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Purpose: The Spinal Appearance Questionnaire (SAQ) is a widely validated tool for assessing perceptions of spinal deformity in adolescent idiopathic scoliosis (AIS) patients. This study aimed to develop and validate a Greek version of the SAQ (GR-SAQ)., Methods: A cross-cultural adaptation of the SAQ following international guidelines was performed. Internal consistency and test-retest reliability were evaluated. Convergent validity was assessed by correlating the GR-SAQ with the Appearance domain of Scoliosis Research Society-22 (SRS-22) and the Cobb angle with the Trunk Shift domain of GR-SAQ. Divergent validity was examined through the relationship between GR-SAQ, patient characteristics, and clinical measures including Cobb angle, DIERS Formetric 4D angle, and scoliometer readings., Results: The study included 61 AIS patients (52 females, 13.91 ± 2.57 years, 25.33 ± 10.14° Cobb angle). GR-SAQ exhibited good internal consistency (Cronbach's α = 0.794) and excellent test-retest reliability (ICC = 0.931, 95%CI: 0.880-0.960). Correlations between GR-SAQ and SRS-22 showed a low-to-moderate negative correlation (r = -0.351, p = 0.006). The Trunk Shift domain moderately correlated with the Cobb Angle (r = 0.393, p = 0.002). Divergent validity analyses did not demonstrate statistical significance (p > 0.05)., Conclusion: The GR-SAQ is a valid and reliable tool for evaluating spinal deformity perception in Greek AIS patients., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: The psychological effects of scoliosis bracing can be difficult, and thus clinicians sometimes recommend a brace holiday when the curve corrects to less than 25°. However, the clinical indications for taking a break from the brace before reaching maturity have yet to be described. We hypothesized there would be a relationship between brace holiday eligibility and degree of curve at presentation, change in curve magnitude while bracing, and level of bracing compliance., Methods: A retrospective cohort study at a single institution was performed from 2016 to 2022. Objective brace compliance I-button data were collected on patients aged 3-9 years old. Patients with other etiologies besides idiopathic scoliosis before the age of 10 were excluded. Binary logistic regression was performed to determine the effect of significant variables on the likelihood of brace holiday., Results: Fifty-six patients met inclusion criteria. Of these, 20 were able to get a brace holiday. Patients with higher brace compliance and larger in-brace curve correction were more likely to get a brace holiday (P = 0.015, 0.004). Patients with higher BMIs and larger curves at initial presentation were less likely to get a brace holiday (P = 0.002, 0.014)., Conclusion: Compliant brace wearers with good in-brace correction are most likely to be eligible for a brace holiday. While some elements remain immutable, others are modifiable, such as bracing compliance. Understanding how outcomes differ between patients who do and do not take a brace holiday will be crucial to elucidating if the psychological benefit of taking a break from the brace can be justified., (© 2024. The Author(s).)

Purpose: The goal of this study is to characterize the self-reported prevalence of psychiatric comorbidities among patients with adolescent scoliosis., Methods: Eligible patients across the US were surveyed using ResearchMatch, a validated online platform. The survey collected patient demographics, type of scoliosis, scoliosis treatment received, and the mental health diagnoses and interventions., Results: Nearly all (98%) of the 162 respondents were patients themselves, the remainder of which were parents. The majority of whom were female (93%), Caucasian (85%), and diagnosed with idiopathic scoliosis (63%). The median age of diagnosis was 13 (IQR 11-18). Most respondents had mild to moderate scoliosis (65%), and 17% received surgical treatment. 76 of 158 (48%) responded that scoliosis affected their overall mental health, and 92 (58%) had received a mental health diagnosis-76% were diagnosed after their scoliosis diagnosis. Of the 92 with mental health diagnoses, the most common diagnoses were clinical depression (83%), anxiety (71%), negative body image (62%). Over 80% of patients received medical treatment or therapy. Of those with depression, 38.4% received counseling and 45.2% received medication. 52% of the respondents also had immediate family members with mental health diagnoses, with siblings (48%) having the highest proportion., Conclusion: According to the CDC, the prevalence of US teenagers with diagnosed depression was found to be 3.9% and anxiety disorder to be 4.7%, notably higher among adolescent girls. In this national sample, over half of adolescent scoliosis patients report psychiatric comorbidity, often diagnosed years later. The most prevalent psychiatric condition is depression, anxiety, and body-image disturbances. These findings highlight the importance of awareness of the psychiatric impact of adolescent scoliosis, and importance of screening and treatment of comorbid mental health conditions., Level of Evidence: IV., (© 2024. The Author(s).)

Purpose: To perform a cross-cultural adaptation and validation of the Brazilian-Portuguese versions of the Brace Questionnaire in adolescent idiopathic scoliosis., Methods: A forward-backward translation process was employed to produce a Brazilian Portuguese version of the Brace Questionnaire, followed by comprehensive cross-cultural adaptation stages. The measurements of internal consistency and test-retest reliability were assessed by Cronbach's a and intraclass correlation coefficient (ICC), respectively. The Pearson's correlation coefficient was used to analyze the concurrent validity by comparison with the Scoliosis Research Society-22r questionnaire., Results: A total of 84 scoliosis patients (age 13.4 ± 2.0 years, thoracic Cobb angle 33.3° ± 13.8°, and lumbar Cobb angle 29.8° ± 14.3°) were included. The Brace Questionnaire showed excellent internal consistency (Cronbach α = 0.93) and moderate reliability (ICC = 0.86). The correlations between the Brace Questionnaire and Scoliosis Research Society-22 were r = 0.66; p = 0.011. In addition, it was found that the Brazilian version of the Brace Questionnaire does not have ceiling and floor effects., Conclusions: The Brazilian-Portuguese adaptation of the brace questionnaire shows excellent reliability and can be a valid tool for psychometric assessment in adolescent idiopathic scoliosis., (© 2024. The Author(s).)

