Overheard while leaving the Doctors office

[Ballet Mom]

hdugger, here is the thread you are interested in.

http://www.scoliosis-support.org/showthread.php?t=6954

This quote is quite interesting from Lori Dolan:

we are indeed looking at digital bone age - we just didn't use it as an inclusion criteria. All subjects in BrAIST have a left hand film at each visit.

According to the Braist study, these additional x-rays are not a safety issue, so, there should be no problem with all of these orthopedists using left hand x-rays to determine skeletal maturity for these scoli kids when they come in for diagnosis and are post-menarchal. Glad to know that everyone was worrying about x-ray exposure for nothing.

[concerned dad]

According to the Braist study, these additional x-rays are not a safety issue, so, there should be no problem with all of these orthopedists using left hand x-rays to determine skeletal maturity for these scoli kids when they come in for diagnosis and are post-menarchal. Glad to know that everyone was worrying about x-ray exposure for nothing.

Been away for a while.
Balletmom, I'm not sure I understand what you're saying here.

It would be great to avoid all xrays all together, but a hand xray seems to have less risk than a full spine xray. I mean, isnt the main concern the radiation exposure to the thyroid, breast and ovaries?

I recall reading one of the arguments in support of hand xrays for age assessment was that it had the potential to reduce exposure. (why image down to the illiac crest if you dont need to?)

But risk is risk and it is all a balancing act. The risk of a hand xray to reduce the risk of bracing "for nothing" (in the event of skeletal maturity) seems to out weigh the risk of the radiation exposure ot the hand.

[Ballet Mom]

Hi CD! Nice to see you back.

I think the reduction in x-ray exposure is achieved by not taking the additional hand x-ray at the visit. The surgeons will definitely take the full-spine x-ray in order to see what is going on with the spine. I think they have avoided taking the hand x-ray in addition to the full-spine x-ray in order to avoid the additional radiation exposure, since they can see approximately what is going on with the Risser score. If, however, these digital x-rays are now so safe that the Braist researchers can do both a full-spine x-ray and the hand x-ray at ever visit, it seems to me that they are safe enough for other doctors to also use to determine skeletal maturity more accurately. Maybe like Braist is doing....on every visit if necessary, to let kids out of their braces earlier.

[concerned dad]

It is interesting to note that, even though my daughter's doctor is a big advocate of hand xrays to determine skeletal maturity, at our recent visit he did not give her a hand xray (just a spine xray).
I asked him why and he said that it was unnecessary since he knew her skeletal maturity from her previous hand xray.
I dont know if he was limiting radiation exposure or limiting costs, maybe both. But after thinking about it it makes sense.

I just reread the Equipoise paper (prompted by your and hdugger's comments). I still think the Braist study is worthwhile to do but I have to admit I am bothered by both

• the exclusion of european studies that employed excercise and bracing in the metanalysis paper and
• the point hdugger made about the uniformity of opinion regarding increased perceived risk (albeit small in some groups) in all profiles

.

[Ballet Mom]

It is interesting to note that, even though my daughter's doctor is a big advocate of hand xrays to determine skeletal maturity, at our recent visit he did not give her a hand xray (just a spine xray).

I do think it's very interesting that Braist is going to do the hand x-ray at every visit, I would still not allow my daughter to be exposed to that additional radiation (at every vist), even though it's less radiation than with the older machines.

And here's a quote from Lori Dolan herself regarding the uniformity of opinion off of the Scoliosis Support thread:

You're correct about the equipoise paper - we did see agreement in outcomes/benefits of bracing for most presentations including post-menarchal girls.

So she admits that everyone agrees with the outcomes/benefits of bracing, but they're not going to brace the kids anyway.....astonishing.

I agree about the exercise and bracing you mention. With the results my daughter has had, I believe the right kind of exercise, whether ballet or torso rotational, seems to be a key ingredient for success. And additionally, everything I read shows that ballet dancers show their scoliosis much less than non-ballet kids. I think those studies to help kids cosmetically would be very valuable.

[concerned dad]

And here's a quote from Lori Dolan herself regarding the uniformity of opinion off of the Scoliosis Support thread:

You're correct about the equipoise paper - we did see agreement in outcomes/benefits of bracing for most presentations including post-menarchal girls.

So she admits that everyone agrees with the outcomes/benefits of bracing, but they're not going to brace the kids anyway.....astonishing.

I think you are misinterpreting what she said.
They agreement they saw in post-menarchal girls was that bracing would have little effect.

So, what is astonishing to me is not that "they're NOT going to brace the kids anyway". It is astonishing that they ARE going to brace those kids anyway.

