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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 6-12

Changes of shoulder balance, sagittal alignments, and curve correction in the treatment of Lenke 1 and 2 adolescent idiopathic scoliosis using a three-dimensional-based correction strategy in correlation to health-related quality of life using the Scoliosis Research Society-22 Questionnaire


Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong, China

Date of Submission12-Nov-2019
Date of Acceptance23-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Bobby Kin-Wah Ng
Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_46_19

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  Abstract 


Background: Shoulder balance in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) is a complex condition without a reliable strategy to achieve full correction. Moreover, none reported health-related quality of life of surgically treated Lenke 1 and 2 suffering severe AIS patients before and after the surgery. Subjects and Methods: Preoperative standing, side bend, and postoperative Cobb angles were analyzed to determine the relationship between shoulder balance, curve flexibility, and correction rates. The sagittal alignment was analyzed in these patients by cervical lordosis (CL) (C2–C7), thoracic kyphosis (TK) (T1–T12), lumbar lordosis (LL) (L1-S1), pelvic incidence, pelvis tilt, sacral slope, and C7 sagittal vertical axis (SVA). All recruited patients completed the Scoliosis Research Society-22 questionnaire before, after surgery, and follow-up. Results: There were 26 Lenke 1 and 2 severely AIS patients recruited in this study. The shoulder balance changed from left down to the left up after the operation as reflected by the changes in T1tilt (medial shoulder) and clavicular angles (lateral shoulder). The sagittal alignment changes of this group of patients moved toward increased CL, TK, and LL and an SVA toward zero. “Function” and “Self-image” were significantly improved after surgery, particularly in female Lenke 2 patients regardless of age. Conclusions: The sagittal alignment changes of this group of patients moved toward increased CL, TK, LL and SVA toward zero. “Function” and “Self-image” were significantly improved after the surgery. Sex and age-specific analysis showed that female Lenke 2 AIS patients were the group of patients showing the improvements regardless of age at operation.

Keywords: Adolescent idiopathic scoliosis, Lenke classification, quality of life, shoulder balance


How to cite this article:
Ng BK, Chau WW. Changes of shoulder balance, sagittal alignments, and curve correction in the treatment of Lenke 1 and 2 adolescent idiopathic scoliosis using a three-dimensional-based correction strategy in correlation to health-related quality of life using the Scoliosis Research Society-22 Questionnaire. J Orthop Traumatol Rehabil 2020;12:6-12

How to cite this URL:
Ng BK, Chau WW. Changes of shoulder balance, sagittal alignments, and curve correction in the treatment of Lenke 1 and 2 adolescent idiopathic scoliosis using a three-dimensional-based correction strategy in correlation to health-related quality of life using the Scoliosis Research Society-22 Questionnaire. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Jul 6];12:6-12. Available from: http://www.jotr.in/text.asp?2020/12/1/6/287717




  Introduction Top


Shoulder balance in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) is a complex condition without a reliable strategy to achieve full correction. Shoulder balance can be assessed by T1 tilt ( first rib angle as medial shoulder hump), clavicle angle, radiographic shoulder height, coracoid height distance, and clavicle rib intersection difference. It often presents mild before the surgery but can worsen after good curve correction. Upper instrumented vertebrae (UIV) to T2, T3, T4, under correction of the main thoracic curve are proposed solutions, but the outcome is still unpredictable. Shoulder imbalance is very complex problem, and treatment is challenging.

Many clinical observations have yet to be solved. Lenke 1 cases bear more flexible curve leading to a compensatory proximal thoracic curve. UIV selection fusion to T2 better than T3 and T4 for Lenke 2 curves.[1] Fusion or leveling at T2 might not solve the problem.[2],[3] Compensation was achieved by distal adding on and rod tilt. However, patients with Lenke B or C curves are more prone to risk.

Shoulder balance in AIS is a complex condition that we do not understand or have an answer yet. Risk factors causing shoulder imbalance, for example, proximal thoracic curve >40, anterior spinal fusion, and preoperative left shoulder up, occurred despite “correct” UIV by all methods: Lenke, ilharrebordes, and trobisch.[4],[5]

Moreover, there were the number of reports on surgical treatment of Lenke 1 (main thoracic) and Lenke 2 (double thoracic) suffering severe AIS patients, without discussing the change in the health-related quality of life (HRQOL) of this group of patients before and after surgery. Structural changes after the surgery leading to change in the quality of life in these two groups of patients have yet to be discussed.

The objective of this study is to analyze the change of shoulder balance, sagittal alignment, and curve correction rate (CR) of Lenke 1 and 2 AIS patients after surgery associated with the change in HRQOL.


