Background
Scoliosis, as a general medical term is better known as a lateral curvature of the spine 1, and is conventionally measured using the Cobb angle technique of X-rays taken of the coronal plane view 2. But as it presents clinically, the condition is actually a much more complex deformity and to correctly measure and define the different effects it has upon the human spine it is necessary to use 3D terminology along with observations taken on the three anatomical planes 1.
The underlying cause of scoliosis may on some occasions be clearly determined, such as congenital changes, or neuropathic or myopathic conditions, or a form of degenerative spondylosis. In the majority of cases, the causes are unfortunately unknown and have come to be known as having 'idiopathic' scoliosis 3. Adolescent Idiopathic Scoliosis (AIS), the most common form of scoliosis, is a three-dimensional structural deformity of the spine and of the trunk, occurring in otherwise healthy children during puberty, while early onset idiopathic scoliosis occurs before puberty 4. AIS has been classified according to specific curve patterns and these patterns clinically may appear more or less pronounced (Figure 1).
<p>Figure 1</p>
Similar Cobb angles clinically may look different depending on curve pattern
Similar Cobb angles clinically may look different depending on curve pattern. All patients on this figure have a Cobb angle of 40 degrees. As can be seen, the more decompensated a curve, the more visible the deformation. Double major curvatures are compensated; the most stable curves present after the end of growth 4 and therefore rarely requiring surgical treatment.
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Historically, in central Europe the treatment for AIS – and for some other forms of scoliosis as well – includes; Physiotherapy (PT) on an outpatient basis; Scoliosis In-patient Rehabilitation (SIR); corrective bracing and surgery, with or without spinal fusion 567. Conservative Scoliosis Management is usually regarded as effective when curvature progression has been stopped below specific limits, although parameters other than curve progression may play an important role in terms of outcome 456.
Spinal fusion surgery, which is recommended when magnitude of curvature exceeds 40–45 degrees, has been used as a treatment for nearly a century 8910. The aims and goals of surgery have varied widely. Early hopes that spinal fusion could be used to leave the patient with a mild residual deformity were not successful as a third of patients lost all postoperative correction within 1–10 years post surgery 11. Expectations have been revised to the more modest goals of preventing progression, restoring 'acceptability,' and reducing curvature. In spinal fusion the vertebrae are accessed by posterior, anterior, or thoracoscopic incision. The main principle these surgical techniques have in common, is the use of the spine as a structural scaffold, cementing the parts onto this via a bone paste, giving it an overall straighter shape. 10121314. These surgical methods are based on the expectation that this operation will heal well and remain sturdy for the lifespan of the patient. Steel rods, screws, wires etc. have been used to reinforce the stability of the spinal fusion 131415161718 and the choice of the instrumentation used is based upon the preferences of the surgeon 1920212223. The specific choice of these has been reviewed recently 212223. Failure of spinal fusion requires re-operation to restore curvature correction 19 (Figure 2). In a recent review 24, the different kinds of complications which may arise during or after scoliosis surgery have been listed:
<p>Figure 2</p>
Failure of spinal fusion often requires salvage surgery
Failure of spinal fusion often requires salvage surgery. Failure of the ventral instrumentation (VDS): An additional dorsal rod was implanted to stabilize the spine.
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Complications of Spine Surgery independent of aetiology
In principle, all kinds of complications may occur in all scoliosis aetiologies 24. However, in the otherwise healthy subjects with AIS the incidence of major complications may not be as high as in neuromuscular disorders 24. Before outlining the incidence and prevalence of complications (Tables 1, 2 and 3) it is of primary importance to describe the possible complications independent of the aetiology.
<p>Table 1</p>
Pooled rate 122 of complications for the different aetiologies
Studies
Average rate
Range
Neuromuscular Scoliosis
22
35% (SD 21)
0 – 89%
Adult Scoliosis
11
44% (SD 24)
10 – 78%
Idiopathic Scoliosis
11
20% (SD 22)
0 – 73%*
Early onset Scoliosis
1
48%
Congenital Scoliosis
4
14% (SD 23)
0 – 48%
Congenital Heart Disease
1
27%
This table shows the wide range of variability of the overall complication rate in the different entities. * In the IS group one study on fusion down to the pelvis 69 showed the highest rate of 73%.