Boy, that doesnt read very well. Hope you know what I'm trying to say.

The point is, the only thing they saw agreement with was for post menarchal girls. The agreement was that bracing would have little effect. They are randomly assigning some of these kids to be braced anyway. That is what I may have an issue with, you seem to have an issue that they are not bracing some of these post menarchal girls.

So, you and I are both astonished, but for polar different reasons. But I am guessing that you misunderstood just what the "agreement" amongst the survey respondents was regarding post menarchal girls. Or maybe I misunderstood something.

I think she would have been more clear if she said
You're correct about the equipoise paper - we did see agreement in outcomes/benefits of bracing for only those presentations including post-menarchal girls. (with the bold text my substitution)

I think her use of the word "including" preceeded by the words "we did see agreement in outcomes/benefits of bracing" makes it easy to interpret that they saw agreement in benefits of bracing for most presentations. Reread the paper and you will see that the only thing they saw agreement on was for post menarchal girls.

[concerned dad]

text from the paper
According to this definition, there was clinical agreement on only 4 of the 12 profiles, all of which proposed a small RR due to bracing in postmenarcheal patients. These agreements are highlighted in Table 4. More than 80% of the experts indicated that bracing would have a small effect on postmenarcheal patients with thoracic curves (for both small and large curves), postmenarcheal patients with small thoracolumbar/lumbar curves, and postmenarcheal patients with small double major curves. The respondents were very close to agreement (77% and 79%) that bracing would have only a small effect on postmenarcheal patients with either large thoracolumbar/lumber curves or double major curves.

[Ballet Mom]

I think you are misinterpreting what she said.
They agreement they saw in post-menarchal girls was that bracing would have little effect.

The point is, the only thing they saw agreement with was for post menarchal girls. The agreement was that bracing would have little effect. They are randomly assigning some of these kids to be braced anyway. That is what I may have an issue with, you seem to have an issue that they are not bracing some of these post menarchal girls.

I still see red when Braist and Lori Dolan gets mentioned which is why I was speed reading this thread when I posted that comment. I probably picked the wrong comment to post from, I was thinking more of hdugger's comment i.e.

but all of the variability was in the same direction. No matter what the presentation, they generally thought that there was a lower risk of progression with bracing then without. Variability in *how much* risk there is of progression is very different from variability about *whether or not there is* risk.

I may at some point get back to looking at that study, but frankly, it simply doesn't interest me and actually infuriates me.

Note: my daughter has grown over an inch since menarche, I'm sure she would have progressed considerably during that time if she wasn't in a brace (unless antibiotics are perhaps helping her scoliosis.....who knows). Why would you find it astonishing that they would brace those kids? Someone just posted that their daughter had grown a lot....two years post menarche!

Please let me know what you think about the research subjects getting multiple extra hand x-rays during these studies? I also noticed a study that was done, I believe at Scottish Rite, that also took these extra hand x-rays at every visit, but can't find it right now. Either it's safe for all these "subjects" and therefore, all other scoliosis patients, or if not, it shouldn't be being done on these subjects either.

Also, I didn't see this comment of yours when I was speed reading , sorry.

I recall reading one of the arguments in support of hand xrays for age assessment was that it had the potential to reduce exposure. (why image down to the illiac crest if you dont need to?)

I don't know about you, but I can't imagine the caliber of x-ray techs we've seen, being able to image down to a specific point and get the entire spine too. They don't have x-ray vision, and they certainly aren't the brightest bulbs on the block and they can't even get shields into the x-ray...perhaps deliberately, who knows. I think you give them too much credit.

[concerned dad]

Why would you find it astonishing that they would brace those kids? Someone just posted that their daughter had grown a lot....two years post menarche!

It is astonishing to me because the consensus was that it would have little beneficial effect. I mean, they demonstrated equipoise on that issue and braced anyway. Maybe "astonishing" wasnt the best word to use, I just took your lead while trying to make my point. But I certainly would not have been "astonished" if they did NOT brace them as that was basically the concensus opinion.

Regarding the recent posting from someone whose daughter grew 2 inches post menarche: well, that tells me that perhaps menarchal status may not be the best indicator of remaining skeletal growth. But I dont think the issue is so much remaining growth as it is the timing of the curve acceleration stage.