  Subjects and Methods Top


There are 26 Lenke 1 (1A = 9, 1B = 1) and Lenke 2 (2A = 14, 2B = 1, 2C = 1) severely suffering AIS patients who underwent posterior spinal fusion between year 2016 and 2017 in a specialized clinic at a tertiary university hospital. Ethical approval was obtained from the Ethics Review Board of the Joint Chinese University of Hong Kong - New Territories East Cluster Clinical Research Ethics Committee (Research Ethics Committee approval number: 2019.213). Informed consent was obtained before the first Scoliosis Research Society (SRS)-22 questionnaire at “Preoperative.”

Shoulder balance measurements

Preoperative standing, side bend (SB), and postoperative Cobb angles were analyzed to determine the relationship between shoulder balance, curve flexibility, and CRs. The sagittal alignment was analyzed in these patients by cervical lordosis (CL) (C2–C7), thoracic kyphosis (TK) (T1–T12), lumbar lordosis (LL) (L1–S1), pelvic incidence (PI), pelvis tilt (PT), sacral slope, and C7 sagittal vertical axis (SVA).

Scoliosis Research Society-22 questionnaire

All recruited patients completed SRS-22 questionnaire before surgery (time point “Preoperative”), immediate after surgery before hospital discharge (“Postoperative”), and subsequent 3 follow-up clinic visits representing 2 years after surgery (“Postoperative 1”, “Postoperative 2”, and “Postoperative 3”). SRS-22 questionnaire comprises 22 questions under five domains (function, pain, self-image, mental health, and satisfaction). Patients provided the answers on a 5-point Likert scale. Calculations of the five domain scores followed the scoring algorithms provided by SRS.[6] The SRS-22 questionnaire has been transformed into an electronic format.[7]

Statistical analysis

Variables were calculated using the Student's t-test or Chi-square test where appropriate. Surgical information regarding the three curvatures was tabulated. SRS-22 domain scores (function, pain, self-image, mental, satisfaction, and mean) and years between the date of preoperative, maximally 3 postoperative follow-up sessions (postoperative 1, 2, and 3), and data of the surgery were compared using the ANOVA. Data analysis was carried out using IBM SPSS 25.0 (Armonk, New York, USA). A two-sided P ≤ 0.05 was considered statistically significant.


  Results Top


There are 26 patients with 20 females and 6 males. Mean age at the surgery was 17.71 (Lenke 1) and 18.18 (Lenke 2). Their bone age was Thumb Ossification Composite Index Stage 4 in 10 patients and Stage 5 in 16 patients.[8],[9] Major thoracic curve was corrected by 71.9% after surgery for both Lenke 1 and 2 curves [Table 1].
Table 1: Demographic characteristics of the 26 Lenke 1 and 2 patients

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The length of follow-up is 1.63 years. Ten Lenke 2 and 16 Lenke 2 cases. The preoperative, SB, postoperative, and follow-up Cobb angles of Lenke 1 (1) and 2 (2) cases were as follows: Proximal thoracic (Lenke 1: 29°, 19°, 15° CR47%, 15°), (Lenke 2: 46°, 41°, 25° CR43%, 28°); main thoracic (Lenke 1: 58°, 32°, 12° CR79%, 12°), (Lenke 2: 71°, 48°, 20° CR72%, 22°); lumbar (Lenke 1: 32°, 7°, 10° CR72%, 9°), (Lenke 2: 33°, 9°, 6° CR82%, 8°); T1Tilt angles (Lenke 1: 1°, −7°, −6°), (Lenke 2: −3°, −8°, −9°); clavicular angles (Lenke 1: 3°, −4°, −3°), (Lenke 2: 2°, −3°, −4°) [Table 2]. The sagittal alignment of the all both Lenke cases is as follows: CL (2.1°, −0.5°, 6°); TK (29°, 29°, 32°); LL (45°, 40°, 51°); PI (42°, 42°, 44°); PT (9°, 13°, 7°); SL (33°, 30°, 36°); SVA (1.4°, 0.8°, 1.3°).
Table 2: Clinical characteristics of the patients before and after surgery

