| Background and Objectives:Degenerative scoliosis(DS) is defined as a structural scoliosis accompanied bydegenerative intervertebral facets joints in a skeletally mature patient, whose spine waspreviously straight and normal without any lesions. It’s also termed as de novoscoliosis(DNS). Up to date the precise etiology of DS is still unknown, but it is thought thatthe asymmetric degeneration of thoracolumbar or lumbar intervertebral disc andintervertebral joint is the cause of scoliosis. Besides the scoliosis on the coronal plane andlateral olisthesis between the adjacent vertebral body, DS is often associated with lumbarspondylolisthesis on the sagittal plane and spinal imbalance, and finally cause the discherniation, spinal stenosis, and so on. The severe DS patients often have intractable lowback pain and intermittent claudication, which seriously affect their quality of life.The elderly(>60years) are the population with high risk of DS, who are associated withmany chronical diseases usually, so it is the best to choose the minimum invasive treatments.The conservative treatments such as the the oral drug and the nerve root block anaesthesiaare ever thought to be the first choice. However many patients failing in the non-operativetreatments turn to surgery which means more injuries. Given to these specific group of highsurgery risk, decompression of vertebral canal or nerve root canal alone has superiority ofrelief the pain and little trauma. However some limitations must be mentioned thatdecompression could destruct bony structure and has the possibility of accelerating the localinstability, at the same time, some patients relapse soon after the surgery and need therevision surgery for instrumented fusion.The incidence of degenerative scoliosis gradually increases along with the arrival ofaging society. Meanwhile, as the increasing demands of the life quality, more and morepatients with pain and disability go to hospital for medical aids. But there are still a lot ofquestion to be addressed, such as how to make the right medical decision between the operative and nonoperative treatments, whether to get a instrumented fusion afterdecompression and the curative effect of different treatments. Nowadays the evaluationsystems of treatments are focused on either the improvement of radiographic paremeters orthe patient’s self-assessment, failing to compare the outcomes among different treatments.The purpose of this study is to extensively evaluate the outcomes of surgery on degenerativescoliosis and compare the curative effect of treatments for the patients with sever disability,and to explore the most useful treatment for the patients.Methods:The radiographic parameters before and after treatments were recorded in detail, whilepatients were asked to complete a battery of health elated quality of life (HRQOL)questionnaire such as Owestry Disability Index (ODI), Euro Quality of Life five-DimensionQuestionnaire (EQ-5D), Scoliosis Research Society-22(SRS-22) questionnaires and VisualAnalogue Scale (VAS) for both back and leg pain. Statistical analysis was performed withSPSS Statistics19.0. All data were presented as mean SD. P <0.05was consideredstatistically significant.Part1To analyze the outcomes of intermediate-term after a posteriordecompression and instrumented fusion surgery for degenerative scoliosis1. The clinical data of36patients with degenerative scoliosis were collected, whounderwent posterior decompression and fusion surgery From March2008to March2012inXin Qiao Hospital, Third Military Medical University. Standing posterior-anterior andlateral x-rays images, CT and MRI were performed preoperatively for all patients and thedata including age, sex, the number of decompression and fusion and complications werewell documented.2. Full-length scoliosis radiographs were obtained for all patients separatively at1week,1month,3months,6months and1year after surgery and once a year afterwards.The scores of ODI and VAS for the back pain and leg pain were recorded preoperativelyand at each follow-up, for evaluate the outcomes.3. Differences of VAS(back pian, leg pain), ODI and the radiographic parametersbetween the preoperative and postoperative were evaluated using Paired t tests.Part2. Validity of variable options of treatment for patients with degenerativescoliosis suffering severe symptom 1. The clinical data of61degenerative scoliosis patients with severe symptom in ourhospital from March2010to March2012，were analyzed retrospectively.2. The clinical records of