Danielsson AJ, Nachemson AL. Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals

Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg University, Sweden.
Spine (Impact Factor: 2.3). 04/2001; 26(5):516-25. DOI: 10.1097/00007632-200103010-00015
Source: PubMed


This study is a follow-up investigation for a consecutive series of patients with adolescent idiopathic scoliosis treated between 1968 and 1977. In this series, 156 patients underwent surgery with distraction and fusion using Harrington rods, and 127 were treated with brace.
To determine the long-term outcome in terms of radiologic findings and curve progression at least 20 years after completion of the treatment.
Radiologic appearance is important in comparing the outcome of different treatment options and in evaluating clinical results. Earlier studies have shown a slight increase of the Cobb angle in brace-treated patients with time, but not in fused patients.
Of 283 patients, 252 attended a clinical and radiologic follow-up assessment by an unbiased observer (91% of the surgically treated and 87% of the brace-treated patients). This evaluation included chart reviews, validated questionnaires, clinical examination, and full-length standing frontal and lateral roentgenographs. Curve size was measured by the Cobb method on anteroposterior roentgenograms as well as by sagittal contour and balance on lateral films. The occurrence of any degenerative changes or other complications was noted. An age- and gender-matched control group of 100 individuals was randomly selected and subjected to the same examinations.
The mean follow-up times were 23 years for surgically treated group and 22 years for brace-treated group. The deterioration of the curves was 3.5 degrees for all the surgically treated curves and 7.9 degrees for all the brace-treated curves (P < 0.001). Five patients, all brace-treated, had a curve increase of 20 degrees or more. The overall complication rate after surgery was low: Pseudarthrosis occurred in three patients, and flat back syndrome developed in four patients. Eight of the patients treated with fusion (5.1%) had undergone some additional curve-related surgical procedure. The lumbar lordosis was less in the surgically treated than in the brace-treated patients or the control group (mean, 33 degrees vs 45 degrees and 44 degrees, respectively). Both surgically treated and brace-treated patients had more degenerative disc changes than the control participants (P < 0.001), but no significant differences were found between the scoliosis groups. No statistically significant difference in terms of radiographically detectable degenerative changes in the unfused lumbar discs was found between patients fused below L3 or those fused to L3 and above (P = 0.22). A study on intra- and interobserver measurements of kyphosis, lordosis, and sagittal vertical axis on two films for each patient demonstrated that the repeatability of measuring sagittal plumbline on two different lateral radiographs, with patients moving between radiograms, was unreliable for comparison.
Although more than 20 years had passed since completion of the treatment, most of the curves did not increase. The surgical complication rate was low. Degenerative disc changes were more common in both patient groups than in the control group.

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    • "L'évaluation à court terme des SIA opérées a été étudiée par de nombreux auteurs et montre en général de bons résultats [1] [2] [3] [4]. En revanche, il n'existe que peu d'études s'attachant à décrire l'évolution à long terme de ce type de patients et peu d'entre elles fournissent des données radiologiques et cliniques avec un long recul [2] [5]. Par ailleurs, il n'existe que peu de séries s'intéressant à l'évaluation de la qualité de vie des patients opérés [1]. "
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    ABSTRACT: À ce jour, il n’existe pas de solution thérapeutique consensuelle pour les scolioses idiopathiques de l’adolescent (SIA) dont la courbure est comprise entre 30 et 60° en fin de croissance.
    Full-text · Article · Sep 2015 · Revue de Chirurgie Orthopédique et Traumatologique
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    • "These findings are comparable to those of Danielsson and Nachemson [2] in a series of patients managed by the Harrington technique. In the present series, however, sagittal balance , thoracic kyphosis and lumbar lordosis and its correlation with pelvic incidence were nearly normal; in Danielsson's study [2], sagittal values at follow-up were lower, confirming the superiority of the multi-level technique in terms of sagittal correction [8] [9] [10]. The lack of adolescent lateral radiographs in the present study prevented comparison of these parameters between preoperative , postoperative and last follow-up time points. "
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    ABSTRACT: To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth. The objective of this study was to assess outcome in patients with moderate AIS. A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30-60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up. A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P < 0.001. In lumbar scoliosis, the risk of progression to ≥ 20° was significantly higher for initial Cobb angle > 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores. Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation. IV, retrospective study. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    Full-text · Article · Jul 2015 · Orthopaedics & Traumatology Surgery & Research
    • "An extensive surface area was available for bone grafting bilaterally due to very low implant density compared to modern segmental instrumentation.84 However, the rates of implant failure and pseudarthrosis were high because the system provided a nonsegmental fixation.85 In addition, pure distraction and compression forces between the points of fixation produced flattening of the spine across the curve and a flat back deformity leading to sagittal decompensation and postoperative pain.8687 "
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    ABSTRACT: A new era in the surgical treatment of adolescent idiopathic scoliosis (AIS) opened with the introduction of pedicle screw instrumentation, which provides 3-column vertebral fixation and allows major deformity correction on the coronal, sagittal, and axial planes. A steep learning curve can be expected for spinal surgeons to become familiar with pedicle screw placement and correction techniques. Potential complications including injury to adjacent neural, vascular, and visceral structures can occur due to screw misplacement or pull-out during correction maneuvers. These major complications are better recognized as pedicle screw techniques become more popular and may result in serious morbidity and mortality. Extensive laboratory and clinical training is mandatory before pedicle screw techniques in scoliosis surgery are put to practice. Wider application, especially in developing countries, is limited by the high cost of implants. Refined correction techniques are currently developed and these utilize a lesser number of pedicle anchors which are strategically positioned to allow optimum deformity correction while reducing the neurological risk, surgical time, and blood loss, as well as instrumentation cost. Such techniques can be particularly attractive at a time when cost has major implications on provision of health care as they can make scoliosis treatment available to a wider population of patients. Pedicle screw techniques are currently considered the gold standard for scoliosis correction due to their documented superior biomechanical properties and ability to produce improved clinical outcomes as reflected by health-related quality-of-life questionnaires. Ongoing research promises further advances with the future of AIS treatment incorporating genetic counseling and possibly fusionless techniques.
    No preview · Article · Mar 2013 · Indian Journal of Orthopaedics
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