Scoliosis News

Surgery for spinal deformity correction can be painful.  Because of this, pain medications are often prescribed to use after discharge from the hospital.  These medications can include: opioid narcotics, benzodiazepines/muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and gabapentin.  With increased concern for opioid narcotic misuse, surgeons are attempting to limit this medication, while still maintaining good pain control after surgery.  

In a recent study, 24 patients who underwent scoliosis surgery kept track of the pain medications they used for the first month after leaving the hospital.  Patients who were given more opioid narcotic medications used more of those medications than patients who were given less.  Importantly, the overall pain control was the same between these two groups. 

This study shows that good pain control can still be achieved, even with decreased opioid narcotic medication prescription and use, while using other medications such as acetaminophen, NSAIDS, and gabapentin.

• Benzodiazepines/muscle relaxants: non-opioid medication to reduce muscle spasm/tightness
• NSAIDS: non-opioid pain and anti-inflammatory medication
• Acetaminophen: non-opioid pain medication and fever reducer
• Gabapentin: non-opioid pain medication

Lindgren AM, Bennett R, Yaszay B, Newton PO, Upasani VV. Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion. Spine Deform. 2020 Jun;8(3):441-445.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine marked by abnormal curvature and rotation.  AIS affects body alignment, which may eventually lead to problems such as posture changes, cosmetic concerns, and respiratory difficulties. Treatment for scoliosis depends on the severity of the curve. In growing teenagers with moderate curves, bracing is usually prescribed to help prevent progression and prevent the need for future invasive surgery.

To augment bracing treatment, physical therapy may be recommended to improve spine flexibility, muscle strength, and elasticity.  A scoliosis-specific exercise program, as an adjunct to bracing, has compelling evidence to support therapeutic effects to decrease scoliosis progression. Although potentially beneficial, an intensive exercise program can present a unique set of barriers to patients and families. 

What are scoliosis-specific exercises?

A scoliosis specific exercise program focuses on posture correction and breathing exercises to boost back muscle strength and increase breathing quality. Through a series of exercises that target lengthening asymmetric muscles of the spine, the AIS patient can realign the spine across all dimensions. Some studies have demonstrated that this therapy, when added to a bracing program, may help prevent curve progression, improve posture and appearance, and avoid surgery. 

Barriers to Physical Therapy

As adolescents juggle academic, social, and athletic responsibilities, incorporating an intensive exercise program presents challenges. Patients are taught the exercises by skilled physical therapists during in-person sessions, and expected to practice these skills at home 3-5 times per week for most optimal outcomes. Treatment sessions generally last for approximately 1-1.5 hours. Some teens have trouble focusing on learning intensive exercises and may become easily distracted.  Furthermore, socioeconomical obstacles are common factors that prevent caregivers from maintaining compliance. 

Future Directions

Addressing the barriers to AIS patients who are ideal scoliosis exercise candidates presents a set of unique challenges. Attempting group exercise programs may provide an avenue for social support and relationship building within the narrow patient population of AIS. Training with other teens has the potential to increase enjoyment and combat frequent feelings of boredom during repetitive exercise. Likewise, involving the entire family with the exercise program may be helpful with engagement and buy-in. Lastly, clinicians checking in and providing positive feedback improves motivation. Open discussion with patients and families at the time of prescribing scoliosis-specific exercise allows for opportunity to discuss potential barriers, devise a strategy, and agree on achievable goals of therapy. 
 

This study was conducted to better understand back pain 10 years after surgery for scoliosis. Patients from six hospitals were included. A total of 171 patients were assessed with questionnaires. They were compared to peers of the same age and gender but without scoliosis. These patients are “typical” scoliosis patients with an age at surgery of 14 years. As expected, most patients were women (87%). About three quarters had a single curve in the chest part of the spine.

Overall, the patients were doing well 10 years after surgery. Only one in eight patients had much worse pain than those without scoliosis. Surgical characteristics such as length of fusion, lowest level fused, or highest level fused did not matter. Painful patients had been slightly older at the time of surgery, but their curves were the same. Painful patients had larger residual curves at 10 years. If the residual curve was less than 26 degrees, only 6% had pain. In contrast, 24% of patients with larger residual curves had abnormal pain. Patients with abnormal pain scores were also more likely to need more surgery.

