View Full Version : article on patient satisfaction and fusion surgery

12-18-2012, 04:57 PM
This is an interesting article from 2008 about patient satisfaction and fusion surgery.


12-18-2012, 06:09 PM
Ask yourself why that was published in that journal and not Spine.

There are much larger studies (one that crunched over 100,000 cases) that are more honestly done and more enlightening because of the large study sizes and more expert authorship.

12-18-2012, 06:18 PM

Just went to take a look at this article and immediately noticed the author and affiliations:

Corresponding author: Hans-Rudolf Weiss hr.weiss@asklepios.com
Author Affiliations
1 Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, D-55566, Bad Sobernheim, Germany

Hmmmmm, can you say "conflict of interest"????

Remember, critical thinking about articles is always necessary.

A more accurate article is the compilation of over 100,000 cases that Sharon mentions, with prominent authors such as Lenke, Hart, and many other well-known names. It can be found on pub med.

12-18-2012, 06:24 PM
I am still searching for the paper on over 100,000 cases. I did post it on the forum but I can't now find it. In the mean time, here is one with over 58,000 cases that focuses on the new instrumentation that is more relevant for parents and patients today. Any paper that talks about H rods and implies it is relevant is dishonest.

Complications in Spinal Fusion for Adolescent Idiopathic Scoliosis in the New Millennium. A Report of the Scoliosis Research Society Morbidity and Mortality Committee
Coe, Jeffrey D.; Arlet, Vincent; Donaldson, William; Berven, Sigurd; Hanson, Darrell S.; Mudiyam, Ram; Perra, Joseph H.; Shaffrey, Christopher I.
Spine. 31(3):345-349, February 1, 2006.

Study Design. The Morbidity and Mortality database of the Scoliosis Research Society (SRS) was queried as to the incidence and type of complications as reported by its members for the treatment of adolescent idiopathic scoliosis (AIS) with spinal fusion and instrumentation procedures regarding surgical approach (anterior, posterior, or combined anterior-posterior) during a recent 3-year period.

Objective. To evaluate the incidence of surgeon-reported complications in a large series of spinal fusions with instrumentation for a single spinal deformity diagnosis and age group regarding surgical approach.

Summary of Background Data. The SRS has been collecting morbidity and mortality data from its members since its formation in 1965 with the intent of using these data to assess the complications and adverse outcomes (death and/or spinal cord injury) of surgical treatment for spinal deformity. Surgical approaches to the management of treatment of AIS have a measurable impact on efficacy of correction, levels fused, and operative morbidity. However, there is a lack of consensus on the choice of surgical approach for the treatment of spinal deformity.

Methods. Of the 58,197 surgical cases submitted by members of the SRS in the years 2001, 2002, and 2003, 10.9% were identified as having had anterior, posterior, or combined spinal fusion with instrumentation for the diagnosis of AIS, and comprised the study cohort. All reported complications were tabulated and totaled for each of the 3 types of procedures, and statistical analysis was conducted.

Results. Complications were reported in 5.7% of the 6334 patients in this series. Of the 1164 patients who underwent anterior fusion and instrumentation, 5.2% had complications, of the 4369 who underwent posterior instrumentation and fusion, 5.1% had complications, and of the 801 who underwent combined instrumentation and fusion, 10.2% had complications. There were 2 patients (0.03%) who died of their complications. There was no statistical difference in overall complication rates between anterior and posterior procedures. However, the difference in complication rates between anterior or posterior procedures compared to combined procedures was highly significant (P < 0.0001). The differences in neurologic complication rates between combined and anterior procedures, as well as combined and posterior procedures were also highly statistically significant (P < 0.0001), but not between anterior and posterior procedures.

Conclusions. This study shows that complication rates are similar for anterior versus posterior approaches to AIS deformity correction. Combined anterior and posterior instrumentation and fusion has double the complication rate of either anterior or posterior instrumentation and fusion alone. Combined anterior and posterior instrumentation and fusion also has a significantly higher rate of neurologic complications than anterior or posterior instrumentation and fusion alone.

