Racial and Socioeconomic Factors in the Treatment of Scoliosis

According to this study, if you have idiopathic scoliosis, you are more likely to be treated surgically if you are 1) white, 2) have private insurance, and 3) have access to a large hospital. These racial and socioeconomic trends represent differences in treatment between white and non-whites referred to as disparities in health care.

Idiopathic scoliosis refers to a curvature of the spine of unknown cause. There is no underlying neurologic problem such as cerebral palsy or spina bifida. Idiopathic scoliosis is the most common type and affects about two to three per cent of the population. It tends to run in families and is more common in girls than in boys. Most often it develops in middle or late childhood during a rapid growth spurt.

There are several ways to treat scoliosis in children: do nothing (observation), exercise, bracing, and surgery. The optimal treatment depends on the degree or severity of the scoliosis. If bracing doesn’t stop the progression of scoliosis, then surgery may be needed.

Surgery for idiopathic scoliosis is generally suggested when the curve is 50 degrees or more and bracing fails. Surgery is recommended with two goals in mind; 1) prevent progression of the spine deformity, and 2) to lessen the existing spine deformity.

The surgical procedure most often used to correct idiopathic adolescent scoliosis is a posterior (through the back) fusion with instrumentation (rods, hooks, screws and wires) and bone grafting. Sometimes if the curve is severe, additional surgery may be required through the front of the body.

To assess national trends in the surgical treatment of idiopathic scoliosis, researchers at Cedars-Sinai Medical Center in Los Angeles, California used data from the Nationwide Inpatient Sample or NIS. The NIS is a computer database with information collected on all patients who enter a hospital. Patient demographics (e.g., age, sex, race, income, insurance information, education) and hospital characteristics (e.g., size, bed capacity, teaching versus nonteaching) can be evaluated.

They used information from the NIS to compare the number and types of patients who had spinal fusion surgery for idiopathic scoliosis. They also analyzed information on postoperative complications. Data collected in the NIS do not reflect the severity of each person’s scoliosis, the presence of other spinal problems, or the reasons why surgery was done.

There are some limitations of this study because all the information wasn’t always collected and entered on each patient. The lack of complete data entry can be considered a weakness of the system and possibly misrepresent the true outcomes studied. Having said all that, let’s look at what the study did uncover in terms of trends observed.

As mentioned, whites or Caucasians had the highest rate of surgery for idiopathic scoliosis. Patients with private insurance were two times more likely to have spinal fusion surgery for this condition. Non-Caucasians (African Americans, Hispanics, Asian/Pacific Islanders, Native Americans) were much more likely to have complications after surgery.

Hispanic patients had the highest rate of complications. In all age groups and for all races and income levels, pulmonary (lung) problems were the most common followed by hematoma (bleeding). African Americans were more likely to suffer cardiac complications. Their death rate was also the highest. This finding was attributed to “less frequent use of effective cardiac medications” and “poorer overall quality of care” for this group.

The authors concluded that like so many other studies that show health care disparities based on race and ethnicity, surgical treatment of idiopathic scoliosis follows the same trend. Bringing these patterns to the awareness of policy makers may help solve this complex problem. There may be cultural reasons for some of the differences that must also be addressed. For example, minority patients are less likely to accept recommended services or treatment and less likely to follow through with treatment suggestions.

Future studies using the National Inpatient Sample (NIS) will need better control over missing data, especially if the information is related to important data about patient income, race, and age. A closer look at the high rate of complications (causes and risk factors) might be helpful in preventing or reducing postoperative problems.