Subjective evaluation of treatment outcomes of instrumentation with pedicle screws or hybrid constructs in Lenke Type 1 and 2 adolescent idiopathic scoliosis: what happens when judges are blinded to the instrumentation?

Superiority of pedicle screws over hybrid/hook instrumentation or vice versa in the treatment of Lenke Type 1 and 2 adolescent idiopathic scoliosis (AIS) remains unresolved for moderate curves. Our objective was therefore to compare the assessment of pedicle screw and hybrid/hooks instrumentation with special attention to cosmesis and uninstrumented spine using novel assessment methods. We carried out a retrospective study of radiographs and clinical photos of 40 cases of thoracic AIS between 40A degrees and 70A degrees of Cobb angle Lenke Type 1 and 2, treated with either pedicle screws or hybrid/hooks. The cases were subjectively assessed by four spine surgeons (SRS Travelling Fellows) for radiographic and operative cosmetic result, shoulder balance, trunk shift, rib hump, and waist asymmetry. Instrumentation in the radiographs was obscured with only the non-instrumented part visible, and the surgeons were asked to guess the instrumentation being used. Eighty photographs of patients before and after surgery were assessed for cosmesis by ten non-medical judges for overall cosmetic score, shoulder balance, waist asymmetry, and shoulder blade prominence. Objective assessment of radiographs and clinical photos was performed for Cobb angle of instrumented and non-instrumented spine, global coronal and sagittal balance, number of unfused vertebrae, disc angulation, tilt of last instrumented vertebra, shoulder balance, waist asymmetry, rib prominence, and percent correction. SRS-24 questionnaire was used to measure health-related quality of life in patients. Subjective assessments by surgeons and non-medical judges showed no significant difference by instrumentation (P a parts per thousand yen 0.05) for all variables. Out of the 160 guesses by surgeons of the cases with instrumentation blocked in the radiographs, they were unable to guess the instrumentation in 92% of the cases. Objective assessment of all variables and SRS-24 scores of all five domains showed no significant difference by instrumentation (P a parts per thousand yen 0.05). In this first-ever conducted study in a blinded-fashion, we conclude that there is no significant difference between the pedicle screw and hybrid/hooks instrumentations used to treat AIS for Lenke Type 1 and 2 curves for moderate curves between 40A degrees and 70A degrees.