Dr. Dolans response to my question about her equipoise paper (from scoliosis-support.org) was:

You're correct about the equipoise paper - we did see agreement in outcomes/benefits of bracing for most presentations including post-menarchal girls. So, this tells us that the community tends to agree that the benefits of bracing are lower in post-menarchal girls. But we still don't know if their estimates were correct, only that they were in agreement. Additionally, girls at <1 year post-menarche are frequently indicated for bracing in the US. Therefore, we wanted to include these girls in BrAIST. The equipoise study was only one piece of evidence we used to make our case for the ethics of this trial. We can talk some more about this later if you're still interested.

We wanted to base the inclusion criteria for BrAIST on current indications. When we were planning this study, Jim Sanders hadn't yet finished the analysis of his digital bone age data. Dr. Sanders is also an investigator in BrAIST, and we are indeed looking at digital bone age - we just didn't use it as an inclusion criteria. All subjects in BrAIST have a left hand film at each visit.

Please let me know what you think about the research subjects getting multiple extra hand x-rays during these studies? I also noticed a study that was done, I believe at Scottish Rite, that also took these extra hand x-rays at every visit, but can't find it right now. Either it's safe for all these "subjects" and therefore, all other scoliosis patients, or if not, it shouldn't be being done on these subjects either.

It is my understanding that xray exposure from hand xrays is not a big deal.
I think the concern is much more (still very small) for exposure of the breasts and reproductive organs. The breast exposure is mitigated by taking posteria Anterior films (back to front) and the reproductive organ exposure is mitigated by use of shields (although, as you point out, this is often done haphazardly).

[Pooka1]

There might be some confusion on the "maturity" and "post menarche" thing.

I know I heard or read or somehow got the idea that growth stops two years AFTER menarche, not at the beginning. That would explain why bracing is even routinely done after menarche but it would not explain bracing two years after that.

So it was strange to me to see there was agreement on low efficacy of bracing post menarche. When I read that I assumed they meant 2 years AFTER menarche but of course I have no idea what they were thinking.

[Ballet Mom]

It is my understanding that xray exposure from hand xrays is not a big deal.
I think the concern is much more (still very small) for exposure of the breasts and reproductive organs. The breast exposure is mitigated by taking posteria Anterior films (back to front) and the reproductive organ exposure is mitigated by use of shields (although, as you point out, this is often done haphazardly).

I also think with the digital x-rays that it can't be that great a concern or much of a cost, seeing as they're digital, so why aren't these orthopedic docs moving to hand x-rays when girls are post-menarchal for at least one hand x-ray? I think it seems pretty clear that menarche isn't a good indicator of skeletal maturity and yet it seems these doctors use it quite predictably. It seems to me it could save a lot of kids from bracing or being able to discontinue the brace earlier than what would be normal, and save some of these kids who are not being braced due to menarchal status and then continue to grow and progress.

Also, my daughter's x-ray techs can't even get the x-rays taken with her back to the front to protect her breasts. It really is irritating when it does state quite clearly in the procedural guide for scoliosis x-ray procedures that they should be taken back to front.

[concerned dad]

so why aren't these orthopedic docs moving to hand x-rays when girls are post-menarchal for at least one hand x-ray? I think it seems pretty clear that menarche isn't a good indicator of skeletal maturity and yet it seems these doctors use it quite predictably.

Well, Sanders only recently came out with the research documenting the superiority of hand xrays in assessing skeletal maturity. Maybe it will take a while to catch on.
In 2008 he published a paper offering a Simplified Classification System
In his paper he says (as usual, bolded emphasis is mine):
Both the Tanner-Whitehouse-III RUS score, which is based on the radiographic appearance of the epiphyses of the distal part of the radius, the distal part of the ulna, and small bones of the hand, and the digital skeletal age skeletal maturity scoring system, which is based on just the metacarpals and phalanges, correlate highly with the curve acceleration phase in girls with idiopathic scoliosis. However, these systems require an atlas and access to the scoring system, making their use impractical in a busy clinical setting. We sought to develop a simplified system that would correlate highly with scoliosis behavior but that would also be rapid and reliable for clinical practice.


Maybe it is just tough to teach an old dog new tricks.

he goes on to elaborate in the paper

Previous work identified the DSA scores from the Tanner- Whitehouse-III RUS method as the maturity indicator most closely correlated with curve behavior in a cohort of girls with idiopathic scoliosis. The DSA score, however, is cumbersome to obtain and is more appropriate for a research study than for clinical use unless reliable, rapid computerized measurements can be obtained, as suggested by several investigators 8-11. Because of these limitations, we sought to develop a reliable but rapid skeletal maturity assessment system based on the findings used to determine the DSA score.

[Ballet Mom]

Thanks CD, that explains it! I had no idea we were at the forefront of the research curve...hee hee