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Commentary by Baron S. Lonner, MD and Shawn Gilbert, MD
Black teens with idiopathic scoliosis are more likely than white teens to present with curves in the surgical range, according to a retrospective study reported in The Spine Journal. The treatments offered to teens with similar degrees of curvature did not differ by race, suggesting that race and socioeconomic status did not impact treatment decision-making.
“Black patients (inclusive of African American and other ethnicities) in my practice were more likely to have a recommendation for surgery versus white patients based on the severity of adolescent idiopathic scoliosis (AIS) at presentation,” explained lead author Baron S. Lonner, MD, Chief, Division of Spine Surgery and Professor of Orthopaedic Surgery Mount Sinai Beth Israel, New York, NY. “The finding suggests that early detection, a tenet of nonoperative care of the AIS patient, is not achieved as reliably in the black community for this diagnosis as it is in the white population,” said Dr. Lonner, who also is Director of Scoliosis Associates of New York.
“This implies an unequal access to primary care and scoliosis screening, which may be impacted by cultural norms, socioeconomic status, and health insurance type,” Dr. Lonner said. “In order for nonoperative care to be successful, scoliosis should be detected early and bracing initiated when indicated in order to avoid surgery and to halt curve progression, as shown in the landmark Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST),” Dr. Lonner added.
Retrospective Chart Review From a Single Practice
The study was designed to investigate whether race or socioeconomic status are associated with the severity or initial treatment offered to adolescents with idiopathic scoliosis. The study included 219 white, 86 black, 44 Hispanic, 37 Asian, and 17 patients of other racial/ethnic groups between the ages of 10 to 21 years at the time of diagnosis. The patients presented to Dr. Lonner’s practice between 2004 and 2009.
Black patients had a significantly greater mean curve magnitude and were significantly more likely to have curves in the surgical range (>40°) and to receive surgery as their initial treatment (Table). In addition, black patients were significantly more likely to have more limited managed health care plans and lower incomes than white patients (P<0.001). Regardless of race, the mean age at presentation was significantly younger in patients with higher access insurance plans than in those with more limited access plans (13.6 vs 14.1 years; P<0.05).
“Hopefully, the findings of this study and other related investigations will lead to a better understanding among healthcare providers, in this case, scoliosis specialists, and healthcare systems of the nature of disparities in access to care or racial and or ethnic differences in disease severity,” Dr. Lonner said. “This should encourage efforts in various communities to promote early detection through school screening and regular primary care (pediatrician) evaluations per protocol. Education of individual patients and their families and communities through school nurses, pediatricians, and perhaps through other organizations such as the Scoliosis Research Society, the National Scoliosis Foundation, as well as Curvy Girls and other patient advocacy groups may be beneficial in this regard,” he said.
“Disparities in access to care due to socioeconomic status and health insurance variations require further study beyond a private practice setting represented by my practice,” Dr. Lonner said. “Promotion of early detection of scoliosis in all communities is essential to optimal care,” he added.
Study Highlights the Importance of Detecting Curves Early
“The study raises an interesting point that black patients present with larger curves in this select patient population, and are more likely to be in a surgical range,” commented Shawn Gilbert, MD, Associate Professor, Orthopaedic Surgery, The Children’s Hospital of Alabama, and Associate Scientist, Center for Metabolic Bone Disease, University of Alabama at Birmingham.
The findings “highlight the importance of detecting curves while still small (through physical exam screening) to maximize the chances of having non-surgical treatment,” Dr. Gilbert said. “It does not change how surgeons would treat patients or definitely indicate that black patents have a more severe form of scoliosis,” Dr. Gilbert said.
“The ‘private’ clinic setting of the study somewhat limits [the study’s] generalizability to other settings and the population as a whole,” Dr. Gilbert said.
Second Study Shows Link Between BMI and Curve Magnitude
Dr. Gilbert and colleagues recently published a study examining this topic from a different angle. Their retrospective chart review showed a positive correlation between BMI and curve magnitude in both the thoracic (P=0.03) and lumbar curves (P=0.02).
“We were attempting to address whether the patient’s body habits (obesity) might lead to a delay in presentation, presumably due to difficulty in detecting the curvature by physical exam,” Dr. Gilbert said. “We looked at socioeconomic factors like income and distance to facility to try to rule out that the differences we attributed to the obesity might actually be related to these other factors,” Dr. Gilbert said. Race, distance, and insurance status were not correlated with curve magnitude in this study.