12-18-2012, 06:26 PM
Here's a paper on re-operation rate at 2 years.

Revision Surgery After Primary Spine Fusion for Idiopathic Scoliosis
Luhmann, Scott J.; Lenke, Lawrence G.; Bridwell, Keith H.; Schootman, Mario
Spine. 34(20):2191-2197, September 15, 2009.
doi: 10.1097/BRS.0b013e3181b3515a
Revision Surgery After Primary Spine Fusion for Idiopathic Scoliosis in 2006, reoperations after in...

Study Design. Retrospective case series.

Objective. The objective of this study was to review the overall prevalence of, and indications for, reoperations after the index spine fusion for idiopathic scoliosis at our center.

Summary of Background Data. Spine fusions for idiopathic scoliosis are expected to be the final therapeutic intervention in management. In a recent publication in 2006, reoperations after index spine fusion for idiopathic scoliosis were reported in 12.9% of patients at a single institution (n = 1046).

Methods. A spinal deformity database search at our center identified all primary anterior, posterior, and circumferential spinal fusions performed for idiopathic scoliosis (1985–2003). A total of 1057 patients were identified whose mean age was 14.4 years (7–22 years) with minimum 2 year follow-up after index surgery. Study cohort consisted patients who underwent reoperation for any reason after index fusion procedure.

Results. Of the 1057 spinal fusions for idiopathic scoliosis, 41 (3.9%) underwent reoperation. Primary surgeries were: 11 anterior spinal fusions, 25 posterior spinal fusions, and 5 circumferential spinal fusions. Mean follow-up was 5.7 years (2–10.8). Forty-seven additional procedures were performed during 46 reoperations at an average of 26 months after index procedure (1 week–73 months). Of the 47 reoperations, 20 (43%) were revision spinal fusions (for pseudarthroses, uninstrumented curve progression or junctional kyphosis), 16 (34%) because of infections (5 acute, 11 chronic), 7 (15%) for implant removals due to pain and/or prominence (4 complete, 3 partial), 2 (4%) were revision of loosened implants, and 2 (4%) were elective thoracoplasties.

Conclusion. This study documented a 3.9% overall reoperation rate at our medical center, a 3-fold lower reoperation rate than the previously reported 12.9%. The most common reoperations were for infections (34%), pseudarthroses (26%), and postoperative curve progression of the adjacent unfused spine (17%).

12-18-2012, 06:33 PM
Here's a study going a long way to show that selective T fusions are a long-term solution for those with T curves...

Lumbar Curve Is Stable After Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: A 20-Year Follow-up
Larson, A. Noelle; Fletcher, Nicholas D.; Daniel, Cindy; Richards, B. Stephens
Spine. 37(10):833-839, May 01, 2012.

Study Design. A retrospective cohort study comparing long-term clinical and radiographical outcomes using selective thoracic instrumented fusion versus long instrumented fusion for the treatment of adolescent idiopathic scoliosis (AIS).

Objective. To evaluate long-term behavior of the lumbar curve in patients with AIS treated with selective thoracic fusion and to assess clinical outcome measures in this patient population compared with those patients treated with fusion in the lumbar spine.

Summary of Background Data. Selective thoracic fusion for the treatment of AIS preserves motion segments, but leaves residual lumbar deformity. Long-term results of selective fusion using segmental fixation are limited.

Methods. Nineteen patients with AIS treated with selective thoracic fusion and 9 patients treated with a long fusion returned at a mean 20 years (range, 14–24 years) postoperatively for radiographs, clinical evaluation, and outcome surveys (Short Form-12, Scoliosis Research Society-24, Spinal Appearance Questionnaire, Oswestry Disability Index, and visual analogue scale for pain and stiffness). Curve types were Lenke 1B, 1C, or 3C. All patients underwent posterior fusion with Texas Scottish Rite Hospital or Cotrel-Dubousset hook-rod instrumentation.

