Seven patients had a total of 8 perioperative complications: anemia requiring transfusion (2), ileus necessitating nasogastric tube insertion (2), superficial wound infection treated with oral antibiotics and local wound care (2), wound drainage and erythema (1), and pneumonia (1). Mean (SD) length of clinical and radiographic follow-up was 57.9 (36.3) months.
Table 4 summarizes the long-term complications. Of the 38 patients with long-term complications, 14 required reoperation. The indications were disc herniation (2 patients), painful instrumentation (7), crankshaft phenomenon (1), nonunion (1), and adjacent-level degeneration (3). Both disc herniations were at L5–S1, several segments below the distal extent of the fusion. Of the 7 patients who had painful instrumentation removed, 6 had the entire construct removed, and 1 had the proximal half of a rod taken out. The 3 patients with adjacent-level degeneration had stenosis at the distal end of the construct—at L5–S1 (2 patients) or L2–L3 (1 patient).
Mean (SD) time between surgery and completion of the surveys/questionnaires was 12.7 (3.2) years (range, 10-18 years). Mean age of respondents was 26.8 years. Twenty-five respondents (21%) were smokers. Mean (SD) outcome scores were 50.9 (9.4) for SF-12 PCS and 49.4 (10.2) for SF-12 MCS. Eighteen patients (15%) had SF-12 PCS scores 1 SD below normal, and 15 (13%) had SF-12 MCS scores 1 SD below normal. Mean (SD) SRS-22R Total score was 4.0 (0.7). Means, standard deviations, and distribution of SRS domain scores are summarized in Table 5. Of the variables, only current smoking (P < .001) was predictive of SRS-22R Total scores, accounting for 20% of their variability (Table 6).
One hundred patients (85%) had jobs, mostly desk jobs. The postoperative limitations most commonly reported are summarized in Table 7. These included at least intermittent back pain in 90 patients (76%), limited ROM in 52 (44%), and activity limitations in 54 (46%). Less common limitations were waistline imbalance in 41 (35%), rib prominence in 28 (24%), wound/scar problems in 18 (15%), and shortness of breath in 18 (15%). Other related medical problems were lung disease/asthma in 11 (9%), osteoarthritis/degenerative arthritis in 11 (9%), heart disease in 3 (3%), and high blood pressure in 2 (2%).
A minority of patients also participated in postoperative treatment regimens. The most common treatment was regular use of NSAIDs (25 patients, 21%). Other treatments were physical therapy (14, 12%), narcotic pain medication use (5, 4%), and epidural steroid injections (5, 4%). Table 8 summarizes the postoperative treatments used by patients with scoliosis.
Discussion
A major concern about prophylactic interventions for diseases is that the treatment will harm the patient. This is especially true for major spine surgery performed on adolescents with minimal symptoms. Although the incidence of perioperative complications in children undergoing corrective spinal surgery for AIS has been reported,30-32 the effect of the surgery on the disease-specific HR-QOL outcomes of these individuals as young adults has not been previously studied. Over the past few decades, a paradigm shift in understanding health and disability has occurred, with increased emphasis being placed on HR-QOL outcomes measures and understanding disability as relating to a measureable impact of the functioning of an individual after a change in health or environment. This change was substantiated when the World Health Organization endorsed the International Classification of Functioning, Disability and Health.33 In light of this shift, we present the disease-specific and general HR-QOL outcomes of young adults who had undergone surgical correction for spinal deformity during adolescence, as well as their associated complications and reoperations, in an attempt to identify targets for improvement.
Our patient-reported outcomes demonstrated a high incidence of occasional back pain, activity-related complaints, and limited ROM. Comparison of our cohort’s SRS-22R outcomes with previously published normative values for the unaffected adolescent population28,34 suggests worse scores for the disease-specific SRS-22R domains of pain and appearance. In 2012, Daubs and colleagues34 reported that normative scores on various SRS-22 domains were statistically lower with age (scores decreased from age 10 to age 19 years). Both Verma and colleagues28 and Daubs and colleagues34 reported lower scores for females than for males. Therefore, it is unclear whether the differences observed in our cohort may be accounted for by the larger proportion of females compared with the normative data.
General health scores on the SF-12 were similar to the population norm (mean [SD]) of 50 (10) referenced by Ware and colleagues.16 These findings suggest that, though pain and appearance may be statistically lower in our cohort—as measured with the SRS-22R—the cohort’s spine-related symptoms do not seem to lower its general health. Eighty-five percent of the patients were working at the time of the survey, further supporting a relatively normal level of overall function. In a retrospective review by Takayama and colleagues,9 similar results were found with regard to working after AIS fusion surgery. Of 32 patients treated surgically for scoliosis, at a mean of 21.1 years after the index fusion 27 (84.4%) were or had been engaged in various occupations without marked difficulty.