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Point of View

A 14-year-old, postmenarchal patient walks into our clinic with a slightly progressive 47° right thoracic curve; and whose parents want to consider surgery. While presenting the indications for surgical treatment of scoliosis, we must present a balanced discussion on the risks of surgery in light of what would happen to the patient if nothing were done. For decades, surgeons have acknowledged that some curves could be expected to progress and that surgery is beneficial to prevent the occurrence of cardiopulmonary problems seen in those patients with curves greater than 100° to 110°. Yet the bulk of patients with adolescent idiopathic scoliosis are unlikely to eventually have curves to this degree and therefore do not have increased mortality when compared with general population. When this information is presented, the next appropriate question by this patient is: “what else can be affected by the scoliosis if the curve is not operatively stabilized?” Recent papers by Weinstein et al and Dannielsson et al and the current paper by Haefeli et al provide important insight to this question. In the current manuscript, the authors review 121 patients who were not treated with surgery but underwent bracing, therapy, or electrical stimulation and had an average 23-year follow-up. This paper documented the Health Related Quality of Life (HRQL), and most patients also had clinical and radiologic follow-up. Unfortunately, this study does not make comparisons with untreated patients with scoliosis, and comparison to normal individuals falsely assumes that untreated individuals are the same. The authors do a good job of preventing bias by including the last radiographs from the 40 patients who did not return for radiographs. However, they assume that the curves would not have changed from the end of nonoperative treatment to follow-up 20 years later. Review of this manuscript demonstrates that most individuals function fairly well at a mean age of 38 years. No increased mortality was noted, but a history of restrictive lung disease was more common in the few patients that had curves that were greater than 80°. The authors present important differences from the previous literature. For instance, older age at follow-up was noted to increase rates of pain and disability. This is in contradistinction to the papers from Iowa, which demonstrate no significant changes as the patients aged throughout the follow-up years. In addition, the paper by Haefeli et al demonstrated increased pain on a visual analog scale in those patients with curves greater than 45°, which is counter to the studies from Iowa and Sweden. From these long-term follow-up studies, it appears that patients without treatment function very well over their lifetime, and patients treated with bracing or Harrington instrumentation also do reasonably well over several decades. As a result, it could be argued that most scoliosis is a cosmetic deformity resulting in a diminished body image with the potential for psychological effects. Yet it appears that, over time, a mild increase in pain and disability is likely when compared with people without scoliosis, and perhaps more pain is likely with larger curves. We need to ask ourselves if this natural history merits operative intervention in the 14-year-old girl with a 47° curve. On the other hand, Weinstein et al also suggest that the published natural history may not be as well tolerated in today’s patients. Interestingly, Danielsson et al reported that surgically treated patients were more likely to feel emotionally better than those treated with bracing. This is certainly corroborated by the current study where 28% of individuals have emotional problems with nonoperative treatment for their scoliosis. At the current time, it is known that our hypothetical 14-year-old patient with the 47° curve has a slight chance to progress to a degree resulting in symptomatic restrictive lung disease; however, she will not die of untreated scoliosis. We do not know if a group of these patients treated with contemporary surgical methods would have an improved HRQL in comparison with untreated patients (slight pain, disability, and lower body image). Further studies are needed that compare operatively and nonoperatively treated patients with scoliosis to patients with untreated scoliosis. Until that moment, most of us will continue to present a balanced discussion on the potential natural history for our patient and generate a treatment plan that is optimal for each individual patient.