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. 2019;39(2):66–72.

Impact of Surgery on the Quality of Life of Adolescent Idiopathic Scoliosis

Pedro Fernandes 1, Joaquim Soares Do Brito 1, Isabel Flores 2, Jacinto Monteiro 1
PMCID: PMC7047296  PMID: 32577110

Abstract

Background:

The impact of surgery on the quality of life of adolescents with idiopathic scoliosis (AIS) remains to be clarified as most of the studies are retrospective and few include quality of life questionnaires completed in the pre- and postoperative periods.

Methods:

Operated patients with AIS who completed preoperative and postoperative SRS-22 questionnaires were selected for evaluation. The demographic data were collected and quality of life improvement was assessed by comparing deviation to the means with standard deviation at both moments. Using the Minimal Important Clinical Difference (MICD) concept, individual improvement was also assessed.

Results:

28 patients (27 females) with an average age of 14.4 years (min: 12 – max: 18) and an average Cobb angle of 61.46º (min: 35º– max: 98º) were retrospectively reviewed. The correction rate was 68% with a final Cobb angle of 18.97º (min: 7.37º – max: 37.6º). The Global SRS22 score and all sub domains showed a significant variation (p<0,01). Self-image, followed by mental health, were the subdomains where the mean differences was more relevant, with the highest effect dimension given by d-Cohen analyses (Self-image d-Cohen 2.51; Mental health –d-Cohen 0.86). Both mean score differences as well as global SRS22 score reached the MICD but, while 96.4% of the patients did so for self-image ,the same only happened in 50% of the patients in Mental health and global score. No clinical relevant change occurred in pain or activity domains.

Conclusion:

Taking into consideration the AIS natural history and the fact that the most relevant change after surgery occurs in patients’ self-esteem, the advantages of a surgical treatment should be thoroughly evaluated not only based on curve severity but also by looking at which quality of life subdomains are mostly affected and which are expected to improve in order to meet proper patient expectations.

Level of evidence: III

Keywords: idiopathic scoliosis, surgery, quality of life, SRS-22

Introduction

Adolescent idiopathic scoliosis (AIS) is a tridimensional deformity of the spine which usually manifests itself at the beginning of puberty through an esthetical alteration of the trunk. This disease has a 2-3% prevalence in the general population and predominantly affects the female gender, with 10% of the patients requiring treatment and only 0.1% surgical correction.1-3 Weinstein et al., who studied a population of patients with scoliosis untreated for 50 years and compared it with an equivalent population with no scoliosis, revealed a similar survival rate and dyspnea on exertion in 22% of the population with scoliosis (15% in the control population, odds ratio=9.25 scoliosis > 80º and thoracic apex). Regarding pain, 61% of the scoliosis patients presented lumbar pain (35% in the control population), even though the pain was considered mild to moderate in most of the cases. Self-image and the perception of functional limitation were the most affected areas, despite the almost overlapping of the psychosocial indexes of the two populations.4 Conversely, other retrospective studies suggest that untreated patients refer reduced activity level, pain and psychosocial problems, including lack of self-esteem and depression.5-7

In fact, even though scoliosis is easily recognizable, the greatest difficulty lies in realizing to what extent deformity affects the quality of life of adolescents. Freidel K et al. mentioned that adolescents are less enthusiastic with their lives and present greater tendency for depression and physical incapacity when compared to peers.8 Payne et al. stated that, regardless of treatment phase, scoliosis in itself was considered a risk factor for psychiatric disorder,9 which may explain the differences in young people’s adherence to conservative treatments with braces, or even in the interpretation of the clinical results of the surgery.11-13 In recent years an effort has been made to include evaluation scales filled in by patients themselves in clinical research interpretation, particularly those from the Scoliosis Research Society (SRS),14 The validity of the SRS scale with 22 questions (SRS-22) was well demonstrated by Arsher et al. in the context of idiopathic scoliosis, and it has been validated for several idioms and is amply used.15-17 Yet there are still difficulties in the interpretation of the studies which applied these scales due to a relative lack of data on normality and the fact that statistically significant differences might not be clinically relevant. Therefore, the concept of Minimal Important Clinical Difference (MICD) emerged, which helps to compare populations with and without scoliosis, as well as to determine the clinical outcome of the treatment.18-20

AIS surgery aims to stop deformity progression by preventing the emergence of degenerative disorders of the spine, as well as the compromise of the cardiorespiratory function present in progressive deformities of the thoracic spine. Even though recent studies show that 23-54% of the patients report spine pain, this disease is still considered asymptomatic and rarely is pain the main surgical indication.21-25 And if surgical correction is usually effective in reducing deformity, an objective improvement in the quality of life of the adolescent is not always easily foreseen, as there is no direct correlation with the radiographic result. Hence, the importance of clarification for both the adolescent and their parents on the purpose of surgical indication and, above all, on what to expect from scoliosis surgery, is paramount, as most of the patients are highly functional.

