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BACKGROUND: Spinal fusion for scoliosis associated with cerebral palsy (CP) is challenging to study because specialized outcome measures are needed. Therefore, evidence in favor of the benefits of surgery has not been firmly established. This study aimed to determine if corrective spinal fusion improves health-related quality of life (HRQoL) in children with CP scoliosis at 2 years. METHODS: Children with CP and scoliosis who met the criteria for posterior spinal fusion were offered enrollment at 16 US and Canada centers. Participants' families selected either operative intervention (OP) or nonoperative treatment (NON) in discussion with their surgeon with no influence by the decision to participate in the research study. Demographic, clinical data (function level, magnitude of deformity, comorbidities), and HRQoL (CPCHILD Questionnaire) were collected at baseline and 2 years. Change (from baseline) in total CPCHIL scores was the primary outcome. RESULTS: Three hundred one OP and 34 NON subjects had complete baseline and 2-year data. At baseline, both groups were comparable in function level, comorbid status, and CPCHILD scores (52.1 ±15.3 vs. 53.4 ±14.5; P=0.66). The OP group had a larger spinal deformity magnitude (84.5˚ ± 21.8˚ vs. 66.3˚ ± 18.1˚) (P=0.001). The total CPCHILD score improved in the OP group by 6.6 points (P<0.001). NON scores were unchanged (+1.2; P=0.65) during follow-up. There were also significant score increases in the OP group for 5 of 6 CPCHILD domains. The change in CPCHILD scores from enrollment to 2 years was more significant in the OP group (P=0.05). CONCLUSION: For children with CP who undergo spinal fusion, HRQoL improved over preoperative levels and an unchanged nonoperative control group. LEVEL OF EVIDENCE: Level II.

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STUDY DESIGN: Retrospective review of a prospectively collected multicenter registry. OBJECTIVE: To evaluate health-related quality of life (HRQOL) measures in an operative cohort of patients (OP) and compare them with a matched nonoperative cohort (NON). SUMMARY OF BACKGROUND DATA: Historically, the surgical outcomes of adolescent idiopathic scoliosis (AIS) have been radiographically evaluated. However, the importance of HRQOL measures and their impact on surgical outcomes are increasingly being understood. MATERIALS AND METHODS: We identified 90 NON patients with curves in the operative range who were observed for at least two years. These patients were matched with an OP cohort of 689 patients. All patients completed the Scoliosis Research Society-22 (SRS-22) questionnaire at the initial evaluation and at a minimum of two-year follow-up. Subgroup comparisons were based on curve type: primary thoracic (Th), primary thoracolumbar/lumbar (TL/L), and double major (DM) curves. RESULTS: The preoperative major curves in the Th, TL/L, and DM OP subgroups averaged 50.4°, 45.4°, and 51.5°, respectively, and 49.4°, 43.7°, and 48.9° in the NON cohort ( P >0.05). At two years postoperatively, the major curve in the Th, TL/L, and DM OP subgroups improved to 19.0°, 19.2°, and 19.3°, respectively, compared with the progression to 51.3°, 44.5°, and 49.7° in the NON group at two-year follow-up ( P <0.05). The SRS-22 self-image, mental health, satisfaction, and total scores at the two-year follow-up were significantly better in all OP subgroups ( P <0.001) but remained largely unchanged in the NON group. A significant percentage of patients ( P <0.001) in the OP cohort reported better SRS-22 scores at the two-year follow-up in the self-image, mental health, and satisfaction domains than the NON group at two years. CONCLUSIONS: Surgically treated patients with AIS have improved HRQOL outcomes in several domains compared with age-matched and curve magnitude-matched nonoperatively treated patients at two-year follow-up.

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The concept of evidence-based medicine has evolved over the past 2 decades, and has become a cornerstone to clinical decision-making in virtually every aspect of medicine. With a commitment to providing its members with high-quality evidence-based guidelines, the American Academy of Orthopaedic Surgeons has instituted concerted efforts since 2006 to develop clinical practice guidelines (CPGs) and appropriate use criteria (AUCs) for certain orthopaedic conditions. Many of these CPGs and AUCs detail the management of pediatric orthopaedic conditions. By the same token, members of the Pediatric Orthopaedic Society of North America (POSNA) Evidence Based Practice Committee have been publishing succinct evaluations of randomized controlled trials in pediatric orthopaedic surgery to create an evidence-based repository for quick reference to available high-level evidence as well as resource to identify gaps in the current research and identify opportunities for future investigation. In instances where higher-level evidence needed to develop CPGs is not available to address a critically important clinical question, consensus recommendations from experts in the field have been obtained to develop best practice guidelines (BPGs). The purpose of this review is to provide readers with a deeper understanding of the key principles of evidence-based medicine and methodologies used for the development of CPGs, AUCs, and BPGs.

