|Year : 2020 | Volume
| Issue : 1 | Page : 95-98
A case of malignant scoliosis and its relationship with pulmonary lung function and long-term health-related quality of life
Bobby Kin-Wah Ng, Victor Illescas, Wai-Wang Chau
Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong, China
|Date of Submission||09-Mar-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||26-Jun-2020|
Dr. Bobby Kin-Wah Ng
Department of Orthopaedics and Traumatology, Chinese University of Hong Kong
Source of Support: None, Conflict of Interest: None
The relationship of spinal deformity and pulmonary impairment is so variable that it is still to be established. This study is to report the clinical pulmonary improvements of a patient with severe adolescent idiopathic scoliosis treated with corrective scoliosis surgery using posterior spinal instrumented fusion. The patient was an 11-year-old premenarche adolescent female. Preoperative Cobb angles were 102° from T4 toT12 and 58° from T12 to L4. The patient was already complaining of shortness of breath and chest pains with exertion. Pulmonary function tests (PFTs) were performed before surgery and 8 months postsurgery. Postoperative Cobb angle improved with the thoracic curve at 36° and lumbar curve at 10°. There was a marked improvement with her previous symptoms. Significant improvements were observed in her lung volume parameters on PFT. Her health-related quality of life continued to improve. This study reconfirms the influence of spinal deformities on pulmonary impairment in patients with severe scoliosis.
Keywords: Adolescent idiopathic scoliosis, malignant, pulmonary function, severe cases
|How to cite this article:|
Ng BK, Illescas V, Chau WW. A case of malignant scoliosis and its relationship with pulmonary lung function and long-term health-related quality of life. J Orthop Traumatol Rehabil 2020;12:95-8
|How to cite this URL:|
Ng BK, Illescas V, Chau WW. A case of malignant scoliosis and its relationship with pulmonary lung function and long-term health-related quality of life. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Jul 6];12:95-8. Available from: http://www.jotr.in/text.asp?2020/12/1/95/287707
| Introduction|| |
Great progress has been made with the treatment of severe and rigid type of adolescent idiopathic scoliosis. These cases usually present at the clinic with years of neglected back deformity with associated cardiopulmonary symptoms. Patients treated with posterior spinal arthrodesis with iliac bone graft show a significant increase in absolute pulmonary function.
The purpose of this study is to report the clinical pulmonary improvements and changes in health-related quality of life of a patient with severe adolescent idiopathic scoliosis treated with corrective scoliosis surgery using posterior spinal instrumented fusion (PSIF).
| Case Report|| |
Our patient is an 11-year-old premenarche adolescent female, who presented at our institution due to back deformity. The patient is underweight at 25 kg with a body mass index (BMI) of 11 kg/m2 [Figure 1]. At such a young age, she is already in poor health and complaining of shortness of breath and easy fatigability, with chest pain on exertion. Exercise test lasted 4 min and 11 s and was stopped after Bruce Stage II (4 min 11 s at 4.5 mph) due to patient's fatigue with a maximum heart rate at 176 beats/min. Her Risser sign was 0 and Thumb Ossification Composite Index was 5., The patient is a case of scoliosis classified as Lenke 3A N. She was still extremely underweight with a BMI of 11 kg/m2. The progression rate of the curve at this time was 10°/month [Figure 2].
|Figure 2: Progression of scoliosis. (a) April 2016, (b) July 2016, (c) January 2017, (d) October 2017|
Click here to view
Corrective scoliosis surgery was done using PSIF. All pedicle screw constructs were used in this case from T2 to L3. Postoperative X-rays are depicted in [Figure 3]. Postoperative Cobb angle improved with the thoracic curve at 36° and lumbar curve at 10°.
Pulmonary function tests (PFTs) were performed in the present case to evaluate the pulmonary volume and flow preoperatively and at 8 months after surgery. All PFTs were performed on the same computerized spirometer (6200 Autobox; SensorMedics, Yorba Linda, California) that had an accuracy of ±3%, which met the criteria of the American Thoracic Society. The tests were performed with the patient standing; each measurement was repeated three times, and the highest reading was selected [Figure 1]. Pulmonary volume was evaluated using forced vital capacity (FVC) and total lung capacity (TLC).
