Fusion can decrease disc degeneration

[Pooka1]

How corrective surgery affects 10-year postop disc degeneration for scoliosis patients: 5 insights Featured
By Megan Wood | Monday, 29 January 2018 21:24
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Researchers from Tokyo Shinjuku Medical Center and Nagoya-based Meijo Hospital in Japan compared disc degeneration occurrence for patients with idiopathic scoliosis who underwent surgery against those who didn't at 10-years follow-up.

The study included female patients with scoliosis, categorized as follows:
• Surgical group: postoperative 10-year patients with severe scoliosis prior to surgery
• Mild scoliosis group: similar scoliosis to postoperative patients of the same age at 10 years follow-up
• Severe scoliosis group: no corrective surgery

Spine published the study.

Here are five insights:

1. Within the surgical group, 62.7 percent experienced disc degeneration with the highest rate at L5/S, according to MRI findings.

2. Of the mild scoliosis group, 47.7 percent of the patients had disc degeneration, with high rates at L4/5 and L5/S.

3. The severe scoliosis group saw 81.8 percent experiencing disc degeneration, with the highest rates at L3/5 and L4/5.

4. Additionally, the severe scoliosis group saw higher rates of low back pain compared to the surgical group.

5. Researchers concluded corrective surgery can decrease disc degeneration occurrence.

https://www.beckersspine.com/spine/i...-insights.html

[titaniumed]

Sharon, They don't mention age.... Can we assume that these are all roughly 24 year old females? Do you see it this way?


Ed

[LindaRacine]

Sharon, They don't mention age.... Can we assume that these are all roughly 24 year old females? Do you see it this way?


Ed

Damn... just threw out the journal about a week ago, and I no longer have access to full text via the University. I read the paper, but don't remember the age info. Sorry.

[Pooka1]

Sharon, They don't mention age.... Can we assume that these are all roughly 24 year old females? Do you see it this way?


Ed

I think we have to read it that way although I can't believe they found enough severe scoliosis cases that were not surgical in that group That doesn't happen any more in the US at least as far as i know. There is a strong medical consensus on this.

[Pooka1]

Here's the abstract from Spine but it doesn't talk about ages.

Intervertebral Disc Degeneration During Postoperative Follow-up More Than 10 Years After Corrective Surgery in Idiopathic Scoliosis: Comparison Between Patients With and Without...
Nohara, Ayato; Kawakami, Noriaki; Tsuji, Taichi; More
Spine. 43(4):255-261, February 15, 2018.

Abstract
Abstract:
Study Design.
A retrospective comparative study.

Objective.
The aim of this study was to evaluate the difference in trends of disc degeneration (DD) at lower unfused segments (LUS) for postoperative patients who have gone through spinal instrumentation at 10-year follow-up with the natural progression of idiopathic scoliosis.

Summary of Background Data.
Studies that used magnetic resonance imaging (MRI) state that DD rates at LUS are higher than in the normal population. However, current studies do not prove that surgery is the most effective clinical method to treat idiopathic scoliosis, as no existing report compares the rates of DD with the natural history of idiopathic scoliosis.

Methods.
Female patients diagnosed of scoliosis were divided into three groups: 1) surgical group: postoperative 10-year patients with severe scoliosis before operation; 2) mild scoliosis group: with comparatively equal scoliosis to postoperative patients of the same age at 10 years follow-up; 3) severe scoliosis group: without any record of corrective surgery under the assumption that the scoliosis of the surgical group have progressed according to natural history.

Results.
MRI findings of the surgical group show DD in 32 patients (62.7%) where the highest rate of DD occurred at L5/S. In the mild scoliosis group, 21 patients (47.7%) had DD, with higher rates at L4/5 and L5/S. DD was most common in L3/4 and L4/5 in the severe scoliosis group where 27 patients (81.8%) had DD. As such, DD rates were significantly higher in the severe scoliosis group than the surgical group at the same spinal level. The same was true for the existence of low back pain, where the severe scoliosis group had greater incidence of low back pain than the surgical group.