Results. The selective thoracic fusion group had no significant progression in the lumbar curve magnitude and no worsening of L4 obliquity to the pelvis between initial postoperative and 20-year follow-up. Mean preoperative lumbar curve magnitude (mean, 44°; range, 32–64) corrected 43% on initial postoperative films versus 38% at latest follow-up. Mean L4 obliquity to the pelvis, trunk shift, sagittal balance, and coronal balance were stable over time. Outcome scores between the 2 groups were similar. Scores in long fusion group, when compared with the selective group, were higher for 2 Scoliosis Research Society domains: self-image after surgery (P = 0.005) and function after surgery (P = 0.0006).

Conclusion. Spinal balance and correction of the lumbar curve remain stable over time in selective thoracic fusion. Those with selective fusions have outcome measures comparable with those with long fusions.

12-18-2012, 06:49 PM
I think I need to voice the universal caution again about the literature. Even Spine has material that is wrong and it falls off from there for other journals. You should bookmark Retractionwatch for a while just to marvel at it.

One famous study showed that a majority of research literature is false for various reasons. It is ultimately false but provisionally true given whatever knowledge base ins in hand at that time.

It is impossible to say anything without controls. A stark example of this was a pub that showed disc damage below even short fusions. Then another paper showed that NORMAL age-matched people had about the same amount of disc damage in those spots. I hope I am remembering that correctly but it's close. It is easy to fool yourself even if you are a seasoned researcher and the peer reviewers don't seem to be guarding the gate well.

You have to understand that everything is provisional and we keep gaining knowledge through the tireless efforts of experts. Also, you look for articles that disagree with your hypothesis and try to find the errors. Of course you need to limit yourself to top shelf journals when doing this because there is more pseudoscientific nonsense (pardon that redundancy) out there than you can shake a stick at.

12-18-2012, 06:54 PM
Dissecting the Effects of Spinal Fusion and Deformity Magnitude on Quality of Life in Patients With Adolescent Idiopathic Scoliosis
Tsutsui, Shunji; Pawelek, Jeff; Bastrom, Tracey; Lenke, Lawrence; Lowe, Thomas; Betz, Randal; Clements, David; Newton, Peter O.
Spine. 34(18):E653-E658, August 15, 2009.

Study Design. A retrospective review of scores from the Scoliosis Research Society outcomes instrument (SRS-24 questionnaire).

Objective. To quantify the isolated effects of spinal fusion and deformity magnitude on quality of life in patients with adolescent idiopathic scoliosis (AIS).

Summary of Background Data. Significant improvements in 2-year postoperative SRS-24 questionnaire scores have been reported despite the loss of spinal motion due to instrumentation and arthrodesis. As deformity reduction may influence patient perception, it has been difficult to isolate the effect of spinal fusion on quality of life after scoliosis surgery.

Methods. SRS-24 scores were compared between 3 cohorts of AIS patients (preoperative, postoperative, and nonoperative) using an ANOVA (P < 0.05) to determine the isolated effects of spinal fusion and deformity magnitude. Preoperative SRS-24 scores were collected from a group of patients with preoperative major Cobb angles greater than 40° (n = 194). Postoperative SRS-24 scores were collected from patients with preoperative major Cobb angles greater than 40° and 2-year postoperative major Cobb angles between 20° and 40° (n = 196). Finally, SRS-24 scores were collected from a nonoperative group of patients with major Cobb angles between 20° and 40° (n = 112).

Results. Spinal fusion was found to have a negative isolated effect on the Activity domain (−0.3) and on the Total score (−0.2) (P = 0.001) of the SRS-24 questionnaire (score range: 1–5). A smaller deformity magnitude, on the other hand, was found to have a significantly positive isolated effect on all 4 preoperative domains (P < 0.001) and on the Total score (P < 0.001). The combined effect of surgery (spinal fusion and deformity correction) was found to be significantly positive for the Total score (P < 0.001) and for the domains of Pain, Self-Image, and Function (P < 0.001).