Purpose: To review the current literature surrounding the assessment of self-image in pediatric and adult spinal deformity., Methods: The literature were reviewed for studies examining patient-reported outcome measurements (PROM) and self-image in pediatric and adult spinal deformity. PROM performance metrics were collected and described. The relationships between self-image PROM and patient outcomes, including satisfaction, were described., Results: Several self-image PROM exist, including the Scoliosis Research Society-22r (SRS-22r) self-image domain, the Body Image Disturbance Questionnaire (BIDQ), and the Spinal Appearance Questionnaire (SAQ). The most commonly used is the self-image domain of the SRS-22r. It is validated in adult and pediatric spinal deformity and is correlated with patient desire for surgery and satisfaction after surgery. This domain is limited by floor and ceiling effects., Conclusion: Self-image assessment is critical to both pediatric and adult spinal deformity surgeries. The SRS-22r self-image domain is the most frequently reported PROM for this health domain. While valid in both surgical cohorts, this PROM is affected by floor and ceiling effects which limits the ability to discriminate between health states. Given the overall importance of this domain to patients with spinal deformity further efforts are needed to improve discrimination without gross increases in PROM question burden, which may limit broad acceptance and use., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: EOSQ-24 is a disease specific patient-reported outcome score used to assess the quality of life in patients with early-onset scoliosis. The aim of this study was to translate and cross-culturally adapt the English version of the EOSQ-24 to Finnish language and to assess the reliability and validity of the translation., Methods: Cross-cultural adaptation and cross-cultural validation were performed to the Finnish translation of the EOSQ-24. Patients and/or their caretakers were then recruited to assess the psychometric properties of the translation. We assessed the internal consistency, test-retest reliability, floor and ceiling effects, and discriminative abilities. One-hundred-and-three patients filled the questionnaire., Results: EOSQ-24 was successfully translated into Finnish. The translation showed excellent internal consistency (Cronbach alpha 0.94), satisfactory item-total correlations ranging from 0.6 to 0.9, and moderate to strong inter item correlations. Test-retest reliability ranged from 0.7 to 0.96 indicating good to excellent agreement. Patients with neuromuscular and syndromic scoliosis reported lower EOSQ-24 scores when compared to patients' idiopathic and congenital scoliosis. There was a significant negative correlation between major curve and EOSQ-24 scores in patients with idiopathic early onset scoliosis., Conclusion: The internal consistency and test-retest reliability of the measure were found to be satisfactory. A marked ceiling effect was observed, indicating a potential source of error., (© 2024. The Author(s).)

Purpose: Our objective was to collect the experience and current attitude of those patients, now adults, operated on for adolescent idiopathic scoliosis (AIS) more than 25 years ago with CD instrumentation (CDI)., Methods: Prospective qualitative cross-sectional study with interpretive phenomenological analysis approach of AIS patients operated in a single center with CDI between 1985 and 1995. Patients underwent a semi-structured interview with their original surgeon. Seven agreed themes were open for conversation, and several subthemes emerged related to their experience during their journey in life. Filed notes were recorded and transcribed verbatim. We used the method of content, semantic and pragmatic analysis., Results: We contacted 103 patients, 100 agreed to participate. Mean age was 47.5 ± 3.3, mean follow-up was 30.9 ± 2.7 years. Three fundamental concerns stood out: discomfort with self-image; low back pain with daily activities; and lack of spinal flexibility. 50% were engaged in continuous physical exercise, and only some referred limitations with load-bearing work. Patients commonly described negative memories of the conservative treatment, but positive memories of the surgical process. In general, there was a good adaptation to social life (occupation, social and family relationships). Two-thirds were married, and 65 women had offspring. A frequent concern was the excess of radiographs over the years, and three developed breast cancer., Conclusions: Factors such as dissatisfaction with self-image, low back pain, and spine stiffness were relevant to patients throughout their journeys. Despite this, the great majority were satisfied with the treatment received, which allowed them to lead an integrated life in society., Level of Evidence: Level II., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: The aim of our study was to determine the relationship between Patient Health Questionnaire (PHQ) scores-a simple, validated depression screening tool-and Scoliosis Research Society (SRS)-22 questionnaire scores in patients with idiopathic scoliosis (IS)., Methods: IS patients screened for depression with the PHQ-2 who completed the SRS-22 over a 2-year period were reviewed. If PHQ-2 scores were positive (> 3), the more comprehensive PHQ-9 was administered. Median SRS-22 scores between positive and negative PHQ screens were compared. Nonparametric correlation between PHQ and SRS-22 Mental Health (MH) domain was performed. The ability of the MH domain to discriminate between patients with positive versus negative screens and patients with moderate-severe depression risk versus no-mild risk was evaluated with ROC analysis., Results: 521 patients were included. Patients with + PHQ-2 screens had significantly lower total and individual domain SRS scores, especially within the MH domain (4.0 vs. 3.2). For those with moderate-severe depression risk, total and individual domain scores were also significantly lower (MH domain, 4.0 vs. 3.0, p < 0.05). A weak, but significant correlation was observed between the PHQ and MH domain scores (rho = 0.32, p < 0.001). A cut-off of ≥ 3.6 on the MH domain demonstrated sensitivity of 0.75 and specificity of 0.86 for identifying patients at no-mild risk for depression., Conclusion: Recognizing mental health conditions is critical to successful IS treatment as psychosocial conditions can negatively affect treatment outcomes. IS patients scoring < 3.6 on the SRS-22 MH domain should be considered for depression screening due to an increased risk of moderate-severe depression., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: To identify the prevalence and predictors of nonspecific back pain in primary thoracic adolescent idiopathic scoliosis (AIS) patients at 10 years after surgery., Methods: This was a case-control multi-center study. A query of patients who underwent surgical correction of major thoracic AIS between 1997 and 2007 with 10-year follow-up was reviewed. SRS-22 pain scores at 10 years were classified as below normal (≤ 2 standard deviations below average for controls of similar age/sex from published literature) or within/above the control range., Results: One hundred and seventy-one patients with an average of 10.5 ± 0.8-years follow-up were included. Average age at surgery was 14 ± 2 years. The rate of pain was 23% for males and 11% for females (p = 0.08). Differences in age, 10-year SRS mental health score, and radiographic measures were noted. Of 12 patients who underwent revision surgery, 42% reported below normal pain scores versus 11% in cases without revision (p = 0.012). Classification and regression tree (CART) analysis identified 10-year thoracic curve magnitude and 10-year mental health scores as significant predictors. Thoracic Cobb of ≤ 26° at 10 years was associated with a 7% rate of below normal pain scores compared to 27.5% when the curve was > 26° (OR = 4.8, p < 0.05). Of those with a curve ≤ 26°, no patients had abnormal pain if the SRS mental health score was > 4.2 and 15% had more pain than normal if mental health score was ≤ 4.2 (OR 23, p < 0.05)., Conclusion: Increased primary thoracic curve magnitude (> 26°) at 10 years was the primary predictor of increased pain. For patients with less coronal deformity (< 26°), a poor mental health score was associated with an increased rate of pain. Male gender and revision surgery may also play a role in increased pain, however, the overall frequency of these variables were low., Level of Evidence: Level 3., (© 2021. Scoliosis Research Society.)

