Abstract
Background:
Spondylolysis is a common etiology of back pain in adolescents, especially in athletes whose sport involves repetitive spine hyperextension and rotation; however, there is a paucity of research characterizing the associated the health-related-quality-of-life (HRQL) in this population. The Scoliosis Research Society (SRS) developed an HQRL outcome instrument, the SRS-22, originally to evaluate adolescent idiopathic scoliosis (AIS) treatments, but its use has broadened to other spine conditions, such as spondylolisthesis. The SRS-22 evaluates four clinical domains, five questions for each domain: pain, self-image, function, and mental health; a fifth domain has two questions that assesses satisfaction with treatment. The purpose of this study is to characterize the SRS-22 scores for patients who are diagnosed with spondylolysis, without listhesis, and subsequently compare them to the scores of normal adolescent controls and AIS patients found in the literature.
Methods:
A retrospective single-institution cohort of pediatric patients with spondylolysis was created from billing data using an ICD-9/ICD-10 diagnosis code filter in the period from January 2014 to December 2017. Charts were reviewed for patients’ SRS-22 survey results, initial patient-intake questionnaires, demographic data, and initial management decisions from medical records. Patients who had incomplete SRS-22 data or were diagnosed with other spinal pathology were excluded. Data was analyzed using descriptive analyses in Microsoft Excel.
The averages obtained were compared directly to previously published domain scores for both a normal adolescent cohort and AIS patients (See Table 1). The presence of meaningful clinical difference (MCID) was determined using the values published by Rushton, et al (Spine 2013): pain 0.6, self-image 0.5, function 0.8, and mental health 0.4.
Results:
Initially, 46 adolescent patients were identified who met the inclusion criteria. Eleven patients were excluded: nine for other spinal pathology (e.g. disc herniation or spondylolisthesis) and two for absence of SRS-22 surveys. The remaining thirty-five patients (23 female, 12 male) had a mean age of 15?1.6 (range 12-18) years. Eighty-three percent of patients (29 of 35) played sports including, most commonly, soccer (6, 17%), basketball (6, 17%) and gymnastics (5, 14%). Eight patients played multiple sports (23%). Symptom onset prior to presentation was a median of 6 (range 0.5-42) months. L5 was involved in 85.5% of patients (30/35), L4 in 8.5% (3/35), L1 in 3% (1/35) and both L4 & L5 in 3% (1/35).
SRS-22 domain scores, reported on a 1-5 scale, at initial presentation were: pain 2.99 (SD, 0.66, range 1.4-4.6), self-image 3.45 (SD 0.70, range 1.6-4.0), function 3.81 (SD 0.61, range 2.3-4.8), mental-health 3.82 (SD 0.86, range 2.0-5.0); the total clinical sub-score was 3.52 (SD 0.55, range 2.1-4.4). The difference between our cohorts’ domain scores and published norms exceeded the MCID for pain (2.7-times the MCID), self-image (2.4xMCID), and function (1.2xMCID) (see Table 1). Also, the difference between our cohort’s and published AIS cohort scores exceeded the MCID for pain (1.9xMCID). Domain scores for self-image and function were less in our cohort than the published AIS scores, but did not exceed the MCID. Finally, the spondylolysis cohort had lower total clinical sub-scores than published results for both controls and AIS patients.
Conclusions/Significance:
Spondylolysis is a common cause of low back pain in the adolescent population, especially in active athletes. Heretofore, there has been no published evaluation of the HRQL using the SRS-22 for those patients presenting with spondylolysis without listhesis. This cohort study has established the presence of a unique constellation of domain scores, increased pain, decreased self-image and decreased function, compared to published normal SRS-22 values. These findings also establish that pain has a much bigger impact on the quality of life in the spondylolysis population than those with AIS. The data from this study can serve as a baseline from which the impacts of treatment, such as activity modification, oral non-steroidal pain medications, physical therapy, bracing and surgery. Future research, tracking longitudinal changes in SRS-22 stratified by treatment modality, would enrich the shared decision-making between patient and provider when initially discussing management of this painful condition.
| Gender (N, % female) | Age (Mean, SD) | Pain | Self-Image | Function | Mental Health | Sub-Total | |
|---|---|---|---|---|---|---|---|
| 23 (66%) | 15.0 (1.6) | 2.99 (0.66) | 3.45 (0.70) | 3.81 (0.61) | 3.82 (0.86) | 3.52 (0.55) | |
| 123 (85%) | 15.0 (2.3) | 4.14 (0.79) | 3.80 (0.68) | 4.09 (0.54) | 3.95 (0.63) | 4.00 (0.50) | |
| 41 (64%) | 14.1 (2.1) | 4.65 (0.48) | 4.22 (0.46) | 4.78 (0.31) | 4.07 (0.58) | 4.43 (0.35) |
* Beausejour, et al 2009