Adolescent idiopathic scoliosis curves requiring surgery may be related to race

ORLANDO, Fla. — A patient’s race was related to their likelihood of initially undergoing surgery for adolescent idiopathic scoliosis rather than observation or bracing in a study conducted by NYU Hospital for Joint Diseases’ researchers.

The research team recently explored whether race and socioeconomic status of patients with adolescent idiopathic scoliosis are related to disease severity by studying patients seen at one investigator’s practice in New York. Although they identified some connections between race and scoliosis, they found no association between socioeconomic status or income and treatment for the condition, according to the study’s results.

“In our paper, we found that major curve magnitude and percentage of patients with curves in the surgical range were greater in the black (African-American and Caribbean) than in the white patients,” Baron S. Lonner, MD, said.

He presented the results at the North American Spine Society 2010 Annual Meeting here, and said Neil J. Bharucha, the study’s first author, did the bulk of the work.

Baron S. Lonner

Similar demographics

The retrospective analysis of prospectively collected data reflected findings for 403 patients seen in Lonner’s office over the 5-year period 2004 to 2009. Based on the abstract, 219 patients were white, with blacks being the next most prevalent patient group by race (86).

After assessing such patient factors as age, skeletal maturity, family income, major curve magnitude at presentation and which treatments were initially prescribed — observation, bracing or surgery — investigators found that patient age, gender and scoliosis severity by Risser sign were similar among the Asians, blacks, Hispanics, whites and other groups they studied.

“There was a difference in the mean major curve magnitude between the black and white patients,” Lonner said, explaining there was a 5° difference between the mean 33° curve in black patients and 28° curve in white patients.

Curves in surgical range

Scoliosis curves in the surgical range occurred more often in the black patients (34%) than the white patients (24%) and black patients in the study group had significantly higher chances of undergoing surgery for their initial treatment (P < 0.05, for both), according to Lonner.

“The question is, are these differences genetic? Do they reflect some difference in access to care? I think these questions are not fully answered by our study, but we intend to assess this more fully by comparing across multiple clinics and comparing privately insured vs. government insured patients and perhaps getting a better assessment of cultural norms amongst the different racial groups,” he said.

“A multicenter trial should be conducted to determine if these trends are widespread,” Lonner and colleagues wrote in their abstract.

During his presentation Lonner reviewed some other studies that looked at race differences for scoliosis, particularly for its prevalence, as well as research conducted by others into worldwide racial disparities in orthopedics related to pain scores, delayed treatment and health status. – by Susan M. Rapp

Reference:

• Bharucha NJ, et al. Disease severity and treatment in adolescent idiopathic scoliosis: The impact of race and socioeconomic status. Paper #6. Presented at the 2010 Annual Meeting of the North American Spine Society. Oct. 4-9, 2010. Orlando, Fla.

• Baron S. Lonner, MD, Clinical Professor of Orthopaedic Surgery, can be reached at NYU Hospital for Joint Diseases, Scoliosis and Spine Associates, 820 2nd Ave. #7A, New York, NY 10017; 212-986-0140; e-mail: BLonner@nyc.rr.com.
  Disclosure: Lonner is a consultant to, has speaking/teaching arrangements with, receives research and travel support from DePuy Spine.

Both Orthopedics Today and I need to be very cautious about what one says regarding papers with loaded social data concerning racial differences and availability of medical treatment. This paper suggests that black patients who have scoliosis are less likely to have an early diagnosis and/or early referral to an orthopedic surgeon’s office at a time early in their scoliosis condition which might allow brace treatment rather than surgical treatment.

There are many difficulties with this study, and without a complete scientific, cultural and sociological analysis being performed the paper cannot be taken very seriously and one can draw few conclusions from it.

Early referral to an orthopedist’s office implies that the child would have had scoliosis screening to detect a mild curve, performed in either a primary care doctor’s office or in school. Such programs may be less available in schools with a high percentage of African American children. On the other hand, in many advanced parts of the world, scoliosis screening has been abandoned. This has been for two reasons:

School scoliosis screening has not been proven to be justified by medical and economic principles as established at a World Health Organization level (even though the Scoliosis Research Society disagrees with this interpretation, the WHO viewpoint remains).

The efficacy of brace wear has not been scientifically documented. A corrective brace is of questionable efficacy and can be a severe psychological burden on a teenager. Many centers worldwide do not consider bracing patients with mild curves, and instead wait until the curve is severe enough to require surgery. There is currently an NIH study being conducted at the University of Iowa (Stuart Weinstein, principal investigator) that prospectively assesses the efficacy of the brace.

With the above facts in mind, it is not clear that children greatly benefit by early referral to an orthopedic surgeon.

– Dennis R. Wenger, MD
Director, Pediatric Orthopedic Training Program
Rady Children’s Hospital-San Diego
Clinical Professor of Orthopedic Surgery
University of California-San Diego
Disclosure: He has no relevant financial disclosures.