Background Context: Patients and their families are increasingly turning to the internet for medical information. Most of these patients believe the information to be accurate and reliable. However, the quality and accuracy of that information on the internet is variable and unregulated. Accurate and applicable information may align patients' expectations and improve satisfaction and overall outcomes., Purpose: This study aimed to evaluate the quality and accuracy of scoliosis-related information available on the internet., Study Design: Cross-sectional analysis., Methods: Independent searches were conducted on the three most commonly accessed search engines (Google, Yahoo and Bing) using the keyword "scoliosis". The top 30 sites from each search engine were reviewed. Each website was categorized as per its authorship and sourcing. Each site was then evaluated for accuracy, readability and with quality-assurance markers such as Health on the Net code (HONcode), DISCERN, Journal of American Medical Association (JAMA) systems. The accuracy of the website was assessed by two fellowship-trained spine specialists. Website accuracy was rated on a scale of 1-4 based on the level of agreement with the information presented. Websites with greater than 75% agreement were rated 4. Finally, the sites were evaluated with a validated website distraction index and assessed for mobile friendliness., Results: 42 unique websites were analyzed. 31% of the sites were categorized as academic (13 academic, 9 healthcare system, 12 health news outlets and 8 unspecified) and had the highest rate of physician authorship (54%). Accuracy ranged from less than 25% to more than 75% were recorded with a mean accuracy of 3 signifying 50-75% agreement. Academic sites had the highest scoliosis specific accuracy score (P < 0.05). Overall, average readability was at a 12th grade reading level. More than 90% of the sites were mobile friendly. Approximately 71% of the websites did not have HONcode certification, although health news outlets had the highest rate of certification (67%). There was a significant effect of HONcode certification on DISCERN, JAMA, grade level and reading ease. On average, HONcode certified websites had lower grade level readability with greater reading ease and higher DISCERN and JAMA scores than un-certified sites (p < 0.05). On average, health news outlets had the highest DISCERN, JAMA, and reading ease scores and were written at the lowest grade reading level but had the highest level of distraction (p < 0.05)., Conclusion: For the iGeneration and their care-givers, the internet remains the most popular source of health-related and medical information. Despite the wide number of sources available, the quality, accuracy, pertinence and intelligibility of the information remains highly variable. As clinicians, we should direct patients to verifiable sites with regulated information and, where possible, contribute high quality information to those sites.

Hypothesis: AIS patients and their parents will have distinct perspectives regarding the impact of AIS on patients' lives., Introduction: Current outcome assessment tools for AIS do not fully assess patient-specific disease impact and fail to distinguish between patient and parent perspectives. Patient Generated Index (PGI) has been used in other disease states to assess individual experiences. This study assesses PGI in operative AIS patients and their parents., Design: Level 1, prospective multi-center study., Methods: 44 AIS patient and parent pairs completed the PGI questionnaire comprised of three stages (S1, S2, S3) and decision regret (DR). S1 asks for five areas of the patient's life most affected by AIS and a 6th encompassing all other areas of their lives affected, S2 focuses on the magnitude of effect, S3 identifies desire to improve affected areas and DR if the surgery did not improve the specific area. S1 free responses were organized into 14 domains. Descriptive statistics were reported for stage scores; free-response format of PGI and DR limited ability for paired sample t test analysis., Results: Mean age at surgery was 14.3 years, 84% female, and mean major curve magnitude was 61°. The three most common patient-reported concerns prior to surgery were (in descending order): sports, general function, and general fitness. However, the three most common parent-reported concerns were (in descending order): general function, sports, and appearance. Patients reported self-esteem and parents reported physical appearance as the most affected domain (S2). Patients reported pain and self-esteem and parents reported sleep and self-esteem as main operative aspirations (S3). Decision regret was the highest for uncertainty of future health in patients and sleep in parents., Conclusion: AIS patients and their parents reported different concerns and DR regarding surgical treatment. PGI provides insight into patient and parent views toward the disease as well as treatment aspirations.

Introduction: Serial body casting plays an important role in the treatment of early onset scoliosis (EOS), serving as a safer method compared to surgical intervention. There is no published evidence documenting the impact of casting on health-related quality of life (HRQoL) of patients and their caregivers. The purpose of this study was to utilize the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) to compare the HRQoL of patients with EOS and the burden of care for their caregivers before, during, and after treatment with Mehta casting., Methods: In this multicenter retrospective cohort study, two EOS databases were queried for patients with EOS who underwent serial casting from 2005 to 2016. Patients who had treatment prior to their initial cast application, including bracing or surgical intervention, were excluded from the study. Patients were stratified into two subgroups and analyzed separately: those with idiopathic etiology, and those with non-idiopathic etiology. HRQoL and burden of care were assessed using the EOSQ-24 completed before, during, and after cast treatment., Results: 91 patients were identified in this study (mean age at the index casting: 2.1 ± 1.2 years, mean age at final cast removal: 4.1 ± 1.3 years). 59 (64.8%) had EOS of idiopathic etiology, while 32 (35.2%) had EOS of non-idiopathic etiology, including 10 congenital, 6 neuromuscular, and 16 syndromic. Idiopathic patients and non-idiopathic patients experienced an improvement in the coronal deformity from 45° pre-cast to 26° post-cast, and from 59° pre-cast to 34° post-cast, respectively. Patients with idiopathic scoliosis experienced a decrease from baseline in nearly all EOSQ-24 sub-domain scores except for general health. Furthermore, even after the removal of the cast, patients with idiopathic etiology suffered residual negative effects of casting on emotion and transfer sub-domains. Among patients with non-idiopathic etiology, decreased scores from baseline were observed only in transfer and emotion sub-domains during the casting intervention. After brace removal, patients with non-idiopathic etiology had increased scores compared to their baseline scores in most sub-domains., Discussion: Serial body casting can prevent curve correction in patients with EOS. However, the psychosocial stresses secondary to this non-operative intervention can have significant negative impacts on HRQoL for both idiopathic and non-idiopathic patients during the course of treatment. Although non-idiopathic patients experience improved HRQoL following treatment, idiopathic patients do not seem to exhibit much improvement in HRQoL from baseline even years after the final cast removal.

Study Design: Retrospective, cross-sectional., Objective: To evaluate the impact of unoperated adolescent idiopathic scoliosis (AIS) in adulthood on pain, quality of life, and need for operative management., Background: Long-term studies of AIS in adulthood demonstrate most patients function well, though some have increased disability. The Oswestry Disability Index (ODI) and SRS-22r are validated questionnaires for assessing back disability and quality of life. Correlation of these questionnaires to patient outcomes and necessity for surgery have not been fully defined., Methods: Unoperated adults with AIS seen in a tertiary deformity clinic from 2008-2018 were identified. Variables included demographics, comorbidities, family history, curve size/location, pain score, ODI, SRS-22r, and previous treatment. ODI and SRS-22r scores were analyzed across three age groups: 20-39, 40-59, and ≥ 60., Results: 275 eligible patients were identified and 255 (93%) patients had an ODI and/or SRS-22r score. ODI scores (220 patients) had a positive correlation with age, BMI, and curve size (p < .001). SRS-22r (204 patients) pain score was worse in all age-gender-matched domains (p < .05). Of the 255 patients in the study, 10% underwent surgery after presentation. In 118 patients with surgical-size curves (thoracic ≥ 50°; thoracolumbar ≥ 40°), no difference was seen in age or curve size between surgical and non-surgical patients; however, ODI and SRS-22r scores (excluding mental health) were significantly worse in surgical patients (p ≤ .01)., Conclusions: Patients with AIS have SRS-22r scores that are lower than age-gender-matched controls in most domains. ODI had a positive linear correlation with age, body mass index, and curve size. Only 10% of adults with surgical-size curves evaluated for scoliosis elected to undergo surgery. Patients treated surgically reported worse preoperative quality-of-life scores than their non-surgical counterparts. These results can help healthcare providers when counseling patients and families concerning management options., Level of Evidence: III.

