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Archived Comments for: Adolescent Idiopathic Scoliosis – case report of a patient with clinical deterioration after surgery

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  1. Unbiased, evidence-based scientific decision making

    Evalina Burger, University of Colorado Hospital

    20 December 2007

    I read with high interest the case report by Dr. Weiss on a young patient who deteriorated after surgery for adolescent idiopathic scoliosis (AIS). Despite the lack of detailed reporting on parameters which influence the decision making for surgery, such as the Risser sign, I agree with author that the fusion levels selected in this patient were probably inadequate, leading to a residual imbalance. However, the presentation of the discussion appears almost as imbalanced as the patient described in this paper, due to an obvious, unjustified bias by the author against surgery for scoliosis.

    A large percentage of patients with scoliotic curves of more than 45 degrees will deteriorate without surgery. Spontaneous regression is reported in a small number of patients with AIS. The long-term effect of truncal imbalance can lead to debilitating pain. Even though patients with untreated scoliosis seem to function well as adults, it comes at a high price, as patients in modern day society tend to stay more active and may present with debilitating long-term pain.

    Outcomes have been scientifically documented through the Scoliosis Research Society (SRS) outcome tools (Berven et al., Spine. 2003;28:2164-9). The most recent literature has clearly demonstrated beneficial outcomes after surgery for scoliosis (Bridwell et al., Spine. 2007;32:2220-5). In contrast to these recent findings, which are not referenced in the present paper, the citations used by the author are predominantly outdated. Furthermore, the author should make a clear distinction in the discussion between the complication rates reported for adults vs. adolescents. These are two very distinct groups with completely different outcomes and complication rates. With regard to the “key” reference used throughout this paper (ref #5), this particular article is based on pediatric (infantile) scoliosis and unrelated to the AIS case presented in the present article.

    In summary, the important aspect of patient safety for scoliosis patients merits an unbiased, evidence-based scientific decision making process which should be independent of the subjective preferences by the treating physician.

    Competing interests


  2. Adolescent Idiopathic Scoliosis – an indication for surgery?

    Hans-Rudolf Weiss, Asklepios Katharina Schroth Klinik

    30 December 2007

    I´d like to thank Evalina Burger for her input regarding my case report published in Patient Safety in Surgery. Indeed, the Risser sign was missing in the case presentation which was grade IV not promising a significant residual growth in relation to this relatively small curve operated on of 28 degrees with a generally benign prognosis. However menarchial status documented here also shows there was little residual growth left before the operation was performed.

    In an unbiased comment I would have expected a statement that in this benign curve obviously no indication for surgery is given. I would have expected that Dr. Burger to be aware of the fact that the paper cited as reference #5 [1], although being published in Pediatric Rehabilitation, is related to Adolescent Idiopathic Scoliosis (AIS) in the first place, and by no means can be attributed as “outdated”.

    This paper [1] clearly demonstrates the lack of scientific knowledge about the long-term effects of surgery for AIS. I am personally not aware of any scientific publication which demonstrated that surgery for scoliosis has saved a single life. The above-mentioned reference [1] also shows that signs and symptoms of scoliosis cannot be cured by surgery. But if this is the case, how can someone claim for a medical indication for surgery in patients with AIS?

    Recently, a paper [2] was published with a prospective design, showing that the rate of complications is more than 3 times higher in the short-term (>15%) than previously expected (<5%). How big would the long-term re-operation rate be when someone would have a long-term prospective study instead of retrospective ones already showing the re-operation rate might be as high as 40% [1]. Do we know how the instrumented spine behaves in the elderly? How long does the cosmetic effect of an operation last? Is there a prospective controlled study clearly showing that scoliosis surgery really prevents progression in the long term? Does the patient really feel more sick when having 10 degrees more in 20 years?

    Today, from the patients perspective, we do have more open questions than answers when we look into the subject of spine surgery in patients with AIS.

    Unfortunately outcomes measured with the help of questionnaires [3] do not provide evidence enough to justify a risky procedure:

    Studies containing psychological questionnaires may be compromised by the dissonance effect [4-8], which applies to all situations that include important decisions to be made. Cognitive dissonance occurs most often in situations where an individual must choose between two incompatible beliefs or actions and there is a tendency for individuals to seek consistency among their cognitions. Unable to face an inconsistency, such as being dissatisfied with a surgical procedure, a person will often change an attitude or action. Surgery is impossible to reverse, but subjective beliefs and public attitude can be altered more easily. That means a patient not satisfied with a surgical treatment may not necessarily publicly admit this, as Moses et al. have described in their paper [8].

    There is also a spine surgery related paper [9] highlighting the problem with such questionnaires: ”Patient satisfaction is subjective. It does not reflect the benefits of surgery with respect to the future preservation of pulmonary function in thoracic curves nor the prevention of osteoarthritis in lumbar curves.”

    And another [10] also discussing the problems with such reports: “Radiographic and physical measures of deformity do not correlate well with patients' and parents' perceptions of appearance. Patients and parents do not strongly agree on the cosmetic outcome of AIS surgery.”

    From all of the studies based on questionnaires, no evidence can be derived that supports the assumption that patients have experienced benefits from undergoing surgery, as none were able to rule out the cognitive effect of dissonance. Without being able to rule out such effects on the post-operative experience these outcomes do not appear to be valid [8,9,10].

    Finally, to come back to the paper which Dr. Burger presents as a “proof” for a beneficial effect of surgery in patients with scoliosis [3]: This is only a two year follow-up which has nothing to do with the long-term negative effects the patients might suffer from and today still are not even revealed. Therefore I´d like to cite an outdated paper at this place, but there is no new evidence that speaks against it:

    In view of the high rate of complications, the gains to be derived from spinal fusion should be assessed and clearly explained to patients before the procedure is undertaken [11].

    I do agree that patient safety for scoliosis patients merits an unbiased, evidence-based scientific decision making process which should be independent of the subjective preferences by the treating physician. In view of the very many open questions, the lack of medical benefit and the high amount of long-term risks of the surgical procedures applied [1] the only possible way of decision making can be: Let the patient decide after providing all the objective facts available.

    Last but not least there is a question which remains to be answered: Is the decision making process in a surgeons office independent of subjective preferences, when the surgeon has an affiliation to industry which benefits from the implants used for surgery [12]?


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    Competing interests