Most scoliosis patients (87%) had pain scores equal to non-scoliosis peers. Of patients with a residual curve of over 25 degrees at ten years after surgery, 24% had abnormal pain.

Bastrom T.P., Ohashi M., Bartley C.E. et al.
Spine Deformity (2022) 10:55-62.
https://doi.org/10.1007/s43390-021-00384-6

Summary provided by the SRS Patient Education Committee.

The incidence of adult spinal deformity (ASD) continues to increase with our aging population. Surgeries not considered possible or reasonable 20 years ago are now being performed on a regular basis, with good results but complication rates are high. It is the cost of complications, particularly those that leads to reoperation and readmission, that makes this kind of surgery unsustainable for the economy as a whole. Through a multi-disciplinary team evaluation of patients considered for surgery, improvements in outcomes and decrease in complications can occur. Critics of this approach claim this denial of care.  While it is true that some patients are just not candidates for surgery, it is our belief that many may not currently be a candidate, but could become one when their overall health is optimized.

Preoperative Patient Factors

Albumin

• Albumin is measurable protein in our blood. Preoperative albumin levels of 3.5 g/dl or lower is associated with a 13.8 chance of dying and a 2.5 chance of developing a wound infection and is an independent factor predicting readmission.

Smoking

• The use of nicotine, particularly smoking, is known to cause a wide range of health problems, including lung cancer and other forms of cancer.
• Smoking is also associated with an increased risk of medical complications after adult spinal surgery including wound problems and non-healing of the bone and fusion. Patients may need help to quite smoking prior to surgery.

Bone Mineral Density

• Several studies identified an association between decreased BMD and screw loosening in adult spinal surgery.
• Bone density is an indication of the strength of the bone and when it is low, you have osteoporosis, which is associated with a higher risk of reoperation.
• A DEXA scan is used to screen for osteoporosis and specific medications might be needed prior to surgery, including Vitamin D, when you have osteoporosis.

Preoperative Hemoglobin

• Hemoglobin is and indicator of the amount of iron in your blood and directly correlated to the capacity of the red blood cells to carry oxygen.   
• There is an association between a low preoperative hemoglobin and complications and increased need for a blood transfusion. Several studies also indicate a longer length of stay in the hospital and more complications including a higher incidence of death in the first 30 days. 
• Hemoglobin level of lower than 12 should be worked up prior to surgery.

Body Mass Index

• Obesity is now widely recognized as a significant health problem in the United States and elsewhere. The Centers for Disease Control and Prevention (CDC) currently uses the following ranges and definitions as they relate to BMI:  Underweight <18.5; Normal 18.5to <25; Overweight 25 to <30; Obese 30 or higher.  They further categorize obesity as Class 1 (BMI 30 to < 35), Class 2 (BMI 35 to < 40), or Class 3 (BMI 40 or greater). 
• Patients with a BMI ≥ 30 kg/m2 was associated with a higher incidence of major complications and wound infections as well as rod fractures and implant failures. BMI increases the risk of proximal junctional kyphosis, or topping off at the top of the construct.
• We recommend Weight Management and even bariatric surgery to achieve the desired goal, but many patients are able to lose the needed weight through modified eating habits alone.  Improved diabetic control and blood pressure are two of the positive side effects from losing weight.

Frailty

• Frailty is defined as age-associated declines in physiologic reserves and function across several organ systems.  The modified Frailty Index (mFI) is a scale that uses 11 of the 70 variables proposed by the Canadian Study of Health and Aging Frailty Index. 
• Complications are increased in frail patients.
• We believe this is an important part of the preoperative assessment of patients prior to major spinal surgery.  Exercising pre-surgery and staying active is encouraged.

Hemoglobin A1c

• Diabetes Mellitus is currently an epidemic in the United States and parts of Europe and is a leading cause of death and disability in the Western world. 
• It serves as an evaluation of the average amount of glucose in the blood over the previous 2-3 months.  A normal level is a HbA1c below 5.7%.  Pre-diabetes is HbA1c between 5.7% and 6.4% and diabetes is generally identified as a HbA1c of 6.5% or higher. 
• Improved diabetic control can lessen the risk of complications with surgery.  Increased levels above 7 is associated with infection. It is critical to control blood sugar levels before and during surgery.

Mental Health

• Impaired mental health has been known for years to affect spinal complaints. Studies have shown a correlation between impaired mental health and diminished outcomes after spine surgery.  However, there was tremendous variability in the measures used to evaluate mental health. 
•  Your provider will ask you to fill out several forms in an attempt to assess your mental health. You might need to see a counsellor prior to surgery.

Vitamin D

• Vitamin D is produced by the body in response to exposure of the skin to sunlight and it occurs naturally in some foods (some fish and egg yolks) and in fortified dairy and other products.  It is essential to aid the body in utilizing calcium to maintain proper mineralization of bone. 
• The two commonly measured forms of Vitamin D are Vitamin D2 (ergocalciferol) and Vitamin D3 (cholecalciferol).  Both of these can be converted in the body into the active form of the vitamin D.
• Levels below 30 ng/ml is associated with a higher complication rate. You might need to take supplemental Vit D, before and after surgery and lifelong in order to maintain your bone health.

Conclusion

Our surgical techniques and implants to treat adult spinal deformity have progressed remarkably over the last 20 years; however, our complication rates remain unacceptably high.  The optimization of patients’ co-morbidities has the potential to help us reduce these complications and enable us to deliver better and safer care to the growing number of patients with adult spinal deformity.

Provided by the SRS Patient Education Committee

Most people who get scoliosis corrective surgery are healthy teenagers. They often wonder if their surgery will lead to problems as an adult. The authors of this study try to answer that question. They looked at x-rays and surveys about 20 years after surgery.

The study looks at over 100 patients that had scoliosis surgery as teenagers. Their x-rays improved greatly after the surgery. Little change was seen 20 years later. Additionally, the spine below the area of surgery did not degrade. Signs of arthritis were rare.

The surveys given to these patients looked at their quality of life. This included overall health, pain and function. The ratings for those who had a surgery were normal. About 1 in 10 had back pain. This study shows that most patients have a good quality of life many years after surgery.

Darnis A, Grobost P, Roussouly P. Very long-term clinical and radiographic outcomes after posterior spinal fusion with pedicular screws for thoracic adolescent idiopathic scoliosis. Spine Deform. 2021 Mar;9(2):441-449.

Summary provided by the SRS Patient Education Committee.

The exact reason some children have scoliosis is unknown. Some think it is due to genes and others due to how a child lives. This study hopes to help answer this question by looking at siblings that are twins. Identical twins share the exact same genes. Other studies have shown that if one twin has scoliosis the other probably will as well. The goal of the current study is to look at the exact shape of a child’s curve in both the side and front views amongst identical twins.

The x-rays of 12 sets of twins were measured. All 12 twins both had scoliosis which is a strong case for genes being a reason for scoliosis. One half of twin sets had similar curve shape in front and side view and the other half did not. If genes were the only reason for curve shape, likely all 12 sets would have identical curves. However, only half of the twins sets had matching curves. The non-matching curves between twins points to other factors as a strong influence on how a curve develops.

Schlösser TPC, Simony A, et al. The heritability of coronal and sagittal phenotype in idiopathic scoliosis: a report of 12 monozygotic twin pairs. Spine Deformity 2021 9:51-55.

Summary provided by the SRS Patient Education Committee.

Scoliosis occurs in 1-3% of all children. It appears when children are 10-12 years old. As children grow, scoliosis will often worsen. Scoliosis can be mild, moderate or severe. Mild scoliosis requires no treatment. Moderate scoliosis can be treated with a brace. The goal of bracing is to prevent worsening. It works very well at preventing the need for surgery. Severe scoliosis is treated with spine surgery. It is very important that children with mild scoliosis see a specialist while they are young. Once children finish growing, a brace cannot help them. The scoliosis Research Society recommends brace treatment for growing children with moderate scoliosis.