Study Design: Cross-sectional, observational., Objectives: (i) To develop a cross-culturally adapted Hindi translation of the Scoliosis Research Society (SRS)-22r (refined) questionnaire and (ii) validate it in Hindi-speaking Indian patients with adolescent idiopathic scoliosis (AIS)., Background Data: Health-related quality of life (HRQoL)-based questionnaires have superseded objective clinical and radiological measurements as tools to assess the outcome of health-related interventions. The SRS-22r is an extensively validated HRQoL-based questionnaire for AIS patients and has been adapted and translated in other languages., Methodology: A Hindi version of SRS-22r was developed in accordance with standard guidelines for cross-cultural adaptation. The final Hindi version was administered to 108 AIS patients. Subsequently, 58/108 patients answered the Hindi version again after 10-14 days. Another 50/108 bilingual patients answered the original English version after 10-14 days. In addition, 52/108 patients answered a previously validated Hindi version of Short Form (SF)-36 health survey. Content analysis, floor/ceiling effects, internal consistency, test/retest reproducibility and concurrent validity with the English version and the SF-36 questionnaire were determined for the Hindi version of SRS-22r., Results: High ceiling effect was noted for the pain and satisfaction with management domains of Hindi version of SRS-22r. Overall internal consistency was good (Cronbach α = 0.77)-all domains, except the function domain (α = 0.61) had good or excellent internal consistency. The test/retest reliability for all domains was excellent (intraclass coefficient/ICC > 0.80). The concurrent validity with the English version showed an excellent correlation for all domains (ICC > 0.80). Concurrent validity with SF-36 showed good correlation between relevant domains of SRS-22r and SF-36, except for the self-image and satisfaction with management domains of SRS-22r., Conclusion: Based on the results proving its reliability and validity, the adapted Hindi version of SRS-22r can be effectively used in Hindi-speaking, Indian AIS patients., Level of Evidence: 3.

Study Design: A retrospective longitudinal follow-up study., Objectives: The aim of this study is to evaluate the health-related quality of life (HRQOL) of post-operative AIS patients from less than 1 year to over 30 years using SRS-22 questionnaire. Some of our AIS patients who operated since the establishment of the scoliosis clinic have passed the 30th year. The HRQOL of patients many years after surgery had yet to be summarized and reported., Methods: SRS-22 questionnaire was conducted by 254 operated patients between the year 2016 and 2018. All post-operative patients who visited a specialized clinic for annual check-up within the study period completed SRS-22. The number of years since surgery per questionnaire was grouped per 1 year until the 10th year, and per 5 years afterwards. The 6 SRS-22 domain scores (function, pain, self-image, mental, satisfaction, mean) were compared across time period., Results: All SRS-22 domain scores in post-operative patients, except "Self-image", were relatively stable in the first 5 years until a steady drop starting from the 10th year. "Self-image" was statistically lower than "Function" and "Pain" from the 10th years to more than 30 years., Conclusions: HRQOL of post-operative AIS patients remained stable until 10 years after surgery and was steadily decreasing. "Self-image" was consistently and statistically lower than the other scores. Patients who have surgically treated for more than 25 years are now at their perimenopause. Specific medical and psychosocial cares for this kind of patients are recommended to provide during the routine medical check-up., Level of Evidence: II.

Study Design: Literature Review., Objective: Review the pathophysiology, causes, and treatment of breast asymmetry in patients with adolescent idiopathic scoliosis (AIS), as well as postoperative patient assessment and health-related quality of life., Background Data: Female breast development begins at 35-day gestation and continues 2-4-year post-thelarche to achieve final volume and shape. During the post-pubertal period, errors in growth and development may result in breast asymmetry. Breast asymmetry typically attenuates with time, but can be pronounced in individuals with AIS. During adolescence, there is rapid development and, thus AIS patients are increasingly sensitive, physically and emotionally, to breast changes. While breast asymmetry can be monitored through radiographic measures and surface topography, pre- and postoperative patient assessment is also critical in determination of optimal patient treatment., Methods: A comprehensive literature review was performed on the pathophysiology, causes, and treatment of breast asymmetry. The advantages and limitations of various treatment options based on patient satisfaction were also investigated., Results: Various treatment options exist for breast asymmetry correction in AIS patients. Surgical correction involves an aesthetic outcome, as well as social, physical, and psychological impact on the patient. Despite the benefit of correction surgery, in terms of function and self-image, patient-reported outcomes still appear lower postoperatively in the domains of pain and mental health., Conclusion: Breast asymmetry is very common, especially among AIS patients, and is often corrected with surgical augmentation. AIS correction surgery has been shown to aggravate breast asymmetry and negatively affect patient-reported outcomes. Other treatment modalities should thus be considered when presented with an adolescent patient. Understanding patient concerns and their relation to quality of life will help guide surgical and medical interventions in correction of AIS deformities. Long-term follow-up studies are necessary to determine whether such interventions are successful and if patients remain healthy., Level of Evidence: N/A.

Scoliosis-specific exercises are prescribed and used by many centers either primarily or as an adjunct to other treatment methods for adolescent idiopathic scoliosis of mild to moderate severity. These methods are often used in Europe and are being used in the United States with increasing frequency. There are few publications about these methods in the spine or orthopedic literature. We have performed a review of the relevant literature from the PubMed database to evaluate the evidence for effectiveness of these treatments. We found no studies that provide valid evidence that an exercise method prevents progression of AIS (adolescent idiopathic scoliosis) in patients during their peak growth period. We report our review of selected relevant efforts and provide a description of many of the available treatment programs.

