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Thread: Surgery is no cure.

  1. #1
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    Surgery is no cure.

    “It is very difficult to know precisely what the natural history of untreated surgical idiopathic scoliosis is, because most patients have surgical treatment of their curves when the Cobb measurement exceeds 50°. The only way of definitively proving that the natural history of surgical treatment of idiopathic scoliosis is better than untreated scoliosis would be to undertake a study involving a prospective, randomized group of patients with curves more than 50°, treated surgically with modern-day instrumentation and then compare the results with those of a similar group of untreated patients matched for age, deformity, and other parameters. Those two groups of patients would then have to be followed up in 10-year intervals to determine their relative function, pain and cosmetic appearance. No such study exists. If it were possible, it would take between 20 and 40 years to obtain a definitive answer.”

    Too bad this was not written on a lunch napkin by a neighborhood quack, so that it could have been easily dismissed by many, but it was written by Keith H. Bridwell, MD a former President of SRS and was published in SPINE.

    Dr. Bridwell is also the Asa C. and Dorothy W. Jones Professor of Orthopaedic Surgery at Washington University School of Medicine, and he is Chief of Pediatric and Adult Spinal Surgery in the Orthopaedic Department at Washington University in St. Louis.

    What Dr Bridwell is saying that there is no solid proof that surgery gives a better outcome in Idiopathic Scoliosis than leaving it alone.

    He also stated:
    "Many surgeons feel that 50° is the surgical tidemark for treating idiopathic scoliosis … This “magic number” comes in part as an extrapolation from … studies of natural history and in part that most 50° curves are very visible cosmetically.”



    Almost forgot the reference:
    1: Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis. Spine.
    1999 Dec 15;24(24):2607-16. Review.


    Links on Dr Bridwell
    http://www.srs.org/professionals/mee...m03/photos.php
    http://www.bridwell-spinal-deformity...keith-bridwell
    A practitioner seeking answers to enhance the treatment of Idiopathic Scoliosis

    Blog: www.fixscoliosis.com/

  2. #2
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    Very interesting from a former president of SRS! Thanks for posting.

  3. #3
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    Yes, but it would never be ethical to put someone with a 100 degree curve into a control group.

    Dr. Bridwell is not saying that surgery isn't a cure. He's saying that they can't prove surgery is a cure.

    --Linda

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    Doesn't the fact that there is an agreed upon angle for surgery suggest that failure to operate at that point is likely to lead to a worse outcome?

    They selected 50* for a reason.

    I wish they would revisit that number with some more data evaluation because I suspect more than 5% of folks with curves > 40* but < 50* at maturity go on to need surgery in their lifetime. And they tend to get it when they are less able to cope.

    Maybe it isn't half but maybe it's 30%.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
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    "We are all African."

  5. #5
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    Smile suggests, points, indicate etc.

    If we are all comfortable with those terms for accepting surgery as a treatment option for surgery, without having no solid proof we should then give alternative ways the same leeway.

    and also, like Linda writes
    "He's saying that they can't prove surgery is a cure."

    It is true they can't prove it, so we should not blame others for lacking proof and continuing with their practice.
    But, what he is really saying, is that they can't prove that surgery lead to a better outcome than no surgery. He doesn't even talk about cure.

    I thought solid PROOF was the only thing that counted here on the NSF and not mere suggestions. Well, that's what it seems like when I have read many posts.

    I am glad now that, suggestions and lack of proof is acceptable and I wish it will remain that way.

    It would keep this forum a lot more pleasant for everybody.
    A practitioner seeking answers to enhance the treatment of Idiopathic Scoliosis

    Blog: www.fixscoliosis.com/

  6. #6
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    Quote Originally Posted by FixScoliosis View Post
    If we are all comfortable with those terms for accepting surgery as a treatment option for surgery, without having no solid proof we should then give alternative ways the same leeway.

    and also, like Linda writes
    "He's saying that they can't prove surgery is a cure."

    It is true they can't prove it, so we should not blame others for lacking proof and continuing with their practice.
    But, what he is really saying, is that they can't prove that surgery lead to a better outcome than no surgery. He doesn't even talk about cure.

    I thought solid PROOF was the only thing that counted here on the NSF and not mere suggestions. Well, that's what it seems like when I have read many posts.

    I am glad now that, suggestions and lack of proof is acceptable and I wish it will remain that way.

    It would keep this forum a lot more pleasant for everybody.
    Fix...

    At least there are long-term followup studies for surgery. When the alternatives start publishing those, I'll be delighted to jump on board.

    --Linda

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    Quote Originally Posted by FixScoliosis View Post
    He also stated:
    "Many surgeons feel that 50° is the surgical tidemark for treating idiopathic scoliosis … This “magic number” comes in part as an extrapolation from … studies of natural history and in part that most 50° curves are very visible cosmetically.”
    Maybe this 1999 article is stale because our surgeon seems to think there is evidence why 50* is "magic." It has to do with the percentages that progress at particular rates above that point. Given the average life span, 50* is the magic number.

    In re the longer Bridwell quote at the top of the OP, I'm going to ask for a comment on this comment from our surgeon. I think we might be missing some context.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  8. #8
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    Quote Originally Posted by LindaRacine View Post
    Fix...

    At least there are long-term followup studies for surgery. When the alternatives start publishing those, I'll be delighted to jump on board.

    --Linda
    Hi Linda - I've been looking for some long term follow up studies for surgery but am not very good at it - can you cite some please? Thanks.


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    Long-term outcome of nonoperative treatment of AIS

    pain is the issue

    "Conclusions. Although pain, disability, HRQOL, and psychological general well-being are quite satisfactory on an absolute level, curve size was found to be a significant predictor for pain in a long-term follow-up."

    Hence, they operate above a certain target angle.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  10. #10
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    Quote Originally Posted by mamamax View Post
    Hi Linda - I've been looking for some long term follow up studies for surgery but am not very good at it - can you cite some please? Thanks.

    The only long-term studies would be for old instrumentation no longer in use.

    I think they extrapolate from that and the known the improvements in the current instrumentation over the historical-use instrumentation to predict the long-term outcomes of the current instrumentation.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  11. #11
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    Quote Originally Posted by Pooka1 View Post
    The only long-term studies would be for old instrumentation no longer in use.

    I think they extrapolate from that and the known the improvements in the current instrumentation over the historical-use instrumentation to predict the long-term outcomes of the current instrumentation.
    I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?

  12. #12
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    Quote Originally Posted by mamamax View Post
    I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?
    Not sure it is just for the screws and not other newer techniques used.

    I don't even know how long the screws have been in use.

    Linda would know.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  13. #13
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    Quote Originally Posted by Pooka1 View Post
    The only long-term studies would be for old instrumentation no longer in use.

    I think they extrapolate from that and the known the improvements in the current instrumentation over the historical-use instrumentation to predict the long-term outcomes of the current instrumentation.
    Sharon is correct. This is as close as one can get to current implant outcomes:

    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

    Long-term clinical and radiographic results of Cotrel-Dubousset instrumentation of right thoracic adolescent idiopathic scoliosis.
    Boos N, Dolan LA, Weinstein SL.

    Dept. of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. nboos@balgrist.unizh.ch

    Little substantive data is available in the literature on the long-term clinical and radiological results of Cotrel-Dubousset instrumentation (CDI) for the treatment of adolescent idiopathic scoliosis. We therefore retrospectively investigated the long-term clinical and radiographic outcome of patients who underwent (CDI) for right thoracic adolescent idiopathic scoliosis. 54 consecutive patients (45 females, 9 males) who underwent CDI for right thoracic adolescent idiopathic scoliosis with an average age of 14 years (range 10-21 years) at surgery were included in this series. There were 18 King Type II, 19 Type III, 5 Type IV, 3 Type V and 9 double major curves. The average coronal Cobb angle of the primary thoracic curve preoperatively, postoperatively and at latest follow-up was 55 degrees, 17 degrees and 22 degrees, respectively. The lumbar curve (secondary and double major) averaged 40 degrees, 21 degrees and 23 degrees, respectively. Coronal balance (deviation from the central sacral line) was slightly improved from 13 mm to 11 mm. The average shoulder elevation increased from 3 degrees to 5 degrees, presumably as a result of the rod derotation maneuver. Thoracic kyphosis (20 degrees to 22 degrees) and lumbar lordosis (49 degrees to 54 degrees) was preserved or even improved by the instrumentation. All patients were doing well and had no complaints with regard to a substantial limitation of professional or sports activity. There were no apparent non-unions, infections or neurological complications. CDI of adolescent right thoracic idiopathic scoliosis provides encouraging clinical and radiographic results at an average follow-up of 9 years (2 to 16 years). Overall patient satisfaction, functional status and subjective cosmetic improvement is high.

    And, from a separate spine center:

    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

    Idiopathic scoliosis treated with Cotrel-Dubousset instrumentation: evaluation 10 years after surgery.
    Bjerkreim I, Steen H, Brox JI.

    Rikshospitalet-Radiumhospitalet Medical Center, Orthopaedic Department, University of Oslo, Oslo, Norway.

    STUDY DESIGN: Prospective cohort study with 10-year follow-up. OBJECTIVE: To evaluate long-term results after operative treatment with Cotrel-Dubousset (CD) instrumentation for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Limited knowledge exists in the evaluation of long-term function with quality of life measures after CD instrumentation in patients with AIS. METHODS: A total of 100 (76 females and 24 males) consecutive AIS patients all with single primary curves were included. Radiologic measures and pain were registered at baseline and at 1- to 5-year follow-up. Quality of life and back specific measures, including EuroQol (EQ) and Oswestry Disability Index (ODI), were obtained by a questionnaire mailed to the patients at 10 years after surgery. RESULTS: Mean age at operation was 16.8 (SD, 5.3) years, mean Risser sign was Grade 3.2 (SD, 1.5). All patients were observed for 2 years. The average primary curve was reduced from 56 degrees to 19 degrees, and this correction was maintained during follow-up. Fourteen patients had minor complications, and 5 patients had implants removed because of late clinically suspected infections. A total of 86 patients answered the 10-year questionnaire; 97% of the patients considered back function as excellent, good, or fair, and 96% would have done the operation again. Scores for EQ-5D and ODI were slightly worse than in the normal population. Despite this observation, 45% of the patients reported to have consulted a physician or received physiotherapy for back pain during the last year before the 10-year follow-up. CONCLUSION: Radiologic results, patient satisfaction, and mean scores for quality of life and back function were excellent after CD instrumentation for AIS, but a considerable number of patients had treatment for back problems.

    And, for TSRH implants (not sure if they're still being used):

    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

    Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation.
    Benli IT, Ates B, Akalin S, Citak M, Kaya A, Alanay A.

    Department of Orthopedics and Traumatology, Faculty of Medicine, UFUK University, Mithatpasa Cad. 59/2, Kyzylay, Ankara 06420, Turkey. cutku@ada.net.tr

    Last two decades witnessed great advances in the surgical treatment of idiopathic scoliosis. However, the number of studies evaluating the long-term results of these treatment methods is relatively low. During recent years, besides radiological and clinical studies, questionnaires like SRS-22 assessing subjective functional and mental status and life-quality of patients have gained importance for the evaluation of these results. In this study, surgical outcome and Turkish SRS-22 questionnaire results of 109 late-onset adolescent idiopathic scoliosis patients surgically treated with third-generation instrumentation [Texas Scottish Rite Hospital (TSRH) System] and followed for a minimum of 10 years were evaluated. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT), shift of head (SH), and shift of stable vertebra (SS). Mean age of the patients was 14.4+/-1.9 and mean follow-up period was 136.9+/-12.7 months. When all the patients were included, the preoperative mean Cobb angle of major curves in the frontal plane was 60.8 degrees +/-17.5 degrees . Major curves that were corrected by 38.7+/-22.1% in the bending radiograms, postoperatively achieved a correction of 64.0+/-15.8%. At the last follow-up visit, 10.3 degrees +/-10.8 degrees of correction loss was recorded in major curves in the frontal plane with 50.5+/-23.1% final correction rate. Also, the mean postoperative and final kyphosis angles and lumbar lordosis angles were 37.7 degrees +/-7.4 degrees , 37.0 degrees +/-8.4 degrees , 37.5 degrees +/-8.7 degrees , and 36.3 degrees +/-8.5 degrees , respectively. A statistically significant correction was obtained at the sagittal plane; mean postoperative changes compared to preoperative values were 7.9 degrees and 12.9 degrees for thoracic and lumbar regions, respectively. On the other hand, normal physiological thoracic and lumbar sagittal contours were achieved in 83.5% and 67.9% of the patients, respectively. Postoperatively, a statistically significant correction was obtained in LT, SH, and SS values (P<0.05). Although, none of the patients had completely balanced curves preoperatively, in 95.4% of the patients the curves were found to be completely balanced or clinically well balanced postoperatively. This rate was maintained at the last follow-up visit. Overall, four patients (3.7%) had implant failure. Early superficial infection was observed in three (2.8%) patients. Radiologically presence of significant consolidation, absence of implant failure, and correction loss, and clinical relief of pain were considered as the proof of a posterior solid fusion mass. About ten (9.2%) patients were considered to have pseudoarthrosis: four patients with implant failure and six patients with correction loss over 15 degrees at the frontal plane. About four (3.7%) patients among the first 20 patients had neurological deficit only wake-up test was used for neurological monitoring of these patients. No neurological deficit was observed in the 89 patients for whom intraoperative neurological monitoring with SSEP and TkMMEP was performed. Overall, average scores of SRS-22 questionnaire for general self-image, function, mental status, pain, and satisfaction from treatment were 3.8+/-0.7, 3.6+/-0.7, 4.0+/-0.8, 3.6+/-0.8, and 4.6+/-0.3, respectively at the last follow-up visit. Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

