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Distal adding-on in adolescent idiopathic scoliosis results in diminished health-related quality of life at 10 years following posterior spinal fusion

Abstract

Purpose

The purpose of this study was to investigate associations between the various definitions of adding-on identified in the literature and HRQoL at 10 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) to identify a clinically relevant definition.

Methods

In this retrospective cohort study, patients with Lenke type 1 or 2 AIS with 10-year follow-up after PSF were identified in a multicenter registry. Adding-on was identified independently using 5 published definitions and expert spine surgeons’ visual confirmation. Worsening of HRQoL was defined as a preoperative to 10-year postoperative decrease in SRS-22 domain score ≥ the minimal clinically important difference (MCID).

Results

One hundred fifty patients were included, and 118 had HRQoL data available for the main analysis. Worsening pain was noted in 49 (41.5%) patients, appearance in 1 (0.8%), and activity in 70 (59.3%) from preoperative to postoperative. 4 of the 5 definitions of adding-on demonstrated no evidence of association with worsening HRQoL. By Cho’s definition (either 1. ≥ 5° increase in Cobb angle AND increase in number of vertebrae in curve distally, or 2. ≥ 5° increase in angulation of 1st disc below LIV), adding-on (27 patients, 22.9%) was associated with an increased risk of worsening pain (59.3% vs. 36.3%, p = 0.033) and activity (77.8% vs. 53.8%, p = 0.026). There was no evidence of association with changes in appearance. Risk of worsening pain and activity was increased by 1.75 and 1.51 times (p = 0.023 and p = 0.002), respectively.

Conclusion

Cho’s definition of adding-on was associated with worsening HRQoL at 10 years following PSF for Lenke type 1 and 2 AIS. Consistent use of this definition will allow us to compare studies and obtain meaningful information in this population.

Level of evidence

Level II.

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References

  1. 1.

    Cho RH, Yaszay B, Bartley CE et al (2012) Which Lenke 1A curves are at the greatest risk for adding-on... and why? Spine 37:1384–1390. https://doi.org/10.1097/BRS.0b013e31824bac7a

    Article  PubMed  Google Scholar 

  2. 2.

    Lakhal W, Loret J-E, de Bodman C et al (2014) The progression of lumbar curves in adolescent Lenke 1 scoliosis and the distal adding-on phenomenon. Orthop Traumatol Surg Res 100:S249–S254. https://doi.org/10.1016/j.otsr.2014.03.012

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Sponseller PD, Betz R, Newton PO et al (2009) Differences in curve behavior after fusion in adolescent idiopathic scoliosis patients with open triradiate cartilages. Spine 34:827–831 (OD-2009/04/02)

    Article  Google Scholar 

  4. 4.

    Wang Y, Hansen ES, Høy K et al (2011) Distal adding-on phenomenon in Lenke 1A scoliosis: risk factor identification and treatment strategy comparison. Spine 36:1113–1122. https://doi.org/10.1097/BRS.0b013e3181f51e95

    Article  PubMed  Google Scholar 

  5. 5.

    Wang Y, Bünger CE, Zhang Y et al (2013) Distal adding-on in Lenke 1A scoliosis: how to more effectively determine the onset of distal adding-on. Spine 38:490–495. https://doi.org/10.1097/BRS.0b013e318273ed11

    Article  PubMed  Google Scholar 

  6. 6.

    Suk S-I, Lee S-M, Chung E-R et al (2005) Selective thoracic fusion with segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis: more than 5-year follow-up. Spine 30:1602–1609

    Article  Google Scholar 

  7. 7.

    Cao K, Watanabe K, Kawakami N et al (2014) Selection of lower instrumented vertebra in treating Lenke type 2A adolescent idiopathic scoliosis. Spine 39:253–261. https://doi.org/10.1097/BRS.0000000000000126

    Article  Google Scholar 

  8. 8.

    Cao K, Watanabe K, Hosogane N et al (2014) Association of postoperative shoulder balance with adding-on in Lenke type ii adolescent idiopathic scoliosis. Spine 39:E705–E712. https://doi.org/10.1097/BRS.0000000000000325

    Article  PubMed  Google Scholar 

  9. 9.

    Yang C, Li Y, Yang M et al (2016) Adding-on phenomenon after surgery in Lenke type 1, 2 adolescent idiopathic scoliosis: is it predictable? Spine 41:698–704. https://doi.org/10.1097/BRS.0000000000001303

    Article  PubMed  Google Scholar 

  10. 10.