Conclusion.
Corrective surgeries were able to reduce the incidence of DD. Radiological analysis also suggests that surgical intervention is a clinically feasible treatment for idiopathic scoliosis patients.

Level of Evidence: 3

[burdle]

If we don't know the age how can they evaluate disk degeneration. I would have thought they should include a group with no scoliosis to evaluate normal disk degeneration against these findings?. Disk degeneration is not linear in the normal population - it occurs late in life usually or at least isn't detected because no-one looks for it earlier in life.

[burdle]

Sharon, They don't mention age.... Can we assume that these are all roughly 24 year old females? Do you see it this way?


Ed

I am missing something- how are you concluding 24 years. is it because you are suggesting that most surgery for severe scoliosis is done at Age 14?

[Pooka1]

If we don't know the age how can they evaluate disk degeneration. I would have thought they should include a group with no scoliosis to evaluate normal disk degeneration against these findings?. Disk degeneration is not linear in the normal population - it occurs late in life usually or at least isn't detected because no-one looks for it earlier in life.

Well if the study design was whack, I don't think it would have been published. That makes me think all the subjects were of similar age. There is no reason to publish an apples and oranges article.

There is probably almost no disc degeneration in normal 24 year olds. That may be why that group wasn't included. Another reason is that we should not be comparing scoliosis patients to normal patients. Normal is off the table. This is a game of cutting losses.

[Pooka1]

I am missing something- how are you concluding 24 years. is it because you are suggesting that most surgery for severe scoliosis is done at Age 14?

I think he is assuming that and I agree with the assumption.

[burdle]

Well you would not expect DD in a 24 year old without scoliosis so I wonder why they don't do a follow up at 44 or55 30 or 40 years after surgery.

Current 'Pain Management' thought is that evidence of DD does not necessarily mean that the person with it has any problems.. I know the scope of the research is just looking at evidence of DD and not the effects of having DD but still I wish that research like this was done later. There is so little real long-term ( 10 years is not long-term) follow up done on post fusion patients and allowing for the length of time fusion has now been being done it should be possible to do it. I'll bet that long-term follow up of scoliosis fusion patients would show that there was evidence of DD AND problems with having DD

[burdle]

Well if the study design was whack, I don't think it would have been published. That makes me think all the subjects were of similar age. There is no reason t publish an apples and oranges article.

There is probably almost no disc degeneration in normal 24 year olds. That may be why that group wasn't included. Another reason is that we should not be comparing scoliosis patients to normal patients. Normal is of the table. This is a game of cutting losses.

A lot of studies that are published are 'whack' when I get a minute I will find a link to a classic one that disobeys even the basic rules.

However do we not have to ask what is the value of evaluating DD in the scoliosis environment?. If is has no value we might as well do research into whether more people with scoliosis have brown eyes than have brown. It is a pointless study!

We have to include 'normal' because this research is nothing to do with what causes scoliosis but much more to do with living with its consequences compared with normal living.

Surely research has to be guided by what use the outcome is- what can we draw from the research? - we can see that for some reason the 24 year olds who had had surgery had less DD than the ones with severe scoliosis who hadn't. But unless we know the value of having DD or not having DD then what is the point. And we can only do that if we look at 'normal' and what to expect from normal.

I am not knocking the science just wishing that sometimes we had more applied science!

[LindaRacine]

"Female subjects diagnosed with idiopathic scoliosis at a single institution were selected. These patients were subdivided among three groups: 1) surgical group (Surgical Group) who have gone through corrective fusion at 10-year follow-up; 2) nonsurgical mild scoliosis group (Mild Group) whose scoliosis have comparative curvature to postoperative
scoliosis in the surgical group; 3) nonsurgical severe scoliosis group (Severe Group) whose scoliosis is comparable to that of the surgical group in 10 years if the surgical group did not go through surgery (Figure 1).

Surgical Group consisted of 51 patients of ages 14 to 25 years (average age 18.2) at pre-operation, and 24 to 35 years (average age 28.2) at the time of postoperative 10 years (Table 1). Surgical Group was selected under the following criteria: 1) patients who have gone through surgery between 1992 and 2002; 2) patients of 14 to 25 years of age at time of operation; 3) LIV (lower instrumented vertebra) at L1-L3; 4) minimum follow-up of 10 years; and 5) MRI taken at postoperative 10-year follow-up.

