Delayed Diagnosis of Pediatric Scoliosis

Delayed Diagnosis of Pediatric Scoliosis – When to Suspect Medical Malpractice

Pediatric scoliosis is a medical condition that involves an abnormal curvature of the spine in children. While many cases are mild, if left untreated, scoliosis can lead to significant physical deformity, pain, and other health complications.

Pediatric scoliosis is defined as a lateral curvature of the spine that is greater than 10 degrees when measured on an X-ray. It typically presents as an “S” or “C” shaped curve and can affect different regions of the spine, including the cervical, thoracic, and lumbar areas.

Scoliosis in children can be categorized into different types based on age and underlying causes:

• Infantile Scoliosis: Occurs in children aged 0 to 3 years. It’s relatively rare and can sometimes resolve on its own.
• Juvenile Scoliosis: Occurs in children aged 4 to 10 years. This type has a higher likelihood of progression and may require treatment.
• Adolescent Idiopathic Scoliosis: The most common type, occurring in children aged 10 to 18 years. The cause is unknown, and it often becomes noticeable during the growth spurt before puberty.

Causes of Pediatric Scoliosis

The exact cause of pediatric scoliosis often depends on the type of scoliosis the child has. Here are the primary causes and contributing factors:

1. Idiopathic Scoliosis: The most common form of scoliosis in children, especially adolescents. The cause is unknown, though there is evidence suggesting a genetic component, as scoliosis can run in families.
2. Congenital Scoliosis: This type is present at birth and results from malformations of the spine that occur during fetal development. These spinal abnormalities can cause the spine to curve as the child grows.
3. Neuromuscular Scoliosis: This type is associated with neurological or muscular conditions that affect the muscles supporting the spine. Common conditions linked to neuromuscular scoliosis include:
   • Cerebral palsy
   • Muscular dystrophy
   • Spina bifida
   • Spinal cord injuries
4. Syndromic Scoliosis: This type occurs as part of a syndrome or disorder. Various syndromes are associated with scoliosis, such as:
   • Marfan syndrome
   • Ehlers-Danlos syndrome
   • Down syndrome
   • Rett syndrome
5. Other Causes: Less common causes of pediatric scoliosis include:
   • Infections or tumors: Infections or tumors in the spine can cause scoliosis.
   • Trauma: Severe injuries to the spine can lead to scoliosis.
   • Metabolic diseases: Conditions that affect bone metabolism, such as rickets or osteogenesis imperfecta, can lead to spinal curvature.

Risk Factors for Pediatric Scoliosis

Certain factors can increase the risk of developing scoliosis in children, including:

• Family history: A family history of scoliosis increases the likelihood of a child developing the condition.
• Gender: Girls are more likely than boys to develop severe scoliosis that requires treatment.
• Age: Symptoms often begin during the adolescent growth spurt.

While the exact mechanisms behind many cases of pediatric scoliosis remain unclear, ongoing research aims to better understand the genetic and environmental factors contributing to the condition. Early detection and intervention can help manage the progression and impact of scoliosis on a child’s health.

How Common is Pediatric Scoliosis?

Pediatric scoliosis is relatively common. Here are some statistics and information regarding its prevalence:

1. General Prevalence: Scoliosis affects approximately 2-3% of the population, which translates to hundreds of thousands of children in the United States.
2. Adolescent Idiopathic Scoliosis (AIS): This is the most common type of scoliosis, typically developing in children between the ages of 10 and 18. AIS accounts for about 80% of all scoliosis cases. It is estimated that around 1 in 1,000 adolescents will have a curvature significant enough to require treatment.
3. Gender Differences: While mild scoliosis affects boys and girls equally, girls are more likely to develop more severe curves that require medical intervention. Severe scoliosis is about eight times more common in girls than boys.
4. Congenital Scoliosis: This type, resulting from spinal malformations present at birth, is much less common. It occurs in about 1 in 10,000 newborns.
5. Neuromuscular Scoliosis: This type is associated with neuromuscular conditions and varies depending on the specific disorder. For example, about 60% of children with cerebral palsy and nearly all children with Duchenne muscular dystrophy will develop scoliosis.
6. Early Onset Scoliosis: Scoliosis diagnosed before the age of 10 is less common than adolescent scoliosis but can be more complex to treat due to the ongoing growth and development of the child.