    Matsumoto M, Watanabe K, Hosogane N et al (2013) Postoperative distal adding-on and related factors in Lenke type 1A curve. Spine 38:737–744. https://doi.org/10.1097/BRS.0b013e318279b666

    Article  PubMed  Google Scholar 

  11. 11.

    Shigematsu H, Cheung JPY, Bruzzone M et al (2017) Preventing fusion mass shift avoids postoperative distal curve adding-on in adolescent idiopathic scoliosis. Clin Orthop Relat Res 475:1448–1460. https://doi.org/10.1007/s11999-016-5216-2

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Zang L, Hai Y, Yuan S et al (2017) Distal adding-on and risk factors in severe and rigid scoliosis. Spine 42:160–168. https://doi.org/10.1097/BRS.0000000000001684

    Article  PubMed  Google Scholar 

  13. 13.

    Qin X, Sun W, Xu L et al (2016) Selecting the last “substantially” touching vertebra as lowest instrumented vertebra in Lenke type 1A curve: radiographic outcomes with a minimum of 2-year follow-up. Spine 41:E742–E750. https://doi.org/10.1097/BRS.0000000000001374

    Article  PubMed  Google Scholar 

  14. 14.

    Suk S-I, Lee S-M, Chung E-R et al (2003) Determination of distal fusion level with segmental pedicle screw fixation in single thoracic idiopathic scoliosis. Spine 28:484–491. https://doi.org/10.1097/01.BRS.0000048653.75549.40

    Article  PubMed  Google Scholar 

  15. 15.

    Yang M, Zhao Y, Yin X et al (2018) Prevalence, risk factors, and characteristics of the “adding-on” phenomenon in idiopathic scoliosis after correction surgery. Spine 43:780–790. https://doi.org/10.1097/BRS.0000000000002423

    Article  PubMed  Google Scholar 

  16. 16.

    Upasani VV, Hedequist DJ, Hresko MT et al (2015) Spinal deformity progression after posterior segmental instrumentation and fusion for idiopathic scoliosis. J Child Orthop 9:29–37. https://doi.org/10.1007/s11832-015-0632-5

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Asher M, Min Lai S, Burton D et al (2003) The reliability and concurrent validity of the scoliosis research society-22 patient questionnaire for idiopathic scoliosis. Spine 28:63–69 (OD-2003/01/25)

    Article  Google Scholar 

  18. 18.

    Carreon LY, Sanders JO, Diab M et al (2010) The minimum clinically important difference in scoliosis research society-22 appearance, activity, and pain domains after surgical correction of adolescent idiopathic scoliosis. Spine 35:2079–2083 (OD-2010/04/17)

    Article  Google Scholar 

  19. 19.

    Kim HJ, Bridwell KH, Lenke LG et al (2013) Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients. Spine 38:896–901. https://doi.org/10.1097/BRS.0b013e3182815b42

    Article  PubMed  Google Scholar 

  20. 20.

    Kim HJ, Bridwell KH, Lenke LG et al (2014) Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections. Spine 39:576–580. https://doi.org/10.1097/BRS.0000000000000246

