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Why Do Patients Seek a Spine Surgeon?
Spine Deformity 4 (2016) 358e364 www.spine-deformity.org
Why Do Patients Seek a Spine Surgeon? Roy Norris, MD, Timothy Garvey, MD*, Robert Winter, MDy Twin Cities Spine Center, 913 E. 26th St, Minneapolis, MN 55404, USA Received 16 July 2015; revised 4 April 2016; accepted 10 May 2016
Abstract Study Design: Retrospective review of chief complaints (CCs) of patients seeking care at a specialty spine clinic with the diagnosis of degenerative scoliosis or lumbar stenosis. Objectives: The purpose of the study was to ascertain why patients seek care from spine surgeons. Specifically, we asked whether pain or deformity was more common. Secondarily, we studied the correlation of progressive curve magnitude with perceived functionality. Background: Scant research is available on what leads a patient to be seen in a clinic. Degenerative scoliosis is often correlated with pain in the low back and extremities, symptoms that impinge on quality of life in the elderly. Some research suggests there is no correlation between progressive curve magnitude and perceived functionality. Methods: Charts and radiographs of 351 consecutive patients were reviewed. Patient inclusion criteria were as follows: 1) they were seen at our spine clinic in one 12-month period, 2) their chief diagnosis was degenerative scoliosis or lumbar stenosis, 3) they were 50 years of age or older, and 4) they had no known prior history of scoliosis. Oswestry Disability Index (ODI) data were recorded. Results: Of 351 patients, 160 reported their CC was combination back þ leg pain on the initial visit survey, 123 complained of back pain only, and 42 complained of leg pain only. Ten complained of deformity or deformity þ pain. Patients with degenerative scoliosis þ spinal stenosis represented 25% of the study population; 11% were diagnosed with degenerative scoliosis only; 64% with stenosis only. Of the 122 patients with a Cobb angle of greater than 10 , only 10 complained of deformity or deformity þ pain on the initial visit survey. Conclusions: Patients most often presented because of pain, specifically back, leg, or a combination of both. Patients seldom complained of deformity only, even among patients exhibiting a Cobb angle of greater than 30 degrees. Ó 2016 Scoliosis Research Society. Keywords: Chief complaint; Spine deformity; Scoliosis; Stenosis; Back pain; Leg pain
Introduction Adult degenerative de novo scoliosis (DDS) is characterized by scoliosis forming after the spine has reached maturity [1]. The number of patients presenting in clinic with DDS is increasing, probably because of the aging population. Scoliosis in adults has been associated with low back and leg pain, as well as deformity, and affects the quality of life of the elderly [2]. What leads patients to be seen in clinic remains a matter of speculation. Research exists on treatment of DDS given certain indications [3], yet scant literature exists on what motivates patients to be IRB approval: This study was reviewed and approved by Abbott Northwestern Hospital IRB by expedited review under 45 CFR 46.110 #(5). Author disclosures: RN (none), TG (none), RW (none). *Corresponding author. Twin Cities Spine Center, 913 E. 26th St., Minneapolis, MN 55404, USA. Tel.: (612) 775-6200; fax: (612) 775-6222. E-mail address: [email protected] (T. Garvey). y Deceased. 2212-134X/$ - see front matter Ó 2016 Scoliosis Research Society. http://dx.doi.org/10.1016/j.jspd.2016.05.002
seen. Because of DDS’s association with pain and deformity, we sought to identify whether these associations are motivational factors for patients to be seen for treatment by a spine surgeon. Specifically, we sought to quantify the number of patients who complained primarily of pain, deformity, or both. Because the incidence of degenerative scoliosis represents a prevalence ranging from 6% to 68% [4-6], identifying the motivational factors for clinical presentation may shed light on DDS’s etiology, an area that is also not yet well understood [1]. A corollary to this study is the recognition that increasing curve size is not necessarily causal of pain or loss of function [7,8]. Rather, it has been found that sagittal imbalance is a greater indicator of pain and loss of function [8], and coronal imbalance has been correlated with decreased functionality [9]. For this reason, the Oswestry Disability Index (ODI) was collected to ascertain if there was a correlation, if any, between increasing Cobb angle and functionality. We did not study whether these patients had received surgery or what
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surgery, if any, had been performed, this topic having been recently commented upon by others [10]. Materials A chart review was conducted using electronic medical records. Patients were included in the study based on three criteria. They were 1) seen at our center during one 12-month period, 2) aged 50 years or older, 3) recorded as having a chief diagnosis of degenerative scoliosis or lumbar stenosis, and 4) not known to have a prior history of scoliosis. Those with known idiopathic adolescent scoliosis were excluded. Whether patients had been previously evaluated by a spine surgeon or treated by nonsurgeon health care provider is not known.
