Topographical, Kinesiological and Psychological

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Abstract. Scoliosis is a three dimensional spinal deformity which is serious enough to warrant .... Curve types included 70 thoracic, 20 thoracolumbar, 26 lumbar.
Three Dimensional Analysis of Spinal Deformities M. D'Amico et al. (Eds.) IOS Press, 1995

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Topographical, Kinesiological and Psychological Factors in the Surgical Management of Adolescent Idiopathic Scoliosis Josette BETTANY 1 Ph.D, Cecily PARTRIDGE 2 Ph.D and Michael EDGARS F.R.C.S.., 1 State University of New York at Buffalo, Department of Physical Therapy and Exercise Science, 410 Kimball Tower, Main Street Campus, Buffalo, N.Y. 14214. U.S.A. 2King's College ,University of London, U.K. 3Middlesex Hospital, London U.K.

Abstract. Scoliosis is a three dimensional spinal deformity which is serious enough to warrant assessment and treatment in two per hundred of the population in the United Kingdom. It presents as a lateral-rotatory deformity of the spine with a resulting rib hump. Symptoms include a gross deformity in the shape of the back, decreased spinal mobility, back pain, as well as a number of psychological problems. Patients with severe scoliosis are usually referred to surgery. The purpose of this study was to investigate the topographical, kinesiological and psychological factors and interactions in the surgical management of a group of adolescent idiopathic scoliosis patients. One hundred and thirty patients with adolescent idiopathic scoliosis were included in the study. All patients had their back shape assessed by an optical computer system. Spinal mobility was measured by an electronic inclinometer and subjects were also given a questionnaire which included five sections relating to their pain, activities of daily living, body-image, self-esteem and anxiety. The patients then underwent one of five different operative procedures depending on their age, and the site and severity of their scoliosis curvature. All patients were re-assessed six months after surgery. Results demonstrated a significant improvement in the lateral curvature and rib hump of the back. Spinal balance was only improved in two-fifths of the groups following surgery and the sagittal profiles and volume difference between the two sides of the back were unchanged or worse after the operation. Thoracic and lumbar spinal mobility were significantly decreased both in the frontal and sagittal planes, except for thoracic extension and side-flexion to the convexity of the curve which were unchanged following surgery. Rod instrumentation on one side of the spine was found to limit lumbar side-flexion to that side and costoplasty on one side of the back permitted greater lumbar side flexion to the contralateral side of the spine for the patients in this study. Increasing spinal curvature and rib hump corresponded with an overall decrease in spinal mobility except for spinal extension where an overall increase in mobility was found. Most surgical techniques did not relieve the pain or the problems with activities of daily living associated with adolescent scoliosis. Patients worries were only significantly decreased in three-fifth's of the groups while self-esteem was unchanged in four-fifth's of the groups after surgery. In conclusion therefore although surgery significantly improved some aspects of the surface shape of the back it did not correct all three dimensions of the deformity. Further the mobility of the spine was severely restricted following surgery and while some psychological variables improved others were unchanged or worse.

1. Introduction

Scoliosis is a three dimensional spinal deformity which is serious enough to warrant assessment and treatment in two per cent of the population in the United Kingdom. It

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consists of a lateral curvature of the spine associated with a deformation of the thoracic cage, which causes an unsightly rib hump. These underlying skeletal changes result in detrimental changes in the shape and mobility of the back. Indeed, this devastating condition affects adolescents at a time when concerns with appearance and body function are at their peak and occur at a stage in life when deviation from normal causes painful psychological embarrassment [1]. Up to 20% of those affected are referred for surgery. Unfortunately untreated scoliosis in adolescence tends to progress in later life and may lead to a grotesque deformity with intense pain, greatly limited mobility and function, respiratory and cardiac complications, increased suicide rates and markedly restricted social lifes [2]. The aims in surgery are multiple and include the correction of the curvature of the spine, the reduction of the rib-hump, the improvement of back cosmesis, the improvement of back pain and the patients psychological well-being, as well as the improvement of the respiratory function. The results of treatment are generally only assessed radiologically. However X-rays have been shown to be inadequate in assessing the three dimensional surface shape of the back, which is the patients main concern [3]. Indeed whilst changes in the internal bony skeletal elements have been well documented little is known of the topography of the back in scoliosis and the restricted spinal range of motion which occurs as a result of surgery. Further little has been documented on the associated psychological factors in scoliosis and the interrelationships of the topographical, kinesiological and psychological factors following scoliosis surgery. The main hypotheses proposed in this study were: 1. Would surgery improve all three dimensions of back shape? 2. What effect would the change in back shape have on the mobility of the spine ? To what extent would the mobility of the spine be restricted following surgery ? 3. How are the psychological factors related to back shape and mobility in scoliosis and how does surgery effect these relationships ? 4. Are topographical, kinesiological and psychological variations present following different surgical procedures, and if so what are these variations ? In this investigation the hypotheses above were tested and related questions appertaining to the topographical, kinesiological and psychological factors in the surgical management of adolescent idiopathic scoliosis were addressed. 2. Materials and methods

