Structural Drivers of Race and Sex Disparities in Adolescent Idiopathic Scoliosis Care: A Narrative Review

Abstract

Purpose

Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity of adolescence and disproportionately affects females, with outcomes strongly dependent on curve magnitude and timing of detection. Increasing evidence demonstrates that structural and systemic factors influence multiple stages of the AIS care continuum and may be the primary drivers of disparities in care amongst this population. This narrative review synthesizes contemporary evidence on sex- and race-based inequities in AIS, emphasizing structural drivers rather than biologic explanations for these disparities and highlighting priorities for future research.

Recent findings

Studies examining presentation severity show heterogeneous results, but intersectional analyses consistently identify compounded disadvantage among Black adolescents with public insurance. Delayed detection and loss to follow-up emerge as central mechanisms linking social context to higher surgical rates and greater economic burden. In contrast, disparities in short-term postoperative complications appear attenuated after adjustment in many cohorts. However, differences in length of stay, hospital charges, and the geographic distribution of care persist, primarily related to patient race and insurance coverage. Most variation in findings across settings reflects differences in screening policies, insurance structures, and the socioeconomic indices used to characterize disadvantage, as well as limitations inherent to administrative databases and registry attrition.

Summary

The available evidence indicates that structural and systemic factors, rather than biological factors, have a direct impact on disparate care in AIS. This impact is most noticeable at the initial stages of care, such as screening and diagnosis, where sociocultural and socioeconomic differences can affect patients’ access to timely non-operative care. However, it seems once the decision to treat with surgery has been made, the previously existing disparities do not affect surgical outcomes but can affect long-term follow-up.

Introduction

Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity of adolescence and demonstrates a marked female predominance [1, 2]. Progression risk is strongly associated with skeletal maturity and curve magnitude at detection [1, 2]. Early identification is crucial for clinical decision making, as brace treatment reduces progression to surgical thresholds in skeletally immature patients [1, 2]. Conversely, delayed presentation is associated with higher surgical rates and substantially increased costs [3, 4].

An expanding body of literature now suggests that race, sex, insurance status, and neighborhood-level socioeconomic conditions influence multiple stages of the AIS care pathway, including presentation severity [5–8], access to nonoperative treatment [7, 9], surgical utilization and resource use [10–12], and longitudinal follow-up [13, 14]. However, reported associations are heterogeneous across studies and appear strongly affected by regional screening practices, insurance structures, and the social deprivation indices used to characterize disadvantage, including the Childhood Opportunity Index (COI), Area Deprivation Index (ADI), and Index of Concentration at the Extremes (ICE) [6, 15, 16].

Extensive registry-based analyses and national administrative datasets have broadened the understanding of AIS disparities [10, 12, 16]. Consistent with pediatric equity frameworks, these patterns point primarily to structural and systemic factors as the primary drivers of disparities in AIS rather than to intrinsic biological differences [17]. This review synthesizes contemporary evidence regarding sex- and race-based inequities across the AIS care pathway, with particular attention to how screening policies, insurance coverage, and neighborhood context modify observed disparities.

The Structural Determinants of AIS Disparities

The public health sector characterizes socioeconomic status as a “fundamental cause” of health inequality because it governs access to flexible resources (e.g., transportation, health literacy, time, advocacy) that shape a patient’s access to effective interventions when treatments exist [17]. When applied to AIS, this framework predicts that adolescents from disadvantaged communities may experience delays at multiple inflection points in their treatment.

AIS-specific equity frameworks echo this view. Boozé et al. emphasize screening mandates, payer mix, geographic access to pediatric spine centers, and registry participation as upstream system features that may amplify or mitigate disparities [16]. Todderud et al. [14] argue that differential enrollment and retention in registries risk distorting estimates of AIS outcomes for marginalized populations, as these populations are systematically excluded from databases and research. Thus, this review interprets observed race- and sex-associated differences primarily through a systems-of-care approach, asking where inequities emerge, how they compound across stages, and where there is room for growth.