Fig. 1. Distribution of patients by attending surgeon.
Methods Patient self-reported chief complaint (Patient CC) was obtained from either the initial visit survey or the initial visit note made by the attending surgeon. In the initial visit survey, patients are asked to fill out a terse, one-line description of their symptoms prompted by ‘‘Chief Complaint.’’ The second prompt, ‘‘Describe the onset, symptoms and related issues of the condition for which you are seeking treatment,’’ is followed by a six-line space for response. Six possible data were recorded for patient self-reported CC: 1) back pain only, 2) leg pain only, 3) combination back and leg pain, 4) deformity only, 5) deformity and pain, and 6) no response or blank. Where the first prompt was insufficiently specific, did not mention one of the above categories 1e5, or was blank, the second prompt was consulted. For example, if the first response was ‘‘pins and needles, numbness, and pain,’’ the second prompt may have shed light on where these sensations occurred, thus allowing the patient’s complaint to be categorized. If both prompts were blank, the Patient CC was recorded as ‘‘blank.’’ The patient’s ODI was obtained from the initial visit survey. If it was left blank, no values were recorded. The attending surgeon’s recorded patient chief complaint (Attending CC) was obtained from the patient initial visit note. The response was recorded as it fell into one of the above six categories. The patient’s radiograph was checked to confirm the presence of a degenerative scoliosis and obtain the Cobb angle measurement. Cohen’s Kappa was used to measure agreement between Patient CC and Attending CC. The chi-square test was used to compare the proportions of patients complaining of deformity or deformity þ pain between patients with curves greater than 30 and patients with curves of less than 30 .
Fig. 2. Distribution of patient self-reported chief complaints.
differences in the numbers of included patients from each surgeon (Fig. 1). Nevertheless, none were excluded from the final data set. One surgeon, whose practice primarily treats patients with degenerative scoliosis and/or stenosis, accounted for 42% of the data. Chief complaints The most common Patient CC was combination back and leg pain (46% of patients), followed by back pain only (35%) and leg pain only (12%). Four of 351 patients complained of deformity only (1%) and 6 of combination
Results Included in the study were 351 patients: 199 women and 152 men. Patients received care from one of nine surgeons whose practices differ by subspecialty (e.g., adolescent deformity vs adult degeneration). This resulted in
Fig. 3. Distribution of attending surgeon’s recorded chief complaints.
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Fig. 4. Agreement between attending surgeon’s and patient’s chief complaint.
Fig. 6. Distribution of patients by degree of curvature.
Table Summary of agreement/disagreement in chief complaint (CC). Attending CC
Patient CC
Back þ leg pain Back pain Leg pain Deformity Deformity þ pain
Back þ leg pain
Back pain
Leg pain
Deformity
Deformity þ pain
133 50 11 1 1
8 66 0 0 2
17 7 31 0 0
1 0 0 2 0
1 0 0 1 3
deformity þ pain (2%) (Fig. 2). Therefore, combination back and leg pain was the greatest Patient CC and deformity was the least. Sixteen patients did not have a self-reported CC and were recorded as blank. The most common Attending CC was combination back and leg pain (58% of patients) followed by back pain only (23%) and leg pain only (17%); three of 351 patients complained of deformity only (1%) and five of combination deformity þ pain (1%) (Fig. 3). Consistency between Patient CC and Attending CC is shown in Fig. 4. Excluding the 16 patients who did not provide their chief complaint (i.e., blank), 335 patients had both Patient CC and Attending CC. The Table accounts for numbers of agreement and disagreement between patient and attending CC. After accounting for the possibility that the patient and the
Fig. 5. Distribution of patients by diagnosis.
Fig. 7. Distribution of Patient CC among patients with curves greater than 10 .
clinician agree simply by chance, there is 52% agreement between the two, with a 95% confidence interval of 44% to 60%. The Patient CC matched with the Attending CC most often when the patient listed ‘‘Back and leg pain’’ on their initial visit survey (83% of the time). Radiographic evaluation Patients with both degenerative scoliosis and spinal stenosis represented 25% of the study population, 11%
Fig. 8. Distribution of diagnoses among patients with large scoliotic curves.
