Moderate? Really??

[loves to skate]

Thanks so much. When I went in for the x-ray, they took the front ones and said I was done...I said, "hang on! You need to do the side view." I mean, going ALL the time as a kid, I remember that. They asked the radiologist and even called the physiatrist, and said nope...they only needed the front. That made me suspicious right there.

Then, at the office, I even asked about the way they drew it and said that it didn't look like a Cobb angle. It looked like he weirdly traced along the spine! But, then I thought perhaps that's just the way they do it when the "write" it on the xray via computer....y'know...not like he took a pencil to it and drew out the curves. I thought perhaps there was a computer program he used for measuring the Cobb angles that drew it that way.

I'm really kinda nervous about the congenital part. I thought the apex of that curve looked pretty remarkable to me, and not at all like I remember in my childhood xrays. Hmmmm...anybody know a good scoliosis specialist in Boston I could drive down to?

Thanks, everyone. I really do appreciate your help. Maybe this is why my original post "moderate...really?" is funny....maybe it isn't at all, which would explain why the heck I am in a lot of pain all the time. I mean, I know you don't go to the Internet to get medical advice...we're all here to share what we know and search for information and support, but ideally you need a doctor of course...but I really appreciate your opinions since I thought the doctor's assessment seemed a bit fishy, but I didn't want to overreact and seem all gung ho for some surgery or something.

To answer your question about a good scoliosis specialist in Boston, Dr. Frank Rand is an excellent choice. He specializes in adults, degenerative conditions and other spinal abnormalities. He is at the New England Baptist Hospital. He is very kind and caring and confident without being the least bit arrogant. It takes awhile to get an appointment with him because he is so busy, but just be persistent. There are a couple of other specialists in Boston, but I have no first hand experience with them. You probably can find them on the SRS website.

Take care, Sally

[cbeem]

mamamax...you should always challenge if you have questions! My dear friend just brought her son in for surgery (not scoliosis, something else) anyway, it was Mom who reminded the surgeon that since they were only doing one hip, the cast on the other leg needn't come all the way down the little guy's leg. I mean, that's a big thing when a 2 1/2 year old will be in a body cast for a month and a half.

My point is, that even with the best doctors in the world, our health (and the health of our children) is most important to US. I'm not happy with the explanation of my x-rays, or my x-rays (I mean, without a side view they can't even tell about the natural curve of the back from back to front--and I believe that my back is flatter than most so there was no evaluation of kyphosis or lordosis--I think I've got those terms right), so I am going to challenge the radiologist and get another opinion.

When I was a kid, they "noted" the rotation, but it was never one of the measurements they took. But hey, that was quite a while ago now. I would imagine that the twisting of our spines would have a large impact on our spine health. So, while measurements of these twists may be new or not even widely done, it concerns me that side x-rays weren't taken to determine progression of the twist later.

Now I'm completely convinced that I need to get the opinion of a specialist. I just wish some offices were open TODAY so I could call! Now I'll have to wait until Tuesday! I was really hoping to find out the whole story before my new semester starts, but I've waited this long so a couple of days shouldn't kill me!

[cbeem]

Thanks, Sally!

-Cristy

[mamamax]

Now I'm completely convinced that I need to get the opinion of a specialist. I just wish some offices were open TODAY so I could call! Now I'll have to wait until Tuesday! I was really hoping to find out the whole story before my new semester starts, but I've waited this long so a couple of days shouldn't kill me!

Agree with all you have said - and this (seeking an opinion from a scoliosis specialist) a wise move on your part. Best of Luck!

[Pooka1]

I noticed that - so now I have a new question. Is rotation a factor that should be considered in an accurate measurement of one's condition ... for purposes of treatment recommendations?

I'm guessing it is. Of course that doesn't change the fact that surgeons are using the same techniques to measure curvature that are readily available to you.

Yes I know - and apologize - I ask too many questions. Guess it would not surprise anyone to hear I was tagged as precocious in childhood :-)

Never apologize for that. Precocious is good. Thinking is always in order and you do a lot of thinking in my opinion.

And I guess I'm just dumb as a rock - I still cannot see any easy way to challenge the measurements of a surgeon - or - someone with more knowledge of this than myself. *faints*

You are clearly not as dumb as rocks for heavensakes. And you are NOT challenging the surgeon's measurements by measuring the curves yourself. You very likely will get a very similar measurement.

Again, just to make this as clear as possible, the Cobb technique and the centroid technique are purely graphical analyses. That is, you get the answer from drawing lines and measuring angles, NOT making a single calculation or using a single formula. Is that clearer?

ETA: It is fair to say that a person adept at mechanical drawing or an artist will get a more precise, less biased result using a graphical technique than many other folks with more medical training.

