ChiroACCESS Article



Idiopathic Juvenile Scoliosis & Surgery



This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

ChiroACCESS Editorial Staff

  

ChiroACCESS



Published on

March 29, 2012

Text Size:   (-) Decrease the text size for the main body of this article    (+) Increase the text size for the main body of this article
Share this:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo
The current scientific evidence does not support the medical necessity for the surgical intervention of idiopathic juvenile scoliosis, yet these procedures continue to be performed and often reimbursed by the insurance industry.  “No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this.”  In addition to the lack of evidence that this course of treatment is optimal, there are a host of risks associated with scoliosis surgery which include failed surgery, neurological damage and infection. 

Despite the lack of scientific evidence, the cost of these surgical procedures is often reimbursed by the insurance industry.  A 2010 study of 125 consecutive patients found the cost of idiopathic juvenile scoliosis surgery ranged from $30,000 to $60,000 dependent upon the nature of the surgical procedure.   A larger study that same year of 955 scoliosis spinal fusion patients found the average cost to be $113,303 including hospital and other associated costs.  The cost of spinal fusion has increased dramatically. 

The U.S. “health” industry clearly favors reimbursement to some health providers and for some procedures at the expense of others.  Despite the rhetoric related to evidence based medicine little attention is paid to the actual evidence.  Scoliosis treatment is just one of many issues that demonstrate this.  Why would a rational health care system pay $113,303.00 for each scoliosis spinal fusion when there is no evidence to support the necessity?  Similarly, why is reimbursement denied for more reasonably priced conservative procedures that have at least some research support and no significant adverse effects?

For more content on scoliosis:

Note:  These mini-reviews are designed as updates and direct the reader to the full text of current research.  The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research.  Where permitted we will direct the reader to that full text.

Adolescent idiopathic scoliosis: 5-year to 20-year evidence-based surgical results.  [Link]

J Pediatr Orthop. 2011 Jan-Feb;31(1 Suppl):S61-8.

Westrick ER, Ward WT.
Division of Pediatric Orthopaedic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.

Surgical intervention for adolescent idiopathic scoliosis (AIS) should be proven to alter the natural history without introducing iatrogenic complications. The risks of surgery should be substantiated by a body of scientific research, which should show a clear superiority of surgery over observation, both in the short term and the long term. The purpose of this review was to conduct a systematic search of the literature to critically evaluate the scientific evidence on the long-term outcomes and complications of surgical intervention for AIS. Our search identified 39 distinct patient populations with a minimum average follow-up of 5 years. No long-term, prospective controlled studies exist to support the hypothesis that surgical intervention for AIS is superior to natural history. Although surgery reliably arrests the progression of deformity, achieves permanent correction, and improves appearance, there is no medical necessity for surgery based on the current body of literature. However, the surgeon must not underestimate the psychological indication that occurs when a patient is no longer able to cope with the deformity.


Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases.  [Link]

J Bone Joint Surg Am. 2010 May;92(5):1097-104.

Kamerlink JR, Quirno M, Auerbach JD, Milby AH, Windsor L, Dean L, Dryer JW, Errico TJ, Lonner BS.
Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Medical Center, New York, NY 10017, USA.

BACKGROUND: Although achieving clinical success is the main goal in the surgical treatment of adolescent idiopathic scoliosis, it is becoming increasingly important to do so in a cost-effective manner. The goal of the present study was to determine the surgical and hospitalization costs, charges, and reimbursements for adolescent idiopathic scoliosis correction surgery at one institution.

METHODS: We performed a retrospective review of 16,536 individual costs and charges, including overall reimbursements, for 125 consecutive patients who were managed surgically for the treatment of adolescent idiopathic scoliosis by three different surgeons between 2006 and 2007. Demographic, surgical, and radiographic data were recorded for each patient. Stepwise multiple linear regression analysis was employed to assess independent correlation with total cost and charge. Nonparametric descriptive statistics were calculated for total cost with use of the Lenke curve-classification system.