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cohort (4 in 21) versus the other curve cohorts (6 in 331) was statistically significant per the chi-square test (p ! .01). Therefore, proportionally more patients with curves of O30 complained of deformity or deformity þ pain than did patients with curves of less than 30 . Functional evaluation
Fig. 9. Distribution of ODI scores among patients with measurable scoliosis.
were diagnosed with degenerative scoliosis only, and 64% with stenosis only (Fig. 5). Just under half of the 351 patients exhibited small or no scoliosis curvature. However, 122 patients had a measurable Cobb angle of 10 or greater (Fig. 6), thus meeting the Scoliosis Research Society’s definition of scoliosis. Among these, 58 had small curves (10 e15 ) and 21 had a curve angle greater than 30 . Among the 122 patients with measurable curves (curves 10 or greater), the most common Patient CC were back pain (41%) and combination back and leg pain (38%). The least common complaint was deformity (3%) (Fig. 7). Among patients exhibiting a curve of 30 or greater, 2 complained of deformity alone (10%), and 2 complained of deformity þ pain (10%). Thus, for 4 in 21 patients among the large-curve cohort (19%), deformity was an issue (Fig. 8). The difference in the rate of deformity complaints for the large-curve
The average ODI for the different curve cohorts ranged from 25 to 17 (Fig. 9). ODI scores were not found to be significantly related to Cobb angles when analyzed by a oneway analysis of variance on ranks (p 5 .57). However, the power of the test was low (0.05) because there were relatively few patients in that group with a Cobb angle between 26 and 30 (n 5 7) and because the variation in the data between groups was less than within each group. It is possible given future sufficiently powered studies that a correlation between ODI and Cobb angle could be demonstrated. Case reports This paper is not intended to direct the decision-making of surgical management. However, a patient’s chief complaint can and should impact on that decision. Two examples are described of patients who presented in our clinic with complaints of leg pain with varying degrees of deformity: Patient 1 is an 87-year-woman who presented with 90% right leg pain. She had a previous L4eL5 decompression. She was diagnosed with degenerative scoliosis, degenerative spondylolisthesis, and severe remnant L4eL5 foraminal stenosis. A right L4 selective nerve root block
Fig. 10. 87 y.o. patient presenting for right leg pain diagnosed with degenerative lumbar scoliosis, degenerative spondylolisthesis, and L4-5 foraminal stenosis (Preoperative images: Left, frontal; Right, sagittal).
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Fig. 11. Patient’s symptoms resolved after a limited L4-5 decompression and fusion. The arrow indicates the severe L4-5 foraminal stenosis.
Fig. 12. 65 y.o. patient presenting for bilateral leg pain diagnosed with degenerative lumbar scoliosis, degenerative lateral listhesis and stenosis. She has mild sagittal imbalance. (Preoperative images: Left, frontal; Right, sagittal).
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Fig. 13. Patient’s symptoms resolved after multilevel decompression with deformity correction.
alleviated the pain. A limited L4eL5 decompression and fusion completely resolved her symptoms. Fig. 10 shows preoperative imaging and Fig. 11 shows postoperative radiograph and preoperative MRI. Patient 2 is a 65-year-old woman who presented with a chief complaint of bilateral leg pain She was diagnosed with degenerative scoliosis (her radiographs show a T12eL4 50 curve with a fractional curve of 28 ), lateral listhesis, and stenosis. She has mild sagittal imbalance on radiographs. Her surgery included multilevel decompression, as well as deformity correction. Her leg pain was resolved. Fig. 12 shows preoperative imaging and Fig. 13 shows postoperative imaging. Discussion DDS affects the quality of life of the elderly [7,8]. Because what motivates a patient to be seen in clinic with DDS can impact on DDS’s treatment, we reviewed patient intake data from our spine center. As our data suggested
that both patients and physicians seldom recorded deformity as the CC, it seems likely that deformity was rarely a motivating factor for patients to seek a spine surgeon. Although pain may be the most common motivational factor, increasing curvature of the spine, and thus a greater magnitude of DDS, was not correlated with decreasing functionality as measured by the ODI results (Fig. 8). Therefore, it seems that when nerve-root compression causes sufficient pain and loss of functionality, it may motivate patients to be seen in clinic. To some degree, a benchmark for tolerance of imbalance or deformity might exist among patients with a large scoliosis, that is, greater than 30 . Support for this kind of benchmark has been suggested in a 2009 study of standing radiographs, which suggested that patients with a coronal imbalance of greater than 5 cm was correlated with decreased functionality [9]. Further, sagittal imbalance has been implicated in poor outcomes for DDS patients who underwent surgery postoperatively [7] and is a factor correlated with decreased functionality preoperatively [8]. These findings provide
