Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Paul D. Sponseller, MD*,
Johns Hopkins Medical Institutions, Baltimore, Maryland
Posted June 2008
It is rare in orthopaedic surgery that we have the
opportunity to look at the effects of our treatments over a substantial portion
of our patients' lives. This paper studied two patient populations. The stated
aim of the authors was "to evaluate whether spinal deformity or back pain in
adolescence affects quality of life more in midterm to long-term follow-up." Their
hypothesis was that the surgically-treated spondylolisthesis patients, because
they require shorter fusions, would have better long-term health-related
quality-of-life scores compared with patients with adolescent idiopathic
scoliosis. Their method was a long-term look at surgical spine treatments with
use of two accepted general and disease-specific outcomes tools. The authors
had excellent retrieval (84%) at a mean follow-up time of fifteen-years (with
the patients still only thirty years of age!).
This retrospective study has several limitations: They did
not have benefit of controls—there were no patients who had been conservatively
treated—and there were no preoperative evaluations of these patients with which
to compare the postoperative outcomes. Data on the patients who had scoliosis were
collected first, and data on the patients who had spondylolisthesis were
collected several years later. Both populations have been reported on previously
and separately1,2 from this same center. This report is a comparison
of these two patient groups with a greater number of patients in each group.
The authors use these populations to attempt to answer a
somewhat philosophical question about pain compared with deformity. However,
scoliosis and spondylolisthesis involve elements of both pain and deformity. Scoliosis
is a deformity that is associated with back pain in about one-third of
adolescents. Spondylolisthesis is a deformity of segmental lumbosacral kyphosis
and translation that initiates a compensatory lordosis. It also is associated
with varying degrees of pain. Both patient populations had partial correction
of the deformity; the residual scoliosis for a large portion of this population
was previously reported to be >30°, and the residual spondylolisthesis was
41%.
The Scoliosis Research Society-24 (SRS-24)
and SF-36 measures correlated well with each other for pain and several SF-36
subscores. However, there was no correlation between the magnitude of residual deformity
(scoliosis or slip) and the SRS-24 or the
SF-36 total or subscales. Perhaps if the residual deformities were more severe,
a relationship would have been evident. The contemporary surgeon will wonder
how current techniques would compare, as there would be a greater correction of
deformity currently possible, but with different complications. By the time we
can achieve comparable follow-up, treatment algorithms will have changed
further still. Such is the challenge of evidence-based decision-making.
What can we learn from this retrospective study? Both
patient populations seem to function well into young adulthood. A
half-generation follow-up of more than 400 patients comprising 84% of the index
population is good evidence of that. Only 6% to 8% of the patients had daily
back pain often or at rest. Overall, the patients who had scoliosis scored more
favorably than the patients with spondylolisthesis did. We do not know what the
comparison will show in another forty years.
The finding that spondylolisthesis leads to lower general
and disease-specific health outcomes, even after surgical treatment, is
sensible. In apparent answer to the authors' hypothesis, even though the
surgical fusion is more focal in
patients with spondylolisthesis than in patients with scoliosis, the deformity
and initial pain may be more challenging. Sagittal deformities tend to be more
physically evident and functionally compromising than coronal deformities are.
This study illustrates the difficulty and the work that remains to be done as
health professionals begin to objectively compare different diseases and/or
deformities and their treatment and translate them into meaningful terms.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Helenius I, Remes V, Yrjönen T, Ylikoski M, Schlenzka D, Helenius M, Poussa M.. Harrington and Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis. Long-term functional and radiographic outcomes. J Bone Joint Surg Am. 2003;85:2303-9.
2. Lamberg T, Remes V, Helenius I, Schlenzka D, Seitsalo S, Poussa M. Uninstrumented in-situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: long-term outcome. J Bone Joint Surg Am. 2007;89:512-8.
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