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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 17-20

The coronal and sagittal parameters before and after posterior spinal fusion with all pedicle screw construct in adolescent idiopathic scoliosis (AIS) patients and comparing their health-related outcomes through SRS-22 questionnaire


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

Date of Submission31-Oct-2019
Date of Acceptance11-Apr-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Alec Lik-Hang Hung
Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong SAR
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_43_19

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  Abstract 


Background: Sagittal balance in severe androgen insensitivity syndrome (AIS) patient has been difficult to study due to problems with imaging technique. Abnormal sagittal profiles have been frequently observed in AIS patients presenting as cervical kyphosis, thoracic hypokyphosis, and positive sagittal vertical axis (SVA) off set. The significance of these changes is not understood in these patients. The purpose of this study is to assess the sagittal profile of AIS patients before and after surgery. Subjects and Methods: Changes in curve correction in both coronal and sagittal planes before and after surgery. Curve type, Cobb angles, sagittal parameters, and fusion level were analyzed with conventional parameters. Patient outcomes were measured using mobile device friendly Scoliosis Research Society-22 questionnaire online. Results: Fourteen patients were recruited. Average age was 16 years (13–36). Postoperation and final follow-up Cobb angles were reduced to 27°, 26°, and 16° and 29°, 28°, and 16°, respectively. In the sagittal plane, the Cobb angles pre- and postoperation and final follow-up are as follows: Cervical lordosis (36.7, 39.1, and 41.9), thoracic kyphosis (33.1, 35.8, and 39.1), lumbar lordosis (51.1, 45.2, and 54.2), SVA (1.3, 1.6, and 0), pelvic tilt (19, 21, and 18), sacral slope (47, 46, and 55), and pelvic tilt (43.7, 45, and 43.5). “Function”, “satisfaction,” and “mean” were significantly improved over the period, particularly between the last seen visit and before surgery. Conclusions: Abnormal coronal and sagittal parameters and their changes after surgery are reported in AIS patients. Patients expressed significant improvements in their function abilities and satisfied with clinical management, as well as their general quality of life.

Keywords: Adolescent idiopathic scoliosis, coronal plane, pedicle screw, quality of life, sagittal plane


How to cite this article:
Chau WW, Ng BK, Hung AL. The coronal and sagittal parameters before and after posterior spinal fusion with all pedicle screw construct in adolescent idiopathic scoliosis (AIS) patients and comparing their health-related outcomes through SRS-22 questionnaire. J Orthop Traumatol Rehabil 2021;13:17-20

How to cite this URL:
Chau WW, Ng BK, Hung AL. The coronal and sagittal parameters before and after posterior spinal fusion with all pedicle screw construct in adolescent idiopathic scoliosis (AIS) patients and comparing their health-related outcomes through SRS-22 questionnaire. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Nov 27];13:17-20. Available from: https://www.jotr.in/text.asp?2021/13/1/17/318413




  Introduction Top


Surgical treatment of scoliosis aims to corrects three-dimensional (3D) spinal deformity and restores normal 3D profiles.[1] Pedicle screw construct allows three plane corrections. The outcome of 3D correction is difficult to quantify without serial computed tomography scans.[2]

Sagittal balance in androgen insensitivity syndrome (AIS) patient has been difficult to study due to problems with imaging technique, the 3D deformity of the spine particularly in severe curves.[3] Abnormal sagittal profiles have been frequently observed in AIS patients presenting as cervical kyphosis, thoracic hypokyphosis, and positive Sagittal Vertical Axis (SVA) off set.[4],[5] The significance of these changes is not understood in these patients. Apart from clinical considerations, health outcomes and satisfactions in this specific group of patients have not been discussed elsewhere. AIS patients under sagittal balance considerations may have different postsurgical experiences compared with other surgical cases.[6],[7] Measuring patient's outcome in terms of different quality of life measurable parameters could be carried out using patient outcome questionnaires, which are now easily accessible through the mobile technology in digital format offering many features which conventional printed format cannot deliver in terms of user experience, data collection, storage, and retrieval.

The purpose of this study is to assess the sagittal profile of AIS patients before and after surgery and evaluate and quantify the coronal and sagittal changes. Patient outcomes represented by quality of life measures measured before surgery, after surgery, and the latest follow-up sessions were compared.


  Subjects and Methods Top


AIS patients who had undergone posterior spinal fusion from year 2014 with at least 24 months follow-ups were recruited for study. Ethical approval was obtained from the ethics review board of the Joint NTEC/CUHK ethics committee.