RESULTS: The mean age of the patients was 15.2 years. The mean main thoracic curve measured 50 degrees, and the thoracolumbar curve measured 41 degrees. The cost varied with Lenke curve type: $29,955 for type 1, $31,414 for type 2, $31,975 for type 3, $60,754 for type 4, $32,652 for type 5, and $33,416 for type 6. Independently significant increases for total cost were found in association with the number of pedicle screws placed, the total number of vertebral levels fused, and the type of surgical approach (R(2) = 0.35, p <or= 0.03). Independently significant increases for reimbursement were found in association with the number of pedicle screws placed and the type of surgical approach (R(2) = 0.12, p <or= 0.02). The hospital was reimbursed 53% of total charges and 120% of total costs. Reimbursement was highly correlated with charge (r = 0.45, p < 0.001). For rehospitalizations, the hospital was reimbursed 65% of charges and 93% of costs.

CONCLUSIONS: The largest contributors to overall cost were implants (29%), intensive care unit and inpatient room costs (22%), operating room time (9.9%), and bone grafts (6%). There were three significant independent predictors of increased total cost: the surgical approach used, the number of pedicle screws placed, and the number of vertebral levels fused. This study characterizes the relative contributions of factors that contribute to total costs, charges, and reimbursements that can, in time, identify potential areas for cost reduction or redistribution of resources in the surgical treatment of adolescent idiopathic scoliosis.


Geographic and demographic variability of cost and surgical treatment of idiopathic scoliosis.  [Link]

Spine (Phila Pa 1976). 2010 May 15;35(11):1165-9.

Daffner SD, Beimesch CF, Wang JC.
Department of Orthopaedics, WV University, Morgantown, WV 26506, USA. sdaffner@hsc.wvu.edu

STUDY DESIGN: Retrospective database review.

OBJECTIVE: To determine the variability in cost and surgical technique by geographic region and patient demographic.

SUMMARY OF BACKGROUND DATA: Some patients with idiopathic scoliosis (IS) ultimately require surgical treatment. The costs associated with hospitalization can be substantial, yet it is unknown how these vary depending on geographic region.

METHODS: Patients aged 10 to 24 who underwent surgical fusion for idiopathic scoliosis from 2004 to 2006 were identified in a publicly available, searchable national database of insurance billing records for patients with orthopaedic diagnoses (PearlDiver Patient Record Database) by searching ICD-9 diagnosis and procedure codes. Inpatient hospital charges for the procedure, length of stay (LOS), and surgical procedure (anterior, posterior, anterior-posterior, posterior interbody) were recorded. Patients were stratified by geographic region (Northeast, South, Midwest, West) and age group (10-14, 15-19, and 20-24).

RESULTS: Seventy-six thousand seven hundred forty-one patients had IS and 955 patients had spinal fusion procedure codes. Per patient average charge (PPAC) was $113,303 with average LOS 5.6 days. There was no significant difference in procedure type based on geographic region or age. The Northeast had the lowest rate of posterior surgery and highest rate of anterior only procedures. The Midwest had the highest rate of anterior-posterior surgery and Northeast had the lowest. Patients age 10 to 14 had the highest rate of posterior only procedures, those age 20 to 24 had the lowest. Patients age 15 to 19 were more likely to have anterior only procedures. Taken together, anterior-posterior and posterior interbody techniques were most common in patients age 20 to 24. Inpatient hospital charges varied significantly from region to region. Charges were highest in the West ($152,637) and lowest in the South ($103,256). There was no significant difference in PPAC based on age. LOS was significantly highest in the Midwest (6.5 days) and lowest in the South (5.2 days). LOS was significantly higher in the oldest age group compared with the younger groups.

CONCLUSION: PPAC and LOS varied by region. Although there was no significant difference in treatment type based on age or region, older patients tended to have more complex procedures and a higher LOS. This did not translate into a significant change in PPAC based on age. These data point to the need for further studies examining reasons for geographic variability in idiopathic scoliosis surgeries.


Adolescent idiopathic scoliosis (AIS) - an indication for surgery? A systematic review of the literature.  [Link]

Disabil Rehabil. 2008;30(10):799-807.

Weiss HR.
Asklepios Katharina Schroth, Spinal Deformities Rehabilitation Centre, Bad Sobernheim, Germany. hr.weiss@asklepios.com

PURPOSE: Historically, the treatment options for AIS, the most common form of scoliosis are: Exercises, in-patient rehabilitation, braces and surgery. While there is evidence in the form of prospective controlled studies that Scoliosis Intensive Rehabilitation (SIR) and braces can alter the natural history of the condition, there is no review on prospective controlled trials for surgical treatment. The aim of this review was to perform a systematic search of the Pub Med literature to reveal the evidence on scoliosis surgery.