2.1. Subjects One hundred and thirty scoliosis patients who were admitted for scoliosis surgery at the Royal National Orthopaedic Hospital, were included in this investigation. The criteria for inclusion in this study was a diagnosis of adolescent idiopathic scoliosis; no associated pathological or orthopaedic condition and no previous operative procedure. Any patient with associated Schuermann's kyphosis was excluded from this investigation. All patients underwent surgery between April, 1990 and December, 1991. The age range at the time of operation was 11 to 38 years (mean = 17.76 years). There were 100 female and 30 male patients. 117 patients were under 20 years old, the 13 patients over 20 years of age had scoliosis since their teens. Curve types included 70 thoracic, 20 thoracolumbar, 26 lumbar and 14 double major. Of this total group 38 patients had single-stage Harrington-luque surgery (HL), 19 patients had single stage Harrington-Luque surgery combined with costoplasty (CHL), 28

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patients had two-stage anterior spinal release followed by the Harrington-Luque procedure (RHL), 19 patients had two stage anterior instrumentation followed by Harrington-Luque posterior instrumentation (AHL) and 26 patients had single stage anterior surgery (A). Instrumentation and Procedure

Back shape was assessed by an optical-computer apparatus, the Integrated Shape Imaging System (ISIS). An electronic digital inclinometer was employed for the assessment of coronal and sagittal plane spinal mobility and a questionnaire containing questions related to pain, body-image, problems of daily living, worries and self-esteem was employed for the investigation of psychological variables. 3. Results Due to space restrictions only a selection of the results can be shown. A full description of the results can be found at the University of London Library [4] Table 1: Lateral Asymmetry (degrees). Means, standard deviations and levels of significance for all operative groups before and after surgery.

GROUP

LATERAL ASYMMETRY MEAN VALUE + S.D. BEFORE

AFTER

51.60 +10.01 57.35 +14.90 49.31 +13.48 58.10 +11.15 42.30 +11.70

26.34 +12.26 26.07 +14.23 21.47 + 9.48 23.57 +11.77 17.96 + 8.99

P VALUE

p=0.0001 p=0.0001 p=0.0001 p=0.0001 p=0.0001

Table 2. Hump Severity Index. Means, standard deviations and levels of significance in the five surgical procedures before and after surgery.

GROUP

HUMP SEVERITY INDEX MEAN VALUE + S.D.

A8 4,

BEFORE

AFTER

5.34+2.93 5.30+2.54 4.89 + 2.07 4.08+2.58 3.71+1.60

4.21 +2.37 4.61+2.15 3.96 + 1.71 2.87+ 1.92 2.17+1.20

P VALUE

P= 0.001 N.S. P = 0.026 P = 0.05 P= 0.001

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Table 3: Imbalance (millimeters): Means, standard deviations and levels of significance for all surgical groups before and after surgery.

GROUP

HL RHL CHL AHL A

IMBALANCE MEAN VALUE + S.D. BEFORE

AFTER

17.52 + 13.98 12.32 + 8.81 15.63 + 15.07 11.31 + 9.42 18.42 + 10.65

11.42 + 10.29 11.46 + 9.96 13.05 + 9.50 10.11 + 8.25 13.26 + 9.07

P VALUE

p= 0.018 p= N.S.

p= N.S. p= N.S. p= 0.03

Table 4 : Lumbar flexion (degrees). Means, standard deviations and levels of significance in the five operative groups.

GROUP

GROSS LUMBAR FLEXION MEAN VALUE AND S.D. BEFORE

(,

70.81 + 21.88 66.39 + 22.37 67.36 + 15.85 73.63 + 15.75 72.88 + 15.07

P VALUE

AFTER 49.92 + 22.19 50.10 + 18.44 54.00 + 12.67 52.68 + 24.72 52.26 + 15.46

p < 0.0001 p < 0.0001 p < 0.0001 p < 0.0001 p < 0.0001

Table 5 : Thoracic flexion (degrees). Means, standard deviations and levels of significance in the five operative groups.

GROUP

GROSS THORACIC FLEXION MEAN VALUE AND S.D.

AM,

BEFORE

AFTER

147.78 + 27.77 151.39+23.19 151.15 + 14.55 146.26 + 24.53 159.96+ 16.88

126.94 + 27.77 130.25+21.98 134.84 + 21.22 109.89 + 27.88 137.34+24.31

P VALUE

p < 0.0001 p