<p>Table 2</p>
Pooled rate 122 of major complications for the different aetiologies
Studies
Average rate
Range
Neuromuscular Scoliosis
17
17,4%
0 – 39%
Adult Scoliosis
6
30%
10 – 62%
Idiopathic Scoliosis
7
8,6%
0 – 37%*
Congenital Scoliosis
3
3%
0 – 9%
The pooled data 122 seems incomplete in comparison to the total rate of complications, because in the various papers major complications were not always shown. Therefore, a statistical analysis does not make sense. However, this table shows the wide range of variability of major complications in the different entities. * In the IS group one study on fusion down to the pelvis 69 showed the highest rate of major complications (37%), whilst the range in the IS group, excluding this paper was 0 – 9,5%.
<p>Table 3</p>
List of individual complications occurring in the different scoliosis aetiologies as found in the reviewed literature
Complication
NM
AS
IS
CS
Mixed
Death
6,5%
(3S) 2,5%
0,03%
Pseudarthrosis
(7S) 13,1%
(7S) 17,5%
(5S) 5%
(4S) 23%
Deep wound infection
(3S) 13,2%
(S2) 3,1%
4,7%
Neurologic Complications
(2S) 7,5%
(3S) 1,5%
9%
(4S) 2,7%
Delayed Infection
(2S) 2,9%
Pedicle screw mispl.
(2S) 15,8%
10,5%
Delayed Paraparesis
X
Individual complications as have been found in the literature reviewed for the rates of complications 136869717788135138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215 as a descriptive analysis for neuromuscular scoliosis (NM), adult scoliosis (AS), idiopathic scoliosis (IS), congenital scoliosis (CS) and scoliosis of mixed aetiology (Mixed). Whenever there was more than one study found describing a certain complication rate, the number of studies (S) has been given and the rates have been averaged. X = described once.
Risks of spinal fusion include those occurring in any major surgery, such as severe blood loss; urinary infections due to catheterization; pancreatitis; and obstructive bowel dysfunction due to immobilisation during and after surgery 25262728293031. The frequency of specific complications, including death is unknown. This is due to problems in reporting such as; mandatory reporting, definitions, interpretation of complications and compliance varies 32. Information is based on voluntary reporting by clinicians. Other risks of scoliosis surgery are summarised below.
Death and neurological damage
The incidence of death as a complication of spinal surgery, for otherwise healthy patients is reported to be less than 1% 33. In one survey, only one child out of 352 patients died of peritonitis 34 and in a group of 447 patients, two deaths occurred due to pulmonary complications 35. The life expectancy of patients with a complex neuromuscular condition was significantly reduced by spinal surgery 36. Another study involving adults with a less than 60% vital capacity measure, 20% had died within 1 year post surgery 37. In a survey further highlighting these complications 38, 21% were contributed to be secondary to spinal fusion surgery.
Symptoms of neurological damage post-surgery include; partial or total paraplegia, quadriplegia, or peripheral nerve deficit 2539. Neurological deficits can result from vascular, metabolic, or mechanical complications of spine surgery 404142434445464748495051. Published cases include migration of bone graft into the spinal canal 48; breakage of implants 52; penetration of instrumentation into the spinal canal 49 and compression of the nerve roots by components of implants 39.
Loss of normal spinal function
In each spinal surgery case there is an irreversible loss of the normal active range of movement in the spinal column 535455, including the non-fused segments 565758. When compared with control subjects, the ability of surgical patients to side flex was reduced by 20–60% 59. This loss of spinal mobility has gained little significance in the literature, especially in relation to the detrimental effects upon patient health, function, and quality of life. Winter et al. 59 argued that 'it has long been a clinical observation by surgeons who manage scoliosis that patients seem to function well and be relatively unaware of spinal stiffness, even after many motion segments have been fused.' No data in support of this observation is provided. In actual fact, it has been shown that in non-surgical cases, pain increases as flexibility is reduced 60.
Strain on un-fused vertebrae
The post surgical rigid spine causes strain on the un-fused parts of the skeletal framework 545556575859 and in a severe case, a woman sustained stress fractures to the pelvis 61. More commonly reported are post surgical degenerative changes, which occur in young adults 62 and in adults, sometimes within 2 years post-surgery 52. A higher degree of correction results in a higher rate of degenerative osteoarthritis and the high stress on the rigid spine means that even low impact can cause serious injuries 63. Surgeons now recommend that in surgically treated scoliosis patients, 'trauma physicians should have a high index of suspicion for potential spinal injuries above a previous multi-level fusion' 63.
