Should Orthopedic Surgeons Be Managing Scoliosis Cases? Recent Study Says No

Changing of the Guard in Scoliosis Treatment

Scoliosis Treatment Management Should Not Be Realm of Orthopedic Surgeons Suggest New Study

Editorial by Dr. Marc Lamantia, D.C. B.S. MS, DACNB Science Advisor of Scoliosis Care Foundation– Non-profit educational organization, dedicated to improving awareness and development of non-surgical scoliosis treatment approaches

Changing of the Guard in Scoliosis Treatment

For years we at Scoliosis Systems have been saying the Orthopedic Specialist (Surgeon) is the wrong case-manager  for non-surgical scoliosis patients. The current standards of care call for initial referral by the Primary Care physician to the Orthopedic Surgical specialist, then a course of Observation is employed until surgery is needed. If the patient times her visits when the curvature is between 25 and 40 degrees, the surgeon may suggest a rigid TLSO, or full back brace.  This is of course baffling to me as a rehabilitation specialist.

Contemporary practices crossing many domains of healthcare have been shown to be of benefit to any individual with postural issues, including those with scoliosis. The orthopedic specialist should only be consulted with if and when a curvature is progressive and non-surgical approaches become ill advised as a replacement for surgery.

A recent study in the Journal Pediatrics reported a successful approach to reducing “unnecessary” doctors visits to Orthopedic specialists. The objective of the study was to support a movement in organized medicine to change the “locus” of healthcare from the “Specialist” to the “Primary”, thereby reducing costs, and only mildly reducing efficacy, in my opinion. The authors support changes in referral patterns of Primary Care Physicians who routinely refer to Orthopedic specialists for scoliosis, to “not” refer as much.  

The results showed, through Physician education and decision making matrices  based on longitudinal outcome studies, they were able to change the way the Primary physicians referred, reducing otherwise “unnecessary” visits to the Orthopedist. The authors went on to say, “Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to orthopedic surgery, but most referred patients do not require bracing or surgery.”

What they failed to say is what these patients do need. While we agree, the majority of these patients would benefit firstly from education, so they understand their spine is susceptible to worsen if they do not use care in maintaining good posture and are aware of the changes they can make to improve the health of their spine, not only at the time of growth, but throughout their lives.

Patients with scoliosis with recent diagnoses do need education, and support to find evidenced based approaches to improving posture and scoliosis at the same time. Practitioners from every discipline believe they can help scoliosis, from the chiropractor to the yoga teacher, to the physical trainer at your local gym. The problem is very little of it is evidenced based. Even the often, over zealous evidence based practicing Physical Therapists, apply common physical therapy to patients with scoliosis, as if they were injured in a car accident, or have a palsy, dystrophy or myopathy, none of it being shown to be effective for scoliosis.  

Scoliosis is unique, and requires an understanding of the neurological mechanisms responsible for posture, the affect of the gross spinal subluxations on the other systems of the body, and the clinical applications to positively effect them. My training as a rehabilitation neuroscientist, a clinical functional neurologist, an upper cervical chiropractor, a practicing clinician for 15 plus years, an educator, and an trained orthotist, uniquely qualifies me to speak on the subject.  

The greatest thing we can do for patients with non-surgical scoliosis, is provide them with all that is evidence to be helpful, regardless of which domain in science or healthcare it comes from, that is why as a licensed Doctor of Chiropractic, I believe we are the appropriate manager of scoliosis referrals, and hope we can continue to provide quality healthcare to those in need, and hope to publish our findings as to help to continue to educate those in the healthcare fields.  

The greatest obstacle is the lack of knowledge by allied health professions commonly being referred to by the Orthopedist and the lack of referrals to chiropractic doctors who have pioneered combining rehabilitation approaches from stroke, movement and cognitive domains.  The future is bright, and this article is evidence that we have a chance to change scoliosis care for the better. 

A Quality Improvement Program to Reduce Unnecessary Referrals for Adolescent Scoliosis

  1. Louis Vernacchio, MD, MSca,b,c,
  2. Emily K. Trudell, MPHa,
  3. M. Timothy Hresko, MDd,e,
  4. Lawrence I. Karlin, MDd,e, and
  5. Wanessa Risko, MD, ScDa,b,c

+Author Affiliations


  1. aPediatric Physicians’ Organization at Children’s, Brookline, Massachusetts;

  2. bDivision of General Pediatrics and

  3. dDepartment of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts; and

  4. Departments of cPediatrics and

  5. eOrthopaedic Surgery, Harvard Medical School, Boston, Massachusetts

ABSTRACT

OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to orthopedic surgery, but most referred patients do not require bracing or surgery. We developed a quality improvement (QI) program within the Pediatric Physicians’ Organization at Children’s, an independent practice association affiliated with Boston Children’s Hospital, to reduce unnecessary specialty referrals for AIS.

METHODS: The QI program consisted of physician education, decision support tools available at the point of care, and longitudinal feedback of data on physician referrals for AIS. Referral patterns in the 2-year postintervention period were tracked and compared with those of the 2-year preintervention period. Clinical characteristics of referred patients were compared through claims analysis and chart review.

RESULTS: Initial visits to orthopedic surgery for AIS declined from 5.1 to 4.1 per 1000 adolescents per year, a reduction of 20.4% (P = .01). Process control chart analysis showed a rapid change in referral patterns after the initiation of the program which was sustained over the 2-year postintervention period and demonstrated that 66 initial and 131 total AIS specialty visits were avoided as a result of the program.

CONCLUSIONS: A QI program consisting of physician education, decision support available at the point of care, and longitudinal data feedback led to a sustained reduction in unnecessary referrals for AIS. This program can serve as a model for other programs that seek to shift the locus of care from specialists to primary care providers.