Detection, Screening, and Referral: Where Disparities Begin

Reviews of U.S. scoliosis screening programs show that adoption and persistence of screening policies have been shaped not only by epidemiologic evidence but also by advocacy organizations, reimbursement incentives, and political forces [1, 18]. Such contextual factors intersect with broader inequities in access to primary care, school health and screening services, and pediatric orthopaedic subspecialists, all of which disproportionately affect families with limited resources. Table 1 summarizes structural factors that may affect AIS disparities at this stage of the care pathway.

Table 1.

Detection, screening, and referral in adolescent idiopathic scoliosis. System-level factors influencing detection, referral timing, eligibility for conservative treatment, and downstream cost in adolescent idiopathic scoliosis. Quantitative estimates are shown where available

Structural factor / Exposure	Outcome affected	Direction of association	Quantitative findings (if available)	Evidence base
Presence of school screening	Severity at presentation	Earlier detection → smaller curves	Cobb increased 20°→23° after cessation (P = 0.001)	Thomas, 2018 [20]
Screening test performance	Referral accuracy	Improves appropriate referral	Sensitivity 93.8%; specificity 99.2%	Dunn, 2018 [1]; Fong, 2010 [19]
Screening cessation	Eligibility for bracing	Fewer brace-eligible cases	Bracing at first visit ↑ 13.2%→19.0%	Thomas, 2018 [20]
Fragmented referral networks	Surgical-range presentation	Increased	Larger Cobb at referral in disadvantaged groups	Zavatsky, 2015 [5]; Heffernan, 2022 [7]; Diebo, 2019 [9]
Screening policy heterogeneity	Geographic inequity	Variable	—	Oetgen, 2021 [18]; Grossman, 2018 [2]
Delayed referral	Cost; surgery	Increased downstream utilization	Modeled cost ↑ >$40k/patient	Nadler, 2025 [4]

A meta-analysis of 36 international screening programs reported a pooled AIS prevalence of 1.34% (95% CI 0.98–1.70) for Cobb angles ≥ 10° and 0.22% (95% CI 0.15–0.30) for Cobb angles ≥ 20° [19]. Additionally, referral rates for further evaluation reached 5.0% (95% CI 3.3–6.7), with multimodal strategies outperforming forward-bend testing alone [19]. The United States Preventive Services Task Force (USPSTF) reported screening sensitivity of 93.8% (95% CI 93.3–94.3) and specificity of 99.2% (95% CI 99.2–99.2) and confirmed brace efficacy in preventing progression [1, 2]. However, the USPSTF continues to issue an “insufficient evidence” recommendation against universal screening, citing limited data linking screening to improved adult health outcomes, uncertainty about cost-effectiveness, and incomplete reporting of potential harms. Unfortunately, this recommendation is based on limited research on the possible impact of universal scoliosis screening into adulthood and has contributed to wide state-level variability in implementation [2].

Natural experiments created by the discontinuation of screening programs provide insight into the role of detection systems in shaping AIS presentation. Following cessation of countywide school screening, the mean Cobb angle increased from 20° to 23° (P = 0.001), and bracing at the first visit rose from 13.2% to 19.0% (P = 0.04), despite fewer referrals [20]. Similar findings were reported in Canadian cohorts evaluating post-screening eras, in which adolescents were more likely to present with curves beyond conservative-management thresholds [21, 22].

Referral-pattern studies in underserved settings highlight how structural barriers intersect with race and insurance. Zavatsky et al. [5] and Heffernan et al. [7] reported that disadvantaged racial and payer groups were more likely to present with surgical-range curves. Similarly, Diebo et al. [9] observed that nearly 60% of brace-eligible adolescents in an urban safety-net cohort had never received orthotic treatment before referral.

This body of evidence suggests that detection systems serve as equity levers only when downstream access to treatment is available. Screening heterogeneity, referral infrastructure, and primary-care access likely explain much of the regional variability in presentation severity.

Curve Severity at Presentation

Curve magnitude at presentation strongly predicts progression and determines eligibility for brace treatment in skeletally immature adolescents [1, 2]. Evidence linking race, insurance status, and neighborhood deprivation to presentation severity is heterogeneous and appears strongly modified by screening exposure and health-system context [5, 6, 15, 23, 24]. Intersectional analyses, particularly those examining the intersection of race and insurance, provide some of the strongest indications of structural disadvantage [7, 14]. Table 2 summarizes all factors that impact curve severity at presentation.

