Candidates for orthopaedic training programs often say they are attracted to our profession because the problems we treat and the indications for the interventions we employ are clear-cut. Patients with open fractures “need” irrigation and fixation; patients with painful end-stage arthritis “need” joint replacements; patients with bone tumors “need” excision and reconstruction.
But most surgeons who perform these interventions believe that the reality is a great deal more nuanced (and most who believe in the power of language will understand why the word “need” receives scare quotes in this context ). Some patients with those conditions may benefit from those interventions, but many others won’t, and some may even be worse off for having surgery. A popular Oslerism suggests that, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has” .
While most residents and registrars recognize that not all patients with adolescent idiopathic scoliosis (AIS) “need” to have their spines straightened, even thoughtful surgeons—whether pediatric orthopaedic surgeons who treat teenagers, or any of us who have (or know) teenagers with this condition—wonder why some with this condition hardly are aware of it and others experience debilitating back pain. And, importantly, the answers to this question, which come in this month’s Editor’s Spotlight article in Clinical Orthopaedics and Related Research®  are relevant to all orthopaedic surgeons, and not merely to those who take care of children with scoliosis.
This large-scale, cross-sectional, epidemiological study surveyed nearly 1000 patients—nearly all of those treated for the condition at an enormous referral center during the timespan of the project—and did so thoughtfully. Arnold Y.L. Wong and his team at the University of Hong Kong looked at factors related to the curves (“the disease a patient has”) and the interventions used to treat them, but also quite thoroughly at the patients who had those curves. The research group surveyed for the usual parameters of physical function, activity, anthropometrics, and demography, but also—and with considerable care and forethought—for satisfaction with appearance, insomnia, sleepiness, depression, anxiety, and education level. They found back pain is common in these patients, but chronic back pain is seen in fewer than 10% of patients with AIS, something that patients (and their parents) may find reassuring. More importantly, though, they identified several biopsychosocial parameters associated with an increased risk of back pain becoming chronic, including depression of at least moderate severity, a larger curve, and use of a brace.
Since few of us treat patients with AIS, the question really must be: What can this tell us about our patients with shoulder arthritis, low-grade chondrosarcomas, or meniscal tears? I believe the answer is “quite a bit.”
First, the cross-sectional study design used here provides answers to important questions—along with a considerable ability to generate testable hypotheses for future studies—without the need for long-term followup. Studies of this design require ample clinical volume, but many more sites can do studies of this type than are doing them; I hope to see that change.
More importantly, we can look at this study as a model approach to finding explanations (or at least associations) for common presenting complaints, provided that we are open-minded about symptoms being associated with factors other than ones that are visible on radiographs and MRIs [1, 2, 4, 6, 7]. I believe that inadequately treated depression and anxiety are underrecognized by surgeons, and account for a great deal more disappointment and disability after elective orthopaedic interventions than are technical errors, implant designs, or surgical approaches.
Please join me as I take a deeper dive on these and other important topics with Dr. Arnold Y. L. Wong, first author of “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” in the Take-5 interview that follows.
Take-5 Interview with Arnold Y. L. Wong PT, PhD, MPhil, first author of “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?”
Seth S. Leopold MD:Congratulations on this thoughtful and well-performed study. Since most readers will not treat patients with AIS, what do you see as the most-important messages of your work for the orthopaedic surgeon who does not treat patients with this diagnosis?
Arnold Y. L. Wong PT, PhD, MPhil: On behalf of my coauthors, we thank you and the journal for your interest in our study, and for your kind words. I also immensely appreciate the opportunity you have provided to share my viewpoints with the readers of the journal. Adolescent idiopathic scoliosis is largely perceived as a spine deformity typically developing in teenagers; because of this, clinicians and laypeople may focus on the onset, magnitude, and progression of the curve rather than the symptoms (such as pain) that might be associated with it. We have found that most clinicians regard back pain in patients with scoliosis to be a clinical problem that develops later—perhaps a patient’s third or fourth decades. We were surprised to find that back pain is quite common among teenagers with AIS: Nearly 9% of patients with AIS had back pain that persisted for more than 3 months. Many of these patients also experienced signs of depression and insomnia. Based on this, we believe orthopaedic surgeons should screen patients with AIS for back pain. But for those clinicians who do not treat patients with AIS—and for those who do—another key message of our study is that healthcare professionals need to be more cognizant of the pain profile of their patients, to investigate all possible mechanisms for it, and to identify risk factors that can help explain it, in order to develop more-effective treatments.
Dr. Leopold:Obviously a cross-sectional study design can generate hypotheses and identify associations that are worth considering, but it cannot confirm causation, and it is silent on what mechanisms may be behind the findings it makes. In light of those limitations, how can a thoughtful orthopaedic surgeon use the findings from studies of this design in practice, and what sorts of studies should be done to followup on the kinds of findings these studies make?