Study Design: Observational., Objective: To examine changes in patient-reported two-year postoperative outcomes via the Scoliosis Research Society (SRS)-24 Outcomes Instrument from 2001 through 2015., Summary of Background Data: Techniques for correction of adolescent idiopathic scoliosis (AIS) have evolved over the years, but it is unclear how these changes have impacted patient-reported outcomes., Methods: AIS patients with two-year postoperative follow-up from a prospective multicenter registry were divided into three-year groups based on trends in surgical approach and construct type (2010-2014: 52% anterior, 43% posterior hybrids; 2005-2011: 3% anterior, 5% posterior hybrids; 2012-2015: 0% anterior, 0.2% posterior hybrids). Because of the ordinal scale (1-5) and bipolar nature of the response sets for the SRS-24, domain/total scores were categorized as ≤3 (predominantly negative) or 4-5 (predominantly positive). Variables were compared across the three groups., Results: A total of 1,695 patients were analyzed; 172 (2010-2014), 926 (2005-2011), and 597 (2012-2015). Average age was 14.7 ± 2 years, the average primary curve was 55° ± 13°, and the group was primarily female (82%). There was a decline in the rate of positive scores for preoperative pain and self-image across the three groups (p < .05). There was an increase in the rate of positive scores for two-year postoperative self-image after surgery, function after surgery, and satisfaction (p < .05). Decreases in length of hospital stay, blood loss, surgical time, preoperative kyphosis, and postoperative trunk shift were observed (p < .05). Increases were observed in levels fused, preoperative major coronal curve, preoperative rib prominence, preoperative trunk shift, percentage correction of major curve, kyphosis restoration, and the rate of double/triple curves (p < .05)., Conclusion: The percentage of patients with positive postoperative SRS scores has increased in the modern era, providing evidence that newer surgical techniques are resulting in improved outcomes based on the patients' perspectives. Interestingly, recent patients were more afflicted with negative pain and self-image before surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Study Design: Observational cohort study., Objectives: To measure and compare the structural validity of the Oswestry Disability Index (ODI) and the Scoliosis Research Society-30 (SRS-30) questionnaire in an adult population with prolonged degenerative thoracolumbar disease., Summary of Background Data: The ODI and the SRS-30 are commonly used patient-reported outcome instruments to assess back-specific disability and symptoms related to scoliosis. Still, these instruments have not been validated for degenerative spinal disease with different stages of deformity., Methods: Altogether, 637 consecutive adult patients with degenerative spinal pathologies were included. The patients completed the ODI (version 2.0), the 23 preoperative items of the SRS-30, a general health survey, the Kasari Frequency Intensity Time (FIT) index, the Depression Scale (DEPS), the RAND-36, and visual analog scales for leg and back pain instruments. Psychometric statistical and illustrative analyses were conducted. Deformity groups were analyzed to assess how well the two instruments reflect deformity-related back problems., Results: Both instruments reflected good coverage and targeting. Correlation between the ODI and the SRS-30 was high (r = 0.70; p < .001). Both measures could distinguish between different general health states. The SRS-30 strongly reflected mental state and social well-being. The SRS-30 was less sensitive for pain and function. Furthermore, the principal component of pain/function explained more variance in the SRS-30 compared with the ODI score. The ODI was more sensitive for variance of disability among different age and deformity groups., Conclusions: Both the ODI and the the SRS-30 provide valid scores in evaluating health-related quality of life and/or level of disability among patients with prolonged degenerative thoracolumbar disease. The ODI has slightly higher correlation with physical functioning. The SRS-30 seems to be better when evaluating the emotional and psychological functions., Level of Evidence: Level III., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Hypothesis: Body Image Disturbance Questionnaire-Scoliosis version (BIDQ-S) is a sensitive outcomes instrument to evaluate improvements in body image-related psychosocial effects with surgical correction., Design: Prospective observational study., Introduction: The BIDQ-S was previously validated (convergent validity, internal consistency) as a tool to assess body image-related distress and psychosocial impairment in adolescent idiopathic scoliosis (AIS). This study was conducted to evaluate responsiveness to change in the BIDQ-S associated with surgical treatment of AIS two years postoperatively to complete the validation of this questionnaire., Methods: Seventy-five consecutive operative AIS patients were enrolled and completed BIDQ-S and Scoliosis Research Society-22 (SRS-22) at preoperative and two-year postoperative visits. Demographic and radiographic data were collected. Preoperative and two-year postoperative BIDQ-S (1 = best, 5 = worst) and SRS-22 scores (1 = worst, 5 = best) were compared using paired t test. Correlations between BIDQ-S and SRS-22 scores were evaluated by linear regression., Results: Eighty-four percent of the subjects were females, with average age at surgery of 14.4 ± 1.6 years. The mean follow-up was 2.26 years (range 2.0-4.5). The major Cobb was corrected from 50.0° ± 7.2° to 14.2° ± 5.8° (Δ = 71.3% ± 12.1%; p < .0001). There was a significant improvement in BIDQ-S scores after surgery (1.64 ± 0.51 to 1.21 ± 0.38, p < .0001). BIDQ-S improvements were correlated with change in SRS self-image (p = .0055), activity (p = .0057), mental (p = .0018), and overall mean (p = .0007) domains. Preoperative, two-year postoperative, and Δ BIDQ-S score were not associated with major Cobb magnitude, truncal rotation, or Lenke curve type. Patients who reached SRS-22r minimal clinically important difference (MCID) in activity and self-image domains had worse preoperative BIDQ scores than those who did not reach MCID (activity 1.91 vs. 1.54 [1 = best, 5 = worst], p = .0099; self-image 2.08 vs. 1.51, p < .0001). Greater improvement in BIDQ-S was noted in patients who reached MCID in SRS-22 self-image than those who did not (Δ = 0.77 vs. 0.38, p = .0052)., Conclusion: BIDQ-S is responsive to surgical correction of AIS. The BIDQ-S is a valuable clinical outcome tool to assess the psychosocial effects of scoliosis in adolescents augmenting existing outcome instruments., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objectives: To investigate a possible linkage between idiopathic scoliosis (IS) and schizophrenia in an adolescent population., Summary of Background Data: There is an interesting link between schizophrenia and idiopathic scoliosis: schizophrenia is a disturbance of mental equilibrium, and scoliosis of physical equilibrium, both are multifactorial, genetically determined, start at a young age, and brain development is thought to play a role. Furthermore, both may be presenting symptoms of the genetic disorder 22q11 deletion syndrome. This study poses the question whether these two poorly understood disorders are related., Methods: A retrospective cohort study was conducted and consisted of 3,702 Swedish adolescents, collected from the National Patient Register, that underwent inpatient care for IS during 1997-2015. These were matched by age, sex, and date of diagnosis to 370,200 controls, collected from Swedish population data, and then followed up in the National Patient Register to identify in- and outpatient care for schizophrenia diagnosis. Follow-up time was calculated from first IS diagnosis date until date of schizophrenia diagnosis or end of follow-up. Cox proportional regression analysis was performed to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for being diagnosed with schizophrenia., Results: Over a median follow-up time of 9.5 years, 0.7% of patients with IS developed schizophrenia versus 0.5% of controls (p = .04). The risk of schizophrenia was significantly higher in patients with IS (HR, 1.52; 95% CI, 1.03-2.23). Using only hospitalized schizophrenia as event, the prevalence for schizophrenia was 0.5% versus 0.3% (p ≤.01; HR, 1.83; 95% CI, 1.17-2.84)., Conclusion: This study suggests that patients with IS have increased risk of schizophrenia. Dissatisfaction with one's physical appearance might lead to psychological distress and provoke mental illness in predisposed persons. Alternatively, these two disorders may share a common genetic background., Level of Evidence: Level 2B., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective cross-sectional cohort analysis., Objectives: 1) To assess the correlation of Patient-Reported Outcomes Management Information System (PROMIS) domains with SRS-22r/SRS-30 domains in all scoliosis patients; 2) to assess the correlation of PROMIS domains with SRS-30 domains in adult scoliosis patients; 3) to assess the correlation of PROMIS domains with SRS-22r/SRS-30 domains in pediatric scoliosis patients; and 4) to assess ceiling and floor effects of PROMIS and SRS-22r/SRS-30 domains., Summary of Background Data: Studies evaluating correlations between PROMIS and a number of legacy PRO tools have been conducted. To our knowledge, no literature exists examining the correlation of PROMIS and SRS questionnaires in adult and pediatric spinal deformity patients., Methods: Outpatient visits from July 2015 to December 2017 with concurrent PROMIS and SRS questionnaires were analyzed. Pediatric patients completed the SRS-22r, whereas adults completed the SRS-30. PROMIS measured Physical Function/Mobility, Pain Interference, and Depression domains. Spearman correlation coefficients (ρ) were calculated. Ceiling and floor effects were calculated and compared., Results: 227 (164 adult; 64 pediatric) patient visits representing 173 patients were included. Moderate to strong correlation existed between PROMIS Physical Function/Mobility and SRS Function/Activity (F/A) domains (ρ, range 0.59-0.84; p < .001). PROMIS Pain Interference and SRS Pain domains showed strong-moderate to strong correlation (ρ, range -0.68 to -0.83; p < .001). PROMIS Depression and SRS Mental Health (MH) domains demonstrated strong-moderate to strong correlation (ρ, range -0.67 to -0.80; p < .001). Ceiling and floor effects were all less in PROMIS domains (range, 0.44% to 0.88%) compared with SRS domains (range, 0.88% to 17.62%)., Conclusions: PROMIS Physical Function/Mobility, Pain Interference, and Depression domains correlate well with SRS F/A, Pain, and MH. SRS SI/A and Satisfaction are not as well captured. PROMIS showed better ceiling and floor effects than SRS., Level of Evidence: Level III., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of prospectively collected data., Objective: To determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores., Summary of Background Data: There is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients., Methods: Surgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated., Results: 1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p < .05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p < .05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p < .001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10)., Conclusions: When timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score., Level of Evidence: Level III., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Adolescent idiopathic scoliosis (AIS) patients undergoing spine fusion (SF) had their data prospectively collected. The SRS Spine Appearance Questionnaire (SAQ) was the primary outcome measure. The data were reviewed in a retrospective manner., Objectives: Patient concerns about breast/chest wall asymmetry in AIS is high. This study sought to determine the improvement after spinal fusion (SF)., Summary: Breast/chest wall asymmetry is a significant physical deformity associated with AIS. No literature exists on patient satisfaction related to improved breast/chest wall appearance after SF surgery., Methods: 474 patients undergoing SF for AIS from 2006 to 2014 completed the SRS SAQ preoperation and at two years postoperation. Data were prospectively collected and reviewed in a retrospective manner. The SAQ includes two statements regarding breast/chest wall asymmetry (19 and 20). Statistical analysis was performed to determine a relationship between improved SAQ responses and any clinical/radiographic or surgical parameters., Results: 395 females and 79 males (14.4 ± 2.0 years) with preoperation and two-year postoperation Cobb angle 60.6 ± 11.5 and 26.6 ± 12.1 were reviewed. Before surgery, 68.0% of patients identified with the statement "I want to have more even breasts" compared with 37.0% at two years postoperation. In addition, 78.9% identified with the statement "I want to have a more even chest in the front" preoperatively compared with 34.0% at two years postoperation. Positive preoperative responses correlated with scoliometer (p = .029) (p = .044) and Cobb angle of the major curve (p = .048 and p = .006). At two years postoperation, there was a significant number of patients (76%) who had at least a two-point decrease in their response to either statement (p < .0001)., Conclusion: Breast asymmetry is a significant concern of many AIS patients, including males, and correlates with preoperative curve magnitude. SF results in significant improvement in patient perception of breast/chest wall asymmetry, with 76% of patients reporting good outcomes at two years postoperation., Level of Evidence: Level 2., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Multicenter, case-control study., Objectives: Demonstrate altered perception of verticality in AIS compared with matched controls., Summary of Background Data: The cause of adolescent idiopathic scoliosis (AIS) remains to be found. AIS is associated with neurosensorial anomalies, in particular, altered control of orthostatic posture. During kinetic activity, the upright posture, in humans, is determined in reference to the gravitational vertical (GV). We hypothesized that in AIS, there is a discordance in the perception of the GV and the true GV. In AIS, the longitudinal axis of the body would thus be misoriented because of an erroneous perception of the GV., Methods: Thirty adolescents with right thoracic AIS (age 14.23 ± 1.75 years; Cobb angle 31.97°± 12.83°) and 30 controls matched for age (13.93 ± 1.85 years), body mass index, Tanner stage, and handedness were compared for subjective visual vertical (SVV) measured in static and dynamic (optokinetic stimulation) conditions, and subjective postural vertical (SPV)., Results: There was no difference in the two groups, AIS and controls, for SVV. The SPV was significantly different between the two groups (p = .00023). The SPV was shifted to the right for most of the AIS patients (2.13°± 2.22°) compared with controls (-0.08°±1.40°). There was a significant correlation between SPV and clinical frontal tilt in the AIS patients., Conclusion: Our findings demonstrate that patients with right thoracic AIS have an erroneous perception of the GV. In most AIS patients, SPV was shifted to the right, with no alteration of the SVV. AIS might be the consequence of a reoriented longitudinal body axis aligned with an erroneous vertical reference. The underlying mechanism might involve dysfunction of trunk graviceptors. The primary or secondary nature of this dysfunction remains an open question., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Preoperative and two-year follow-up health-related quality of life (HRQOL) data were prospectively collected in 82 Scheuermann kyphosis (SK) and 995 adolescent idiopathic scoliosis (AIS) patients using the Scoliosis Research Society-22 patient questionnaire (SRS-22) outcomes instrument in a multicenter study. Visual analog scale (VAS) scores were also collected for the SK population., Objectives: This study assessed changes in HRQOL prospectively and compared them to those occurring in AIS., Summary of Background Data: There has been limited evaluation of patient-reported HRQOL changes with operative management of SK., Methods: Median SRS values for the SK and AIS cohorts were compared using a repeated measure of analysis of variance with age as a covariate and using a Mann-Whitney U nonparametric comparison., Results: Kyphosis was corrected from 73.9° to 45.8° (p < .001); the major curve in AIS was corrected from 55.5 to 20.2 (p < .001). Preoperative and magnitude of radiographic correction, kyphosis apex and body mass index in SK were not correlated with baseline or change in HRQOL. SK SRS scores improved after surgery in all domains with the greatest change (2.8-4.4) in self-image (p < .001). Changes in SRS Pain, Activity, and Self-Image domains met the minimal clinically important difference. Baseline SK and AIS scores differed significantly in the Self-Image, Mental Health and Total Score domains, with SK having worse scores (p < .001). At two years postoperatively, the greatest improvements were made in Self-Image, along with Mental Health and Total Score, and the SK group achieved greater gains (p < .001). At two years postoperatively, the SK scores improved to reach equivalent values to the AIS scores. VAS scores improved from 3.69 to 1.51, and these changes were correlated with change in the Pain, Mental Health, and Total Score SRS domains (p < .001)., Conclusions: Surgery