Conclusion. Spinal fusion has an isolated negative effect on AIS patients' quality of life (Total score) mostly due to a decrease in scores of the Activity domain. The overall positive effect of surgery depends on the individual effects of spinal fusion (slight reduction in quality of life) and deformity reduction (modest improvement in quality of life).

12-18-2012, 06:58 PM
Selective Thoracic Fusion With Segmental Pedicle Screw Fixation in the Treatment of Thoracic Idiopathic Scoliosis: More than 5-Year Follow-Up
Suk, Se-ll; Lee, Sang-Min; Chung, Ewy-Ryong; Kim, Jin-Hyok; Kim, Sung-Soo
Spine. 30(14):1602-1609, July 15, 2005.

Study Design. Retrospective study.

Objectives. To evaluate outcomes of selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis with a minimum 5-year follow-up.

Summary of Background Data. Segmental pedicle screw fixation has been proven to enable true segmental control and greater correction both in coronal and sagittal planes of scoliosis. However, there is no long-term study of selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis.

Methods. Two hundred and three thoracic idiopathic scoliosis patients with 236 thoracic curves subject to selective thoracic fusion with segmental pedicle screw fixation were analyzed. Mean patient age at the time of operation was 13.8 years (range: 8.9–18).

Results. The preoperative thoracic curve of 51 ± 12° was corrected to 16 ± 7° (69% correction, 3% loss of correction) at the most recent follow-up. The noninstrumented lumbar curve of 30 ± 10° was corrected to 10 ± 8° (66% correction, 5% loss of correction) at the most recent follow-up. The preoperative thoracic kyphosis of 18 ± 11° and the lumbar lordosis of 43 ± 10° were improved to 23 ± 8° and 46 ± 9°, respectively, at the most recent follow-up. There was no junctional kyphosis at the most recent follow-up. Coronal decompensation at the most recent follow-up occurred in 10 patients. Postoperative adding-on occurred in 17 patients, who were fused two levels short of the neutral vertebra. Of the 2,867 thoracic pedicle screws inserted in the thoracic level, 43 screws were found to be malpositioned (1.5%), but they did not cause neurologic complications or adversely affect the long-term results.

Conclusions. Selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis had satisfactory radiographic and clinical outcomes after surgery and has been well-maintained for minimum 5-year follow-up. It is a safe and effective method for preservation of lumbar motion segments as well as for restoration and maintenance of both coronal and sagittal alignment.

12-18-2012, 07:00 PM
Rates of Infection After Spine Surgery Based on 108,419 Procedures: A Report from the Scoliosis Research Society Morbidity and Mortality Committee
Smith, Justin S. MD, PhD*; Shaffrey, Christopher I. MD*; Sansur, Charles A. MD†; Berven, Sigurd H. MD‡; Fu, Kai-Ming G. MD, PhD*; Broadstone, Paul A. MD§; Choma, Theodore J. MD¶; Goytan, Michael J. MD||; Noordeen, Hilali H. MD**; Knapp, Dennis R. Jr. MD††; Hart, Robert A. MD‡‡; Donaldson, William F. III MD§§; Polly, David W. Jr MD|| ||; Perra, Joseph H. MD***; Boachie-Adjei, Oheneba MD†††

Study Design. Retrospective review of a prospectively collected database.

Objective. Our objective was to assess the rates of postoperative wound infection associated with spine surgery.

Summary of Background Data. Although wound infection after spine surgery remains a common source of morbidity, estimates of its rates of occurrence remain relatively limited. The Scoliosis Research Society prospectively collects morbidity and mortality data from its members, including the occurrence of wound infection.

Methods. The Scoliosis Research Society morbidity and mortality database was queried for all reported spine surgery cases from 2004 to 2007. Cases were stratified based on factors including diagnosis, adult (≥21 years) versus pediatric (<21 years), primary versus revision, use of implants, and whether a minimally invasive approach was used. Superficial, deep, and total infection rates were calculated.

