“Long-term outcome of surgery for AIS creates a more negative end result over the course of a lifetime than the natural history of the condition itself.”

A 2013 study, Indication for surgical treatment in patients with adolescent Idiopathic Scoliosis – a critical appraisal (Weiss HR, Moramarco M), searched recent and applicable publications in the field of Adolescent Idiopathic Scoliosis. The authors complied these studies and found:

“There is poor evidence that would support surgical intervention in patients with Adolescent Idiopathic Scoliosis (AIS). With complications estimated to exceed 50% over a lifetime, surgical intervention is unwarranted in the ‘Adolescent Idiopathic Scoliosis’ AIS population. In the relatively benign population of patients with AIS, according to the findings in literature, we may conclude that the long-term outcome of surgery for AIS creates a more negative end result over the course of a lifetime than the natural history of the condition itself. As a result, surgeons electing to recommend surgery are strongly advised to openly discuss and inform patients of the long-term probability of potential complications occurring after spinal fusion surgery, and document their explanations accordingly.”

“For spinal fusion surgery, no prospective controlled or randomized studies have been found [4,5]. Westrick and Ward [6] state: ‘No long-term, prospective controlled studies exist to support the hypothesis that surgical intervention for AIS is superior to natural history. Although surgery reliably arrests the progression of deformity, achieves permanent correction, and improves appearance, there is no medical necessity for surgery based on the current body of literature.’ Therefore, we may conclude from what is available in international literature that there is no medical necessity for surgery in the AIS population. A long list of possible complications have been unveiled during the last decade [5,7,8] regarding AIS fusion surgery. Although the short-term complications may be minimal, long term complications have been estimated to exceed 50% with a rate of salvage surgeries of up to 25% [5,7,8]. Granted, these results were from populations treated with ‘older’ instrumentations such as Harrington rod or VDS procedures that are no longer applied today.”

Salvage surgery is a corrective procedure, also referred to as revision surgery. It is typically performed due to failure of the previous procedure, curvature progression around the fusion site, disk degeneration or poor postural alignment. Source

“Two papers were found on the topic of reoperation rates with a long-term follow-up of at least 10 years [5]. Reoperation rates were between 12.9% and 47.5%. Although the problem with post-surgical complications is highly relevant [5], reporting does not seem to be of utmost importance to surgeons, as evidenced by the lack of published literature. One drawback is that reporting complications is not mandatory [5]. Therefore, in literature we find a variety of non-standardized studies with various follow-up times inhibiting proper comparison.”

“Since there is no evidence indicating surgical correction in patients with AIS [4–6] and post-surgical complications are estimated around 50% over a lifetime [5,7,8], no claims can be made for a medical indication for such surgery. In the relatively benign population of AIS patients according to the findings within this review we may conclude that the long-term outcome of surgery for AIS is worse than the long-term consequences of the condition itself.”

“There are numerous papers that base conclusions on quality of life questionnaires, mainly the SRS-22 claiming for a high patient satisfaction after scoliosis surgery [4]; however, the results or conclusions derived from these studies are questionable when considering the “dissonance” effect, in the paper referred to earlier, as it relates to post-surgical interviews [4]. Cognitive dissonance occurs most often in situations where an individual must choose between two incompatible beliefs or actions and there is a tendency for individuals to seek consistency among their cognitions. Unable to face an inconsistency, such as being dissatisfied with a surgical procedure, a person will often change his/her attitude. Surgery is impossible to reverse, but subjective beliefs and attitudes can be altered more easily. As a result, a patient not satisfied with a surgical procedure may not necessarily admit this [4].”

“However, in a patient requiring surgery, informed consent must be obtained for patient awareness and a surgeon’s liability. The patients must be aware of the high percentage of long-term complications of fusion surgery and the amount of long-term complications to be expected [5,7,8]. Additionally, the stress the patient has due to the deformity must be documented. Therefore, the first author developed a brief questionnaire (BSSQ) in 2006 [5], which has been implemented and validated in several languages [5].”

“Furthermore, in a recent article, ‘metallosis’ is described and it is stated that the consequences of the findings are not yet clear [cited in 5]. Cundy et al. state the following: ‘A significant and rapid rise in serum titanium and niobium levels was observed within the first post-operative week, after which elevated serum levels persisted out to 12 months. Conclusions. We report abnormally elevated serum titanium and niobium levels in patients with titanium-based spinal instrumentation out to 12 months. The long-term systemic consequences of debris generated by wear and corrosion of spinal instrumentation is unclear but concerning, particularly as these implants inserted into the pediatric population may remain in-situ for beyond six decades.'”

Metallosis is the reputed medical condition caused by the deposit and build-up of metal debris in the soft tissues of the body. It is believed to be caused by the abrasion of metallic components in medical implants, against one another.

The abrasion of metal components may cause metal ions to become more soluble. It has been proposed that the immune system identifies these metal ions as foreign bodies and inflames the area around the debris.

Purported symptoms of metallosis include pain around the site of the implant, pseudotumors (a mass of inflamed cells that resembles a tumor but is actually collected fluids), and a noticeable rash. The damaged and inflamed tissue can also contribute to loosening the implant or medical device.

Women, those who are small in stature, and the obese are believed to be at greater risk for metallosis because their body structure causes more tension on the implant, quickening the abrasion and the build-up of debris. Source

“Recently a few critical reviews have been published clearly showing that (1) evidence for spinal fusion surgery is poor, (2) the longer the follow-up time the more complications are documented and (3) the clinical results after surgery do not seem better than the clinical results following conservative management of the latest standard [5,9]. Instead of devaluating conservative treatments [10] the surgical community should focus on the long-term complications of spinal fusion surgery as conservative treatment is far from the disastrous long-term effects as described to impact patients after surgery for scoliosis.”

Conclusions

• After surgery, rate of complication of spinal fusion surgery appears to increase with time .
•  According to current literature, medical indication for spinal fusion surgery is questionable.
•  Long-term complications of spinal fusion surgery  appear to exceed possible limitations patients with AIS may expect.
•  There is poor evidence that spinal fusion surgery would improve signs and symptoms of AIS.

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