Post-surgery pain
Pain is the primary indication for re-operation 646566. The mechanism for increased neck and back pain after surgery is not well understood 67. Bridwell 10 suggests that late-developing pain could be a complication of surgery, or an effect of aging, or 'perhaps a focus on the disability associated with spinal deformity and surgical treatment.' But the answer for surgeons seems to be to re-operate 68. Among 190 patients, 19% required re-operation within 2 to 8 years after surgery 67. For 27 patients who sought treatment 59% felt their pain had been reduced, but 41% did not feel a reduction in their pain levels, and a further 26% were very unhappy with the outcome 68. Among 34 patients with significant post surgical pain, 56% reported reduced pain after additional surgery, while 44% did not; in the same study, 2 patients who did not have pain before surgery reported pain in the follow up 69.
Pain at the iliac graft site, first noted in 1979, has now been formally published 7071; of 87 patients, 24% complained of pain at the graft site, with 15% reporting severity sufficient to interfere with daily activities. As reported by the authors such problems with iliac crest grafting have been severely neglected in literature, especially problems associated with rib-resection.
Infection and inflammatory processes
Infections from surgery may manifest months or years later 72737475767778798081 and has been detected more than 8 years after surgery, with 5 to10% of patients developing deep infections at 11–45 months after surgery 7778 and in some cases, leaving the spinal cord exposed to injury 78. Infections reportedly are becoming more common, perhaps due to larger instrumentation used 77 or perhaps due to the increasing prevalence of multi-drug resistant bacteria in hospital settings. Inflammatory responses to metallic instrumentation can occur independently or in conjunction with infections 79. Particulate debris from implants can stimulate an autoimmune response that can result in bone deterioration 80. In most cases, additional surgery to remove instrumentation and to treat the wound is required 81.
Infection may also be transmitted through blood transfusions needed to replace the large amounts of blood lost during invasive procedures 82 and a similar risk occurs with the use of allograft 83. Some have reported to be infected with HIV following this type of surgery 84. In a survey of spine surgeons, 41% of those using allograft reported having concerns about the risk of disease transmission and 88% of those make it a policy to inform patients or parents 85.
Curvature progression
Some curvatures continue to progress after spinal fusion due to broken rods or other failure of instrumentation. Renshaw 13 has said that, "One would expect that if the patient lives long enough, rod breakage will be a virtual certainty." Furthermore, discomfort may occur when any pressure is placed against the back; this is especially problematical with newer bulky instrumentation implanted in thin patients 10.
'Pseudarthrosis' ('false fusion') or failure of the bone graft, which constitutes the spinal fusion, can occur years after surgery and can be difficult to diagnose 8687. Among 74 patients treated surgically between 1961 and 1976, pseudarthrosis occurred in 27% of patients within a few years of surgery 88. For adult patients, 15% had failure of fusion and/or instrumentation requiring additional surgery 89. Curvatures may continue to progress in young children despite a rigid fusion, due to a 'crankshaft phenomenon' in which spinal growth causes rotation around the fusion 9091.
Decompensation and increased sagittal deformity
Beginning with Harrington rods, surgeons have experimented with instrumentation of increasing complexity and bulk to hold spinal fusions in place 24. Each new variety of instrumentation has brought with it new problems 24. One of the ongoing problems has been decompensation or the development of new deformities involving changes in sagittal contours and coronal balance of the body as a result of surgery 929394959697 (Figure 3 and 4). Reducing the lateral curvature in thoracic scoliosis can exacerbate the sagittal deformity and cause flattening of the cervical, thoracic and/or lumbar spine beyond that which caused the deformity itself 94959697. Development of 'flatback' is a painful condition with potentially devastating complications such as disability 98. In response to such discoveries, focus is shifting towards the sagittal contours and coronal balance of the spine 10.
<p>Figure 3</p>
Ventral decompensation after spinal fusion
Ventral decompensation after spinal fusion. After operation this patient was unable to walk upright. The implant fixed the patient in forward bent position.
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<p>Figure 4</p>
Lateral decompensation after fusion of the lumbar curve
Lateral decompensation after fusion of the lumbar curve. The lumbar curve has been fused; the thoracic curve progressed leading to a decompensation to the thoracic convex side. Because of the imbalanced appearance the patient was dissatisfied. There was no cosmetic/psychological benefit in this case and therefore this surgery should perhaps not have been performed.
