Preoperative Brace = Poorer Outcome After Surgery

[LindaRacine]

Sharon...

You're gonna love this one!

http://www.ncbi.nlm.nih.gov/pubmed/20844423

Spine (Phila Pa 1976). 2010 Sep 15;35(20):1876-9.
Preoperative bracing affects postoperative outcome of posterior spine fusion with instrumentation for adolescent idiopathic scoliosis.

Diab M, Sharkey M, Emans J, Lenke L, Oswald T, Sucato D; Spinal Deformity Study Group.

Departments of Orthopaedic Surgery, University of California, San Francisco, CA, USA. diab@orthosurg.ucsf.edu
Abstract

STUDY DESIGN.: Multicenter, prospective clinical series. OBJECTIVE.: To investigate the effect of preoperative bracing on postoperative outcome of posterior spine fusion with instrumentation for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA.: Bracing is the standard of care for adolescent idiopathic scoliosis between 25° and 45°, yet the efficacy of bracing is questionable. It is important to evaluate the effect of bracing on outcomes in the adolescent idiopathic scoliosis population. METHODS.: We reviewed the outcomes of 281 before surgery braced and 328 before surgery nonbraced patients who underwent posterior spine fusion with instrumentation for adolescent idiopathic scoliosis before operation and at 2 years after operation using the Scoliosis Research Society instrument (SRS-30) and the Spinal Appearance Questionnaire. RESULTS.: At 2 years after operation, nonbraced patients demonstrated a greater improvement in the SRS-30 Pain domain score (0.23 vs. 0.08, P < 0.001), more improvement in back pain at rest (26.7% vs. 20.5%, P = 0.0009), and more improvement in back pain in the past 6 months (42.4% vs. 32.6%, P = 0.039) compared to braced patients. Also at 2 years after operation, nonbraced patients reported higher SRS-30 Activity domain scores (4.38 vs. 4.32, P = 0.031), Satisfaction domain scores (4.53 vs. 4.42, P = 0.007), and Total scores (4.27 vs. 4.35, P = 0.036) compared with braced patients. The 2-year Spinal Appearance Questionnaire scores showed that nonbraced patients reported a greater "decrease in importance" than braced patients in having "more even shoulders" (79.4% vs. 70.5%, P = 0.03), "more even hips" (74.6% vs. 71.6%, P = 0.042), and "more even ribs in back" (78.4% vs. 69.5%, P = 0.05). CONCLUSION.: Before surgery braced patients have more pain, lower activity levels, lower satisfaction, and lower total SRS-30 scores at 2 years after operation. Braced patients also have more "spine-specific" appearance concerns compared to nonbraced patients. These results suggest a negative impact of preoperative bracing on outcomes after posterior spinal fusion for adolescent idiopathic scoliosis. This "brace signature" should be taken into account when brace treatment is being considered.

PMID: 20844423 [PubMed - in process]

[hdugger]

Or, you know, it could mean that there's something different about these patients which leads them to be braced and also leads them to have different surgical outcomes.

[Pooka1]

Well that's interesting.

I can say my braced kid had a less optimal outcome than the one who was never braced. I think that is due to having a different Lenke type curve but it may be due to being braced... I certainly don't know.

Maybe it has to due with the hypolordosing/hypokyphosing/whatever effect of braces?

All that said, neither of my kids has any pain at all now. It's just the one has perfect balance and the other has a small residual L curve (below a now ~0* T). If it turns out that she would have had a better outcome had she never been braced I will be bitter. Yes I will be bitter.

[Pooka1]

Or, you know, it could mean that there's something different about these patients which leads them to be braced and also leads them to have different surgical outcomes.

That too.

It could be ANYTHING at this point. Or nothing.

[Ballet Mom]

Linda,

Surely with such a dramatic title you've posted to this study, hopefully you'll manage to get a copy of this study and provide the details and data to the forum. After all, the lead author is a colleague of yours, surely he would be willing to share the information.

Many questions are raised by this study and should be thoroughly evaluated, especially by parents making important decisions for their child's health.

What comes to my mind immediately is the fact that if you brace, the most aggressive and perhaps rigid curves are the ones that aren't successfully braced and they are the ones that require surgery. If you don't brace, both rigid aggressive curves AND nice flexible curves with space between the vertebrae that would be most successfully braced are in the non-braced surgical cohort. So any post-surgical study that doesn't take this into account is already flawed. And it seems pretty hard to take that into account and most likely wasn't.

It seems apparent that a cohort that had the easier, flexible curves in it would also have a greater satisfaction after surgery including pain and the mysterious ""spine-specific" appearance concerns". Obviously, flexible curves will get the best correction in a surgical fusion procedure.

If the ""spine-specific" appearance concerns" happens to be related to the hypokyphosis found in thoracic curves, do surgeons know for sure that this occurs from the bracing or from the thoracic curve itself? Also, everything I've read states that surgery is able to correct this hypokyphosis, is this not correct after all? That would be important for parents and patients to know.

I also notice that the results of the study show results based in "greater improvement" numbers. Perhaps those patients in the non-braced surgical cohort had greater pain initially due to not being braced and after surgery these numbers account for that greater reduction in pain than in the non-braced patients. Why are the researches not just using the actual numbers instead of a size of improvement number?

And then there's the activity numbers. How much difference are there in these numbers? They hardly seem significant.

Also at 2 years after operation, nonbraced patients reported higher SRS-30 Activity domain scores (4.38 vs. 4.32, P = 0.031), Satisfaction domain scores (4.53 vs. 4.42, P = 0.007), and Total scores (4.27 vs. 4.35, P = 0.036) compared with braced patients.

Plus, isn't the Total score of 4.27 vs. 4.35 actually HIGHER for the braced patients? Weird.

I would be very interested in knowing what this "brace signature" is that apparently marks these braced kids for life. It must be a real secret.

And then ,of course, a better study would have controls. And I guess the controls in this study would be the braced kids who would have likely had surgery without successful bracing and are doing just fine after successful bracing and without surgery. What "brace signature" is left on them for life? I'd be curious what Dr. Weiss had to say about any brace signature left after bracing, if he's still reading the forum.

[Pooka1]

Subjective versus Objective

There is evidence that subjective results such as these are not necessarily linked to objective radiographic or other findings. Until they relate these subjective findings to objectives ones that can be studied, I think all such studies like are of limited utility.

And that's the crux of the problem... the subjective is what people are dealing with but only the objective can be studied. There is no use having a perfect post-surgical radiograph if it doesn't correlate with feeling normal. (It will necessarily correlate with looking normal, though.) For all we know, having a less than perfect post-surgical radiograph of a particular type correlates better with higher well being. There is also at least one study that shows that pain levels were not higher in people who were corrected less versus more. And then they need to correlate post surgery pain levels with pain levels in untreated scoliosis.

Much more information is needed on many fronts.

[LindaRacine]

I have the full text. Here are a few tables of interest: