Long-Term Health-Related Quality of Life After Harrington Instrumentation and Fusion for Adolescent Idiopathic Scoliosis

Abstract

Background:Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms.Methods:A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery.Results:In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means.Conclusions:Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

SRS-22r Self-Image After Surgery for Adolescent Idiopathic Scoliosis at 10-year Follow-up

“…It is possible that this selection bias leads us to overestimate or underestimate the durability of self-image improvement. In general, surgery for AIS is durable with low revision rates at up to 40 years of follow-up and infrequent participation in the adult spinal deformity registries 30,31. However, we investigate the durability of SRS-Self Image scores and report higher scores than those reported at 40 years, those these patients were treated with Harrington constructs and had larger postoperative coronal plane deformities 32,33…”

Health-Related Quality of Life of Patients With Adolescent Idiopathic Scoliosis at Least 40 Years After Surgery

“…Using the RDQ questionnaire, Gotze et al 14 found that 79.3% of patients had constant or occasional low back pain, while only 6.1% had chronic low back pain. Patients with AIS treated with LIV from L4 or caudally had worse ODI scores than those treated with LIV from L3 or cranially, according to Lander et al ,15 who also found that these patients were more likely to need additional surgical treatment. However, despite the tendency for patients whose fusion reached the L4 or L5 level to endure greater pain, a meta-analysis revealed no statistically significant correlation between the distal fusion level and the incidence of later back pain 16.…”

Posterior Column Osteotomies in Adolescent Idiopathic Scoliosis: Panel Discussion

“…Sanders: We recently published our 40-year follow-up of Harrington instrumentation, 1 and those patients did incredibly well over time with function that really matches age-matched controls. These patients are getting no segmental derotation, and their ultimate function is very good.…”