This study was done at The Hospital for Sick Children in Toronto, Canada. They studied 335 children who they saw for scoliosis in 2014. They looked at the treatment options at the first patient visit. Fifty-six of these children needed a brace. Sixty-seven already had severe curves and needed surgery. Another 27 children had curves that were close to needing surgery. This means that 94 of their patients are likely to have spine surgery. Unfortunately, they never had an opportunity to be treated with a brace. If their scoliosis was noticed earlier, a brace might have prevented the need for a surgery. Early discovery of scoliosis can decrease the need for surgery by giving more children a chance of brace treatment.

Anthony, A., Zeller, R., Evans, C. et al. Adolescent idiopathic scoliosis detection and referral trends: impact treatment options. Spine Deform 9, 75–84 (2021). https://doi.org/10.1007/s43390-020-00182-6

Summary provided by the SRS Patient Education Committee.

Introduction

Low back pain is a common complaint among people who seek medical attention. It may originate from different sources in the back or pelvis. The SI joint (articulation of pelvic bone with the sacrum) has been recognized as a common source of sciatic pain since over hundred years ago especially before knowing intervertebral disc as a source of leg pain.

About 15% to 30 % of patients with LBP have SI joint as the pain source and up to 40% may develop such problem after back surgery with fusion of vertebrae together especially after longer fusions to the pelvis. This has been confirmed by an observational long-term study. This joint may become painful after pelvic injury, direct trauma to the joint, repeated micro-trauma, after pregnancy or in some rare joint diseases.

Considering common occurrence and lower quality of life following such problem, spine surgeons should be familiar with diagnosis and treatment of SI joint dysfunction in patients with LBP especially those who undergo fusion. Usually this includes a through history and physical examination, imaging and injection studies, and appropriate treatment.

Anatomy and Biomechanics

The SI joint is a complex joint which includes both cartilage and strong ligaments to transfer loads from the spine to the pelvis and helps childbearing in females. It has reach innervation from the nearby nerve plexus which makes it an important potential pain generator. It has a slight motion which is along its transverse axis (fig 1).

Evaluation and Diagnosis

Among different causes of LBP which includes diseases of the spine and other areas like hip joint, sacroiliac joint problems must be considered by treating physician. According to a study in 289 patients with the complaint of LBP, 65% had problem just in the spine. 17.5% had combination of spine and hip or SI joint problems. They found up to 25% of patient with LBP may have a problem in the hip or SI joint.

The characteristic pain pattern is felt over the medial and distal part of the buttock and groin and lower limb. There may be a vague radicular pain in the leg which may be worsened when sitting on a hard surface for long time, walking upstairs or changing from sitting to standing position and vice versa (fig 2). A complete examination of the lower back, hip and neurological system must be done, and, in some cases, appropriate Lab tests must be done.

There are many physical exam maneuvers to elicit pain in the SI joint (fig 3). Although these tests are not specific or sensitive, if several tests (more than three) are positive this will be more valuable for diagnosis of SI pathology. In some cases, a needle injection done under image control serves both for diagnostic and treatment purposes.

Figure 3. Physical exam maneuvers for diagnosis of SI joint dysfunction. 3 or greater positive tests indicates a significantly increased sensitivity and specificity.

Imaging

Imaging studies are not helpful for diagnosis of SI problem; however, they are useful to find other sources of pain. It must be considered that there is common to find abnormalities in MRI in people without symptoms. Imaging may be helpful to find severe problems like fracture, infection, or tumor as the source of SI joint pain.

Diagnostic Injections

Pain relief after local anesthetic injection in the joint is considered the gold standard to confirm SI joint as a source of pain. Usually this is done under image control by an expert physician (fig 4). It should reduce the pain at least 50 to 75% from the baseline to be considered positive. Some authors advice two injections for confirmation and there are recommendations on the amount and type of anesthetics to be injected.

Figure 4. Diagnostic SI joint injection using fluoroscopic guidance.

