Patients treated surgically were much more satisfied with management than patients treated with a brace, despite Cobb angles after treatment being quite similar in both groups. This difference may partly be attributed to the fact that patients treated surgically had an improved Cobb angle (from 54° before surgery to 32° after surgery), while patients treated with a brace had a larger Cobb angle at the end (32°) than at the first visit to the orthopaedic surgeon (24°). However, this difference in satisfaction cannot only be explained by improvement of Cobb angle, since we only found a weak correlation between improvement in Cobb angle and satisfaction in the S group. Climent et al. [7
] also found that patients treated with a brace were less satisfied with management than patients treated surgically. A similar trend was seen in a study by Danielsson et al. [9
] on HRQoL after follow-up of at least 20 years in patients treated with a brace and patients treated surgically; they reported a more negative effect of the treatment period on patients treated with a brace than on patients treated surgically, but in that study different measures were used than in our study.
Furthermore, in the present study, patients treated only surgically had highest scores on the self-image/appearance domain and on the single-item general health; although significant, these differences were rather small (respectively, 0.2 points on a 5-point scale and 7 points on a 100-point scale). In our study, patients scored around four points on a five-point scale in the self-image/appearance domain, which implies that these patients were satisfied. Weinstein et al. [21
] concluded in their study that untreated AIS patients had cosmetic concerns. Although different measures were used, it seems that treated patients are more satisfied with self-image than untreated patients. However, it is important to know that Cobb angles of the untreated patients in the study by Weinstein et al. were much larger than Cobb angles in our study population.
Patients treated with a brace had a significantly higher mean score in the function/activity domain than patients treated surgically (whether or not being braced before surgery). However, there is a positive correlation between time span between surgery and filling out the questionnaire and function scores in the surgery group; after a longer time span function scores are higher (i.e. better), and there were no significant differences in function scores between patients of the B group and the S group who filled out the questionnaire at least 12 months after completing treatment. Obvious reasons for this short-term difference are that patients are recovering from a major operation and that initial restrictions in the patients’ physical activities, enforced by their surgeon, are no longer required 6–12 months after surgery. These reasons might also explain the worse pain scores found in the surgery group. These findings are in accordance with the findings of Asher et al. [3
] in their study of responsiveness of change.
In line with our results, other studies also found no major impact of gender [7
], Cobb angle [7
] and curve type [2
] on HRQoL after treatment.
In patients treated with a brace, orthopaedic surgeons who recorded their satisfaction with management were more satisfied than the patients themselves (difference not significant). A reason for this could be that patients have a different expectation about outcome than their orthopaedic surgeon. If this is the case, patients should be better informed about possible outcomes. However, surgeons agreed about management results with patients treated surgically. Although not all surgeons expressed their opinion about satisfaction with management for all their patients, this result supports the finding that patients treated with a brace are less satisfied with management than patients treated surgically.
Although the SRS-22 is not fully validated for children younger than 18-years old, mean domain scores in the present study corresponded with mean domain scores found by Asher et al. [4
] and Bago et al. [5
]. Chronbach’s alphas in the Dutch version were good to excellent and comparable with the original version, there were no floor effects and there were less ceiling effects than in the original version. For complete validation of the Dutch version of the SRS-22 Questionnaire, test-retest reliability and responsiveness to change should be further evaluated.
Our design was limited to a cross-sectional assessment after treatment. It means we were not able to evaluate whether differences in HRQoL between the groups existed before treatment, nor were we able to evaluate whether these possible differences had influenced the results after treatment. For instance, patients in the brace group and the surgery group differ in some respects, e.g. Cobb angle at baseline differed significantly between the brace group and the surgery group. This difference is probably also responsible for different expectations and management issues and might have influenced HRQoL, and in particular satisfaction with management. Longitudinal data on different treatment groups (i.e. under observation, brace treatment or surgery) could provide more insight into the impact of baseline characteristics, management issues and expectations on HRQoL.