  14. #14
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    Quote Originally Posted by mamamax View Post
    I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?
    They wouldn't be considered long-term.

    A Pubmed search of scoliosis and pedicle screws brings up 224 references.

  15. #15
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    Quote Originally Posted by mamamax View Post
    I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?
    Here's a 3 year followup:

    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

    Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases.
    Lehman RA Jr, Lenke LG, Keeler KA, Kim YJ, Buchowski JM, Cheh G, Kuhns CA, Bridwell KH.

    Walter Reed Army Medical Center, USA.

    STUDY DESIGN: Preoperative review of a prospective study, single institution, consecutive series. OBJECTIVE.: To analyze the intermediate-term follow-up of consecutive adolescent idiopathic scoliosis (AIS) patients treated with pedicle screw constructs. SUMMARY OF BACKGROUND DATA: There have been no reports of the intermediate-term findings in North America following posterior spinal fusion with the use of pedicle screw-only constructs. METHODS: One hundred and fourteen consecutive patients having a minimum 3-year follow-up (mean 4.8 +/- 1.1; range, 3.0-7.3 years) with AIS were evaluated. The average age at surgery was 14.9 +/- 2.2 years. Radiographic measurements included preoperative (Preop), postoperative (PO), 2-year (2 years), and final follow-up (FFU). A chart review evaluated PFTs, Scoliosis Research Society scores, presence of thoracoplasty, Risser sign, Lenke classification, and complications. RESULTS: The most frequent curve pattern was Lenke type 1 (45.6%), followed by type 3 (21.9%). The average main thoracic curve measured 59.2 degrees +/- 12.2 SD Preop, and corrected to 16.8 degrees +/- 9.9 PO (P < 0.0001). Sagittal thoracic alignment (T5-T12) decreased from 25.8 degrees to 15.5 degrees at FFU (P = 0.05). Nash-Moe grading for apical vertebral rotation (AVR) in the proximal thoracic curve decreased from 2.0 Preop to 1.1 at FFU (P < 0.0001), and AVR in the thoracolumbar/lumbar spine decreased from 1.6 Preop to 1.1 at FFU (P < 0.0001). Importantly, the horizontalization of the subjacent disc measured -8.3 degrees Preop which decreased to -0.9 degrees PO (P < 0.001). PFT follow-up averaged 2.4 years with a 7.1% improvement in FVC (P = 0.004) and 8.8% in FEV1 (P < 0.0001). SRS scores averaged 83.0% at latest follow-up. Age, gender, Risser sign, or complications did not have a significant effect on outcomes. There were 2 cases of adding-on, 3 late onset infections, 1 with a single pseudarthrosis, but no neurologic complications. CONCLUSION: This is the largest (N = 114), consecutive series of North American patients with AIS treated with pedicle screws having a minimum of 3-year follow-up. The average curve correction was 68% for the main thoracic, 50% for the proximal thoracic, and 66% for the thoracolumbar/lumbar curve at final follow-up.

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