Results. In total, 108,419 cases were identified, with an overall total infection rate of 2.1% (superficial = 0.8%, deep = 1.3%). Based on primary diagnosis, total postoperative wound infection rate for adults ranged from 1.4% for degenerative disease to 4.2% for kyphosis. Postoperative wound infection rates for pediatric patients ranged from 0.9% for degenerative disease to 5.4% for kyphosis. Rate of infection was further stratified based on subtype of degenerative disease, type of scoliosis, and type of kyphosis for both adult and pediatric patients. Factors associated with increased rate of infection included revision surgery (P < 0.001), performance of spinal fusion (P < 0.001), and use of implants (P < 0.001). Compared with a traditional open approach, use of a minimally invasive approach was associated with a lower rate of infection for lumbar discectomy (0.4% vs. 1.1%; P < 0.001) and for transforaminal lumbar interbody fusion (1.3% vs. 2.9%; P = 0.005).

Conclusion. Our data suggest that postsurgical infection, even among skilled spine surgeons, is an inherent potential complication. These data provide general benchmarks of infection rates as a basis for ongoing efforts to improve safety of care.

12-18-2012, 07:01 PM
Complications in the Surgical Treatment of 19,360 Cases of Pediatric Scoliosis: A Review of the Scoliosis Research Society Morbidity and Mortality Database
Reames, Davis L.; Smith, Justin S.; Fu, Kai-Ming G.; Polly, David W. Jr.; Ames, Christopher P.; Berven, Sigurd H.; Perra, Joseph H.; Glassman, Steven D.; McCarthy, Richard E.; Knapp, Raymond D. Jr.; Heary, Robert; Shaffrey, Christopher I.; Scoliosis Research Society Morbidity and Mortality Committee
Spine. 36(18):1484-1491, August 15, 2011.

Study Design. Retrospective review of a multicenter database.

Objective. To determine the complication rates associated with surgical treatment of pediatric scoliosis and to assess variables associated with increased complication rates.

Summary of Background Data. Wide variability is reported for complications associated with the operative treatment of pediatric scoliosis. Limited number of patients, surgeons, and diagnoses occur in most reports. The Scoliosis Research Society Morbidity and Mortality (M&M) database aggregates deidentified data, permitting determination of complication rates from large numbers of patients and surgeons.

Methods. Cases of pediatric scoliosis (age ≤18 years), entered into the Scoliosis Research Society M&M database between 2004 and 2007, were analyzed. Age, scoliosis type, type of instrumentation used, and complications were assessed.

Results. A total of 19,360 cases fulfilled inclusion criteria. Of these, complications occurred in 1971 (10.2%) cases. Overall complication rates differed significantly among idiopathic, congenital, and neuromuscular cases (P < 0.001). Neuromuscular scoliosis had the highest rate of complications (17.9%), followed by congenital scoliosis (10.6%) and idiopathic scoliosis (6.3%). Rates of neurologic deficit also differed significantly based on the etiology of scoliosis (P < 0.001), with the highest rate among congenital cases (2.0%), followed by neuromuscular types (1.1%) and idiopathic scoliosis (0.8%). Neur-omuscular scoliosis and congenital scoliosis had the highest rates of mortality (0.3% each), followed by idiopathic scoliosis (0.02%). Higher rates of new neurologic deficits were associated with revision procedures (P < 0.001) and with the use of corrective osteotomies (P < 0.001). The rates of new neurologic deficit were significantly higher for procedures using anterior screw-only constructs (2.0%) or wire-only constructs (1.7%), compared with pedicle screw-only constructs (0.7%) (P < 0.001).

Conclusion. In this review of a large multicenter database of surgically treated pediatric scoliosis, neuromuscular scoliosis had the highest morbidity, but relatively high complication rates occurred in all groups. These data may be useful for preoperative counseling and surgical decision-making in the treatment of pediatric scoliosis.

12-18-2012, 08:34 PM
This is an interesting article from 2008 about patient satisfaction and fusion surgery.


The link is to a study on complication rates, not patient satisfaction.

12-18-2012, 08:41 PM
I tried to pm you, but it says your box is full.


12-18-2012, 10:24 PM
Emptied now.