[mamamax]

Thanks Sharon :-)

You know - it's not all that a precise science when the error rate is +/- 5 degrees either way. That's on the list of things that bother me. Along with the fact that curves themselves may present differently from morning to afternoon/evening.

I agree - the observant artist may be most precise.

[hdugger]

Tangentially related to this discussion, I have routinely had the experience of a greater-than-the-margin-of-error difference between my son's xrays.

So, my first doctor re-measured one xray almost 12 degrees higher because he selected a different vertebrae the second time.

A second dr, looking at the same xray, measured it 7 degrees lower.

My new dr re-measured one of my son's old xrays 6 degrees higher (not sure of the reason)

And, for his latest xray, the radiologist measured the curve as 48 while our doctor measured it as 57.

I'm not certain why we're seeing this amount of variability, but it does make it very hard to figure out whether the curve is stable or progressing.

[Pooka1]

Tangentially related to this discussion, I have routinely had the experience of a greater-than-the-margin-of-error difference between my son's xrays.

So, my first doctor re-measured one xray almost 12 degrees higher because he selected a different vertebrae the second time.

My new dr re-measured one of my son's old xrays 6 degrees higher (not sure of the reason)

And, for his latest xray, the radiologist measured the curve as 48 while our doctor measured it as 57.

I'm not certain why we're seeing this amount of variability, but it does make it very hard to figure out whether the curve is stable or progressing.

I think the claim (and hope) is that using the same vertebrae, the inter-operator error won't be larger than +/- 10*.

My personal opinion as to why the large variability is sloppy drawing of lines. I think the thought is that it is "close enough"and maybe it is. But I still claim that a person adept at CAD would probably do the best job not only of selecting most tilted vertebrae but also drawing accurate lines.

Larger errors are expected to ensue when different vertebrae are selected. The idea that different vertebrae can be selected by various surgeons blows my mind as the principle at least is straightforward - most tilted vertebrae. I guess there are cases where two vertebrae may appear most tilted but I think in that case, using either should return the same angle. I'd have to check that though.

But we can see from the Hawes more recent publication that there are other factors being considered when doing this graphical analysis. Recall that the blinded readers reported a much lower Cobb angle compared to the non-blinded readers. That went by in the discussion without comment for some reason. I think the reason would be edifying to our present discussion.

[Pooka1]

Tangentially

By the way, I wanted to congratulate you on using this word in the present context. Very clever.

[skevimc]

Hi there,

I have never seen that vertebral centroid measurement method before. It's an interesting finding when compared with Cobb's method.

To answer the earlier question about my expertise . Yes I have measured the Cobb angle many times. I have dome quite a bit of measurement looking at various x-rays. If given the x-rays and a pencil I feel confident I could do it in person. Doing it on the computer is a bit different. I measure the upper thoracic curve at 43° and the TL/L curve at 34°. DISCLAIMER:!!!! I am not a clinician!!!! Please disregard everything I have written.

To me it looks like they might be trying to use the vertebral centroid method. The bottom curve looks good but the upper curve looks like they miss the centroid on the lower half. That is, the bottom line isn't going through the centroid of the lower two vertebrae. So it looks like the measurement is too narrow. Hopefully that makes a bit of sense.

I can see the rotation better when I adjusted the contrast levels a bit. I can't measure the rotation because that requires a special type of ruler.

I don't see any obvious deformations in the high thoracic curve, ~ T3-4. But it still looks to me that T4 is a bit wedged. The high thoracic compensatory curves, I don't think, usually look that sharp. Idiopathic curves tend to have an obvious gradual curvature. But to me, the vertebrae look straight and then at T3, the spine changes direction.

Anyway, it might benefit you to go see a spine doc. I don't know that it would/should change your treatment, but it's always nice to have a diagnosis that you trust.

DISCLAIMER AGAIN!!!! I am NOT a clinician. I am just giving you my thoroughly unqualified opinion!! But it does look like they have made at least one measurement error.

[mamamax]

Hi there,

I have never seen that vertebral centroid measurement method before. It's an interesting finding when compared with Cobb's method.

To answer the earlier question about my expertise . Yes I have measured the Cobb angle many times. I have dome quite a bit of measurement looking at various x-rays. If given the x-rays and a pencil I feel confident I could do it in person. Doing it on the computer is a bit different. I measure the upper thoracic curve at 43° and the TL/L curve at 34°. DISCLAIMER:!!!! I am not a clinician!!!! Please disregard everything I have written.

To me it looks like they might be trying to use the vertebral centroid method. The bottom curve looks good but the upper curve looks like they miss the centroid on the lower half. That is, the bottom line isn't going through the centroid of the lower two vertebrae. So it looks like the measurement is too narrow. Hopefully that makes a bit of sense.

