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Vol. XXV
No. 5
Cover
September/October
2009

In This Issue

SPECIALFEATURES
REGULARCOLUMNS
ANDTHEREST
Doc’s Digest Previous Page Next Page
by Dr. Rodger Sayre
- disclaimer -
Scoliosis: Straight Talk on Curvy Spines

There are those who deny the existence of absolute truth. I feel sorry for them. I am so thankful that I am not in that number! I believe God has chosen to reveal to us, via the Holy Bible, some absolutes. Some things are always right and some things are always wrong! No further discussion needed; it’s a done deal. You can take it to the bank.

Scoliosis is the excessive curvature of the spine.
www.istockphoto.com
...
THE STANDARDS
OF CARE REGARDING
SCOLIOSIS HAVE BEEN
IN A STATE OF FLUX
IN RECENT YEARS.
...

Many in our present society think science has the inside rail on truth. If a question is submitted to critical observation and non-biased testing, we can prove or disprove a hypothesis … can’t we? For example, if we toss a ball into the air 1,000 times, it will always return to the ground. Well then, here is an absolute truth: “What goes up must come down.” However, astronauts will tell you that when they toss something up in outer space, it does not come back down! (If you want to confuse an astronaut, ask, “Hey, what’s up?”)

Sometimes new information will change what has long been held to be truth, especially in the natural world. In 1700, the concept of tossing something “up” while outside the earth’s gravitational pull never occurred even to those in the scientific community—except perhaps to a really smart guy named Isaac Newton. Newton dared to think outside the box. By the way, he also believed in the absolute truth of God’s Word.

In my 25 years of doctoring, there have been countless changes to what was thought to have been pretty well-established truth. For example, at one time “good medicine” included subjecting everyone to yearly chest x-rays. I had to have one to get into medical school. Now we have decided that the radiation exposure of such a practice is not worth the information gained. A few years ago, we recommended that most women in their menopausal years take an estrogen replacement hormone to prevent osteoporosis. Now, however, estrogen replacement therapy is far less common, as we have come to realize its potential downsides.

And so I come at last to the issue of scoliosis. As you might have guessed by the dialogue above, the standards of care regarding scoliosis have been in a state of flux in recent years. I have been asked to weigh in on this controversy for the benefit of HSLDA member families. As I see it, there are two main questions to be answered: first, should we routinely screen for scoliosis in children who have no obvious deformity or complaint? Second, how should we treat those who qualify for the diagnosis of scoliosis?

Defining our terms is key to the questions at hand. Scoliosis is a curvature of the spine of at least 10% and can be divided into two main categories: idiopathic and secondary scoliosis. As their names would imply, idiopathic scoliosis (by far the more common form) has a poorly defined cause, whereas secondary scoliosis is due to some underlying and identifiable pathologic process, usually involving the nervous or musculoskeletal systems. Scoliosis is pretty common. About 3% of all adolescents qualify for the diagnosis of idiopathic scoliosis, the type that will be the focus of this article.

New Data Raises Questions

As the school physician for two local school districts, I screen hundreds of children each year for idiopathic scoliosis. However, in recent years, the practice of routine screening for this condition has come under fire. In 1996, the U.S. Preventive Services Task Force (USPSTF) released an opinion that there was “insufficient evidence for or against routine screening of asymptomatic adolescents for idiopathic scoliosis.”1 This ran contrary to the recommendations of the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons, who recommended screening all children for scoliosis during their adolescent years. In 2003, the USPSTF went even further, concluding that “the harms of screening adolescents for idiopathic scoliosis exceed the potential benefits.”2 Wow. That sure throws a monkey wrench into the works for me! I’ll have to admit, my research for this article has caused me to reconsider some of my own medical practice.

The controversy here stems from the presumption that routine screening of all children will lead to an early diagnosis, early diagnosis is necessary for early treatment, and early treatment increases the potential for successful treatment.

But is early diagnosis and early treatment really in the child’s best interest? This has not always been borne out in recent scientific study. The USPSTF update states that there is “fair evidence that treatment of adolescents with idiopathic scoliosis detected through screening leads to moderate harms, including unnecessary brace wear and unnecessary referral for specialty care.”3 A harm cited elsewhere (and one that I have noted often) includes the impact that carrying diagnosis of scoliosis has on the fragile self-image of a teen.

Here is some recent information that has created the about-face on this issue:

1) Only 10% of those who meet the criteria for idiopathic scoliosis (as defined above) will progress to needing treatment. This means that 90% of children confirmed to have scoliosis on x-ray exam will have been subjected to unnecessary radiation and possible referral. Of course, many of the children subjected to x-ray evaluation on the basis of the standard forward-bending screening test are shown not to have scoliosis at all. So the percentage of those experiencing unnecessary work-up is even greater than 90%.

2) Unless the curvature is greater than 30 degrees at the time of “skeletal maturity” (at the end of the adolescent period), there is little chance the curvature will progress to an extent necessitating treatment.

3) Those who will someday benefit from intervention almost always meet one or more of the following easily identifiable criteria:

  • female gender (about 90% of those who eventually require treatment are female),
  • young age at onset of curvature (before or during the early stages of puberty), and
  • marked deformity (obvious curvature even to an untrained eye).

Further complicating the issue is the fact that, unlike idiopathic scoliosis, secondary scoliosis has been shown to respond to bracing, physical therapy, and other modalities of treatment, with early diagnosis and treatment essential for success.

So What’s a Parent to Do?

If your child is seen regularly by a qualified pediatrician or family physician (and I believe he should be), you can be assured your child is being evaluated for spinal deformity. It is not necessary to have special screening done outside of this simple measure. If your child’s physician requests further evaluation (such as spinal x-rays) to assess for scoliosis, keep in mind the above criteria. If none of these criteria are met, I would recommend obtaining a second opinion.

The decisions we make on behalf of our children have lifelong implications and should be made with all the information we can gather. I hope that this discussion has better equipped you as a homeschooling parent to make wise choices regarding scoliosis screening and treatment.

Endnotes

1 U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd Ed. Washington, D.C. Office of Disease Prevention and Health Promotion, 1996.

2“Screening for idiopathic scoliosis in adolescents: update of the evidence for the U.S. Preventive Services Task Force.” Agency for Healthcare Research and Quality, 2003.

3 Ibid.


About the author

Rodger Sayre, MD, FAAFP, has been an HSLDA board member since 1997. He and his wife, Mary, have graduated 5 of their 11 children and continue to teach the rest at home in Pennsylvania. Dr. Sayre is certified as a Diplomat of the American Board of Family Medicine and is a Geisinger Medical Group associate with a busy practice in Tunkhannock.