for SK in the adolescent population results in significant improvements in HRQOL, which outpace those of the AIS population., Level of Evidence: Level II., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Prospective, randomized control study., Objectives: To determine whether the SRS-22r (SRS-22) has a negative effect on the body image of females with adolescent idiopathic scoliosis (AIS) using the Body Appreciation Scale (BAS)., Summary: The SRS-22 is a validated questionnaire designed by the Scoliosis Research Society (SRS) to assess outcomes of scoliosis patients. Parents and nursing staff have expressed concern that the questionnaire may incite body image concerns when administered to teenagers with AIS., Methods: Female AIS patients were prospectively enrolled and randomly assigned to the study or control group. Patients were being observed, braced, or planning operative intervention. Patients in the study group were administered the SRS-22, followed by the BAS. Patients in the control group were administered only the BAS. The BAS is scored from 13 to 65, with higher scores indicating a more positive body image., Results: 45 females were enrolled and assigned to study group (n = 24, SRS-22+BAS) or control group (n = 21, BAS only). There were no differences between the groups in age (p = .55) or Cobb angle (p = .21). There were no differences in overall BAS scores between study (mean = 55.9, range 31-65) and control group participants (mean = 54.2, range 42-64, p = .56). SRS-22 questions and BAS scores had multiple correlations. A higher BAS score is associated with the following SRS-22 questions: being a happy person in the last 6 months, feeling calm and peaceful during the past 6 months, and feeling attractive with one's current back condition. A lower BAS score is associated with the following SRS-22 questions: being down in the dumps, feeling downhearted and blue, and feeling that one's back condition affects personal relationships., Conclusion: Similar BAS scores were observed between the study and control group. Despite concerns regarding the potential negative impact of the SRS-22, taking the questionnaire was not observed to negatively affect patients' body image., Level of Evidence: Level II., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective study of prospectively collected longitudinal data., Objectives: To analyze the Trunk Appearance Perception Scale's (TAPS's) responsiveness to surgical treatment of idiopathic scoliosis (IS)., Summary of Background Data: TAPS is a drawing-based instrument to assess trunk deformity in IS. It shows appropriate metric properties, such as internal consistency and discriminant validity. However, no data on responsiveness to surgical treatment is available., Methods: A total of 109 patients (85.3% females) with IS were included (mean age at surgery 18 years). In all the cases, surgery consisted of posterior spine fusion and instrumentation. The magnitude of the largest curve (MLC) was 63.8° before surgery and 26.3° (correction 58.3%) at a mean follow-up of 20.8 months. Internal and external responsiveness were analyzed on the basis of effect size (ES), standardized response mean (SRM), minimum detectable change (MDC), and correlation between percentage of MLC correction and outcome measure change. Data for TAPS were compared to those of SRS-22 Image domain., Results: TAPS showed somewhat larger internal responsiveness (ES 1.96, SRM 1.73, 86.2% of patients exceeding MDC) than SRS-22 Image scale (ES 1.44, SRM 1.29, 73.4% of patients exceeding MDC). No correlation was found between the percentage of MLC correction and baseline to follow-up change in TAPS or SRS-22 Image scores., Conclusion: The TAPS instrument shows adequate responsiveness to surgical treatment of idiopathic scoliosis and is somewhat larger than SRS-22 Image domain data. The lack of correlation between radiologic correction and clinical improvement indicates that the two outcomes must be independently collected. These data on responsiveness complete the TAPS validation process. TAPS is a valid, reliable, and responsive instrument to evaluate the outcome of surgical treatment of idiopathic scoliosis., Level of Evidence: Level IV., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Prospective study of 92 patients., Objectives: To determine if the incidence of clinically significant psychological and emotional distress in adolescent idiopathic scoliosis (AIS) patients is higher than the general population and if this correlates with deformity severity., Summary of Background Data: Adolescents with scoliosis may exhibit a less positive outlook on life, suffer from lower self-esteem, and have more difficulty connecting with peers; however, there is conflicting evidence whether different stages of treatment prompt different psychological problems and the long-term psychological effect of scoliosis., Methods: Patients aged 12-21 years with a diagnosis of AIS were included. The Behavioral Assessment System for Children, Second Edition (BASC-2), is a validated 139-item survey normed on more than 1 million children in the United States. It can detect clinical and subclinical levels of psychosocial problems in five domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. The BASC-2 self-report form was completed by 92 adolescents with AIS (mean age = 14 years; range 12-18) and a parent. BASC-2 scale scores were compared to validated age-matched normative data. Comparisons were made between those undergoing surgery (n = 31), bracing (n = 31), or observation (n = 30) at the start of treatment., Results: 32% (29/92) of patients scored in the clinically significant range in at least one of the subscales. There were no clinically significant emotional or behavioral differences when stratified by treatment type (p = .560), Cobb angle (0.630), or age (0.313). Twenty-one percent (19/92) of parent responses deemed their kids as having clinically significant emotional or behavioral differences. In only 34% (10/29) of the cases did children and parent concurrently report clinically significant psychological difficulties, such that 66% of parents were unaware that their child has clinically significant emotional or behavioral problems., Conclusions: AIS patients undergoing observation, bracing, and surgery are all at risk for clinically significant psychological symptoms., Level of Evidence: Level II., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Cohort analysis., Objective: Document satisfaction with management and appearance concerns in children of different ethnicity who underwent spinal fusion/instrumentation for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Scoliosis Research Society Questionnaire (SRS-30) outcomes in AIS indicate a link between appearance and satisfaction as well as ethnic variation in appearance domain. Exploration of these findings in the Scoliosis Appearance Questionnaire (SAQ) will allow better understanding of ethnic variation in appearance concerns., Methods: Children with AIS who underwent posterior-only operations and completed the SAQ's question 31 were identified. Univariate logistic regression of SAQ questions 12-30 was used to assess relationships with ethnicity., Results: 1,977 children [boys: 281, girls: 1,290, unspecified: 406; average age 15.1 ± 2.0 years preoperatively and 817 children (boys: 113, girls: 569, unspecified: 135; average age 15.1 ± 2.0 years) at 2 years' follow-up met inclusion criteria. The majority were Caucasian (57.3%). Few were Hispanic (3.4%). Preoperatively, the largest percentage of patients in each ethnic group answered "very true" to "wanting to be more even." Preoperatively, Asians were least likely to be concerned about evenness of shoulders, hips, waist, ribs, and chest in back (p < .05); however, they expressed greatest concern about height (p < .05). African Americans and Hispanics were more likely to be concerned about breast evenness and anterior chest and looking better in clothes (p < .05). African Americans were most concerned about overall evenness and evenness of shoulders, hips, waist, ribs, posterior chest, leg length, and looking more attractive (p < .05). Surgical scar was most important postoperatively for all ethnicities. African Americans and Hispanics were more self-conscious about scar (p < .05). African Americans were most likely to want to be more even and have more even shoulders, hips, waist, leg lengths, ribs, breasts, and chest postoperatively., Conclusions: Ethnicity influenced appearance concerns in pre- and postoperative SAQ evaluation. Ethnic variation in appearance concerns should be taken into account and differentiated when counseling patients about AIS and surgical correction., Level of Evidence: Level III., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort., Objective: To examine Charlson Comorbidity Index (CCMI) as a marker for deterioration in health status not reflected in standard Health Related Quality of Life (HRQOL) measures., Summary of Background Data: HRQOL has become a primary metric for assessing outcomes following spinal deformity surgery. However, studies have reported limited impact of complications on postoperative HRQOL outcomes., Methods: We examined serial CCMI, complications, and HRQOL outcomes for 138 adult lumbar deformity patients treated surgically with a minimum two-year follow-up that included 126 females (91%) with a mean age of 59.8 years (range, 40.2-78.5). Patients with no, minor, or major complications were compared at baseline and at one and two years postoperation., Results: Minor complications were observed in 26 patients (19%) and major complications in 15 (11%). Major complications included motor deficit (7), deep vein thrombosis (4), and respiratory failure (3). There was no difference in preoperative SF-36 Physical Component Summary or Scoliosis Research Society-22R (SRS-22R) scores among the groups at baseline. Preoperative CCMI was lowest in the No Complication group (3.52 ± 1.70) followed by the Major (4.00 ± 1.13) and Minor Complication groups (4.15 ± 1.71, p = .165). At one year, there was a significantly greater CCMI deterioration in the Major Complication group (0.80 ± 1.01) compared to both the Minor (0.08 ± 0.27) and No Complication groups (0.27 ± 0.47, p < .001). There was no significant difference in SF-36 Physical Component Summary or SRS-22R scores among the three groups. Similar findings were observed at two years., Conclusions: Despite similar one- and two-year HRQOL improvement, patients with major complications had greater deterioration in CCMI. As CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including any subsequent spinal surgery. Although this increased risk may not alter the patient's perception of his or her current health status, it may be important, and should be recognized as part of the shared decision-making process., Level of Evidence: Level II, high-quality prognostic study., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Cross-sectional study., Objective: Assess the psychosocial status of children with early-onset scoliosis (EOS) undergoing multiple procedures and evaluate associations with other variables., Summary of Background Data: EOS may require repetitive surgical procedures to control deformity and preserve growth. These procedures impact patients' psychosocial status because of the repetitive surgeries., Methods: EOS patients 6-18 years, undergoing traditional growing rod treatment with more than 5 surgical procedures, and neurologically/mentally intact were included. Patients were screened for psychiatric disorders before inclusion. The Quality of Life Scale for Children (PedsQL), Strengths and Difficulties Questionnaire (SDQ) self-report form, Beck Depression Inventory, Children Depression Inventory (CDI), Beck Anxiety Inventory (BAI), and the Self-Report for Childhood Anxiety Related Disorders (SCARED) were completed by the children. PedsQL Parental Form and SDQ Parent Form were completed by their parents., Results: Twenty-one patients (9 male, 12 female) met the inclusion criteria. Average age was 6.4 years (4-10.5) at index surgery, and 13.5 years (8-17) at final follow-up. The mean number of procedures was 13 (6-18). Mean follow-up was 83.9 months (36-122). Depression was observed in 23.8% of patients, and generalized anxiety disorder in 42.8%. Patients in the study group were more likely than the general population to have a psychiatric diagnosis. Number of procedures undergone was found to correlate negatively with BAI, SCARED, and the behavioral difficulties domain of SDQ parent form score and positively with emotional functioning, psychosocial health summary score, PedsQL total score, and increased social and physical functioning. Nonidiopathic etiology was found to be related to increased behavioral difficulties and lower functioning., Conclusion: A higher prevalence of depressive and anxiety symptoms was observed in patients with EOS along with dysfunctional areas of daily life. Other comorbidities may also contribute to dysfunction and difficulties. Determination of the aspects of EOS treatment that have a negative impact on psychosocial functioning may allow for more competent help for these patients., (Copyright © 2017 Scoliosis Research Society. All rights reserved.)

Study Design: Longitudinal cohort., Objectives: To identify variables that predict 2-year Short Form-36 Physical Composite Summary Score (SF-36PCS) and the Scoliosis Research Society-22R (SRS22-R) Total score after surgery for complex adult spinal deformity., Summary of Background Data: Increasingly, treatment effectiveness is assessed by the extent to which the procedure improves a patient's health-related quality of life (HRQOL). This is especially true in patients with complex adult spinal deformity., Methods: The data set from the Scoli-Risk-1 study was queried for patients with complete 2-year SF-36 and SRS-22R. Regression analysis was performed to determine predictors of 2-year SF-36PCS and SRS-22R Total scores. Factors included were sex, age, smoking status, body mass index, American Society of Anesthesiologists (ASA) grade, Lower Extremity Motor Score improvement, indication for surgery, preoperative and 2-year maximum coronal Cobb angles, number of prior spine surgeries, number of three-column osteotomies, number of surgical levels, number of surgical stages, lowest instrumented level, presence and type of neurologic complication, and number of reported serious adverse events., Results: Of 272 cases enrolled, 206 (76%) cases were included in this analysis, 143 (69%) females, and mean age of 57.69 years. Factors that were significantly associated with of 2-year SF-36PCS were age (p < .001), ASA grade (p < .001), maximum preoperative Cobb angle (p = .007), number of three-column osteotomies (p = .049) and type of neurologic complication (p = .068). Factors predictive of 2-year SRS-22R Total scores were maximum preoperative Cobb angle (p = .001) and the number of serious adverse events (p = .071)., Conclusions: Factors predictive of lower 2-year HRQOLs after surgery for complex adult spinal deformity were older age, higher ASA grade, larger preoperative Cobb angle, larger numbers of three-column osteotomies, and the occurrence of both neurologic and nonneurologic complications. Most of these factors are beyond the control of surgeons. Still, surgeons should medically optimize a patient prior to surgery to minimize the risk of complications and offer the best chance of improving a patient's quality of life., Level of Evidence: Level II. Prospective cohort., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Cross-sectional Objectives: To present a reliable and valid Danish translation of the Scoliosis Research Society-22R (SRS-22R)., Summary of Background Data: The SRS22R was designed as a disease-specific measure of quality of life in surgically treated adolescent idiopathic scoliosis (AIS) patients. It has been translated and adapted into several languages. A reliable and valid Danish version is not available., Methods: A Danish version of the SRS-22R was developed using previously published and widely accepted guidelines. The final Danish SRS-22R and the Danish Short Form-36 were administered to 169 AIS patients and 45 healthy controls. Cronbach's α was computed as a measure of internal consistency. Concordant validity was determined by computing correlations of the SRS-22R Domains with the corresponding SF-36 domains and factor analysis. Discriminant validity was determined by comparing Domain scores between AIS patients treated surgically, AIS patients treated with a brace, and the healthy controls., Results: One hundred sixty-five (97.6%) AIS patients and 42 (93.3%) healthy controls returned their questionnaires. Moderate ceiling effects were observed in the AIS cohort for the Function and Satisfaction Domains. Cronbach's α for each Domain and the Total score were good to excellent. Pearson correlation coefficients were found to be high for the SRS-22R Domains that had similar latent variables as the SF-36 Domains. Factor analysis revealed an underlying factorial structure of the questionnaire accounting for 60% of the explained variance. The SRS-22R Domain scores were statistically significantly different between the AIS cohort that had surgery, the AIS cohort that was treated with a brace, and the healthy controls., Conclusions: The Danish version of the SRS-22R is reliable, with content, concordant, and discriminant validity. The scores, the score distribution, and the ceiling and floor effects were similar to those of the original SRS-22R in English as well as other previous translations., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)