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HRQOL of both Lenke 1 and 2 patients were compared using the longitudinal SRS-22 domain scores by Lenke Type, (1) all patients [Table 3], (2) divided by sex [Table 4], and (3) divided by age (age ≤8 or age >18) [Table 5]. In [Table 3], mean and standard deviation of each data were included to show the data distribution, only mean values are reported in [Table 4] and [Table 5] to make the tables easier to read. Function scores in both Lenke 1 and 2 patients were significantly improved after the surgery (postoperative vs. postoperative 3: Lenke 1 = 3.00 vs. 4.80; Lenke 2 = 3.47 vs. 4.60; both P < 0.01) [Figure 1]. “Self-image” in Lenke 1 and 2 patients was much improved over the 2 years after the surgery (Lenke 1: 3.14 vs. 4.60, P = 0.05; Lenke 2: 3.17 vs. 4.60; P < 0.01). Pain, mental, satisfaction, and mean scores were recovering; however, all had not reached statistically significant. Stratifying the data by sex and by age gave us more insights on the factors affecting HRQOL. Female Lenke 2 patients showed significant “Function” improvements over the timeline. Average “Function” score was significantly dropped at “Postoperative” and recovered from “Postoperative” to “Postoperative 3” in both Lenke 1 (P = 0.04) and Lenke 2 patients (P < 0.01) [Table 4] and [Figure 2]. Lenke 2 patients who divided at younger than or equal to 18 years old or above 18 years old showed significant differences [both groups: P = 0.01; [Table 5] and [Figure 3]. “Self-image” was much improved in female Lenke 2 patients [“Preoperative” = 3.16, “Postoperative” = 3.98, “Postoperative 3” = 4.60; P < 0.01; [Table 4] and [Figure 2]. The significant improvements in “Self-image” happened regardless of age (age ≤18: P <0.01, age >18: P = 0.02). Statistical significances were found in “satisfaction” (male patients: P =0.04) and “self-image” (age ≤18: P = 0.02) in Lenke 1 patients.
Table 3: Longitudinal Scoliosis Research Society-22 domain scores (mean±standard deviation) before and after surgery, and postoperative follow-up of all patients

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Table 4: Longitudinal Scoliosis Research Society-22 domain scores (mean) before and after surgery, and postoperative follow-up of all patients divided by sex

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Table 5: Longitudinal Scoliosis Research Society-22 domain scores (mean) before and after surgery, and postoperative follow-up of all patients divided by age

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Figure 1: Longitudinal average Scoliosis Research Society-22 domain scores before and after surgery, and postoperative follow-up of Lenke 1 and Lenke 2 patients

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Figure 2: Longitudinal average Scoliosis Research Society-22 domain scores before and after surgery, and postoperative follow-up of Lenke 1 and Lenke 2 patients by sex

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Figure 3: Longitudinal average Scoliosis Research Society-22 domain scores before and after surgery, and postoperative follow-up of Lenke 1 and Lenke 2 patients by age

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  Discussion Top


This is the first study on shoulder balance in AIS Lenke 1 and 2 patients, and its association with the HRQOL before and after surgery. Curve correction of main thoracic curves was 72% for both Lenke Type 1 and 2 curves. The shoulder balance changed from left down to left up after operation as reflected by the changes in T1tilt (medial shoulder) and clavicular angles (lateral shoulder). The sagittal alignment changes of this group of patients moved toward increased CL, TK, and LL and an SVA toward zero. “Function” and “Self-image” were significantly improved after surgery, particularly in female Lenke 2 patients regardless of age.

Our results showed that “Function” and “Self-image” were much improved after surgery, particularly in female Lenke 2 patients. Literature search using the MeSH headings “scoliosis,” “quality of life,” “Surgical Procedures, Operative,” and keyword “shoulder balance” returned no result. A retrospective study on reviewing the radiographs and clinical photos, and SRS questionnaire assessing the pedicle screw and hooks implants linking the cosmesis with novel assessment methods in 40 AIS Lenke 1 and 2 patients with thoracic curve of Cobb angle 40°–70°.[10] The authors concluded that there was no significant difference in all SRS domains between the pedicle screw and hooks instrumentations.[10] In a multicenter study originated from San Diego on the change of SRS outcome measures from before surgery to 2 and 5 years follow-up visits, SRS scores in the pain, general self-image, and function from back condition domains increased significantly from before surgery to the 2-year follow-up visit (P ≤ 0.01).[11] Our observations on “Function” and “Self-image” cohered with the results; however, Lenke stage, age, and shoulder balance were not considered in this study. Results from a Korean-led study on factors affecting shoulder balance after the surgery in AIS showed middle or distal curvature corrections were the factors affecting the postoperative shoulder balance.[12] A study comparing the radiographic with cosmetic shoulder balance in 34 Chinese AIS patients found that none of the radiographic parameters accurately reflected the shoulder cosmetic appearance.[13] The results, however, did not consider the effects from different Lenke curvatures or HRQOL by completing any questionnaire.[13] This is, therefore, the first study to report the HRQOL in association with Lenke 1 and 2 AIS patients before and after surgery. “Self-image” was improved in both male and female AIS patients after surgery in a longitudinal cohort study.[14] Our results further elaborated that female with Lenke 2 curve before surgery was the group which was beneficial from the surgery.