    Article  Google Scholar 

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Acknowledgements

Harms Study Group Investigators: Aaron Buckland, MD; New York University; Amer Samdani, MD; Shriners Hospitals for Children—Philadelphia; Amit Jain, MD; Johns Hopkins Hospital; Baron Lonner, MD; Mount Sinai Hospital; Benjamin Roye, MD; Columbia University; Burt Yaszay, MD; Rady Children’s Hospital; Chris Reilly, MD; BC Children’s Hospital; Daniel Hedequist, MD; Boston Children’s Hospital; Daniel Sucato, MD; Texas Scottish Rite Hospital; David Clements, MD; Cooper Bone & Joint Institute New Jersey; Firoz Miyanji, MD; BC Children’s Hospital; Harry Shufflebarger, MD; Paley Orthopedic & Spine Institute; Jack Flynn, MD; Children’s Hospital of Philadelphia; John Asghar, MD; Paley Orthopedic & Spine Institute; Jean Marc Mac Thiong, MD; CHU Sainte-Justine; Joshua Pahys, MD; Shriners Hospitals for Children—Philadelphia; Juergen Harms, MD; Klinikum Karlsbad-Langensteinbach, Karlsbad; Keith Bachmann, MD; University of Virginia; Lawrence Lenke, MD; Columbia University; Lori Karol, MD; Children’s Hospital, Denver Colorado; Mark Abel, MD; University of Virginia; Mark Erickson, MD; Children’s Hospital, Denver Colorado; Michael Glotzbecker, MD; Rainbow Children’s Hospital, Cleveland; Michael Kelly, MD; Washington University; Michael Vitale, MD; Columbia University; Michelle Marks, PT, MA; Setting Scoliosis Straight Foundation; Munish Gupta, MD; Washington University; Nicholas Fletcher, MD; Emory University; Noelle Larson, MD; Mayo Clinic Rochester Minnesota; Patrick Cahill, MD; Children’s Hospital of Philadelphia; Paul Sponseller, MD; Johns Hopkins Hospital; Peter Gabos, MD: Nemours/Alfred I. duPont Hospital for Children; Peter Newton, MD; Rady Children’s Hospital; Peter Sturm, MD; Cincinnati Children’s Hospital; Randal Betz, MD; Institute for Spine & Scoliosis; Stefan Parent, MD: CHU Sainte-Justine; Stephen George, MD; Nicklaus Children's Hospital; Steven Hwang, MD; Shriners Hospitals for Children—Philadelphia; Suken Shah, MD; Nemours/Alfred I. duPont Hospital for Children; Sumeet Garg, MD; Children’s Hospital, Denver Colorado; Tom Errico, MD; Nicklaus Children's Hospital; Vidyadhar Upasani, MD; Rady Children’s Hospital.

Harms Non-Fusion Study Group Investigators: Amer Samdani, MD; Shriners Hospitals for Children—Philadelphia; Ahmet Alanay, MD; Acibadem Maslak Hospital, Turkey; Baron Lonner, MD; Mount Sinai Hospital; Bob Cho, MD; Shriner’s Pasadena CA; Burt Yaszay, MD; Rady Children’s Hospital; Caglar Yilgor, MD; Acibadem Maslak Hospital, Turkey; Dan Hoernschmeyer, MD; University of Missouri Health Care; Firoz Miyanji, MD; BC Children’s Hospital; Harry Shufflebarger, MD; Paley Orthopedic & Spine Institute; John Asghar, MD; Paley Orthopedic & Spine Institute; Josh Murphy, MD; Children's Healthcare of Atlanta; Kevin Neal, MD; Nemours Children’s Clinic, Jacksonville; Laurel Blakemore, MD; Pediatric Specialists of Virginia/Children’s National; Lawrence Haber, MD; Ochsner health center for children New Orleans; Noelle Larson, MD; Mayo Clinic Rochester Minnesota; Patrick Cahill, MD; Children’s Hospital of Philadelphia; Peter Newton, MD; Rady Children’s Hospital; Stefan Parent, MD: CHU Sainte-Justine; Suken Shah, MD; Nemours/Alfred I. duPont Hospital for Children.

Funding

This study was supported in part by grants to the Setting Scoliosis Straight Foundation in support of Harms Study Group research from DePuy Synthes Spine, EOS imaging, Stryker Spine, Medtronic, NuVasive, Zimmer Biomet and the Food and Drug Administration.

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Contributions

BDR, HM, ANF, GFM, RRI, AB, NB, LGL, PON and MGV made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work. BDR, HM, ANF, GFM, RRI, AB, NB, LGL, PON and MGV drafted the work or revised it critically for important intellectual content. BDR, HM, ANF, GFM, RRI, AB, NB, LGL, PON and MGV approved the version to be published. BDR, HM, ANF, GFM, RRI, AB, NB, LGL, PON and MGV agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Benjamin D. Roye.

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Ethics approval

This study was approved by the Columbia University Institutional Review Board (Protocol AAAR3052) and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Informed consent was obtained from each subject upon enrollment in the adolescent idiopathic scoliosis (AIS) registry.

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Roye, B.D., Matsumoto, H., Fano, A.N. et al. Distal adding-on in adolescent idiopathic scoliosis results in diminished health-related quality of life at 10 years following posterior spinal fusion. Spine Deform (2021). https://doi.org/10.1007/s43390-021-00432-1

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Keywords

  • Adding-on
  • Health-related quality of life (HRQoL)
  • Adolescent idiopathic scoliosis (AIS)
  • Posterior spinal fusion (PSF)