PFT of the patient demonstrated the lung volume parameters as follows: TLC of 1.12 (27% predicted), vital capacity (VC) of 0.63 (21% predicted), residual volume (RV) of 0.48 (50% predicted), and functional residual capacity (FRC) of 0.61 (27% predicted). The lung flow parameters were FVC of 0.63 L (21% predicted), forced expiratory volume after 1 s (FEV1) of 10.57 L (20% predicted), and peak expiratory flow (PEF) of 99 L/min (28% predicted) [Table 1]. All these parameters would lead us to conclude that the spinal deformity has caused great amount of compression over her lungs causing compromise. At 8 months after surgery, the patient did not report any episode of shortness of breath and had easy fatigability. There is no more episode of chest pain or paroxysmal nocturnal dyspnea. The patient's weight has significantly increased to 31 kg, and her BMI increased to 12 kg/m2. PFT now shows her TLC at 1.78 (43% predicted), VC at 1.48 (48% predicted), RV at 0.29 (30% predicted), and FRC at 0.5 (23% predicted). Spirometry shows her FVC at 1.48 (48% predicted), FEV1 at 1.25 (44% predicted), and PEF at 186 (52% predicted) [Table 2].
Health-related quality of life
Functionally, she had better SRS-22 scores at 1-year follow-up on function, self-image, satisfaction, and mean total score [Table 3]. More importantly, her mother now notes that she has improved self-esteem and has shown increased interest in going out and socializing. All SRS-22 scores continued to improve 5 years after surgery.
| Discussion|| |
Severe rigid scoliosis is spinal deformity more than 100° with correction of <25% on side bending films [Figure 4]. This condition increases the risk of mortality and premature death. In the patient's case at the age of 11, this is already malignant. The patient showed very high risk of curve progression upon the first consult with the patient at peak height velocity (premenarche).
The relationship of spinal deformity to pulmonary impairment and of pulmonary impairment to disability is so variable that no direct relationship between deformity and disability can be identified. In a study by Johnston et al., the authors noted that underweight patients presented with the greatest pulmonary impairment. In the study of Chu et al., it was proposed that impairment in lung function in Adolescent Idiopathoc Scoliosis (AIS) patients is predominantly due to the restriction of lung volume. Lung volumes diminish with increasing scoliosis; a Cobb angle of 100° correlates with a 29%–37% reduction in volumes. Scoliosis angle of >110°, dyspnea, and wheeze are markers of poor prognosis, and a VC below 45% predicted an increased risk of developing respiratory failure. There is a significant percentage of patients with severe scoliosis that have impaired PFTs noted before surgery, and because of the hypothesized potential for such patients to deteriorate, one may regard pulmonary function testing just as an important preoperative evaluation and possible indication for surgical management as the traditional coronal deformity measurement. Health-related quality of life hugely improved after surgery and continued to improve at follow-up. Results further prove that the improvements of pulmonary function have direct effects on improving the quality of life of severe scoliotic patients.
This study reconfirms the influence of spinal deformities on pulmonary impairment in patients with severe scoliosis. This study highlights the objective measures taken to demonstrate the improvements with lung volumes that corrective scoliosis surgery can provide, thus resulting in improved clinical picture of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kim YJ, Lenke LG, Bridwell KH, Kim KL, Steger-May K. Pulmonary function in adolescent idiopathic scoliosis relative to the surgical procedure. J Bone Joint Surg Am 2005;87:1534-41.
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.
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-white house and sanders simplified skeletal maturity systems. J Bone Joint Surg Am 2018;100:88.
Standardization of Spirometry, 1994 update. American Thoracic Society. Am J Respir Crit Care Med 1995;152:1107-36.
Johnston CE, Richards BS, Sucato DJ, Bridwell KH, Lenke LG, Erickson M, et al
. Correlation of preoperative deformity magnitude and pulmonary function tests in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2011;36:1096-102.
Menon B, Aggarwal B. Influence of spinal deformity on pulmonary function, arterial blood gas values, and exercise capacity in thoracic kyphoscoliosis. Neurosciences (Riyadh) 2007;12:293-8.
Pehrsson K, Bake B, Larsson S, Nachemson A. Lung function in adult idiopathic scoliosis: A 20 year follow up. Thorax1991;46:474-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]