Dr. Wong: Any study with a cross-sectional design has this limitation, as can studies of other designs. In followup, we have initiated a prospective study of our study patients to determine the prognostic/predictive factors for the occurrence, resolution and exacerbation of back pain in individuals with AIS. We hope that this and other future prospective studies will determine whether there is a causal relationship between back pain and the factors we identified . In particular, it is important to determine whether back pain among patients with progressive curves will worsen over time, whether insomnia is the cause or the consequence of back pain in patients with AIS, and whether the presence of back pain is prodromal for worsening of the deformity. In other words, we need to learn more about whether back pain arises as a direct consequence of the spine deformity or as the result of other factors.
Meanwhile, orthopaedic surgeons and other healthcare professionals can screen for back pain and its various interlinked conditions, such as insomnia, in these patients in their daily practices. Although the causal link between insomnia and back pain has not been made, early identification of either problem can help us to guide educational efforts, interventions, and, where appropriate, referrals to other healthcare professionals. Importantly, our study highlights that patients with thoracic Cobb angles > 40° are likely to have chronic back pain. Because of this, clinicians should pay more attention to these patients, but not ignore those with smaller curves. Checking the fitting of braces and inquiring about symptoms of depression both are important.
Dr. Leopold:One does not need to be “old” to recognize that teens are exposed to stressors and stimuli completely unlike those we faced when we were younger, and these may cause both orthopaedic symptoms and the kinds of psychological distress that can amplify them. Here, I am thinking about everything from heavy backpacks to vaping, excessive screen time, and the pressures children face both from social and traditional media. Not all our readers treat teens, but many have (or will have) them. As someone who treats teens—and, I assume, someone who reads on these topics—how do you see these factors influencing the health of the patients whom you treat?
Dr. Wong: Your observations pertain to teens in many parts of the world. In addition to temptations associated with technology (smartphones, tablets, television entertainment), teens are experiencing pressure from school, parents, peers, and media. This combination may lead both to psychosocial and psychosomatic problems. We believe that prolonged video gaming and smartphone usage will adversely affect sleep patterns and increase the risk of adopting poor neck and back postures. The prevailing trends of recreational drug use and vaping can compromise the physical and psychological well-being of teens. Heavy academic pressures may incentivize a more-sedentary lifestyle among some teens, resulting in diminished physical fitness. Obesity is on the rise in many countries and is part of a vicious cycle with insufficient physical activity and psychological consequences. All of these issues threaten the health of children and contribute to an increased global burden of disease. Clinicians should adopt a holistic approach to assess and manage teenagers with or without orthopaedic problems. To the degree that teens and their parents are willing to listen to physicians or other healthcare professionals, clinicians are in a good position to provide proper health education and advice to their patients and their parents.
Dr. Leopold:To what degree do readers need to consider findings like those in your study to be culture-bound? In other words, this study was done in Hong Kong; does it apply to patients in Hoboken, New Jersey or Hannover, Germany? How might you (or might you not) apply a study of this design done in Hoboken or Hannover to patients in Hong Kong?
Dr. Wong: Given the effects of globalization, the impact of culture differences has diminished. In particular, Hong Kong is a “global city”, meaning that children in Hong Kong live in a multicultural environment. Their thoughts and lifestyles may be similar to teens living in developed countries, and so I believe our findings can be generalized to many metropolitan regions worldwide. That said, we acknowledge that there may be some subtle differences across regions. Therefore, I have approached different societies across the globe to initiate an international study to evaluate back pain and associated biopsychosocial factors among teenagers with AIS in different populations and ethnic groups. Interested parties can contact me for details at the following address: firstname.lastname@example.org.
Dr. Leopold:Since there are not too many readers who treat patients with AIS, I’ve saved this one for last. How have your findings in this study changed the way you approach patients with this diagnosis?
Dr. Wong: As you may have noticed, our research team is composed of an orthopaedic surgeon, a physical therapist, and epidemiologists. Our findings have clinical implications to many healthcare professionals. For example, clinicians can routinely ask patients with AIS to fill out the Insomnia Severity Index and a body-pain diagram alongside the SRS-22 questionnaire to assess their sleep health (sleep quantity and quality), and various AIS-related biopsychological problems in daily practice. For patients with thoracic Cobb angles > 40°, spine specialists can and should specifically assess for signs of depression, for the presence of back pain, and whether the brace may be contributing to pain or poor sleep. If clinicians identify patients with sleeping problems, depression, or back pain, they can provide advice, education, treatments, or referrals to manage these problems. In short, AIS is not simply a structural spine problem. I believe that proper assessments and timely interventions can prevent the worsening of pain and other associated psychological issues as the patient continues to grow and age. However, robust prospective, longitudinal studies are needed to further validate these contentions, assess causality, and stratify patients so as to best guide treatment.