Management

Nonsurgical Management

Usually treatment with local ice, reducing activities and NSAIDs can be enough to avoid more intensive treatments. There is no evidence for efficacy of massage or manipulation. Pelvic belts may be used as a diagnostic test for short time. Neither electrotherapy nor rest has been shown to be beneficial. Acupuncture may be effective for SI joint pain during pregnancy. Despite conflicting results, there are some evidence that physical therapy may be effective to improve pain and function.

Intra-articular injection of steroids along with local anesthetic can be therapeutic along with the diagnostic injection. Radiofrequency Ablation (RFA) can be effective but more systemic reviews failed to show benefits when compared to other non-surgical treatments methods.

Surgical Management

In patients with persistent debilitating symptoms surgical treatments may be considered. Many operative techniques have been used for treating SI joint problems including open and limited open surgeries. There are mixed results following these procedures and controversy exists as the results of such approaches. In the recent decade new less invasive approaches have been developed to treat SI joint dysfunction (fig 5). Studies that are mainly sponsored by the industry show significant improvements in pain and functional results after two years and five years compared with non-operative treatment. Clearly these techniques have certain complications and must be done by physicians who are familiar with the anatomy and techniques.

The best comparative effectiveness study of non-surgical, RFA and MIS surgery in 2018 showed that the first two group did not improve while the MIS group achieved meaningful improvements in pain and disability which lasted for 6 years.

Figure 5. Minimally invasive SI joint fusion performed using triangular titanium implants.

Conclusion

A large percentage of patients with low back pain suffer from SI joint dysfunction. The diagnosis and treatment of SI joint dysfunction can be challenging to the clinician given the lack of specific physical exam or imaging findings related to patient complaints.  However, when accurately diagnosed, treatment can markedly decrease pain, while increasing function and quality of life for this patient population. 

Non-surgical measures, while not extensively studied, can be effective at improving symptoms and should be initiated first before surgery is considered. After confirmatory diagnostic sacroiliac joint injection in an appropriate surgical candidate, operative intervention with newer MIS techniques, has the potential to improve pain and disability compared to patients treated non-surgically. Long-term studies beyond five years are lacking, along with studies comparing the various minimally invasive options available.

Summary provided by Ruwan Ratnayake, MD; Fernando E. Silva, MD; David W. Polly, Jr., MD; Jean Charles Le Huec, MD, PhD; Frank Rand, MD; and Robert Eastlack, MD.

Update 03/15/18: In the initial article, it was stated that “your surgeon and his/her team will follow you forever”. The onus is on the patients to return for post-operative appointments as recommended by their surgeon. After the first few years post-op, the visits are generally less frequent and eventually only every 5-10 years. If a long-term study is being done, letters will often be sent to patients that had the type of surgery that is included in the study to ask them to return for an evaluation. If patients haven’t been to the office for a long time or their contact information is not current, that makes it difficult. Regular x-rays and visits are important to catch and treat problems before they become too serious. For example, if changes are noted that indicate early flatback syndrome, a revision surgery may be recommended to keep the spine in an optimal position and prevent worsening and chronic pain. If a patient was told years ago that nothing could be done, that may not be true today – the patient should see a spine specialist for a new evaluation and possible treatment.

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When we mentioned in a previous post that once you have spine surgery your surgeon and his/her team would like to follow you forever, the following study is a good example of that! This was the first paper presented at the SRS Annual Meeting in Philadelphia this past September. I have gone through and spelled out abbreviations and explained different terms to make it more understandable for those reading it.
(When a research study is done and the results written in an abstract and submitted in the hope of being chosen to be presented at one of the SRS meetings, there are specific guidelines that need to be followed, one of which is how many characters - including spaces! - are allowed. So, there are ‘tricks of the trade’ to stay within that limit but much of it wouldn’t be clear to non-medical readers.)