Diagnosing pediatric scoliosis involves a combination of physical examinations and imaging tests. Here are the key steps in the diagnostic process:

Physical Examination

1. Visual Inspection: A healthcare provider will visually inspect the child’s back while they stand and bend forward. This evaluation is performed at well child visits.  Signs pediatricians and family doctors look for include:
   • Uneven shoulders
   • One shoulder blade more prominent than the other
   • Uneven waist or hips
   • Leaning to one side
2. Adam’s Forward Bend Test: The child bends forward at the waist with arms hanging down. This position can make spinal abnormalities more apparent. The examiner looks for asymmetry or a rib hump, which indicates a spinal curvature.
3. Palpation: The examiner may feel along the spine to detect any abnormal curvatures or vertebral rotation.

Imaging Tests

1. X-rays: The primary imaging tool for diagnosing scoliosis. X-rays provide clear images of the spine and allow the doctor to measure the degree of curvature using the Cobb angle. This measurement helps determine the severity of the scoliosis.
2. MRI (Magnetic Resonance Imaging): An MRI may be ordered if there are unusual symptoms or if the scoliosis is suspected to be caused by an underlying condition such as a spinal cord abnormality. MRIs provide detailed images of the soft tissues and spinal cord.
3. CT Scan (Computed Tomography): Less commonly used but can provide detailed cross-sectional images of the spine if needed for further evaluation.

Screening Programs

• School Screenings: Many schools conduct routine scoliosis screenings, typically around ages 10-15, to detect scoliosis early. These screenings usually involve a simple visual inspection and the Adam’s Forward Bend Test.

Clinical Assessment

1. Patient History: The doctor will take a detailed medical history, including any family history of scoliosis, the age of onset, and any associated symptoms such as back pain or neurological symptoms.
2. Assessment of Symptoms: The doctor will assess for any related symptoms like back pain, leg pain, or weakness, which might suggest more complex conditions.

Monitoring and Follow-Up

• Observation: For mild curves, the child may be monitored with regular check-ups and X-rays to track the progression of the curvature.
• Specialist Referral: If scoliosis is detected, the child may be referred to an orthopedic specialist, particularly a pediatric orthopedic surgeon, for further evaluation and management.

Early diagnosis and appropriate monitoring or treatment are crucial in managing pediatric scoliosis effectively, helping to prevent complications and ensuring better outcomes for the child.

When Should a Doctor Suspect Pediatric Scoliosis?

A doctor should suspect pediatric scoliosis during routine check-ups or when a parent or caregiver reports specific signs and symptoms. Here are some key indicators and scenarios that might prompt a doctor to suspect scoliosis in a child:

Physical Signs and Symptoms

1. Visible Asymmetry: When a child has uneven shoulders, hips, or waist, one shoulder blade is more prominent than the other, or there is a visible lean to one side.
2. Rib Hump: When bending forward, a prominence on one side of the ribcage may be noticeable.
3. Uneven Clothing Fit: Clothing that hangs unevenly or skirts that tilt to one side can indicate a spinal curvature.
4. Back Pain: While not always present, some children with scoliosis might report back pain.
5. Gait Abnormalities: An unusual walking pattern or limping could be a sign of an underlying spinal issue.
6. Family History: A known family history of scoliosis increases the likelihood and should prompt careful examination.

What is the Treatment for Pediatric Scoliosis?

The treatment for pediatric scoliosis depends on the severity of the curvature, the age of the child, and the likelihood of the curve progressing. The primary treatment options include observation, bracing, and surgery. Here’s an overview of each approach:

Observation

Mild Curves (less than 20 degrees):

• Regular Monitoring: For mild scoliosis, especially in children who are still growing, regular monitoring is often recommended. The doctor will schedule periodic check-ups and X-rays (every 4 to 6 months) to track the progression of the curvature.
• Physical Therapy: Although it doesn’t correct the curve, physical therapy can help strengthen the back muscles and improve posture

Bracing

Moderate Curves (20 to 40 degrees):

• Purpose: Bracing is used to prevent further progression of the spinal curve. It is most effective when the child is still growing.
• Types of Braces:
  • Thoracolumbosacral Orthosis (TLSO): The most common type, worn under clothes and fitting under the arms and around the rib cage, lower back, and hips.
  • Milwaukee Brace: An older type of brace that includes a neck ring, used less frequently today.
  • Nighttime Braces: Worn only at night and might be an option for certain types of curves.
• Duration: The brace is typically worn for 16 to 23 hours a day until the child stops growing.
• Compliance: The effectiveness of bracing depends on how consistently the child wears it.