This study aimed to assess the impact of AIS surgery on adolescent quality of life by applying the SRS-22 questionnaire before and after the surgery, as well as by trying to identify the subdomains where this impact is more relevant according to well established MICDs.

Methods

From all AIS patients who underwent surgery in our department, the patients who completed the SRS-22 questionnaire on quality of life before and after the surgery at the date of the last assessment at orthopedics outpatient clinic were the ones selected for our study. All deformities were measured in pre- and postoperative long standing radiographs at the last follow-up appointment (Figure 1).

Figure 1.

Figure 1

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Sixteen year old at preoperative (a) with marked deformity of hte trunk presenting a SRS-22 global score of 3.52 (Function: 4; Pain: 3.8; Self-image: 1.8; Mental health: 2.8); 14-year-old at postoperative (b) with corrected deformity presenting a SRS-22 global score of 4.54 (Function: 4.2; Pain: 3.8; Self-image: 5; Mental health: 4.6).

The SRS-22 questionnaire applied to the patients presents 20 questions distributed among four subdomains: Function, Pain, Self-image and Mental health, and two additional questions regarding satisfaction with received treatment. Each subdomain consists of five questions scored from one (worst) to five (best). The questionnaires were answered by the adolescents, alone or in the presence of their parents, out of the consultation office. Data were recorded in a Microsoft Excel spreadsheet and statistical analysis was performed using the IBM SPSS Statistics 23 software.

T-Student tests were used in matched samples to analyze the results, as the goal was to measure the difference of the mean of patients’ answers before and after the surgery by using mean values and standard deviation at both moments. D-Cohen was used as measure of effect size, since it expresses the differences between the means in standard deviations. Differences whose D-Cohen scores were above 0.2 were considered relevant, in compliance with the interpretative table for this indicator. A new variable (Zvariation=global SRS score or the score of each final subdomain - global SRS score or each preoperative subdomain) was created for this assessment, so as to determine the proportion of patients who improved, remained the same or deteriorated, as the information was considered complementary to the interpretation of the differences of the means. Finally, the differences obtained with surgery and the Minimal Important Clinical Difference (MICD), i.e. the difference with impact on the patient’s quality of life18.19 in each subdomain, were compared. The MICD values used, resulting from the method based on the relevant mean effect, which considered the standard deviation and the instrument correlation coefficient for the four subdomains (0.6 for Pain, 0.8 for Function, 0.5 for Self-image and 0.4 for Mental health), were in line with the recommendations of Bago et al.20 Regarding the global SRS-22 score, the difference based on improvement perception tests was applied, as this was higher than the value resulting from the analysis based on the mean effect. Satisfaction results were also analyzed, despite the absence of a Minimal Important Clinical Difference.

Results

This study analyzed 28 adolescents (27 females) with a mean age of 14.4 years (min: 12 years – max: 18 years) suffering from a mean deformity of 61.46º (Cobb angle: min: 35 – max: 98º) whose AIS surgery was performed by the same surgeon and who completed their SRS-22 questionnaires before and after the surgery. The patients presented relatively long spine instrumentations with an average of 11 fixated vertebrae per instrumentation (min: 5 – max: 15). The deformity correction rate obtained with surgery, i.e. the final Cobb angle – initial Cobb angle multiplied by 100, was 68.2% (min: 40 – max: 90.7%), and a mean deformity of the final Cobb angle of 18.97º (min: 7.37 – max: 37.6º) was obtained. Thoracoplasty with the partial resection of three to five ribs at the deformity convexity level was resorted to in 11 cases so as to improve the esthetical result of the surgery. Spine instrumentations were preferably performed with screws to fix vertebrae pedicles and two rods to attach the screws, with a mean implant density (number of screws used per included vertebra multiplied by two, as each vertebra has two pedicles, multipied by 100) of 68% (min: 46% – max: 100%). In 13 patients only the major curve was instrumented. In no case was there any need to return to the operating room to resolve complications. All the patients answered the SRS-22 questionnaire both before and after surgery with a mean follow-up of 36 months (min: 24 – max: 72).