I can see the rotation better when I adjusted the contrast levels a bit. I can't measure the rotation because that requires a special type of ruler.

I don't see any obvious deformations in the high thoracic curve, ~ T3-4. But it still looks to me that T4 is a bit wedged. The high thoracic compensatory curves, I don't think, usually look that sharp. Idiopathic curves tend to have an obvious gradual curvature. But to me, the vertebrae look straight and then at T3, the spine changes direction.

Anyway, it might benefit you to go see a spine doc. I don't know that it would/should change your treatment, but it's always nice to have a diagnosis that you trust.

DISCLAIMER AGAIN!!!! I am NOT a clinician. I am just giving you my thoroughly unqualified opinion!! But it does look like they have made at least one measurement error.

Excellent! Sharon insists that I too can do this, but I have my doubts. Still, cannot help but have lots of admiration for those who can. What gets to me is the wide variation between "readers". Five or ten degrees can be important in terms of treatment recommendations - leaves me feeling a little discombobulated

[cbeem]

Oh, thanks so much for taking the time to answer a question just so specifically for ME. I really appreciate it. That was so nice of you. I have decided to get a second opinion. I have to wait for tomorrow with the holiday, and I'm not sure if I need to get a referral from my primary doc, but I'm going to make those calls after the holiday and see what I can do.

Yes, "wedged" and "changes direction" don't sound too great for one's spine, but I certainly don't have as drastic a curve as many have to deal with. I wonder though if whatever is going on there at T4 is causing me to have more discomfort than one with a 30-40 degree curve typically has. I'm still not jumping into surgery, but I would like to have a complete, accurate, and trustworthy assessment of my scoliosis right now. I'm ready now and I'm motivated, and I worry that if I get too much older, my options will be lessened. So, off I go!

Thank you, everyone! I'll surely keep you posted as I move forward. In the meantime, I've signed my boy up for the daycare program at the gym and tomorrow will be his first time there and my second attempt at pilates! Look out!

Cristy

[mamamax]

I admire you Cristy :-) You were a great sport letting us all discuss your xray - don't know that I would have been (getting old and cranky). And I think your decision to get a second opinion is a wise one. Pilaties (in theory) to me, seems a good way to go. And you seem wise enough to remember that if it hurts - modification maybe in order. I'm excited for you and any benefit you may achieve. I hear you about that window of opportunity! At 60 (with all kinds of wedging and other things I really don't want to confront) I feel time is running shorter. I comfort myself with such sayings as - it's never too late :-) And in the benefit I currently am receiving from bracing. As time marches on, I'm sure I'll need more in terms of daily exercise (and regardless of outcome, being in good shape for whatever - certainly wouldn't be a bad thing). Looking forward to what I hope will be a very rewarding experience for you.

P.s. Let me know what you think of the 100. I actually did that once upon a time - felt like a booby lift!! I may go back to that actually (lol).

[skevimc]

What gets to me is the wide variation between "readers". Five or ten degrees can be important in terms of treatment recommendations - leaves me feeling a little discombobulated

I know what you mean. Part of the discrepancy can come in the form of the x-ray technician. Just like photography is an art form, getting a good and consistent standing x-ray is equally so. Feet placement, posture, shoulders, etc... all of these things can contribute.

As far as treatment recommendations are concerned, this is why clinicians and researchers need to start focusing on other outcome measures and other reasons for suggesting a particular management strategy.

[mamamax]

Well said Kevin. Another component that can also affect readings, is the time of day that an xray may be taken. Don't have the articles I've read about that at my fingertips at the moment, but apparently curves (both young and old) can vary widely throughout the day - depending on the stresses involved. I always try to schedule any xrays for before noon - when I am not as fatigued. Why? Because I *think* it gives me a consistent baseline throughout the years. As opposed to an early morning reading one year - and a late afternoon reading 2 years later, after a very tiring day .. which could make it appear that a large progression has occurred when in fact, maybe it really hasn't. I would personally find a large image difference more concerning & reliable if it were from the same time of day as the preceding image two years prior. Too deep - maybe, maybe not.

There are other methods of assessing overall condition. Why they are not used more often is a question I can't answer. I do wonder sometimes if it has to do with time and money. One of those methods is the Biometrix Formetric - a radiation & contrast free scan. I don't know a lot about it - think it is not meant as an initial diagnostic tool but rather as a tool that can assess any changes that may require further investigation (xray). I believe it may be used in Germany more than other countries at present. My most recent scan attached. Interesting that things like convexities/concavities are pretty easy to see. Are you familiar with this method Kevin?