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support for the belief that DDS is not only a disease that significantly impinges on the quality of life of older patients but also one that is quantifiably diagnosed. Given that our findings suggest deformity was less a motivating factor for being seen than pain, it seems prudent that future research would examine the severity of spinal stenosis associated with DDS, rather than degree of curvature alone, to further quantify what leads a patient to seek a spine surgeon. About half of the time, the Patient CC and Attending CC do not a match. While the patient’s insights on his/her intake form are valuable, it is possible that the physician’s understanding of degenerative disease and perceptions during the initial visit are more important in assessing and diagnosing the patient’s problem. Because the physician synthesizes information from the intake form, clinic examination, and patient history, the Attending CC is likely a more accurate reflection of the underlying pathology and should serve as the criterion standard for future studies investigating patient self-reported CC. One limitation of the study may possibly have been selection bias arising from the fact that this is a singlecenter study conducted in Minnesota. Although data describing geographic variations in care for DDS patients are available [11,12] and there are estimates of the overall prevalence of degenerative scoliosis or lumbar stenosis, there is little data describing geographic variations, and what data are available are highly inconsistent. It is therefore difficult to definitively demonstrate that our patient population is universally representative. Nevertheless, we believe the likelihood of selection bias to be low because our practice sees patients from 14 of the top 20 metropolitan areas in the United States and 42 states and 6 foreign countries overall. We give examples of two patients who presented in our clinic. They were found to have degenerative scoliosis and stenosis, but it was their complaints of leg pain that motivated them to be seen by a spine surgeon. In some cases, the surgeon may perform a relatively smaller decompressive procedure or a limited reconstructive procedure, leaving deformity untreated (as was the case of the first of these two patients). In others, the correction of deformity with its accompanied greater risks will be indicated, as was the case with the second of the two patients. Decompression alone in the presence of deformity may lead to recurrence of radicular pain with progression of deformity; even so, decompression alone remains a viable treatment option for some patients [13]. Either way, the surgeon should perform procedures to address the patients’
expectations of pain relief, rather than focus solely on radiographic findings. Conclusion Patients presenting in a spine clinic with stenosis and/ or degenerative scoliosis seldom complained primarily of deformity and most often complain of back and leg pain. Increasing curve sizes were not found to be correlated to decreasing functionality on an ODI. However, the proportion of patients complaining of deformity or deformity þ pain in the large-curve cohort (O30 ) is significantly different from that of patients with less scoliosis (!30 ). References [1] Ploumis A, Transfeldt EE, Denis F. Degenerative lumbar scoliosis associated with spinal stenosis. Spine J 2007;7:428e36. [2] Gremeuax V, Casillas JM, Fabbro-Peray P, et al. Analysis of low back pain in adults with scoliosis. Spine 2008;33:402e5. [3] Prommahachai A, Wittayapirot K, Jirarattanaphochai K, et al. Correction with instrumented fusion versus non-corrective surgery for degenerative lumbar scoliosis: a systematic review. J Med Assoc Thai 2010;93:920e9. [4] Vanderpool DW, James JI, Winne-Davies R. Scoliosis in the elderly. J Bone Joint Surg Am 1969;51:446e55. [5] Kobayashi T, Autsuta Y, Takemitsu M, et al. A prospective study of de novo scoliosis in a community based cohort. Spine 2006;31:178e82. [6] Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine 2005;30:1082e5. [7] Transfeldt EE, Topp R, Mehbod AA, Winter RB. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine 2010;20:1872e5. [8] Mac-Thiong JM, Transfeldt EE, Mehbod AA, et al. Can C7 Plumbline and Gravity Line Predict Health Related Quality of Life in Adult Scoliosis? Spine 2009;34:E519e27. [9] Ploumis A, Liu H, Mehbod AA, et al. A correlation of radiographic and functional measurements in adult degenerative scoliosis. Spine 2009;34:1581e4. [10] Illingworth KC, Rahman R. Adult degenerative scoliosis: determination of fusion and decompression parameters. Semin Spine Surg 2015;27:122e5. [11] Desai A, Bekelis K, Ball PA, et al. Variation in outcomes across centers after surgery for lumbar stenosis and degenerative spondylolisthesis in the spine patient outcomes research trial. Spine 2013;38: 678e91. [12] Irwin ZN, Hilibrand A, Gustavel M, et al. Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine 2005;30:2208e13. [13] Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine 2010;35: E981e7.