When comparing the questionnaires completed preoperatively and those completed postoperatively at the time of the last assessment, a statistically significant improvement (P≤0.01) was observed both in the global score and in the subdomains. Nevertheless, only the global SRS score, Self-image and Satisfaction, and, to a lesser extent, Mental health, exhibited a meaningful dimension, becoming more relevant (Table 1). Therefore, the difference observed with the surgery in the subdomains Pain (D-Cohen=0.68) and Function (D-Cohen=0.75) were less relevant, with a small mean variance of 0.39 and 0.32, respectively, since high preoperative scores were already present. Self-image and Mental health were the subdomains where the adolescents presented the lowest preoperative scores, which translates the impact that deformity has on the psychosocial sphere (Table 1). On the other hand, Self-image was the subdomain where the most significant variation introduced by surgery was observed, with a mean difference of 1.44 and an effect size of 2.51.

Table 1.

Clinical Result of Adolescent Idiopathic Scoliosis Surgical Treatment Comparing SRS-22 Questionaire Scores in Pre and Post Operative Periods with a Mean Follow Up of 36 Months

SRS22 Domains Pre-operative Post-operative S (p) Mean Difference D-Cohen
SRS Global score 3.79 (0.43) 4.46 (0.32) 0.000 0.67 1.76
Function 4.04(0.45) 4.36 (0.39) 0.002 0.32 0.75
Pain 4.01 (0.61) 4.4 (0.54) 0.01 0.39 0.68
Self-image 2.96 (0.7) 4.4 (0.41) 0.000 1.44 2.51
Mental Health 3.72(0.68) 4.25 (0.54) 0.001 0.53 0.86
Satisfaction 4.15 (0.73) 4.87 (0.49) 0.000 0.72 1.15
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The evolution of the mean of each score after the surgery is presented in Figure 2 (a), where the number of patients which improved, maintained or reduced their scores in the various subdomains (b) can be observed. The same figure also shows that all the patients were satisfied with the surgery, and just in two cases (7.1%) did the SRS-22 score diminish after the surgical intervention. Only Pain and Function correlated with one another (r=0.389, p=0.041), and no relevant direct correlation was observed between Self-image and Mental health.

Figure 2.

Figure 2

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a) evolution of the means for each score after the surgery; b) number of patients which improved, maintained or reduced the score in the various domains.

When calculating the variation of each score pre- and post-surgery (Zvariation) and comparing this with the Minimal Important Clinical Difference, we verified that even though 98% of the patients improved their global SRS-22 score, only 50% reached a MICD of 0.6 (Figure 3). Moreover, only four patients (14.2%) exceeded the MICD threshold in the Function domain (Figure 4a) and nine patients (32%) reached the MICD in the Pain domain (Figure 4b). Improvement was observed in 100% of the patients in Self-image, where 27 adolescents (96.4%) reached the MICD. The same did not, however, occur in Mental health, where greater variability was registered in the evolution of the score, as only 14 patients (50%) reached the MICD (Figures 5a and 5b). Furthermore, a decrease in the global SRS-22 score was observed in two patients, although the MICD was not exceeded (Figure 2b). Notably, a relevant number of patients reported lower scores in the subdomains Pain, Function and Mental health after the surgery. Finally, the satisfaction analysis of the questionnaires completed by the adolescents lead us to state that all the cases presented a higher level of satisfaction postoperatively, when compared to the preoperative period (Figure 6).

Figure 3.

Figure 3

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Value of individual variations of the SRS-22 score, resulting from the subtraction of the initial score from the final score, with horizontal line representing MICD value.

Figure 4.

Figure 4

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Value of individual variations of Function (a) and Pain (b) scores resulting from the subtraction of the initial score from the final score, represented with horizontal line representing MICD value.

Figure 5.

Figure 5

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Value of individual variations of Self-image (a) and Mental health (b) scores resulting from the subtraction of the initial score from the final score, with horizontal line representing MICD value.

Figure 6.

Figure 6

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Level of satisfaction with the treatment, both before and after the surgery.

Discussion

The results emerging from this study can be considered particularly relevant to both the patients and their families and the surgeons who treat scoliosis. This study clearly states that with a deformity correction rate of 68%, which overlaps those published in literature, surgery statistically significantly improved all the domains assessed by the SRS-22 quality of life questionnaire. Nevertheless, only the results of Self-image and Mental health deviate from the mean, with a relevant effect size which also conditions the variation of the global score of the questionnaire. Even though thoracic deformity is quite visible, its repercussions in the quality of life of adolescents is not linear, which may hinder the appreciation of the impact of surgery on the psychometric domains of clinical outcome scales26 and, therefore, explain these results.