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Increased torso deformity
Despite the application of force to straighten and de-rotate the spine during surgery, the rib hump can worsen after surgery 99100101102. Even when rib hump magnitude improves postoperatively, much of the correction can be lost and in many patients the situation is eventually worse than before surgery. In response, surgeons increasingly use costoplasty to assure an improved appearance, by excising the ribs that comprise the prominence 103. This procedure can in actual fact cause a progressive scoliosis 9 and the destabilising effects of rib removal can also result in a disabling condition called 'flail chest' in which the normal function of the rib cage is permanently compromised 104. Rib resection excises a substantial part of the functional components of the chest but the effects on chest expansion has not been documented 24. However, this procedure has been shown to reduce the volume of the chest cage and to substantially impair pulmonary function 24.
Other long-term complications
The complexity of spinal surgery is reflected in the diversity of complications that may occur months or years later. Given the time delay and difficulty in diagnosis, it is likely that only a minority of such events are recognised as surgical complications and when investigated are then recognised as being related to the surgery 88105106107108109110111112113114 (Table 4.).
<p>Table 4</p>
List of other long-term complications as found in literature 24
Complication
Curvature progression after surgery 1013868788899091
Decompensation 929394959697
Increased sagittal deformity 98
Increased torso deformity 99100101102103104
Emotional breakdown 88
Gastrointestinal bleeding (late complication 6 years post surgery) 105
Subarachnoid-pleural fistula 106
Blindness due to central retinal artery occlusion 107
Kidney failure due to compression of a ureter 108
Nerve root injury and degeneration due to compression 109
Recurrent meningitis 110
Chronic intermittent vomiting 111112
Cast syndrome 113114
Salvage surgery
Due to such complications outlined above more re-operation is necessary, sometimes referred to as 'reconstructive,' 're-corrective,' 'revision,' or 'salvage' surgery 115. Even stable fusions may fail in response to sudden force, for example, in the event of automobile accidents 116117. Some authors suggest that patients and their parents should be advised that it may take more than one operation 24. Documented cases of patients having had 5 or more salvage surgeries 69, as in one study, 22% of patients needed a total of 28 additional operations and of 110 adolescent patients 21% required implant removal 118. Complication rates vary; failure of fusion has been found in more than 50% of treated patients 24 and among 25 adult patients, 40% required salvage surgery 119. Even when a solid fusion has been obtained by the time of re-operation, removal of instrumentation 'may lead to spinal collapse and further surgery' 120.
From the patient's perspective, the preferred plan of action would likely to be based upon avoiding unnecessary risk i.e. avoiding surgery, or to keep it as the final option, once all conservative measures have failed. Under this premise, every effort should be undertaken to improve non-operative treatments for at least adolescent idiopathic scoliosis (AIS), the most common form of scoliosis which is regarded to be relatively benign 121. Other forms of scoliosis may have worse prognoses 4, however real long-term natural history studies do not exist for every single possible form of scoliosis.
Recently claims have been made for a randomised controlled trial (RCT) on brace treatment 122123124, although there is some evidence, that conservative treatment approaches can influence natural history of the disease and decrease the rate of progression 7.
Prospective controlled studies on in-patient rehabilitation and bracing 125126127 and consistent results in retrospective studies 7 justify the recommendation of at least grade B research 128. Therefore, to perform a RCT on bracing and withhold treatment on half of the patient population with significant curves until surgery may be recommended would be unethical 129. In view of the fact that there is no evidence that health related signs and symptoms of a scoliosis can be changed by spinal fusion in the long-term 24130131132133134, a clear medical indication cannot be derived from most scoliosis conditions 129131132133134. In the light of an actual publication on adolescent idiopathic scoliosis with a prospective design 135, showing the short-term risks of scoliosis surgery to be more than 3 times higher than previously expected from retrospective reviews, the matter of surgical indications at present should be investigated more closely in order to improve the patient's safety.
The paper by Martha Hawes 24 contains very comprehensive accounts of the reported complications of scoliosis surgery until early 2006. Just recently, new papers on this topic appeared 130135 and in the light of recent discussions about the specific indications for scoliosis surgery 130131132, a review on this topic seems desirable. The knowledge of the rate of complications of scoliosis surgery may enable us to establish a cost/benefit relationship for this intervention and to improve the quality of the advice given to prospective patients. This study will also address the question as to whether the risks of surgery are small enough to justify the 'wait and see – observation only' strategy, which is widely accepted 5.