Why Do Patients Seek a Spine Surgeon? Roy Norris, MD, Timothy Garvey, MD*, Robert Winter, MDy Twin Cities Spine Center, 913 E. 26th St, Minneapolis, MN 55404, USA Received 16 July 2015; revised 4 April 2016; accepted 10 May 2016
Abstract Study Design: Retrospective review of chief complaints (CCs) of patients seeking care at a specialty spine clinic with the diagnosis of degenerative scoliosis or lumbar stenosis. Objectives: The purpose of the study was to ascertain why patients seek care from spine surgeons. Specifically, we asked whether pain or deformity was more common. Secondarily, we studied the correlation of progressive curve magnitude with perceived functionality. Background: Scant research is available on what leads a patient to be seen in a clinic. Degenerative scoliosis is often correlated with pain in the low back and extremities, symptoms that impinge on quality of life in the elderly. Some research suggests there is no correlation between progressive curve magnitude and perceived functionality. Methods: Charts and radiographs of 351 consecutive patients were reviewed. Patient inclusion criteria were as follows: 1) they were seen at our spine clinic in one 12-month period, 2) their chief diagnosis was degenerative scoliosis or lumbar stenosis, 3) they were 50 years of age or older, and 4) they had no known prior history of scoliosis. Oswestry Disability Index (ODI) data were recorded. Results: Of 351 patients, 160 reported their CC was combination back þ leg pain on the initial visit survey, 123 complained of back pain only, and 42 complained of leg pain only. Ten complained of deformity or deformity þ pain. Patients with degenerative scoliosis þ spinal stenosis represented 25% of the study population; 11% were diagnosed with degenerative scoliosis only; 64% with stenosis only. Of the 122 patients with a Cobb angle of greater than 10 , only 10 complained of deformity or deformity þ pain on the initial visit survey. Conclusions: Patients most often presented because of pain, specifically back, leg, or a combination of both. Patients seldom complained of deformity only, even among patients exhibiting a Cobb angle of greater than 30 degrees. Ó 2016 Scoliosis Research Society. Keywords: Chief complaint; Spine deformity; Scoliosis; Stenosis; Back pain; Leg pain
Introduction Adult degenerative de novo scoliosis (DDS) is characterized by scoliosis forming after the spine has reached maturity [1]. The number of patients presenting in clinic with DDS is increasing, probably because of the aging population. Scoliosis in adults has been associated with low back and leg pain, as well as deformity, and affects the quality of life of the elderly [2]. What leads patients to be seen in clinic remains a matter of speculation. Research exists on treatment of DDS given certain indications [3], yet scant literature exists on what motivates patients to be IRB approval: This study was reviewed and approved by Abbott Northwestern Hospital IRB by expedited review under 45 CFR 46.110 #(5). Author disclosures: RN (none), TG (none), RW (none). *Corresponding author. Twin Cities Spine Center, 913 E. 26th St., Minneapolis, MN 55404, USA. Tel.: (612) 775-6200; fax: (612) 775-6222. E-mail address: [email protected] (T. Garvey). y Deceased. 2212-134X/$ - see front matter Ó 2016 Scoliosis Research Society. http://dx.doi.org/10.1016/j.jspd.2016.05.002
seen. Because of DDS’s association with pain and deformity, we sought to identify whether these associations are motivational factors for patients to be seen for treatment by a spine surgeon. Specifically, we sought to quantify the number of patients who complained primarily of pain, deformity, or both. Because the incidence of degenerative scoliosis represents a prevalence ranging from 6% to 68% [4-6], identifying the motivational factors for clinical presentation may shed light on DDS’s etiology, an area that is also not yet well understood [1]. A corollary to this study is the recognition that increasing curve size is not necessarily causal of pain or loss of function [7,8]. Rather, it has been found that sagittal imbalance is a greater indicator of pain and loss of function [8], and coronal imbalance has been correlated with decreased functionality [9]. For this reason, the Oswestry Disability Index (ODI) was collected to ascertain if there was a correlation, if any, between increasing Cobb angle and functionality. We did not study whether these patients had received surgery or what
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surgery, if any, had been performed, this topic having been recently commented upon by others [10]. Materials A chart review was conducted using electronic medical records. Patients were included in the study based on three criteria. They were 1) seen at our center during one 12-month period, 2) aged 50 years or older, 3) recorded as having a chief diagnosis of degenerative scoliosis or lumbar stenosis, and 4) not known to have a prior history of scoliosis. Those with known idiopathic adolescent scoliosis were excluded. Whether patients had been previously evaluated by a spine surgeon or treated by nonsurgeon health care provider is not known.
