Background
Methodology
Adolescent idiopathic scoliosis (AIS) and back pain
Epidemiology
Prevalence of scoliosis
Pain associated with scoliosis
Reference 1st author/year | Design | Tools used for Pain | Results | Comments |
---|---|---|---|---|
N. Ramirez/JBJS 1997 [19] | Retrospective study of 2442 patients with AIS. Mean age was 14 years for those with back pain and 13 years for those who did not have pain. | History of back pain | Back pain was reported by 23 % at the time of presentation. Of 210 patients managed with observation only and who were pain-free initially, 9 % reported back pain during follow-up (about 3 years). | Pain was associated with age >15 years or Risser sign ≥2 but not with gender, type or magnitude of the curves. |
T. Sato/Eur Spine J 2011 [20] | Epidemiological study including 32,083 students without scoliosis and 51 with AIS. Age range was 9–15 years. | Questionnaire Severity of back pain defined according to functional limitation (3 categories) | Adjusted OR of back pain (point or lifetime prevalence) was 2.29 in the scoliosis group compared with the controls. Pain was also more severe, had longer duration and more recurrences in the scoliosis group. | The difference was highly significant only for pain located in the right scapular area. No difference was found for lumbar pain. |
B. Lonner/Spine 2013 [21] | Prospective pretreatment multicenter and retrospective chart review including 894 patients with AIS (mean age 14.9 years) who were compared with 106 patients with Scheuermann’s kyphosis (mean age 16.1 years) and with 31 healthy adolescents (mean age 14.2 years). | SRS-22 | Mean Pain scores were 4.15 in the AIS group versus 4.24 among healthy controls. | MCID for Pain was set at 0.2. Patients with Scheuermann kyphosis reported significantly more pain than AIS patients |
J. Theroux/Pain Res Manag 2015 [22] | Retrospective review of a random sample of 310 charts of AIS adolescents. Mean age was 13.9 years for girls and 14.5 for boys. | Documentation of back pain from different sources. Previous surgery and other spinal pathologies were exclusion criteria. | Almost half of the patients (47.3 %) had chart-documented back pain, most frequently lumbar pain. Pain intensity was specified in only 21 % of charts and described as mild in 9.4 %, moderate in 11 % and severe in 1 % of cases. Pain intensity was not correlated with the Cobb angle. | No comparison group. |
D.W. Roberts/Spine 2011 [23] | Longitudinal cohort study comparing outcomes before and after surgery. N = 744 patients. Mean age was 15.2 years for boys and 14.0 in girls. | SRS-30 | Preoperatively Pain scores were 4.1 for females and 4.3 for males. Of note, the latter were 1.2 years older than females (average age 15.2 versus 14.0 years). | Despite boys were significantly older, the baseline differences between genders were N.S. |
A.J. Boniello/J Neurosurg Spine 2015 [24] | Meta-analysis of preoperative data limited to patients with Lenke type 1C curves. 1 prospective and 6 retrospective case-control studies. Overall 488 patients. Mean age for each group: 14.7 and 14.8 years (N.S.). | SRS-22 | Baseline data from the largest multicenter study showed Pain scores of 4.13 ± 0.77 in the group eventually undergoing selective fusion Vs 3.92 ± 0.79 in those later fused nonselectively. | |
J. Bago/Eur Spine J 2009 [25] | Study designed to identify Minimal important differences in 91 AIS patients undergoing surgical procedures. Mean age was 18.1 years (range 10–38 years). | SRS-22 | Preop scores were 3.8–3.9 | MID for Pain dimensions was identified at 0.6 |
L.Y. Carreon/Spine 2010 [26] | Longitudinal cohort (735 girls & 152 boys. Mean age 14.3 years) to evaluate MCID | SRS-22 & SRS-30 | Baseline scores for Pain: 4.1 ± 0.71 | MCID for Pain domain: 0.2 |
