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Pain, Pain, Go Away...

Presented here are two studies done on pre- and post-operative back pain for adolescents and young adults. One study was done in the US, one in Europe. This is not referring to surgical pain – everyone is going to have that. These studies, both presented at the SRS Annual Meeting in September 2017, attempt to look for patterns or signs as to why patients may have pain before and after the surgery.

Idiopathic scoliosis has long been thought to not be a painful condition. You may then be wondering why you have back pain. Is it from the curvature of the spine? Is it from the muscles and ligaments that are attached to the crooked bones? We don’t really know the answer to that, but we do know that the majority of scoliosis patients do not complain of pain. As these two studies showed, if a patient has pain after surgery, they most likely had it before; and most will report a decrease in their pain level after surgery. In addition, pain is more common as age increases.

So how is pain evaluated? Your doctor will examine you, ask you questions about and listen to how you are feeling, and if you have pain to try to determine the cause of it. A big part of any study done are the outcome questionnaires that you are asked to fill out. Most likely you will be asked to complete one at each appointment. A member of the medical team then scores each answer to the questions and comes up with your pain score. It cannot be stressed enough how important it is for you to fill out the forms with honest answers – YOUR answers! So many different aspects of how you are doing and what could be the reason for pain, etc. are looked at by your doctor and their staff.

By evaluating and treating you, doctors can treat future patients and provide statistics on risks associated with surgery based on what the findings are in studies that are done. Most studies are never really done, per se; if a 5-year follow-up study is done, then five years later, your doctor’s team will try to get in touch with as many prior patients as possible to see how they are doing at 10 years post-op and so on. Those that had surgery before you helped to shape the improvements that were made in treatment leading up to when you had surgery, and by keeping your follow-up appointments as recommended and filling out questionnaires, you are doing the same for future spine patients!

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Back Pain and Its Change after Surgery in Adolescents and Young Adults with Idiopathic Scoliosis
Tamas Fulop Fekete, MD; Anne F. Mannion, PhD; Frank S. Kleinstueck, MD; Markus Loibl; Dezsoe J. Jeszenszky, MD, PhD

Summary
Surgery for adult idiopathic scoliosis (AIS) aims to prevent curve progression but in some patients, it also relieves pain. We found that, in AIS, young adults more frequently have relevant back pain (≥4/10 on pain scale) and have pain of higher average intensity than do adolescents. In patients with relevant back pain at baseline, surgery is associated with a statistically and clinically significant alleviation of pain, independent of age.

Hypothesis
In patients with AIS and notable back pain, surgery is associated with significant pain relief, as much so in adult patients (19-30y) as in adolescents (12-18y).

Design
A retrospective analysis of prospectively collected data from patients aged 12-30 y, operated for AIS in our hospital from 2005 to 2014 and registered in our local patient outcomes database linked to EUROSPSINE’s Spine Tango Registry.

Introduction
The association between back pain and AIS is controversial. Our clinical experience is that a proportion of AIS patients, especially young adults, have relevant back pain. Whether this is related to their deformity and, hence, whether deformity surgery is associated with a relevant reduction in their pain is unclear (1). The influence of age at surgery on back pain relief also remains to be investigated.

Methods
Preoperatively and up to 2 years’ postoperatively, patients completed the Core Outcome Measures Index, which includes two 0-10 scales for back pain and leg/buttock pain. A score of 4/10 or more is considered “relevant pain” (2).

Results
We identified 85 AIS patients (74 (87%) females) fitting the inclusion criteria. Of these, 60 were aged 12-18y (mean 15.5±1.7y) and 25 were 19-30y (mean 22.5±3.1y). There were no significant differences (p>0.05) between the age-groups for coronal Cobb angles of the main curves or Lenke curve types and these curves showed no correlation with pain intensity (p>0.05). Back pain was correlated with age (r=0.31, p=0.004). Preoperatively, 42% patients had a back pain score of ≥4/10 (52% in adults, 38% in adolescents). Just 8% patients had a leg pain score of ≥4/10 (16% in adults, 5% in adolescents). Those with notable back pain showed a significant (p<0.0001) improvement 2 yrs after surgery. There was no significant difference in the extent of improvement in older and younger patients (p=0.22)

Conclusion
In patients with AIS, back pain is correlated with age. In those with relevant back pain at baseline, surgery is associated with a significant alleviation of pain. Skeletally mature young adults benefit as much as adolescents in terms of back pain relief.

References:

  1. Balague F et al Scoliosis & Spinal Disorders (2016) 11:27
  2. Fekete TF et al Spine J 16: S12-18, 2016

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Preoperative SRS Pain Score is the Primary Predictor of Postoperative Back Pain after AIS Surgery
Steven W. Hwang, MD; Amer F. Samdani, MD; Tracey P. Bastrom; Peter O. Newton, MD; Baron S. Lonner, MD; Joshua M. Pahys, MD

Summary
Back pain after surgical correction of AIS is not uncommon, but factors associated with it remain unclear. We reviewed a prospectively collected registry to identify clinical, radiographic or surgical predictors of back pain. 12% of patients had clinically significant back pain postoperatively (PO) with more frequent pain in Lenke 1 and 2 curve patterns (16%). Preoperative (PreO) SRS pain score was the most common predictor of back pain PO.

Hypothesis
Extension of fusions into the lumbar spine may contribute to increased back pain.

Design
Review of prospectively collected data

Introduction
Back pain has been recognized as increasingly common in PO AIS patients; however, various studies have shown conflicting factors associated with back pain.

Methods
We identified AIS patients having undergone surgery with at least 2 years of follow-up. Patients with SRS pain scores ≤ 3 or with a recorded complication of back pain occurring beyond 6 months PO were included in the back pain cohort and compared to the others. Any patient with a concurrent complication (e.g. pseudarthrosis, implant failure) that was associated with pain was excluded from either cohort.

Results
1529 patients comprised the no pain (NP) group and 215 the back pain (BP) group. In multivariate analysis of all patients, (Table) curve type (16% of Lenke 1/2 curves (thoracic) vs. 10% of Lenke 5/6 (thoracolumbar), p=0.002) and pre-op SRS pain score (NP 4.15±0.67 vs. BP 3.75±0.79, p<0.001) remained significant. When comparing T2-4 as the UIV in Lenke 1/2 curves, 9% had pain when fused to T2, 13% when the UIV was T3 and 18% when T4 (p=0.002). Upper thoracic curve magnitude, percent correction, LIV, # levels fused, and C7 to CSVL translation were not significant.

Conclusion
12% of patients had back pain in our cohort after post-op recovery excluding known complications. For Lenke 1 and 2 curves the incidence decreases with more proximal instrumentation; however, the most consistent predictive factor across curve types was a low pre-op SRS pain score signifying greater pre-op pain.

Table of variables significant in multivariate analysis and odds ratios in parentheses
ALL Lenke 1-2 Only Lenke 3-4 Lenke 5-6
Lenke groups: 5/6 vs 1/2 (0.83) UIV: T2 vs 3 vs 4 (0.48) Pre Disc Angulation below EIV (0.87) PreO SRS pain (0.38)
PreO PJK (1.04) PreO SRS pain (0.52)    
PreO SRS pain (0.50)      
2 yr T10-L2 (0.97)