Fig. 1. Distribution of patients by attending surgeon.
Methods Patient self-reported chief complaint (Patient CC) was obtained from either the initial visit survey or the initial visit note made by the attending surgeon. In the initial visit survey, patients are asked to fill out a terse, one-line description of their symptoms prompted by ‘‘Chief Complaint.’’ The second prompt, ‘‘Describe the onset, symptoms and related issues of the condition for which you are seeking treatment,’’ is followed by a six-line space for response. Six possible data were recorded for patient self-reported CC: 1) back pain only, 2) leg pain only, 3) combination back and leg pain, 4) deformity only, 5) deformity and pain, and 6) no response or blank. Where the first prompt was insufficiently specific, did not mention one of the above categories 1e5, or was blank, the second prompt was consulted. For example, if the first response was ‘‘pins and needles, numbness, and pain,’’ the second prompt may have shed light on where these sensations occurred, thus allowing the patient’s complaint to be categorized. If both prompts were blank, the Patient CC was recorded as ‘‘blank.’’ The patient’s ODI was obtained from the initial visit survey. If it was left blank, no values were recorded. The attending surgeon’s recorded patient chief complaint (Attending CC) was obtained from the patient initial visit note. The response was recorded as it fell into one of the above six categories. The patient’s radiograph was checked to confirm the presence of a degenerative scoliosis and obtain the Cobb angle measurement. Cohen’s Kappa was used to measure agreement between Patient CC and Attending CC. The chi-square test was used to compare the proportions of patients complaining of deformity or deformity þ pain between patients with curves greater than 30 and patients with curves of less than 30 .
Fig. 2. Distribution of patient self-reported chief complaints.
differences in the numbers of included patients from each surgeon (Fig. 1). Nevertheless, none were excluded from the final data set. One surgeon, whose practice primarily treats patients with degenerative scoliosis and/or stenosis, accounted for 42% of the data. Chief complaints The most common Patient CC was combination back and leg pain (46% of patients), followed by back pain only (35%) and leg pain only (12%). Four of 351 patients complained of deformity only (1%) and 6 of combination
Results Included in the study were 351 patients: 199 women and 152 men. Patients received care from one of nine surgeons whose practices differ by subspecialty (e.g., adolescent deformity vs adult degeneration). This resulted in
Fig. 3. Distribution of attending surgeon’s recorded chief complaints.
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Fig. 4. Agreement between attending surgeon’s and patient’s chief complaint.
Fig. 6. Distribution of patients by degree of curvature.
Table Summary of agreement/disagreement in chief complaint (CC). Attending CC
Patient CC
Back þ leg pain Back pain Leg pain Deformity Deformity þ pain
Back þ leg pain
Back pain
Leg pain
Deformity
Deformity þ pain
133 50 11 1 1
8 66 0 0 2
17 7 31 0 0
1 0 0 2 0
1 0 0 1 3
deformity þ pain (2%) (Fig. 2). Therefore, combination back and leg pain was the greatest Patient CC and deformity was the least. Sixteen patients did not have a self-reported CC and were recorded as blank. The most common Attending CC was combination back and leg pain (58% of patients) followed by back pain only (23%) and leg pain only (17%); three of 351 patients complained of deformity only (1%) and five of combination deformity þ pain (1%) (Fig. 3). Consistency between Patient CC and Attending CC is shown in Fig. 4. Excluding the 16 patients who did not provide their chief complaint (i.e., blank), 335 patients had both Patient CC and Attending CC. The Table accounts for numbers of agreement and disagreement between patient and attending CC. After accounting for the possibility that the patient and the
Fig. 5. Distribution of patients by diagnosis.
Fig. 7. Distribution of Patient CC among patients with curves greater than 10 .
clinician agree simply by chance, there is 52% agreement between the two, with a 95% confidence interval of 44% to 60%. The Patient CC matched with the Attending CC most often when the patient listed ‘‘Back and leg pain’’ on their initial visit survey (83% of the time). Radiographic evaluation Patients with both degenerative scoliosis and spinal stenosis represented 25% of the study population, 11%
Fig. 8. Distribution of diagnoses among patients with large scoliotic curves.