K. Verma/Spine 2010 [27] | Healthy adolescents. Anonymous survey N = 450 / 16 (10–22) years | SRS-22 | Mean score for Pain domain was 4.3 ± 0.6. Males had higher score. African Americans scored higher than Hispanics. | Normative baseline in healthy adolescents |
L.J. Morse/Spine 2012 [28] | Preoperative comparison of 6 ethnic groups of children with AIS. Total = 1853 composed of US white (1234), black (213), Hispanic (78), and Asian (29), as well as native Japanese (192) and Koreans (107). Overall mean age was 14.85 years ranging from 14.34 (Hispanics) to 14.97 (white). There were statistically significant differences between groups in terms of age, gender, BMI, and major curve magnitude. | SRS-30 | The scores for the Pain domain ranged from 4.52 ± 0.51 among the Japanese patients, to 4.04 ± 0.72 in the US white patients (P < 0.001). | Whites reported more pain than Japanese and Koreans. The authors recommend taken into account cultural and ethnic differences when counseling patients. |
K. Watanabe/Spine 2007 [29] | Comparison of 2 groups of 100 AIS patients each, one American and the other Japanese. Both groups were comparable with regard to age (mean age was 15.0 years in Americans and 14.9 years in Japanese), gender, curve location, Cobb angle and thoracic kyphosis. | SRS-24 | Scores for the total pain domain were 3.7 ± 0.8 among Americans and 4.3 ± 0.4 in the Japanese group | The authors highlight the cultural differences and suggest that a cross-cultural comparison of the SRS-24 content is necessary. |
E. Misterka/Med Sci Monit 2012 [30] | Retrospective study comparing 20 rural and 40 urban Female Polish patients with AIS with ≥ 2 years follow-up after surgery for AIS | SRS-24 | Mean Pain scores were 4.4 in the urban group and 4.3 in the rural one (NS). | Some differences between groups were found but the authors did not end-up with strong conclusions based on the environment. |
J.A. Lerman/Spine 2002 [32] | 102 adolescents with AIS (15.3 years), 47 with congenital scoliosis and 84 “normals”. | PODCI (Pediatric Outcomes Data Collection Instrument). All dimensions scaled 0–100 where highest is best. | Comfort/Pain scores self reported by adolescents (N = 95) (parents’ questionnaires NOT included here) respectively were 86.7 ± 14.5 for “Normals” and 75.2 ± 22.4 in the AIS group (P < 0.05) | No significant differences in Comfort/pain scores according to age, Cobb angle or curve location. |
R.J. Haynes/J Pediatr Orthop 2001 [33] | Only the 1st administration of the questionnaire included. Parents’ questionnaire for patients 2–18 years. Patients’ questionnaire for those aged 11–18 years. | POSNA (Pediatric Orthopaedic Society of North America) | ||
L.N. Pellegrino/J Spinal Disord Tech 2014 [37] | Prospective observational study pre- and postoperative of 33 patients (mean age 15.6 years). | SRS-30 and SF-36 | Preop mean SRS pain score was 3.95 ± 0.09 and SF-36 61.00 ± 4.20 | |
P.R.P. Rushton/Spine 2013 [55] | Review and statistical analysis of the literature. Data on pain were available from 21 cohorts from 15 published studies. | SRS-22r | In 17 cohorts AIS patients reported statistically more pain than controls, in 3 cohorts patients and controls scored similarly, and in 1 study patients had less pain. However, in only 1 study was the difference clinically relevant (>MCID) | |
E.M. Clark/Spine 2016 [36] | Prospective, population-based, birth cohort study. Subjects with spinal curve ≥ 6° at the age 15 (N = 202/3184) were surveyed for back pain at age 18 | 1ary outcome: Pain (≥1 day in the prev. month). | At age 15 202 subjects had spinal curves ≥6°. Median curve size 11°. Curves ≥25° were found in 11 participants. | Spinal curves were identified using the DXA scoliosis method. |
2ary outcomes: Self-reported days off activities | Back pain was reported by 21.3 % of the subjects with curves versus 16 % of those without. | |||
≥7 days off activities in the last 6 months were reported by 21.7 % of those with spinal curves versus 12.3 % of the controls. |
