Dr. Malcolm Ecker, an attending orthopaedic surgeon at The Children’s Hospital of Philadelphia, answers four questions on scoliosis, among other things.  [Related information can be found in the Orthopaedia chapter on scoliosis.]

Orthopaedia: Your surgical practice was unusual by today’s standards in that in the same week that you performed major surgery for scoliosis you might perform a total hip replacement or a rotator cuff repair. These days, most orthopaedic surgeons are highly specialized. What do you make of that change?

MALCOLM ECKER: Undoubtedly, sub-specialization has allowed surgeons to get really efficient, executing innovative procedures with more predictable outcomes. On the other hand, there are costs too. When I began my orthopaedic training in 1965, virtually all orthopaedic surgeons were generalists. We used hand-powered instruments without the benefit of live-action x-ray imaging. The techniques we were taught were easily transferred from one anatomic region to another, and our training as a generalist made us more comfortable listening to all patient concerns, about all anatomic regions. We lose this with excessive specialization.

Operating all over the body prevents the surgeon from becoming bored or complacent, but at the price of stress and effort. When I would do a procedure which I had not done in the last few weeks, I would review the anatomy, the steps in the procedures, and the possible complications and how to resolve them. In some ways, that’s not very efficient, and maybe not even possible in today’s fast-paced world. A related problem of sub-specialization is that surgeons can become too enamored of the procedures they do. Thus, they are at risk not only of becoming little more than superbly talented technicians, but prone to recommending their surgical “hammer” for anything that remotely looks like a nail.

Orthopaedia: Treatment decisions about idiopathic scoliosis involve questions about body image and self-esteem, anxiety, risk and regret– in addition to all of the “major surgery” questions. Making it even harder, the typical patient is old enough to participate in the decision-making process, but not old enough to provide consent with the input of a parent or guardian. What strategies do you employ to ensure you understand the patient’s concerns?

MALCOLM ECKER: During new-patient visits, I ask the patient about the reason for the appointment and specific concerns regarding the patient’s back, including pain. I also ask the responsible adult accompanying the patient the same questions. After conducting a comprehensive examination and reviewing imaging, I explain the diagnosis of scoliosis and discuss its natural course and potential complications if it worsens, including changes in appearance.

If the curvature reaches a point where surgery is necessary, I engage in a thorough discussion with the patient and family, covering the risks, benefits, and typical recovery process. Throughout the conversation, I ensure both the patient and family have the opportunity to ask questions, maintaining eye contact as we talk. Parents play an essential supportive role, but I also emphasize the importance of patients expressing their own feelings, such as fear or sadness, which can be appropriate. It’s crucial for everyone to be on board with the treatment plan. I am fortunate to work at an institution with strengths across various areas, so if I require assistance from one colleague or another, I don’t hesitate to seek their help. In short, I don’t have a short answer. But I hope that the investment of time we make together at least points us to the right treatment option.

Orthopaedia: according to the textbooks (Orthopaedia as well), idiopathic scoliosis should not be considered as a source of, or explanation for, back pain. How do you approach a patient with idiopathic scoliosis reporting back pain as well?

MALCOLM ECKER: I always ask a patient being evaluated for scoliosis if they are having back pain. That’s because having scoliosis does not prevent one from having back pain for other reasons. This is especially pertinent if bracing is being contemplated, as bracing can be itself uncomfortable, and underlying back pain can interfere with compliance. Another important consideration is that some (rare) causes of back pain, such as a tumor, might also cause a curvature of the spine. That is, a patient with back pain and curvature of the spine does not have “idiopathic” scoliosis.

This also gets back to your previous question about decision making. The decision to have surgery is complicated. Even the decision to use a brace can be complicated, as bracing might have significant psychological and social effects. It’s crucial for everyone to be on board with the ultimate txt plan, and taking all complaints seriously is a good way to get there.

Orthopaedia: The U.S. Preventive Services Task Force reported that although bracing may decrease curvature progression in adolescents with mild or moderate curvature severity there was inadequate evidence showing that a reduction in spinal curvature in adolescence leads to meaningfully better long-term health outcomes in adulthood. If you were in charge, would you recommend screening?

MALCOLM ECKER: I would continue to recommend screening. My thinking is strongly influenced by the paper Stuart Weinstein and colleagues published in the New England Journal of Medicine, Effects of Bracing in Adolescents with Idiopathic Scoliosis. Their multicenter trial demonstrated that bracing was able to prevent progression in 75% of patients, versus 42% of those not treated. Beyond that, it’s fair to say that parents will rarely see their adolescent children bending over with minimal clothes (unless they are at the beach, or the like). As such, they probably won’t detect a curve until it is so large that it is not suitable for bracing. Without screening, we will likely miss these.

On the other hand, we have to consider that the Weinstein study looked only at patients with adolescent idiopathic scoliosis who were at risk for curve progression. Their study did not include patients with very mild curves, and to my knowledge, we have no reasonable means of predicting which patients with small curves present before skeletal maturity will progress significantly. Significant curve progression can lead to serious consequences such as pulmonary dysfunction and changes in appearance. I agree that curves less than 40 degrees at maturity are not apt to cause significant problems in adult life. I guess I am expressing confidence that even with a screening program, we won’t over-treat the mild cases, and it should go without saying that my anecdotal experience is not evidence of cost-effectiveness.