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cohort (4 in 21) versus the other curve cohorts (6 in 331) was statistically significant per the chi-square test (p ! .01). Therefore, proportionally more patients with curves of O30 complained of deformity or deformity þ pain than did patients with curves of less than 30 . Functional evaluation
Fig. 9. Distribution of ODI scores among patients with measurable scoliosis.
were diagnosed with degenerative scoliosis only, and 64% with stenosis only (Fig. 5). Just under half of the 351 patients exhibited small or no scoliosis curvature. However, 122 patients had a measurable Cobb angle of 10 or greater (Fig. 6), thus meeting the Scoliosis Research Society’s definition of scoliosis. Among these, 58 had small curves (10 e15 ) and 21 had a curve angle greater than 30 . Among the 122 patients with measurable curves (curves 10 or greater), the most common Patient CC were back pain (41%) and combination back and leg pain (38%). The least common complaint was deformity (3%) (Fig. 7). Among patients exhibiting a curve of 30 or greater, 2 complained of deformity alone (10%), and 2 complained of deformity þ pain (10%). Thus, for 4 in 21 patients among the large-curve cohort (19%), deformity was an issue (Fig. 8). The difference in the rate of deformity complaints for the large-curve
The average ODI for the different curve cohorts ranged from 25 to 17 (Fig. 9). ODI scores were not found to be significantly related to Cobb angles when analyzed by a oneway analysis of variance on ranks (p 5 .57). However, the power of the test was low (0.05) because there were relatively few patients in that group with a Cobb angle between 26 and 30 (n 5 7) and because the variation in the data between groups was less than within each group. It is possible given future sufficiently powered studies that a correlation between ODI and Cobb angle could be demonstrated. Case reports This paper is not intended to direct the decision-making of surgical management. However, a patient’s chief complaint can and should impact on that decision. Two examples are described of patients who presented in our clinic with complaints of leg pain with varying degrees of deformity: Patient 1 is an 87-year-woman who presented with 90% right leg pain. She had a previous L4eL5 decompression. She was diagnosed with degenerative scoliosis, degenerative spondylolisthesis, and severe remnant L4eL5 foraminal stenosis. A right L4 selective nerve root block
Fig. 10. 87 y.o. patient presenting for right leg pain diagnosed with degenerative lumbar scoliosis, degenerative spondylolisthesis, and L4-5 foraminal stenosis (Preoperative images: Left, frontal; Right, sagittal).
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Fig. 11. Patient’s symptoms resolved after a limited L4-5 decompression and fusion. The arrow indicates the severe L4-5 foraminal stenosis.
Fig. 12. 65 y.o. patient presenting for bilateral leg pain diagnosed with degenerative lumbar scoliosis, degenerative lateral listhesis and stenosis. She has mild sagittal imbalance. (Preoperative images: Left, frontal; Right, sagittal).
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Fig. 13. Patient’s symptoms resolved after multilevel decompression with deformity correction.
alleviated the pain. A limited L4eL5 decompression and fusion completely resolved her symptoms. Fig. 10 shows preoperative imaging and Fig. 11 shows postoperative radiograph and preoperative MRI. Patient 2 is a 65-year-old woman who presented with a chief complaint of bilateral leg pain She was diagnosed with degenerative scoliosis (her radiographs show a T12eL4 50 curve with a fractional curve of 28 ), lateral listhesis, and stenosis. She has mild sagittal imbalance on radiographs. Her surgery included multilevel decompression, as well as deformity correction. Her leg pain was resolved. Fig. 12 shows preoperative imaging and Fig. 13 shows postoperative imaging. Discussion DDS affects the quality of life of the elderly [7,8]. Because what motivates a patient to be seen in clinic with DDS can impact on DDS’s treatment, we reviewed patient intake data from our spine center. As our data suggested
that both patients and physicians seldom recorded deformity as the CC, it seems likely that deformity was rarely a motivating factor for patients to seek a spine surgeon. Although pain may be the most common motivational factor, increasing curvature of the spine, and thus a greater magnitude of DDS, was not correlated with decreasing functionality as measured by the ODI results (Fig. 8). Therefore, it seems that when nerve-root compression causes sufficient pain and loss of functionality, it may motivate patients to be seen in clinic. To some degree, a benchmark for tolerance of imbalance or deformity might exist among patients with a large scoliosis, that is, greater than 30 . Support for this kind of benchmark has been suggested in a 2009 study of standing radiographs, which suggested that patients with a coronal imbalance of greater than 5 cm was correlated with decreased functionality [9]. Further, sagittal imbalance has been implicated in poor outcomes for DDS patients who underwent surgery postoperatively [7] and is a factor correlated with decreased functionality preoperatively [8]. These findings provide