Effect of treatments on back pain
Conservative management
Surgical treatment
Untreated scoliosis
Reference 1st author/year | Design | Tools used for Pain | Results | Comments |
---|---|---|---|---|
Conservative Treatment | ||||
S Negrini/Cochrane Database Syst Rev 2015 [39] | Review including 7 studies (5 initially planned as RCTs and 2 as prospective controlled trails) with a total of 662 adolescents, comparing braces with other treatment. | PedsQL (only 1 item in one of the 4 dimensions focus specifically on pain). | Back pain did not change in the long term (very low quality evidence) | The authors highlight that it was not possible to perform a meta-analysis due to important clinical differences among studies. |
T Maruyama/Physiother Theory Pract 2011 [40] | Systematic review including 20 studies: 2 controlled clinical trials and 18 case-control studies. No RCTs found. | Child Health Questionnaire (1 study) and VAS (1 study) | Compared with observation bracing does not influence back pain or HRQoL. Conflicting evidence reported for studies comparing bracing with other forms of treatment | |
ME Alves de Araujo/J Bodyw Mov Ther 2012 [49] | RCT comparing Pilates-based therapy (N = 20) to weekly meetings with no therapeutic intervention (N = 11). Age ranged from 18 to 25 years | Borg CR 10 | Pain decreased from 5.3(1.5) to 1.8 (1.9) (P = 0.0001) in the experimental group and from 4.4(2.3) to 3.8(2.7) in the control group (NS) | All patients were female students with minor non-structural dorso-lumbar scoliosis (Cobb angles 7.6(3.5) (Experimental) and 7.1(2.8) (Control) respectively. |
M Monticone/Eur Spine J 2014 [51] | RCT comparing self-correction, task-oriented spinal exercises and education (N = 55) with traditional spinal exercises (N = 55). Evaluations pre-, post-treatment, and at 1-year follow-up. Mean age at baseline 12.5 and 12.4 years respectively (NS) | SRS-22 | Pain scores at the 3 evaluations were: 3.8 (0.4), 4.6 (0.3), and 4.7 (0.2) in the experimental program and 3.9 (0.5), 4.3 (0.3), and 4.2 (0.4) in the control group. P < 0.001 for time, group, and interaction effects. | |
DK Noh/J Back Musculoskelet Rehabil 2014 [52] | Comparison of a corrective spinal technique (CST) approach with a conventional exercise (CE) program. Two groups of 16 AIS patients each. Mean age 13.8 years Versus 14.9 (N.S.) | SRS-22 | Pain scores improved from baseline to follow-up in both groups. Results were from 4.5 to 4.9 in CST group and from 3.8 to 4.6 in CE group. | The 2 groups were already small at baseline and the attrition rate was substantial with N = 8 (CST) and 4 (CE) at follow-up. |
KA Zapata/Pediatr Phys Ther 2015 [53] | Randomized trial comparing 8 weeks of weekly supervised spinal stabilization exercises (N = 17) with 1-time treatment (N = 17). Patients with AIS aged 10–17 years | Numeric Pain Rating Scale (NPRS) Oswestry Patient-specific functional scale (PSFS) | NPRS scores improved from 5.4(1.5) to 1.5(1.8) in the supervised group and from 5.4(1.3) to 3.4(1.7) in controls (P ≤ 0.05 & > MCID) The reduction in OSW was similar in both groups and the improvement in PSFS was higher in the supervised group but the difference between the 2 groups < MCID in adults. | All the patients included in the trial had low back pain at baseline. |
M Tavernaro/Scoliosis 2012 [54] | Cross-sectional study followed by retrospective case-control study to verify the impact of a complete rehabilitation team in adolescent patients with bracing (N = 28 AIS and 10 hyperkyphosis). Mean age 15.8 years | SRS-22 | Pain scores were 3.93 ± 0.55 among those treated by the team and 3.54 ± 0.83 in those who were not (N.S.) | Other variables were significantly improved by the team management. |
