metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures. Sometimes it is difficult to decide, what exactly the primary cause of the curve was, once it has significantly progressed. However, once an asymmetric load or degeneration occurs, the pathomorphology and pathomechanism in adult scoliosis predominantly located in the lumbar or thoracolumbar spine is quite predictable. Asymmetric degeneration leads to increased asymmetric load and therefore to a progression of the degeneration and deformity, as either scoliosis and/or kyphosis. The progression of a curve is further supported by osteoporosis, particularly in post-menopausal female patients. The destruction of facet joints, joint capsules, discs and ligaments may create mono- or multisegmental instability and finally spinal stenosis. These patients present themselves predominantly with back pain, then leg pain and claudication symptoms, rarely with neurological deficit, and almost never with questions related to cosmetics. The diagnostic evaluation includes static and dynamic imaging, myelo-CT, as well as invasive diagnostic procedures like discograms, facet blocks, epidural and root blocks and immobilization tests. These tests may correlate with the clinical and the pathomorphological findings and may also offer the least invasive and most rational treatment for the patient. The treatment is then tailored to the specific symptomatology of the patient. Surgical management consists of either decompression, correction, stabilization and fusion procedures or a combination of all of these. Surgical procedure is usually complex and has to deal with a whole array of specific problems like the age and the general medical condition of the patient, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis and possibly previous scoliosis surgery, and last but not least, usually with a long history of chronified back pain and muscle imbalance which may be very difficult to be influenced. Although this surgery is demanding, the morbidity cannot be considered significantly higher than in other established orthopaedic procedures, like hip replacement, in the same age group of patients. Overall, a satisfactory outcome can be expected in well-differentiated indications and properly tailored surgical procedures, although until today prospective, controlled studies with outcome measures and pre- and post-operative patient's health status are lacking. As patients, who present themselves with significant clinical problems in the context of adult scoliosis, get older, minimal invasive procedures to address exactly the most relevant clinical problem may become more and more important, basically ignoring the overall deformity and degeneration of the spine.

The adult scoliosis

ContextPrevious long-term studies of idiopathic scoliosis have included patients
with other etiologies, leading to the erroneous conclusion that all types
of idiopathic scoliosis inevitably end in disability. Late-onset idiopathic
scoliosis (LIS) is a distinct entity with a unique natural history.ObjectiveTo present the outcomes related to health and function in untreated
patients with LIS.Design, Setting, and PatientsProspective natural history study performed at a midwestern university
with outpatient evaluation of patients who presented between 1932 and 1948.
At 50-year follow-up, which began in 1992, 117 untreated patients were compared
with 62 age- and sex-matched volunteers. The patients' mean age was 66 years
(range, 54-80 years).Main Outcome MeasuresMortality, back pain, pulmonary symptoms, general function, depression,
and body image.ResultsThe estimated probability of survival was approximately 0.55 (95% confidence
interval [CI], 0.47-0.63) compared with 0.57 expected for the general population.
There was no significant difference in the demographic characteristics of
the 2 groups. Twenty-two (22%) of 98 patients complained of shortness of breath
during everyday activities compared with 8 (15%) of 53 controls. An increased
risk of shortness of breath was also associated with the combination of a
Cobb angle greater than 80° and a thoracic apex (adjusted odds ratio,
9.75; 95% CI, 1.15-82.98). Sixty-six (61%) of 109 patients reported chronic
back pain compared with 22 (35%) of 62 controls (P =
.003). However, of those with pain, 48 (68%) of 71 patients and 12 (71%) of
17 controls reported only little or moderate back pain.ConclusionsUntreated adults with LIS are productive and functional at a high level
at 50-year follow-up. Untreated LIS causes little physical impairment other
than back pain and cosmetic concerns.

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Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study.

Study design A retrospective cohort study was conducted in 5573 female patients with scoliosis who were referred for treatment at 14 orthopedic medical centers in the United States. Patients were less than 20 years of age at diagnosis which occurred between 1912 and 1965. Objectives To evaluate patterns in breast cancer mortality among women with scoliosis, with special emphasis on risk associated with diagnostic radiograph exposures. Summary of background data A pilot study of 1030 women with scoliosis revealed a nearly twofold statistically significant increased risk for incident breast cancer. Although based on only 11 cases, findings were consistent with radiation as a causative factor. Methods Medical records were reviewed for information on personal characteristics and scoliosis history. Diagnostic radiograph exposures were tabulated based on review of radiographs, radiology reports in the medical records, radiograph jackets, and radiology log books. Radiation doses were estimated for individual examinations. The mortality rate of the cohort through January 1, 1997, was determined by using state and national vital statistics records and was compared with that of women in the general U. S. population. Results Nearly 138,000 radiographic examinations were recorded. The average number of examinations per patient was 24.7 (range, 0-618); mean estimated cumulative radiation dose to the breast was 10.8 cGy (range, 0-170). After excluding patients with missing information, 5466 patients were included in breast cancer mortality analyses. Their mean age at diagnosis was 10.6 years and average length of follow-up was 40.1 years. There were 77 breast cancer deaths observed compared with the 45.6 deaths expected on the basis of U.S. mortality rates (standardized mortality ratio [SMR] = 1.69; 95% confidence interval [CI] = 1.3-2.1). Risk increased significantly with increasing number of radiograph exposures and with cumulative radiation dose. The unadjusted excess relative risk per Gy was 5.4 (95% CI = 1.2-14.1); when analyses were restricted to patients who had undergone at least one radiographic examination, the risk estimate was 2.7 (95% CI = -0. 2-9.3). Conclusions These data suggest that exposure to multiple diagnostic radiographic examinations during childhood and adolescence may increase the risk of breast cancer among women with scoliosis; however, potential confounding between radiation dose and severity of disease and thus with reproductive history may explain some of the increased risk observed.

Breast cancer mortality after diagnostic radiography: findings from the U.S. Scoliosis Cohort Study.

A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.

F. Travaglini

Papers

Natural history of untreated idiopathic scoliosis after skeletal maturity.