Commentary & Perspective

Commentary & Perspective on
"Operative Correction of Adolescent Idiopathic Scoliosis in Male Patients: A Radiographic and Functional Outcome Comparison with Female Patients"
by Daniel J. Sucato, MD, MS, et al.

Commentary & Perspective by
John F. Sarwark, MD*,
Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois

In the recently published book In the Sands of Berck¹, Yves Cotrel, MD, importantly attributes advances in scoliosis surgery to the following: "Each new technique represent(s) an improvement in the quality of correction and of the fusion and at the same time a reduction in the constraints of treatment. But each new step had only become possible due to the objective analysis of the immediate and long-term results, as well as the systematic critique of the preceding techniques."

What surgeons have come to understand about the management of idiopathic scoliosis is based primarily on our surgical and nonsurgical experiences in treating adolescent female patients. Etiology aside, for every seven female patients with idiopathic scoliosis, there is only one male patient treated². Experienced surgeons know that male patients undergoing surgery for idiopathic scoliosis (and bracing, for that matter) present different challenges. Now, through the use of scientific comparative cohorts, Sucato et al. have demonstrated this previously undocumented observation.

The authors found that when surgery for idiopathic scoliosis was performed in boys as compared with girls, the surgery in the young male patients was associated with longer operative times, greater intraoperative blood loss, and less coronal plane correction. This information should help both the surgeon and the patient better prepare for surgery and should help promote realistic postoperative expectations.

During the preoperative planning stage, the surgeon should recognize that there is likely to be a greater need for blood salvaging techniques for male patients. It should also be understood that the percentage of coronal-plane correction will be less than that achieved in a similar curve involving a female patient.

Interestingly, the authors found that overall satisfaction, including acceptable coronal and sagittal balance, was achieved, and that the number of complications, complications rates, and functional outcomes were similar in both cohorts.

The observation that patient satisfaction with the cosmetic result is not wholly a function of the magnitude of correction as seen on radiographs has been shown previously^3,4. Postoperative function in that study, based on questionnaires administered after surgery, was perceived as significantly lower in boys. This finding may be explained by the greater functional expectations of male patients in comparison to female patients^5,6 and is noted by the authors of the current study.

In an earlier study by one of the authors, Karol⁷ demonstrated that bracing was less effective in boys as compared with girls and recommended against brace management altogether in boys. Yet, many surgeons today continue to prescribe bracing in skeletally immature boys.

The authors have provided important information regarding gender differences between adolescent boys and girls who undergo corrective surgery for idiopathic scoliosis. These observations should help make the surgery safer and should provide vital information to the patient and his or her family with regard to a realistic outcome.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Cotrel Y. In the sands of Berck. Paris: Institut de France, Fondation Yves Cotrel; 2004.
2. Burwell RG. Aetiology of idiopathic scoliosis: current concepts. Pediatr Rehabil. 2003;6:137-70.
3. D'Andrea LP, Betz RR, Lenke LG, Clements DH, Lowe TG, Merola A, Haher T, Harms J, Huss GK, Blanke K, McGlothlen S. Do radiographic parameters correlate with clinical outcomes in adolescent idiopathic scoliosis? Spine. 2000;25:1795-802.
4. Lenke LG, Bridwell KH, Blanke K, Baldus C, Weston J. Radiographic results of arthrodesis with Cotrel-Dubousset instrumentation for the treatment of adolescent idiopathic scoliosis. A five to ten-year follow-up study. J Bone Joint Surg Am. 1998;80:807-14.
5. Merola AA, Haher TR, Brkaric M, Panagopoulos G, Mathur S, Kohani O, Lowe TG, Lenke LG, Wenger DR, Newton PO, Clements DH 3rd, Betz RR. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument. Spine. 2002;27:2046-51.
6. Koch KD, Buchanan R, Birch JG, Morton AA, Gatchel RJ, Browne RH. Adolescents undergoing surgery for idiopathic scoliosis: how physical and psychological characteristics relate to patient satisfaction with the cosmetic result. Spine. 2001;26:2119-24.
7. Karol LA. Effectiveness of bracing in male patients with idiopathic scoliosis. Spine. 2001;26:2001-5.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.