Inclusion criteria of the Mild Group and the Severe Group were follows: 1) AIS; 2); female; 3) the patients referred to our hospital from 2005 to 2011; 4) availability of MRI and X-ray. These patients who had spondylolysis and spondylolisthesis were excluded.

Mild Group consisted of 45 patients of ages 21 to 34 years (average 27.9). In order to compare the effect of fusion, patients whose age and scoliosis were matched to the Surgical Group at postoperative 10-years follow-up were selected (Table 1). <--See Below

Severe Group consisted of 33 patients whose ages were 24 to 35 years (average 28.8) (Table 1). This group was categorized as patients with scoliosis who were viewed to have equivalent scoliosis to the surgical group in 10 years if surgery was not conducted. This estimation was done under the assumption that after the cessation of growth, if main curve was more than 30 degrees, scoliosis will continue to progress at rate of 0.50.78/year.22 To fit this estimation, patients with 58 to 78 more scoliosis than preoperative magnitude of Surgical Group were included."

Scoli and DDD Table 1.jpg

[Pooka1]

Well you would not expect DD in a 24 year old without scoliosis so I wonder why they don't do a follow up at 44 or55 30 or 40 years after surgery.

Maybe they will.

Current 'Pain Management' thought is that evidence of DD does not necessarily mean that the person with it has any problems.. I know the scope of the research is just looking at evidence of DD and not the effects of having DD but still I wish that research like this was done later. There is so little real long-term ( 10 years is not long-term) follow up done on post fusion patients and allowing for the length of time fusion has now been being done it should be possible to do it. I'll bet that long-term follow up of scoliosis fusion patients would show that there was evidence of DD AND problems with having DD

I think they have to limit it to modern segmental constructions and not H rods. I don't know how long modern constructs have been around.

In re scoliosis patients versus normals the long run, that answer is in.... a huge percentage of people without scoliosis have back pain at some point that is bad enough to drive them to seek treatment. Even if 100% of fusion patients have pain form DD, if 90% or more of normals have the same thing then it becomes pretty hard to say the pain is due to fusion. I have sought treatment of back pain due to a herniated disc when I was in my early thirties. I wasn't treated like I have two heads when I presented myself so I am not so sure it is that unusual even for a person who is in their early 30s. I have since herniated another disc 20 years later.

[Pooka1]

A lot of studies that are published are 'whack' when I get a minute I will find a link to a classic one that disobeys even the basic rules.

However do we not have to ask what is the value of evaluating DD in the scoliosis environment?. If is has no value we might as well do research into whether more people with scoliosis have brown eyes than have brown. It is a pointless study!

We have to include 'normal' because this research is nothing to do with what causes scoliosis but much more to do with living with its consequences compared with normal living.

Surely research has to be guided by what use the outcome is- what can we draw from the research? - we can see that for some reason the 24 year olds who had had surgery had less DD than the ones with severe scoliosis who hadn't. But unless we know the value of having DD or not having DD then what is the point. And we can only do that if we look at 'normal' and what to expect from normal.

I am not knocking the science just wishing that sometimes we had more applied science!

Yes that is a reasonable point but there is no unaffectd population to study given most people will have DDD if they live long enough. So all we have to do is look at that prevalence of DDD in various age groups. I think you are right in that only the long term can answer if DD has any ramifications beyond imaging.

[Pooka1]

(snip) This estimation was done under the assumption that after the cessation of growth, if main curve was more than 30 degrees, scoliosis will continue to progress at rate of 0.50.78/year.22 To fit this estimation, patients with 58 to 78 more scoliosis than preoperative magnitude of Surgical Group were included."

This is the first I have seen of someone fitting an equation for progression given a >30* at skeletal maturity. It's like they are saying most curves >30* will progress and they will progress within that rate range. I did not realize that most curves say in the 30*s could be expected to progress.