This study compares patients who had fusion and instrumentation to or above L3, the 3^rd of 5 vertebrae in the lumbar spine, to those whose surgery extended lower in the spine to L4 (4^th lumbar vertebra) and below. They looked at reoperation rates and the answers the patients gave on the questionnaires to analyze the differences in the 2 groups. They reported that patients with instrumentation extending into the lower part of the lumbar spine had more functional difficulties and a higher rate of repeat surgery. Keep in mind, however, that the instrumentation used on these patients was vastly different than what is used today. A Harrington rod was a straight rod attached to the spine with just 1 hook at each end. Although this was the original instrumentation used in the spine, surgeons learned that inserting a straight rod was not the best idea. Current instrumentation techniques involve inserting 2 or more rods and using multiple screws and hooks to attach them to the spine. The rods are bent and contoured to the spine to restore and maintain the natural curves which resemble a mild ‘S’ shape when viewed from the side. This is a much better position for the spine to be in, thereby avoiding the problems leading to reoperation that were seen in many Harrington rod patients.

Hundreds of abstracts are submitted each year for consideration of being presented. A team of reviewers reads and evaluates each submission and scores it, and approximately 130 with the highest scores are accepted for presentation. The reviewers like to see long-term follow-up and high percentages of the original groups included in the follow-up studies. So keep your information up to date at your surgeon’s office because you never know when they will try to get in touch with you to participate in a long-term study!!

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Correlation of Lowest Level of Instrumentation to Functional Outcomes and Risk of Further Spine Surgery in AIS with Minimum 40 Year Follow-up
Sarah T. Lander, MD; Caroline Thirukumaran; Krista Noble, BS; Ahmed Saleh, MD; Addisu Mesfin, MD; Paul T. Rubery, MD; James O. Sanders, MD

Summary

In long-term follow up of patients undergoing a posterior spinal fusion with Harrington instrumentation comparing the lowest instrumented vertebra (LIV) with patient reported outcome measures and the need for additional surgery, patients with a lower LIV had a higher rate of additional surgery and lower functional outcomes than those with higher LIVs. This could be because of the instrumentation, the fusion, or the nature of curves requiring instrumentation lower on the spine.

Hypothesis

The lower the level of instrumentation the more likely the patient is to receive an additional spine surgery and the lower the patient reported functional outcomes.

Design

Long-term follow-up

Introduction

There is uncertainty in adolescent idiopathic scoliosis (AIS) instrumentation and fusion how the long-term outcomes relate to the level of instrumentation including pain and the need for further surgery.

Methods

We identified records of 314 patients treated by Louis A. Goldstein with Harrington instrumentation and fusion between 1961 and 1977. A search was performed identifying the patients who were then contacted for various assessments including patient related outcomes. This analysis compares the lowest level of fusion with the Oswestry Disability Index (ODI) and the SRS-7 using bivariate and multivariate analysis. (The ODI and SRS forms are two questionnaires given to patients after surgery so see how they are doing. The answers are scored, combined and then analyzed with a statistical program. With the ODI, lower scores indicate better function and with the SRS form, higher scores are best.)

Results

We identified 91 living and 6 deceased patients with follow-up from 40 to 56 years and current patient age from 52 to 71 years old. 81 completed the outcome questionnaires. In those without additional surgery, those with LIV L3 and above had average ODI of 14.12 and SRS-7 of 23.3 compared to LIV L4 and below having 17.9 and 22.7 respectively. 6/47 or 12.8% with LIV L3 and above had further surgery compared to 13/34 or 38.2% L4 and below. Those with LIV L4 and below had 2.4 times higher odds of receiving additional surgery. Patients receiving additional surgery compared to those who did not had an average ODI of 22.8 vs 12.8 and SRS-7 of 19.6 vs 23.1. ODI disability comparison comparing those without to those with additional surgery showed 73% vs. 42% minimum disability, 23% vs. 53% moderate disability, and 2% vs. 5% severe disability.

Conclusion

In long-term follow up patients with lower instrumentation levels had a higher rate of receiving additional surgery and lower functional outcomes than those with an LIV higher on the spine. Those who received additional surgery had lower functional outcomes than those without. There were higher ODI and lower SRS scores in those with LIV L4 or lower compared to L3 and above in patients not receiving additional surgery, but differences were not large or statistically significant.