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BACKGROUND: In juveniles with progressive curves, there is debate regarding the use of growth friendly implants versus definitive fusion. This study presents outcomes of juvenile cerebral palsy (CP) scoliosis patients who underwent definitive fusion before age 11. METHODS: A review of a prospective, multicenter registry identified patients 10 years and younger who had a definitive posterior fusion for their CP scoliosis. Preoperative and postoperative demographic and radiographic changes were evaluated with descriptive statistics. Repeated measures analysis of variance were utilized to compare outcome scores. RESULTS: Fourteen children with a mean age of 9.7 years (8.3 to 10.8 y) and a minimum of 2 years follow-up (range 2 to 3 y) were identified. The mean preoperative curve magnitude and pelvic obliquity was 84±25 degrees (range 63 to 144 degrees) and 25±14 degrees, respectively. All patients were skeletally immature with open triradiate cartilage. Three patients had unit rods with wires while the rest incorporated pedicle screws. Immediately postoperation, the average major curve was 25±17 degrees (P≤0.001, 71% correction rate). At most recent follow-up, the average major curve increased to 30±18 degrees (P≤0.001) for a 65% correction rate. Pelvic obliquity improved to 4±4 degrees (84% correction, P≤0.001) immediately postoperation and to 6±5 degrees (P=0.002) at latest follow-up for a 76% correction rate. None of the patients required revision surgery for progression. From pre to most recent follow-up, the CPchild Health outcome scores improved from 47 to 58 (P=0.019). One patient had a deep infection, and 1 patient had a broken rod that did not require any further treatment. CONCLUSIONS: Progressive scoliosis in juvenile CP patients requires the surgeon to balance the need for further growth with the risks of progression or repeated surgical procedures. Our study demonstrates that definitive fusion once the curves approach 90 degrees results in significant radiographic and quality of life improvements, but further follow-up is needed to determine whether those results remain after skeletal maturity. LEVEL OF EVIDENCE: Level IV-therapeutic.

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STUDY DESIGN: Comparison of the Scoliosis Research Society-22 (SRS-22) questionnaire with a 7-item Rasch-derived questionnaire (SRS-7). OBJECTIVE: To compare the construct and discriminant validity, internal consistency, responsiveness, and dimensionality of SRS-7 against SRS-22 in operatively treated children with adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: SRS-22 has not been shown to possess linearity or unidimensionality (internal validity). METHODS: A multicenter database was queried for children with adolescent idiopathic scoliosis who underwent spinal fusion and answered all preoperative and 1-year postoperative SRS-22 questions. SRS-7 scores for the 685 patients were calculated from SRS-22 item responses. Traditional psychometric properties were assessed for both instruments (significance, P < 0.01). RESULTS: SRS-7 and SRS-22 scores correlated preoperatively and postoperatively (r = 0.78, P < 0.001, and r = 0.78, P < 0.001, respectively). Both instruments showed good discriminant validity in segregating 4 groups of patients with adolescent idiopathic scoliosis by curve magnitudes (F = 8.36, P < 0.001, and F = 8.38, P < 0.001, respectively). Pre- and postoperative SRS-7 and SRS-22 had internal consistency Cronbach α values of 0.64 and 0.67, and 0.85 and 0.85, respectively. With SRS-7, mean postsurgical improvement was 18.7 points (46.6-65.3, P < 0.001), with effect size measures of Cohen d = 1.57, Hedge g = 1.57, and r = 0.62. With SRS-22, mean improvement was 11.6 points (84.5-96.1, P < 0.01), with effect size measures of Cohen d = 1.25, Hedge g = 1.25, and r = 0.53. Iterative principal factor analysis of pre- and postoperative SRS-7 and SRS-22 showed the presence of 1 dominant latent factor (unidimensionality) and 4 latent factors (multidimensionality), respectively. CONCLUSION: SRS-7 shows good concurrent and discriminative validity, reasonable internal consistency, and excellent responsiveness. It has the advantages over SRS-22 of being short, unidimensional, and an interval scale. LEVEL OF EVIDENCE: 4.

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