the patients and radiological parameters such as Cobb’s anglewere documented. Based on the different treatments, patients were classified into3groups:conservative treatment group(A group), decompression alone group(B group) anddecompression and instrument fusion group(C group).3. The spinal X ray, lumbar CT and MR before the treatments and standing position-inanterior-posterior (AP) and lateral radiographs in the follow-up were taken. ODI surveys aswell as SRS-22scores were completed before the treatments and follow-up. At the finalfollow-up, all patiens were asked to complete the EQ-5D for the purpose of general healthevaluation.4. Before and after the treatments,the differences in continuous measurments betweenthe3groups were evaluated using one-way analysis of variance. Within each group thepreoperative and postoperative datas were evaluated using Paired t tests.Results:Part1.1. The radiographic parameters of degenerative scoliosis patients treated by posteriordecompression and fusion surgery were significantly improved. The mean correction rate ofcoronal Cobb’s angle was39.9%as well as the average increase of lumbar lordosis was10°.Compared with1year after the surgery, coronal and sagittal balance recorded at the finalfollow-up were improved obviously(P<0.05).2. There were significant improvement after the operation in VAS for both back andleg and ODI (P<0.05). Comparing with1year post-operation, VAS score for low backpain(1.96±0.90VS2.48±0.77, t=2.942, P<0.05) and ODI score (20.04±8.85VS26.48±6.99,t=3.648, P<0.05)at2years follow-up were further improve, while no meaningful changes ofleg VAS.3. Complication included3cases of dural tears,3cases of superficial wound infectionand5cases of transient peripheral root deficits, but all patients soon obtained favorableoutcomes after effective treatments. Scoliosis aggravated accompanied with worsen pain in1case at1.5year postsurgery, who underwent decompression and short fusion previously.After a corrective surgery with long instrumented fusion, the patients got his quality of life improved significantly. There were no pedicle screw loosing, no screw or rod breakage andno pseudarthrosis for all cases at the ultimate follow-up.Part21. All of61patients were followed up for an average period of26.7months (rang:18to42months). After effectual treatments, patients in the three groups had an improvementof sagittal balance and compared to1year after the treatment, at the final follow-up group Cimproved further(t=4.66, P <0.05).As for the rest of radiographic parameters, at the finalfollow-up, group C didn’t change much, while group A did improve significantly(P <0.05).2. After the treatments people of the three groups had an improvement in function (P<0.05) according the ODI, patients favoring surgery treatment (groups B and C) recoveredbetter than those in the conservation treatment(group A),and group C got better results thangroup C(23.4%vs31.9%). Comparing to the follow-up of1year after treatment, at the lastfollow-up, group C showed a better ODI scores(23.4%vs32.7%, t=5.449, P <0.001), whilegroup B get worse (31.1%vs25.9%; t=2.34, P <0.05). According to mean change ofSRS-22, group C had a better outcome than group B (P <0.001). As compared to thenonoperative group at the final follow-up, the operative group reported significantly betterself-assessment scores for the EQ-5D index and Visual Analogue Score, while group C got abetter quality of life than group B(EQ-5D index:0.70VS0.65, P <0.05; EQ-5D VAS:78.6%VS72.9%, P <0.05)Conclusion:1. Sever degenerative scoliosis may cause intolerable pain and disability; most patientswith symptoms need medical intervention.2. Surgery treatment would be more superior to conservative treatment fordegenerative scoliosis suffering with severe symptom in functional recovery and life qualityimprovement. Decompression alone is effective for the patients whose main symptoms isclaudication, but the fusion-stabilization is absolutely necessary for patients with severespinal deformity or local unstability, in order to rebuild the spinal stability and prevent thescoliosis progress.3. Decompression and fusion surgery is a secure and efficient treatment ofdegenerative scoliosis. The pain and functional disability could be relieved significantly,and it would be further improved over time. Although there are some complications associated with the surgery，they could be well controlled by efficient treatments and won’tweaken the surgery outcomes. |
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