METHODS: A systematic review has been performed using the Pub Med database. Literature has been searched for the outcome parameter; 'rate of progression' and only prospective controlled studies that have considered the treatment versus the natural history have been included.

RESULTS: No controlled study, not in the short, mid or long term, searched within the review, has been found to reveal evidence to support the hypothesis that the effects of surgery as a treatment option for AIS is superior to natural history.

CONCLUSIONS: No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this.


The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence. A systematic review.  [Link]

Eur J Phys Rehabil Med. 2008 Jun;44(2):177-93.

Weiss HR, Goodall D.
Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Bad Sobernheim, Germany. hr.weiss@asklepios.com

Traditionally, the treatment options for adolescent idiopathic scoliosis (AIS), the most common form of scoliosis, are exercises; in-patient rehabilitation; braces and surgery. The outcomes of treatments are usually compared with the natural history or observation (non-intervention). The aim of this paper was to provide a synopsis of all treatment options in the light of evidence based practice (EBP). A systematic review was carried out using the most encompassing databases available. Literature has been searched for the outcome parameter ''rate of progression'' and only prospective controlled studies that have considered the treatment versus the natural history have been included. The search strategy included the following terms: ''adolescent idiopathic scoliosis''; ''idiopathic scoliosis''; ''natural history''; ''observation''; ''physiotherapy''; ''physical therapy''; ''rehabilitation''; ''bracing''; ''orthotics'' and ''surgery''. Prospective short-term studies have been found to support outpatient physiotherapy. One prospective controlled study was found to support scoliosis in-patient rehabilitation (SIR). One prospective multi-centre study, a long-term prospective controlled study and a meta-analysis have been found to support bracing. No controlled study, neither short, mid nor long-term, was found to reveal any substantial evidence to support surgery as a treatment for this condition. There is some evidence supporting the conservative treatment for AIS. No substantial evidence has been found in terms of prospective controlled studies to support surgical intervention. In light of the unknown long-term effects of surgery, a randomised controlled trial (RCT) seems necessary. Due to the presence of evidence to support conservative treatments, a plan to compose a RCT for conservative treatment options seems unethical. But it is also important to conclude that the evidence for conservative treatments is weak in number and length.
Share this:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo


1 Comment on:

Idiopathic Juvenile Scoliosis & Surgery

Discuss this article in the ChiroACCESS Forums
ChiroACCESS Forums

Re:Idiopathic Juvenile Scoliosis & Surgery


by jwoggon   (4/17/2012 4:35:06 PM)
This is a very good article that raises a very compelling question: is the decision to perform spinal surgery for scoliosis influenced by sociopolitical factors, more than the financial considerations or the long-term health implications for the patient?
 
There are now two separate literature reviews conducted by independent authors (Weiss 2008 and Westrick 2011) which both come to the conclusion that there is no medical indication for scoliosis surgery, and no long-term research proving a superior outcome to natural history.
 
In regards to the financial aspects, in a study entitled "Does the outcome of adolescent idiopathic scoliosis surgery justify the rising cost of the procedure?" published in the Journal of Pediatric Orthopedics in 2011, Roach and his colleagues stated, "Patient outcomes when the latest, most expensive implants are used are not significantly different from outcomes when older, less-expensive implants are used. Patient outcomes have not improved in proportion to the increase in costs. Outcomes from the newest, all pedicle screw constructs are not significantly better than outcomes from the older, less-expensive hybrid constructs."
 
Parents of children with scoliosis have a right to know about these research findings before they make a decision which will have life-long consequences for their son or daughter.  As doctors of the spine concerned with natural, holistic healing, chiropractors are in an ideal position to share this knowledge and promote alternative treatment strategies.
 
I'm pleased and encouraged to see this article challenging conventional wisdom, promoting these new research findings, and encouraging chiropractors to get more involved with scoliosis.  Keep up the great work!
 
Warmest Regards,
Dr. Josh Woggon
Dallas, TX