Surgery

Severe Curves (greater than 40 to 50 degrees) or rapidly progressing curves:

• Spinal Fusion: The most common surgical procedure for severe scoliosis. It involves fusing the vertebrae together so they heal into a single, solid bone, which prevents further curvature.
  • Instrumentation: Metal rods, screws, and wires are often used to hold the spine straight while the vertebrae fuse.
  • Recovery: Hospital stay typically lasts about a week, and the child may return to normal activities within 6 months to a year, with restrictions on physical activities during the initial recovery period.
• Growing Rods: For young children who are still growing, growing rods can be an option. These rods are attached to the spine and periodically lengthened to keep up with the child’s growth.
• Vertebral Body Tethering: A newer, less invasive surgical option where a flexible cord is attached to the spine to control the growth on one side of the spine, allowing for some continued growth and correction of the curve.

Additional Considerations

• Post-Surgical Care: Physical therapy and follow-up visits are crucial for recovery and monitoring after surgery.
• Psychological Support: Scoliosis and its treatment can be challenging for children and adolescents. Psychological support and counseling may be beneficial to help them cope with the condition and its treatment.

Choosing the Right Treatment

• Individualized Approach: Treatment plans are tailored to each child’s specific condition, age, and growth potential.
• Consultation with Specialists: A multidisciplinary team approach, including pediatric orthopedic specialists, physical therapists, and, when necessary, psychologists, ensures comprehensive care.

Early detection and appropriate intervention are key to managing pediatric scoliosis effectively and preventing complications, allowing children to lead active and healthy lives.

What Can Happen if Pediatric Scoliosis is not Diagnosed and Treated in Time?

If pediatric scoliosis is not diagnosed and treated in a timely manner, it can lead to a range of complications and long-term health issues. The potential consequences depend on the severity and progression of the spinal curvature. Here are some of the key risks and complications associated with untreated scoliosis:

Progression of the Curve

• Worsening Deformity: Without treatment, the spinal curve may continue to worsen, leading to a more pronounced deformity.
• Asymmetry: Increasing asymmetry in the shoulders, hips, and ribcage, which can become more noticeable and may affect the child’s appearance and self-esteem.

Pain and Discomfort

• Back Pain: Although scoliosis is often painless in children, untreated severe curves can lead to chronic back pain and discomfort, especially in adulthood.
• Muscle Fatigue: Uneven muscle use and strain can lead to fatigue and muscle pain.

Respiratory and Cardiac Issues

• Reduced Lung Capacity: Severe scoliosis, particularly thoracic curves, can restrict the space available for the lungs, leading to reduced lung capacity and respiratory issues.
• Cardiac Problems: In extreme cases, severe spinal deformities can affect the heart, leading to cardiovascular issues.

Functional Limitations

• Limited Mobility: Severe scoliosis can restrict range of motion and flexibility, affecting the ability to perform daily activities and participate in physical activities.
• Difficulty Sitting or Standing: Prolonged sitting or standing can become uncomfortable or painful.

Psychological Impact

• Self-Esteem and Body Image: Visible deformities and asymmetry can affect a child’s self-esteem and body image, leading to social and emotional challenges.
• Mental Health: Anxiety and depression can result from the physical and social impacts of untreated scoliosis.

Degenerative Changes

• Early-Onset Degenerative Joint Disease: Untreated scoliosis can lead to premature wear and tear on the spine and associated joints, increasing the risk of arthritis and degenerative disc disease.

Increased Risk of Complications with Delayed Treatment

• Surgical Complexity: Delaying treatment can make surgical correction more complex and risky. Larger curves often require more extensive surgery with a higher risk of complications.
• Reduced Treatment Efficacy: The effectiveness of non-surgical treatments, like bracing, decreases as the curve progresses and the child ages.

