How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?
Authors: Wong Arnold Y. L. , Samartzis Dino , Cheung Prudence W. H. , Cheung Jason Pui Yin 
Published: December 2018

Abstract

Background
Adolescent idiopathic scoliosis (AIS) is the most common spine deformity in adolescent patients. Although structural deformity may affect spinal biomechanics of patients with AIS, little is known regarding various period prevalence proportions of back pain and chronic back pain and factors associated with back pain in such patients.

Questions/purposes
(1) What are the period prevalence rates of back pain among teenagers with AIS? (2) Is back pain in patients with AIS associated with curve severity?

Methods
A total of 987 patients with AIS who were treated without surgery were recruited from a single center’s scoliosis clinic. Between December 2016 and July 2017, this center treated 1116 patients with suspected AIS. During that time, patients were offered surgery when their Cobb angle was at least 50° and had evidence of curve progression between two visits, and most of the patients who were offered surgery underwent it; other patients with AIS were managed nonsurgically with regular observation, brace prescription, posture training, and reassurance. To be included in this prospective, cross-sectional study, a patient needed to be aged between 10 and 18 years with a Cobb angle > 10°. No followup data were required. A total of 1097 patients with AIS were managed nonsurgically (98.3% of the group seen during the period in question). After obtaining parental consent, patients provided data related to their demographics; physical activity levels; lifetime, 12-month, 30-day, 7-day, and current thoracic pain and low back pain (LBP); chronic back pain (thoracic pain/LBP); brace use; and treatments for scoliosis/back pain. Pain was rated on a 10-point numeric rating scale for pain. The Insomnia Severity Index, Epworth Sleepiness Scale, and Depression Anxiety Stress Scales were also assessed. These features and radiologic study parameters between patients with and without back pain were also compared. Factors associated with current and 12-month back pain as well as chronic back pain were analyzed by multivariate analyses.

Results
Depending on the types of period prevalence, the prevalence of thoracic pain ranged from 6% (55 of 987) within 12 months to 14% (139 of 987) within 7 days, whereas that of LBP ranged from 6% (54 of 987) to 29% (289 of 987). Specifically, chronic thoracic pain or LBP had the lowest prevalence. Compared with the no pain group, patients with current back pain had more severe insomnia (odds ratio [OR], 1.80; p = 0.02; 95% confidence interval [CI], 1.10-2.93) and daytime sleepiness (OR, 2.41; p < 0.001, 95% CI, 1.43-4.07). Those with chronic back pain had the same problems along with moderate depression (OR, 2.49; p = 0.03; 95% CI, 1.08-5.71). Older age (OR range, 1.17–1.42; all p values ≤ 0.030) and Cobb angle > 40° (OR range, 2.38–3.74; all p values ≤ 0.015), daytime sleepiness (OR range, 2.39-2.41; all p values ≤ 0.011), and insomnia (OR range, 1.76–2.31; all p values ≤ 0.001) were associated with episodic and/or chronic back pain. Females were more likely to experience back pain in the last 12 months than males. Moderate depression (OR, 3.29; 1.45-7.47; p = 0.004) and wearing a brace (OR, 3.00; 1.47-6.15; p = 0.003) were independently associated with chronic back pain.

Conclusions
Biopsychosocial factors are associated with the presence and severity of back pain in the AIS population. Our results highlight the importance of considering back pain screening/management for patients with AIS with their psychosocial profile in addition to curve magnitude monitoring. In particular, sleep quality should be routinely assessed. Longitudinal changes and effects of psychotherapy should be determined in future studies.

Level of Evidence
Level II, prognostic study.