Limitations

This is a retrospective study that carried the disadvantages of missing data and misclassification bias. The small sample size of this study might affect the data generalizability. This study requires a larger sample size to confirm these changes and to develop a strategy to better correct the shoulder balance change.


  Conclusions Top


The sagittal alignment changes of this group of patients moved toward increased CL, TK, and LL and an SVA toward zero. “Function” and “Self-image” were significantly improved after 2 years postsurgery. Sex- and age-specific analysis showed that female Lenke 2 AIS patients were the group of patients showing the improvements regardless of age at operation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee CS, Hwang CJ, Lee DH, Cho JH. Does fusion to T2 compared with T3/T4 lead to improved shoulder balance in adolescent idiopathic scoliosis with a double thoracic curve? J Pediatr Orthop B 2019;28:32-9.  Back to cited text no. 1
    
2.
Yang H, Im GH, Hu B, Wang L, Zhou C, Liu L, et al. Shoulder balance in Lenke type 2 adolescent idiopathic scoliosis: Should we fuse to the second thoracic vertebra? Clin Neurol Neurosurg 2017;163:156-62.  Back to cited text no. 2
    
3.
Amir D, Yaszay B, Bartley CE, Bastrom TP, Newton PO. Does leveling the upper thoracic spine have any impact on postoperative clinical shoulder balance in Lenke 1 and 2 patients? Spine (Phila Pa 1976) 2016;41:1122-7.  Back to cited text no. 3
    
4.
Bjerke BT, Cheung ZB, Shifflett GD, Iyer S, Derman PB, Cunningham ME. Do current recommendations for upper instrumented vertebra predict shoulder Imbalance? An attempted validation of level selection for adolescent idiopathic scoliosis. HSS J 2015;11:216-22.  Back to cited text no. 4
    
5.
Koller H, Meier O, McClung A, Hitzl W, Mayer M, Sucato D. Parameters leading to a successful radiographic outcome following surgical treatment for Lenke 2 curves. Eur Spine J 2015;24:1490-501.  Back to cited text no. 5
    
6.
Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS22 health-related quality of life questionnaire function domain. Spine 2006;31:593-7. Available from: https://www.srs.org/UserFiles/file/outcomes/srs-22.pdf. [Last accessed on 2019 Nov 02].  Back to cited text no. 6
    
7.
Department of Orthopaedics and Traumatology. Chinese University of Hong Kong edition. Available from: https://aisq.ort.cuhk.edu.hk. [Last accessed on 2019 Nov 02].  Back to cited text no. 7
    
8.
Hung AL, Chau WW, Shi B, Chow SK, Yu FY, Lam TP, et al. Thumb Ossification Composite Index (TOCI) for predicting peripubertal skeletal maturity and peak height velocity in idiopathic scoliosis: A validation study of premenarchal girls with adolescent idiopathic scoliosis followed longitudinally until skeletal maturity. J Bone Joint Surg Am 2017;99:1438-46.  Back to cited text no. 8
    
9.
Hung AL, Shi B, Chow SK, Chau WW, Hung VW, Wong RM, et al. Validation Study of the Thumb Ossification Composite Index (TOCI) in idiopathic scoliosis: A stage-to-stage correlation with classic tanner-whitehouse and sanders simplified skeletal maturity systems. J Bone Joint Surg Am 2018;100:88.  Back to cited text no. 9
    
10.
Arlet V, Ouellet JA, Shilt J, Shen FH, Wood K, Chan D, et al. Subjective evaluation of treatment outcomes of instrumentation with pedicle screws or hybrid constructs in Lenke Type 1 and 2 adolescent idiopathic scoliosis: What happens when judges are blinded to the instrumentation? Eur Spine J 2009;18:1927-35.  Back to cited text no. 10
    
11.
Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, et al. Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment. Spine (Phila Pa 1976) 2008;33:1107-12.  Back to cited text no. 11
    
12.
Hong JY, Suh SW, Modi HN, Yang JH, Park SY. Analysis of factors that affect shoulder balance after correction surgery in scoliosis: A global analysis of all the curvature types. Eur Spine J 2013;22:1273-85.  Back to cited text no. 12
    
13.
Qiu XS, Ma WW, Li WG, Wang B, Yu Y, Zhu ZZ, et al. Discrepancy between radiographic shoulder balance and cosmetic shoulder balance in adolescent idiopathic scoliosis patients with double thoracic curve. Eur Spine J 2009;18:45-51.  Back to cited text no. 13
    
14.
Roberts DW, Savage JW, Schwartz DG, Carreon LY, Sucato DJ, Sanders JO, et al. Male-female differences in Scoliosis Research Society-30 scores in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2011;36:E53-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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