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support for the belief that DDS is not only a disease that significantly impinges on the quality of life of older patients but also one that is quantifiably diagnosed. Given that our findings suggest deformity was less a motivating factor for being seen than pain, it seems prudent that future research would examine the severity of spinal stenosis associated with DDS, rather than degree of curvature alone, to further quantify what leads a patient to seek a spine surgeon. About half of the time, the Patient CC and Attending CC do not a match. While the patient’s insights on his/her intake form are valuable, it is possible that the physician’s understanding of degenerative disease and perceptions during the initial visit are more important in assessing and diagnosing the patient’s problem. Because the physician synthesizes information from the intake form, clinic examination, and patient history, the Attending CC is likely a more accurate reflection of the underlying pathology and should serve as the criterion standard for future studies investigating patient self-reported CC. One limitation of the study may possibly have been selection bias arising from the fact that this is a singlecenter study conducted in Minnesota. Although data describing geographic variations in care for DDS patients are available [11,12] and there are estimates of the overall prevalence of degenerative scoliosis or lumbar stenosis, there is little data describing geographic variations, and what data are available are highly inconsistent. It is therefore difficult to definitively demonstrate that our patient population is universally representative. Nevertheless, we believe the likelihood of selection bias to be low because our practice sees patients from 14 of the top 20 metropolitan areas in the United States and 42 states and 6 foreign countries overall. We give examples of two patients who presented in our clinic. They were found to have degenerative scoliosis and stenosis, but it was their complaints of leg pain that motivated them to be seen by a spine surgeon. In some cases, the surgeon may perform a relatively smaller decompressive procedure or a limited reconstructive procedure, leaving deformity untreated (as was the case of the first of these two patients). In others, the correction of deformity with its accompanied greater risks will be indicated, as was the case with the second of the two patients. Decompression alone in the presence of deformity may lead to recurrence of radicular pain with progression of deformity; even so, decompression alone remains a viable treatment option for some patients [13]. Either way, the surgeon should perform procedures to address the patients’
expectations of pain relief, rather than focus solely on radiographic findings. Conclusion Patients presenting in a spine clinic with stenosis and/ or degenerative scoliosis seldom complained primarily of deformity and most often complain of back and leg pain. Increasing curve sizes were not found to be correlated to decreasing functionality on an ODI. However, the proportion of patients complaining of deformity or deformity þ pain in the large-curve cohort (O30 ) is significantly different from that of patients with less scoliosis (!30 ). References [1] Ploumis A, Transfeldt EE, Denis F. Degenerative lumbar scoliosis associated with spinal stenosis. Spine J 2007;7:428e36. [2] Gremeuax V, Casillas JM, Fabbro-Peray P, et al. Analysis of low back pain in adults with scoliosis. Spine 2008;33:402e5. [3] Prommahachai A, Wittayapirot K, Jirarattanaphochai K, et al. Correction with instrumented fusion versus non-corrective surgery for degenerative lumbar scoliosis: a systematic review. J Med Assoc Thai 2010;93:920e9. [4] Vanderpool DW, James JI, Winne-Davies R. Scoliosis in the elderly. J Bone Joint Surg Am 1969;51:446e55. [5] Kobayashi T, Autsuta Y, Takemitsu M, et al. A prospective study of de novo scoliosis in a community based cohort. Spine 2006;31:178e82. [6] Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine 2005;30:1082e5. [7] Transfeldt EE, Topp R, Mehbod AA, Winter RB. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine 2010;20:1872e5. [8] Mac-Thiong JM, Transfeldt EE, Mehbod AA, et al. Can C7 Plumbline and Gravity Line Predict Health Related Quality of Life in Adult Scoliosis? Spine 2009;34:E519e27. [9] Ploumis A, Liu H, Mehbod AA, et al. A correlation of radiographic and functional measurements in adult degenerative scoliosis. Spine 2009;34:1581e4. [10] Illingworth KC, Rahman R. Adult degenerative scoliosis: determination of fusion and decompression parameters. Semin Spine Surg 2015;27:122e5. [11] Desai A, Bekelis K, Ball PA, et al. Variation in outcomes across centers after surgery for lumbar stenosis and degenerative spondylolisthesis in the spine patient outcomes research trial. Spine 2013;38: 678e91. [12] Irwin ZN, Hilibrand A, Gustavel M, et al. Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine 2005;30:2208e13. [13] Kelleher MO, Timlin M, Persaud O, Rampersaud YR. Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine 2010;35: E981e7.