The purpose of this review therefore, is to present the research available on the rate of complications in scoliosis surgery.
Results
The search carried out on 1st of February 2008, with the key words "scoliosis", "surgery", "complications" revealed 2590 titles, which not necessarily attributed to our quest for the term "rate of complications". 287 titles have been found when the term "rate of complications" was used as a key word.
Of these, 23 papers were found to report on the rate of complication in patients with neuromuscular scoliosis 138139140141142143144145146147148149150151152153154155156157158159160, 11 papers were found to report on the rate of complication in patients with adult scoliosis 68161162163164165166167168169170, 13 papers were found to report on the rate of complication in patients with idiopathic scoliosis (11 with a general rate of complications) 1369135171172173174175176177178179180181 and 4 papers were found to report on the rate of complication in patients with congenital scoliosis 182183184185. One paper included patients with early onset scoliosis 186 and one included patients with congenital heart disease 187. 11 papers reported on the rate of complication in patients with scoliosis of mixed aetiologies 88188189190191192193194195196197 and one in patients after re-operation 198.
Three papers were found to report on problems associated with pedicle screw fixation 199200201, 5 reported on problems associated with thoracoscopic procedures 202203204205206 and one on problems associated with vertebral body stapling 207.
There were also papers reporting on the rate of certain complications, like pseudarthrosis 208209210211212213, retrolisthesis 214, delayed paraparesis 215, delayed infection 77 and problems with posterior iliac crest bone crafting 71.
In 17 studies, the main focus was on complications, whilst in the others complications have been reported additionally to results, unfortunately most of these utilised different definitions, some of them focussing specifically upon certain complications. Within some of these studies, differences have been made between minor and major complications, however, in most of the articles, the borderline between major and minor have been drawn more or less at random. In one paper a clear definition is given 167, but this definition unfortunately, is not used as a valid general standard.
Major complications were considered to be deep wound infection, pseudarthrosis, transition syndrome, neurologic deficit, and death. Minor complications considered were asymptomatic instrumentation failure (without loss of correction), instrumentation prominence requiring removal, and proximal or distal 'junctional segmental kyphosis' (5–10 degrees) or subsequent disc space narrowing of 2–5 mm without clinical symptoms.
The pooled overall rate of complications for the different aetiologies can be seen on table 1. The pooled rate of major complications is listed on table 2 and the list of complications found within the reviewed papers can be seen on table 3 and 4.
Discussion
The prevalence of complications in scoliosis surgery seems quite high. The variation of the rates surely is dependent on the surgical procedure performed, on the specification of the subset of patients investigated in the various studies and on the distribution of Cobb angles in the different samples of patients. For instance, there are many subsets of conditions, which have to be regarded as neuromuscular (Duchenne muscular dystrophy, myelomeningocele patients, cerebral palsy, neuropathic scoliosis, spinal muscular atrophy and poliomyelitic scoliosis). The adult population may consist of adult patients with idiopathic scoliosis or of patients with degenerative deformity. Even the subset of patients with idiopathic scoliosis may contain more or less patients with early onset scoliosis, patients with different Cobb degrees and different maturity. Congenital scoliosis is no uniform condition as well. Therefore, a standardization of patient subsets does not seem possible.
The definition of major and minor complications also varies in these studies. Some authors report the major complications and some report the whole rate of general complications (Table 1 and 2.).
In one study, a re-operation due to instrumentation prominence 167 has been defined as a minor complication as were 'junctional kyphosis' and disc space narrowing. However, these complications may lead to a re-operation decades after surgery and then might cause major problems. Also, the high rate of pedicle screw misplacements 199200201, thought to be asymptomatic after operation might in fact cause problems in future years after surgery, as has been found in other complications 24.
The follow-up time is also different in the different studies. Long-term follow-up studies have not been found.
As highlighted by Hawes 24, the complexity of spinal surgery is reflected in the diversity of complications that may result months or years later. Given the time delay and difficulty in diagnosis, it is likely that only a minority of such events are recognized as surgical complications.
The data on the rate of complications seems rather in-homogenous and incomplete. Unfortunately there is no mandatory reporting of complications, neither is there a standardized way.