EM Bunge/Eur Spine J 2007 [63] | Cross-sectional evaluation of HRQoL of AIS patients after completing treatment. Patients had been braced (N = 36), treated by brace and surgery (31), or only by surgery (30). Mean age 16.3 years. | SRS-22 | Mean scores for Pain domain in the 3 groups were: Brace: 4.5 (0.57) Brace & surg: 4.1 (0.90) Only surgery: 4.1 (0.71) | Pain was not significantly correlated with the time span between completing treatment and filling out the questionnaire. |
Surgical Management | ||||
PR Rushton/Spine 2013 [68] | Review of the literature and statistical analysis evaluating the effect of surgery on HRQoL of adolescents with AIS and 2 years follow-up. | SRS-24 | 81 % of the included cohorts reported a statistically significant improvement of pain. The reduction was above MCID only in 1/12 cohorts | |
MC Hawes/Disabil Rehabil 2008 [56] | Systematic review of studies on surgery for AIS with ≥ 10 patients and followed for ≥2 years after surgery. 82 articles (5780 patients) included. | Trials’ results presented as “pain-free”: Yes, No, or Not tested/reported. Yes meant that most or all patients reported minimal or no pain and none reported severe, chronic, or increased pain post-op | The authors conclude that there is no evidence to support that the result in terms of reduced magnitude of the spinal curve is correlated with reduced pain. | 65 % of articles did not include pain in their outcome. Of those who did, definitions were quite different |
Z Landman/Spine 2011 [57] | Multicenter, prospective, consecutive clinical series. N = 1433 patients. Changes in pain assessed in 295 patients with complete data and 2 years follow-up | SRS-22 (Z-test for proportions used to analyze preop and postop differences) | Mild to severe pain within the last month in 73.2 % preop, 53.6 % at 1 year and 53.2 % at 2 years. Pain at rest in 70.5 % preop, 56.9 % at 1 year and 60 % at 2 years. Compared with preoperative data, at 2 years 40 % of patients reported a decrease in pain, 38.6 % no change, and 20.3 % an increase in pain. | A significant disagreement between preoperative pain reported by physicians (44 %) and patients (77.9 %) was found. Patients who were more satisfied with their appearance reported less pain. |
DW Roberts/Spine 2011 [23] | Longitudinal multicenter cohort study to compare functional outcomes between genders before and after surgery. N = 744. Mean age was 15.2 years for males and 14 years for females. | SRS-30 | Postop pain improved significantly in both genders from 4.1 to 4.3 in girls and from 4.3 to 4.5 in boys. The difference between genders is NS. | The pain reduction at 2 years does not seem clinically meaningful. |
T Akazawa/Spine 2012 [58] | Case-control study to compare healthy subjects (N = 80) with idiopathic (N = 80) and non-idiopathic (N = 56) scoliosis patients and ≥ 21 years after surgery. | SRS-22 Roland-Morris (RDQ) | Pain dimension scores were 4.3(0.6) in AIS patients and 4.2(0.5) in controls (NS) RDQ scores were 2.4(4.1) and 1.4(3.1) respectively. | At long-term postoperative follow-up AIS patients had similar pain scores as healthy controls |
TP Bastrom/Spine 2013 [60] | Review of a prospective multicenter database registry. N = 584 AIS patients treated surgically with ≥ 2 years follow-up. Age at surgery 14.7 ± 2 years | SRS-22 Self-reported pain Vs pain free (1st 6 months post-op or 6–24 months post-op). The focus is on the patients with unexplained pain >6 months postoperative | The 2-year pain scores were 4.1 ± 0.7 in patients with postoperative pain and 4.5 ± 0.6 in the postop pain free group (P < 0.001). These 2 groups were also significantly different in terms of preoperative pain (3.8 ± 0.8 Vs 4.1 ± 0.7). | |
CB Sieberg/J Pain 2013 [61] | Prospective multicenter registry examining postoperative outcomes of AIS patients. N = 169 at baseline, 1 and 2 years postop and N = 69 for 5 years follow-up. | SRS-30 | Moderate to severe pain in the past month was reported preop by 35 % of patients. The figures were 11 % at 1 year, 15 % at 2 years, and 15 % at 5-years post-surgery. Pain often to very often at rest was reported by 43 % at baseline, 5 % at 1- and 2-years follow-up and 8 % at final follow-up. | Examining the evolution of pain from preoperatively to 5 years follow-up the authors describe 5 trajectories distinguishable on preop age, mental health, and self-image. |