Rushton et al. assessed the impact of scoliosis on the quality of life of adolescents by comparing SRS-22 scores of adolescents with scoliosis with scores of the same questionnaire completed by adolescents without scoliosis. 81% of the published series showed that the adolescents with scoliosis registered a reduction in the Pain score, even though only in 5% of the series was this difference clinically relevant. On the other hand, Self-image decreased in 91% of the series, of which 73% were clinically relevant reductions. Moreover, neither Mental health nor Function presented clinically important differences.27 Similarly, in our population, Self-image was the only clinically decreased subdomain during the preoperative period, whereas the remaining subdomains reflected the scores reported by the normal population published by Verma et al.28 Hence, the need arises to clearly understand the value which may eventually be added with scoliosis surgery. Even though 40% of the adolescents do not seem to be affected by the diagnosis and the eventual treatment of the disease, Danielsson et al. referred that 25% to 43% of the adolescents may present symptoms of depression and isolation, thus translating the impact of the deformity on their psychic sphere.29 In line with this association, Andersen et al. showed that, irrespective of the treatment performed, there is significant improvement in the psychologic outcome when the procedure is performed before the age of 16 years. Therefore, surgery should not be long postponed, especially in cases of children with low psychometric evaluations in the Self-image and Mental health subdomains.30

As shown, adolescent idiopathic scoliosis surgery aims to prevent deformity progression, thus preserving respiratory function, delaying the appearance of degenerative alterations, and, at the same time, improving the appearance of the trunk. In essence, the surgery which treats adolescent idiopathic scoliosis seeks to substantially improve the quality of life of young people and is usually recommended for deformities whose Cobb angle is above 40/50°. It is, therefore, the responsibility of the surgeon to convincingly demonstrate that this goal may be achieved with the surgery. For this reason, clinical outcome studies should include not only radiographic aspects, but also features related to the quality of life of the adolescents, namely the activity, pain, mental health and cosmetic levels. Moreover, patient expectations should be thoroughly included in the study, for, if not very clear, they might not be achieved and might affect the clinical outcome of the procedure.

After comparing the means of each score of the SRS-22 questionnaire, both before and after the surgery, the Minimal Important Clinical Difference (MICD)18,19 concept was applied to the differences recorded for each patient in each subdomain. A gain in Self-image becomes, then, evident, as 98% of the patients exceeded MICD. The same did not occur for Mental health, where only 50% of the patients presented a clinically relevant positive variation. For Pain and Function, our data showed that, based on a sample of 28 patients without any complications, only four (14%) referred an increased activity level and nine (32%) mentioned a clinically relevant improvement in Pain. Regarding the global SRS-22 score, 50% of the patients achieved a clinically relevant improvement. However, as abovementioned, this is mostly due to an improvement in Self-image, which, on its own, conditioned the great level of satisfaction. Bago et al. reached the same conclusion when they reported an improvement above the MICD in the SRS-22 score in only 52% of the adolescents after a 2-year follow-up.20 On the other hand, Upasani et al. registered a deterioration of the scores in the period between two and five years after surgery, namely in Pain, even though the majority of the patients kept a high level of satisfaction.31

The component Pain will probably require reconsideration both of the Minimal Important Clinical Differences for this subdomain and of the content of the questions which provide its score in the SRS-22 questionnaire. For example, in our sample, a variation above 0.42 in this subdomain (preoperative standard deviation multiplied by a D_Cohen of 0.7 – which is considered a relevant effect) would disclose a more expressive improvement in pain. Rushton et al. even questioned if, in the context of idiopathic scoliosis, Pain was not being underrated, since 82% of the published series reported a statistically significant decrease of pain with the surgery. According to Landman et al., the prevalence of pain in idiopathic scoliosis was of 77.9% in a universe of 1,433 adolescents, and it is more correlated with high thoracic curves, obesity and perception of deformity.32 The patients with a lower score in the Pain domain were indeed the ones who, according to Danielsson AJ et al., benefitted more from the surgery, as most pain complaints were resolved.33

Given the relative benignity of the natural history of adolescent idiopathic scoliosis and the insufficient knowledge of the impact of deformity progression on the quality of life of the patients, we also share Danielsson AJ et al.’s concern, who state that the benefit of the surgery reported by the different authors has been, to a certain extent, overvalued.33 When analyzing the goals of surgery in mild to moderate deformities, we verify that, ever so often, we will be prophylactically intervening in the probable progression of scoliosis with no obvious short- to medium-term impact. Moreover, we also emphasize that two patients of our series presented decreased global SRS-22 scores, which represents a reduction in the quality of life of the adolescents, even in the absence of complications, thus showing that sometimes we may fall short of what was expected.

Even though the prevalence of pain in the population with scoliosis and its negative impact on the self-image, with possible repercussions in metal health, is well known, in some cases we may have to face preoperative high scores in all SRS-22 domains. Providing that adding a clinically relevant gain may not be very realistic, these are borderline cases where the benefits of surgical treatment should be carefully assessed and the natural history of the disease, the subdomains affected by the clinical condition and the patient’s expectations should be considered.

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