Clinical measurements

Measurements regarding coronal and sagittal parameters before, after surgery, and at latest follow-up were carried out on screen, namely Cobb angles, cervical lordosis (C1-7), thoracic kyphosis (T1-12), lumbar lordosis (L1-S1), SVA, pelvic incidence, sacral slope (SS), and pelvic tilt (PT). The changes in curve correction in both coronal and sagittal planes before and after surgery are noted.

Patient outcome measurements using Scoliosis Research Society-22 Questionnaire online

Patients' perception on their spinal deformity can be quantified by using “Scoliosis Research Society-22 (SRS-22) questionnaire,” which is a well-established validated health-related quality of life instruments published by SRS.[8],[9],[10],[11],[12],[13],[14] SRS-22 questionnaire contains 22 questions covering different psychosocial and mental health issues and five domain scores (function, pain, self-image, mental health, and satisfaction) are calculated through established methods published by SRS.

Mobile browser-friendly scoliosis research society-22 online[15]

SRS-22 has been establishing for years, by the time mobile Internet access and mobile device technology have not been very popular. Recent rapid advancement of mobile Internet access and mobile devices technology lead us to transform the original SRS-22 questionnaire to be easily accessible whenever and wherever necessary. The “SRS-22 questionnaire mobile” used in this study was delivered using recent advanced mobile technology by revamping the originally published format to a cloud-based mobile browser-friendly version. Conventionally, the questionnaire was administered in prints making data collection difficult to manage with time and spent extra manpower and time on follow-up issues (data entry, data management, and extraction) with systematic errors commonly occurred. It is also not friendly and difficult to compare the results between different time points using printed version. Recent technologies make the SRS-22 questionnaire to be accessed through mobile devices over the Internet. The system layout is browser friendly which means patients can use the system through mobile devices (smartphones and tablets) and computers (laptops and desktops), under the same user experience. The whole SRS-22 questionnaire online system was designed and developed by in-house IT department.

SRS-22 mobile was still self-administered. Patients (or users) registered using their identifiable and memorizable information (full name and identity number) first. Informed consent was completed after reading the informed consent form and agreed to join the study. After logging in the system, patients answered the questions by tabbing the answers. All domain scores and mean scores were automatically and instantly calculated over the cloud and showed on the screen. Details of logistics are shown in [Figure 1].
Figure 1: Flow chart on the logistics using Scoliosis Research Society-22 online

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Statistical analysis

Statistical analysis was carried out using the Analysis of variance to compare curve types, Cobb angles, sagittal parameters, and fusion level from X-rays taken before surgery, after surgery, and last seen visit. The same comparisons were also applied to the 5 SRS-22 domains as well as the mean scores. Between group comparisons were further analyzed using post hoc Bonferroni correction. Data analysis was carried out by IBM SPSS 24 (Armonk, New York, USA). A two-sided P ≤ 0.05 was considered statistically significant.


  Results Top


Fourteen patients, 12 females and 2 males were recruited. Average age 16 (13–36), Lenke types (one case of 1a, 1b, 2b, 8 cases of 2a, one case each of 4a, b and c). Cobb angles of proximal thoracic, main thoracic, and lumbar curves averaged 42°, 75°, and 41°, respectively. Postoperation and final follow-up cobb angles were reduced to 2700B0, 26°, 16° and 29°, 28°, and 16°. In the sagittal plane, the Cobb angles pre-and post-operation and final follow-up are as follows: Cervical lordosis (36.7, 39.1 and 41.9), thoracic kyphosis (33.1, 35.8, and 39.1), lumbar lordosis (51.1, 45.2, and 54.2), SVA (1.3, 1.6, and 0), PT (19, 21, and 18), SS (47, 46, and 55), and PT (43.7, 45, and 43.5). Significant differences were observed in upper thoracic Cobb angle, main thoracic Cobb angle, lumbar Cobb angle, and apical vertebral rotation, of which differences were shown when comparing data collected before surgery and after surgery, as well as before surgery and last seen visit [Table 1].
Table 1: Coronal and sagittal angles and measurements comparisons carried out by the ANOVA with post hoc Bonferroni correction

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Average time to complete registration and questions was <10 min and <5 min for follow-up. “Function” scores were continuously improving from before surgery, after surgery to last seen visit (from 3.73, 4.24, to 4.53, P = 0.03) [Table 2]. Satisfaction and mean scores also showed the same observation, particularly between last seen visit and before surgery (Satisfaction: 4.83 vs. 3.63, P = 0.05; mean score: 4.42 vs. 3.71 (P = 0.02).
Table 2: Average scoliosis research society-22 domain scores of the patients

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  Discussion Top


Cervical kyphosis has been reported to cause degenerative spondylosis and poor outcome score. Particular efforts have been made preoperatively to restore thoracic kyphosis and de-rotation of the deformed spine. Changes in the sagittal profile are observed. Abnormal coronal and sagittal parameters and their changes after surgery are reported in AIS patients. The significance requires further correlation with outcome score and other parameters.