Importance of Early Detection and Treatment

• Better Outcomes: Early detection and intervention can prevent many of these complications, leading to better overall outcomes.
• Less Invasive Treatments: Milder cases can often be managed with less invasive treatments, such as bracing, reducing the need for surgery.
• Improved Quality of Life: Early treatment helps maintain normal physical function and appearance, enhancing the child’s quality of life.

Regular screenings, awareness of the signs of scoliosis, and timely medical consultation are crucial in ensuring early diagnosis and appropriate management of pediatric scoliosis, thereby preventing the potential complications associated with untreated cases.

When is a Delay in Diagnosis Considered Medical Malpractice?

Sometimes (not always) a delay in the diagnosis of pediatric scoliosis can be considered medical malpractice. Medical malpractice occurs when a healthcare provider’s negligence leads to harm or injury to the patient.

For a delay in diagnosis to be considered malpractice, the following elements need to be proven:

Duty of Care

• Established Relationship: There must be a doctor-patient relationship, establishing that the healthcare provider had a duty to provide care to the patient.

Breach of Duty

• Standard of Care: The healthcare provider failed to meet the standard of care expected in the medical community. This standard is based on what a reasonably competent healthcare provider would do under similar circumstances.  Typically, this is performing scoliosis evaluations of the child as well child visits, recognizing when the child has signs of scoliosis, and ensuring the child receives the proper medical care.
• Failure to Diagnose: The delay in diagnosis occurs because the provider did not follow the accepted standards of care. This could include not performing routine screenings, not following up on signs and symptoms, or misinterpreting diagnostic tests.

Causation

• Direct Link: There must be a direct link between the delay in diagnosis and the harm suffered by the patient. The delay must have led to a progression of the scoliosis that could have been prevented with timely intervention.
• Avoidable Harm: It must be shown that earlier diagnosis and treatment would have likely resulted in a better outcome for the patient.

Damages

• Injury or Harm: The patient must have suffered significant harm or injury as a result of the delay in diagnosis. This could include:
  • Worsening of the spinal curvature
  • Increased need for more invasive treatments or surgeries
  • Chronic pain or physical limitations
  • Psychological or emotional distress
  • Reduced quality of life

Examples of Negligence Leading to Malpractice

• Ignoring Symptoms: Failing to investigate or refer a child for further evaluation when symptoms or physical signs of scoliosis are present.
• Failure to Screen: Failing to evaluate a child for scoliosis at each well child visit.
• Inadequate Screening: Not performing routine scoliosis screenings during well-child visits or not following up on abnormal findings.
• Misinterpretation of Tests: Misreading or not acting on abnormal X-rays or other diagnostic tests indicating scoliosis.
• Failure to Refer: Not referring the child to a specialist when scoliosis is suspected or detected.

Legal Process

If a delay in diagnosis of pediatric scoliosis is suspected to be medical malpractice, the following steps are typically involved in pursuing a claim:

1. Consultation with an Attorney: Consulting with a medical malpractice attorney to evaluate the case.
2. Medical Expert Review: Obtaining a review from a medical expert to determine if the standard of care was breached.  In Pennsylvania, a certificate of merit from a doctor in the same specialty as the potential defendant doctor is required by law.
3. Filing a Claim: If the expert review supports the claim, the attorney will file a medical malpractice lawsuit.
4. Discovery and Evidence: Gathering medical records, expert testimony, and other evidence to support the claim.
5. Settlement or Trial: The case may be settled out of court or proceed to trial for a judgment.

A delay in the diagnosis of pediatric scoliosis can be considered medical malpractice if it results from a healthcare provider’s negligence and leads to harm that could have been prevented with timely diagnosis and treatment. If you suspect malpractice, it is important to consult with a qualified attorney who specializes in medical malpractice cases.

How Lupetin & Unatin Can Help

If you suspect that a delayed diagnosis of scoliosis has harmed your child, the Pittsburgh medical malpractice lawyers at Lupetin & Unatin are here to help. We have extensive experience in handling medical malpractice cases and can provide the necessary legal support to pursue justice and compensation for your child’s injury. Our team will thoroughly investigate the circumstances, consult with medical experts, and advocate on your behalf to hold the responsible parties accountable.

Contact Lupetin & Unatin today for a free consultation to discuss your case and learn more about your legal options. We are dedicated to ensuring that medical professionals are held to the highest standards of care and that victims of medical negligence receive the justice they deserve.