LY Carreon/Spine 2011 [62] | Longitudinal cohort of AIS patients treated surgically and evaluated preoperatively and 2 years postop. N = 745. Mean age 14.2 years | SRS-22 and SRS satisfaction | Mean pain domain scores improved from 4.16 ± 0.71 preop to 4.31 ± 0.72 (P < 0.0001) Pain and satisfaction domains were significantly correlated (Spearman 0.260) | The pain reduction does not seem clinically relevant |
EM Bunge/Eur Spine J 2007 a [63] | Cross-sectional evaluation of HRQoL of AIS patients after completing treatment. Patients had been braced (N = 36), treated by brace and surgery (31), or only by surgery (30). Mean age 16.3 years. | SRS-22 | Mean scores for Pain domain in the 3 groups were: Brace: 4.5 (0.57) Brace & surg: 4.1 (0.90) Only surgery: 4.1 (0.71) | A subset of patients’ satisfaction scores was compared with that of their surgeons. No significant differences were reported |
MO Andersen/Spine 2006 [64] | Longitudinal study of consecutive AIS patients (N = 181) treated by brace (BT = 82) or surgery (ST = 99). Follow-up 9.7 years | VAS (6 items) SF-36 | Among the 6 VAS scores only “Do you feel leg pain right now” was significantly different with 0.5 (0.2–0.9) in the BT group and 0.2 (0.0–0.3) in the ST group (P = 0.034). The results for the mean Bodily pain dimension of the SF-36 were 74.6 (BT) and 71.4 (ST) which are significantly lower than the mean of 79.8 of a 408 Danish control cohort. | The difference in pain does not seem clinically meaningful |
B Poitras/Spine 1994 [65] | Retrospective cohort study of patients referred to a single center for AIS compared with a sample (N = 1755) of the general population. Among the 723 patients treated surgically, 555 completed the questionnaire. Follow-up 10–30 years. | Pain assessed by Postal questionnaire (taken from McGill Pain Questionnaire, Oswestry and Roland Morris) Controls evaluated by telephone survey. | Back pain in the past year was reported by almost ¾ of the responders. For controls the same figure was 56 %. | The authors found no correlations with several surgical technical variables evaluated (curve correction, number of vertebrae fused, distal level of fusion). |
Untreated | ||||
PR Rushton/Spine 2013 [55] | Review of the literature and statistical analysis to compare untreated adolescents with AIS with normal controls. | SRS-22r | Of the included cohorts 81 % reported statistically significant worse pain among untreated scoliotic patients but the difference was clinically important only in 5 % of cohorts. | |
VM Pham/Ann Readapt Med Phys 2008 [69] | Comparison of 3 groups of patients with AIS 32 without brace, 41 treated full-time with a corset and 35 wearing the brace during the night only. The 3 groups were significantly different in age, Risser, Cobb angle, etc. | VAS Quality of Life Profile for Spine Deformities | No significant differences in the intensity of pain (VAS) were found | |
OF Ugwonali/Spine J 2004 [70] | Cross-sectional questionnaire-based study. Patients with AIS were braced (N = 78) or observed (N = 136) Mean age was respectively 13.6 Versus 13.8 years (N.S.) | Child Health Questionnaire (CHQ Parental form-28) and PODCI | No differences in pain domains were found between the 2 groups despite the fact that Cobb angles were significantly bigger in the braced group. Regression analysis showed a significant association of the CHQ bodily pain dimension and age but not with gender, cobb angle or treatment. | No information gathered from the adolescents themselves is included in the study. The authors conclude that bracing does not decrease QoL |