Patients' function has been improving after surgery for this particular group of patients (patients with cervical kyphosis, thoracic hypokyphosis, and positive SVA). Surgical treatment (posterior spinal fusion) is proven to improve their activity levels and recommend for patients even with sagittal imbalance. Patients felt satisfied with the clinical management certain period after the surgery. Surgeons are recommended to explain to the patients that they might have to wait for surgical effectiveness. The same applies to general surgical outcome.

Spinal deformity correction in both coronal and sagittal planes has been studied. The significance of this is not certain at present. Cervical segmental kyphosis changes after scoliosis correction and whole sagittal balance changes with efforts to restore thoracic kyphosis. Effort should be made to correct these parameters in the 3D planes.


  Conclusions Top


Abnormal coronal and sagittal parameters and their changes after surgery are reported in AIS patients. Patients' health-related quality of life expressed significant improvements in their function abilities and satisfied with clinical management, as well as their general quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bridwell KH. Surgical treatment of adolescent idiopathic scoliosis: The basics and the controversies. Spine (Phila Pa 1976) 1994;19:1095-100.  Back to cited text no. 1
    
2.
Chan CY, Kwan MK. Safety of pedicle screws in adolescent idiopathic scoliosis surgery. Asian Spine J 2017;11:998-1007.  Back to cited text no. 2
    
3.
Ilharreborde B. Sagittal balance and idiopathic scoliosis: Does final sagittal alignment influence outcomes, degeneration rate or failure rate? Eur Spine J 2018;27:48-58.  Back to cited text no. 3
    
4.
Kim D, Menger RP. Spine Sagittal Balance. StatPearls. Treasure Island, FL: StatPearls Publishing LLC; 2019.  Back to cited text no. 4
    
5.
Pinto EM, Alves J, Teixeira A, Miranda A. Sagittal balance in adolescent idiopathic scoliosis. Coluna/Columna 2019;18:182-6.  Back to cited text no. 5
    
6.
La Maida GA, Zottarelli L, Mineo GV, Misaggi B. Sagittal balance in adolescent idiopathic scoliosis: Radiographic study of spino-pelvic compensation after surgery. Eur Spine J 2013;22 Suppl 6:S859-67.  Back to cited text no. 6
    
7.
Xu XM, Wang F, Zhou XY, Liu ZX, Wei XZ, Bai YS, et al. Sagittal balance in adolescent idiopathic scoliosis: A radiographic study of spinopelvic compensation after selective posterior fusion of thoracolumbar/Lumbar (Lenke 5C) curves. Medicine (Baltimore) 2015;94:e1995.  Back to cited text no. 7
    
8.
Brewer P, Berryman F, Baker D, Pynsent P, Gardner A. Analysis of the Scoliosis Research Society-22 Questionnaire Scores: Is There a Difference Between a Child and Parent and Does Physician Review Change That? Spine Deform. 2014;2:34-39.  Back to cited text no. 8
    
9.
Asher M, Min Lai S, Burton D, Manna B. Scoliosis research society-22 patient questionnaire: Responsiveness to change associated with surgical treatment. Spine (Phila Pa 1976) 2003;28:70-3.  Back to cited text no. 9
    
10.
Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the scoliosis research society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976) 2003;28:63-9.  Back to cited text no. 10
    
11.
Cheung KM, Senkoylu A, Alanay A, Genc Y, Lau S, Luk KD. Reliability and concurrent validity of the adapted Chinese version of Scoliosis Research Society-22 (SRS-22) questionnaire. Spine (Phila Pa 1976) 2007;32:1141-5.  Back to cited text no. 11
    
12.
Climent JM, Bago J, Ey A, Perez-Grueso FJ, Izquierdo E. Validity of the Spanish version of the Scoliosis Research Society-22 (SRS-22) Patient Questionnaire. Spine (Phila Pa 1976) 2005;30:705-9.  Back to cited text no. 12
    
13.
Lee JS, Lee DH, Suh KT, Kim JI, Lim JM, Goh TS. Validation of the Korean version of the Scoliosis Research Society-22 questionnaire. Eur Spine J 2011;20:1751-6.  Back to cited text no. 13
    
14.
Li M, Wang CF, Gu SX, He SS, Zhu XD, Zhao YC, et al. Adapted simplified Chinese (mainland) version of Scoliosis Research Society-22 questionnaire. Spine (Phila Pa 1976) 2009;34:1321-4.  Back to cited text no. 14
    
15.
Available from: https://aisq.ort.cuhk.edu.hk/ [Last assessed on 2019 Aug 29].  Back to cited text no. 15
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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