However, the high variability of complication rates could be clarified should a mandatory reporting system exist, reporting on all types of spinal implants in a standardized way. With a spreadsheet list of all recognized complications 24 a 2-year, 5-year, 10-year and 20-year rate of complications could be established for all implants available including the complications 'progression after operation', 'Increased torso deformity' and 'coronal and/or sagittal decompensation after surgery' which are often not really registered by the surgeon 248687888990919293949596979899100101102103104130.
There is a relatively high rate of complications in patients with neuromuscular scoliosis and the benefit for the patient remains questionable as outlined below:
"Cardio-respiratory function and life expectancy are not improved, but most patients and families are very satisfied by the comfort brought about by the surgical operation"159.
"Surgery should be considered as soon as frontal or sagittal collapse of the spine is observed. However surgery does not result in respiratory improvement, or extending life expectancy" [160].
The signs and symptoms of AIS obviously are not significantly influenced by surgery 24. Patients with rare diseases associated with scoliosis like Prader Willi syndrome do not clearly benefit from spinal fusion 133 and surgery of patients with congenital scoliosis has also specifically been under criticism recently 134. So called long-term studies reporting on congenital scoliosis patients reveal follow-up periods of 3–6 years with most of the patients being still before the pubertal growth spurt at final follow-up 216217218219.
To conclude from single case reports that; "the early fusion prevented the customary severe progression of this condition and early death due to cor pulmonale" 220221, seems biased when there could be the possibility that even without surgery cor pulmonale would not necessarily be the consequence of an untreated congenital scoliosis. The question raised by this research is; where is the research and long-term case reports where patients actually did experience severe problems due to surgery? Without such research one can only assume that the rates of complication may be even higher than those reported 222.
What specific evidence is there to support scoliosis surgery? The signs and symptoms of any kind of scoliosis obviously cannot be changed by scoliosis surgery and long-term beneficial effects have not been reported yet as there are no studies presenting long-term risks 24.
No report of the long-term surgical outcome (balance, rate of fusion, rib hump correction, cosmetic correction, pain, and patient satisfaction) is available for any series. Further prospective studies including these parameters will be required to determine the real benefit of such procedures to the patient 24.
As early as 1973, Paul Harrington envisioned in the future a common database or registry of all SRS members' patient's treatment results 8. Unfortunately the SRS failed to follow this vision until recently. Instead of achieving long-term evidence for surgical treatment on a higher level and addressing the problems after surgery to attempt to improve patient's safety, the surgical community is presenting large numbers of papers describing HRQL after surgery and related research 223224225226227228229230231232233234235236237238239240241. The problem with such studies however, is that they lack validity as they do not investigate the actual signs of scoliosis or the symptoms of the patient post surgery 242.
Those studies containing psychological questionnaires may be compromised by the dissonance effect 242243244245246, which applies to all situations that include important decisions to be made. Cognitive dissonance occurs most often in situations where an individual must choose between two incompatible beliefs or actions and there is a tendency for individuals to seek consistency among their cognitions. Unable to face an inconsistency, such as being dissatisfied with a surgical procedure, a person will often change his attitude or action.
Surgery is impossible to reverse, but subjective beliefs and public attitude can be altered more easily. The clinical significance of this is that a patient not satisfied with a surgical treatment may not necessarily publicly admit this, as Moses et al. have described in their paper 242:
"Slim objective favourable outcomes correlate with high post-surgical patient satisfaction, while a considerable share of patients with whom a highly favourable outcome has been attained express relatively low post-surgical patient satisfaction. This paradoxical trend may be well understood when applying Cognitive Dissonance Theory. The whole pattern of results point again at highly complex and powerful psychological processes, some of them seemingly irrational".
The dissonance effect is reflected in the scoliosis literature as well:
"Patient satisfaction is subjective. It does not reflect the benefits of surgery with respect to the future preservation of pulmonary function in thoracic curves nor the prevention of osteoarthritis in lumbar curves" 247. (Figure 5)
<p>Figure 5</p>
Balanced appearance with marked rib-hump after surgery
Balanced appearance with marked rib-hump after surgery. Although a marked rib-hump is clearly visible after surgery the patient is satisfied with the operation. The rib-hump reappeared after 5 years, however compensation has been maintained. The best cosmetic result was achieved directly after surgery.
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"Radiographic and physical measures of deformity do not correlate well with patients' and parents' perceptions of appearance. Patients and parents do not strongly agree on the cosmetic outcome of AIS surgery" 248. (Figure 6, 7 and 8)
<p>Figure 6</p>
Excellent clinical result without patient satisfaction
Excellent clinical result without patient satisfaction. Excellent clinical result 20 years after Harrington instrumentation. The patient is without pain, however suffers from lack of spinal function although the lumbar spine remained unfused. Additionally, the patient, operated on at the age of 13 years, complained that her parents made the decision. After operation the patient experienced significant functional problems she feels unable to cope with.
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<p>Figure 7</p>
Excellent radiological result without patient satisfaction
Excellent radiological result without patient satisfaction. An 'excellent radiological result' one year after ventral fusion. But the patient complained about the decompensation (clinical overcorrection) and the visual prominence of the shoulder blade.
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<p>Figure 8</p>
Not the best clinical result with patient satisfaction
Not the best clinical result with patient satisfaction. This patient was satisfied although two operations have been necessary and the rib-hump and decompensation are still visible. This satisfaction may be the result of the dissonance effect 242.
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From searching all of the studies based on questionnaires within this review, no evidence can be derived that supports the assumption that patients have experienced benefits from undergoing surgery, as none were able to rule out the cognitive effect of dissonance. Without being able to rule out such effects on the post-operative experience these outcomes do not appear to be reliable 4249250.
Today, from the patient's perspective, healthcare professionals have more open questions than answers when approaching the subject of spinal surgery in patients with scoliosis. For example; What are the long-term effects in the elderly; how long does the cosmetic effect of an operation last; is there a prospective controlled study clearly showing that scoliosis surgery really prevents progression in the long term; does the untreated patient really feel more impaired when progressing 10 degrees more in 20 years?
In view of the questions raised by research 129130, the lack of measurable medical benefit 24 and the high amount of short and long-term risks of the surgical procedures applied, the decision to have surgery does not seem to rely on any valid evidence to support it. The informed patient should perhaps make the final decision after being provided with all the objective facts available. As there is also no clear benefit for the operation in patients with neuromuscular scoliosis 159160, the indication in these cases deserves to be debated and approved by ethical committees.
Claims for a randomized controlled trial on bracing also seem unethical 129. To allow growing patients to continue without conservative treatment (a control group) until surgical intervention may be recommended, is completely unethical, especially when one considers the problems with surgery, such as; primary risks; a re-surgery rate, which might be higher than 44% in the long-term 424250 and still undetected future complications which might comprise the elderly patients 4.
It is recognised that this review is limited to the Pub Med/Medline and SOSORT databases and that further database searches would deepen the topic further. To find more variations in a bigger number of papers would not lead to other conclusions as to those that have already been drawn. The lack of standardization of the reports on complications does not allow final conclusions on the numbers per se. The procedure of averaging rates (pooling) as performed in another paper 122 will not permit the estimation of the risk for the individual case. Like the quality of bracing 122 the quality of treatment in surgery is hardly defined in the literature available. It is possible that clinics with smaller rates of complications exist, but in the same way it is possible that clinics with higher rates also exist, which simply may not report their rates of complication publicly 32222.
A first step into the right direction has been made by the Scoliosis Research Society: In the Scoliosis Research Society Morbidity and Mortality Reports (2002 – 2005) 251 57 of all patients with spinal fusion (0,2%) died mainly due to cardiac causes, 59 of the scoliosis patients (0,8%) had neurological deficits (in patients with dwarfism mainly), infections between 0,9% (Idiopathic Scoliosis) and 3,4% (neuromuscular scoliosis) and an overall complication rate of 8,6% when all scoliosis aetiologies are concerned (SRS 2002 M & M data abstract 251). Unfortunately in the years 1994 to 2005, there is a varying percentage of SRS members submitting data, ranging from 35 to 70% (SRS 2005 M & M data abstract 251). Additionally to that not all types of complications are registered like many of those described in the introduction of this paper. The long-term complications, that may develop years after surgery 24 are not listed in the M & M summaries 251, which are not easily accessible to the public.
In the light of the conflict of interest many spine surgeons have because of their affiliation to industry 251252253, the indication for surgery in the case of scoliosis may well be more appropriately assigned to a more specialized role. For example, a conservative scoliosis specialist that can utilise standardized psychological questionnaires 254 after having discussed all possible benefits and complications of surgery with the patient.