Table 2.

Determinants of curve severity at initial evaluation. Associations between sex, race/ethnicity, insurance status, neighborhood socioeconomic measures, and curve magnitude at presentation. NS denotes not statistically significant

Exposure domain	Direction of association	Quantitative findings	Contextual modifiers	Evidence base
Hispanic ethnicity	↑ Cobb	Larger curves	Screening exposure	Covell, 2024 [24]
Race × insurance	Strong intersectional effect	Black + public insurance = reduced odds of brace-eligible curves at presentation → OR 0.33 (95% CI 0.13–0.83)	Structural barriers	Heffernan, 2022 [7]
Female sex	↑ Cobb	Female Cobb angles approx. 4° larger than males (22.4°±12.8 vs. 18.1°±12.5 [P < 0.05])	Modified by system context	Russell, 2020 [6]
Registry under-representation	Biases severity estimates	Decreased follow-up in Black adolescents and lack of inclusion of other racial and ethnic minorities.	Selection bias	Todderud, 2024 [14]
Race (Black vs. White)	Mixed	Black patients’ Cobb angles are larger than those of White patients [5]. Meta-analysis [24] found no difference between races.	Referral systems; registry bias	Zavatsky, 2015 [5]; Covell, 2024 [24]
Insurance	Mixed	Public insurance ↓ brace eligibility: OR 0.54 (95% CI 0.33–0.86)	Screening presence	Heffernan, 2022 [7]; Russell, 2020 [6]
Neighborhood deprivation	Mixed	ADI NS; higher deprivation → ↑ Cobb	Universal insurance attenuates	Nezwek, 2021 [15]; Orellana, 2024 [23]

Zavatsky et al. [5] found that Black patients had significantly larger mean Cobb angles than White or Hispanic peers and were more likely to undergo surgery as initial treatment. Russell et al. [6] similarly reported modest but statistically significant differences in Cobb angle by insurance status and sex. However, ethnicity was not independently associated with severity in their screened Texas population. Heffernan et al. [7] provided particularly compelling intersectional evidence showing that public insurance reduced the odds of brace-eligible presentation overall (OR 0.54, 95% CI 0.33–0.86), with the most substantial effect among Black adolescents (OR 0.33, 95% CI 0.13–0.83). In contrast, insurance status was not associated with severity among White patients.

Meta-analytic work, however, found no significant difference in the Cobb angle between Black and White patients (mean difference − 2.6°, 95% CI − 7.3 to 2.1), though Hispanic patients had larger curves [24]. Todderud et al. [14] highlighted under-representation and lower follow-up among Black adolescents in registries, raising concerns that apparent severity differences may reflect selection bias rather than actual disease distribution.

Neighborhood deprivation indices also yield heterogeneous findings. In Massachusetts, ADI and COI were not associated with curve severity [15]. Linden et al. [25] similarly reported no association between COI and severity among surgical patients. Russell et al. [6] also observed no relationship between zip-code income proxies and Cobb angle in Texas. By contrast, European cohorts reported higher Cobb angles among adolescents from deprived neighborhoods, even within publicly funded systems [23, 26].

Female sex remains a significant determinant of disease progression [1, 2] and was associated with larger curves in some screened cohorts [6, 26]. However, these differences may not be present between racial groups. Lara et al. [3] examined African American adolescents with AIS. They found that sex was not an independent predictor of curve progression or surgical intervention after adjustment for age and baseline Cobb angle, suggesting that traditional sex-based risk models may be missing granular variations across racial and ethnic differences.

Disparities at presentation are most clinically meaningful when they shift adolescents out of the brace-eligible window. The most significant impact appears to arise where race, insurance, and neighborhood context intersect, suggesting a structural mechanism rather than uniform race- or sex-based effects.

Access to Conservative Treatment and Follow-Up

Data directly examining sex-based differences in brace eligibility or bracing rates are limited. Diebo et al. [9] reported that in underserved urban populations, both male and female adolescents experienced substantial gaps in screening and orthotic treatment prior to referral, without evident sex-stratified disparities. Registry-based studies summarized by Sborov et al. [27] and Arant et al. [28] suggest that sex is less influential than race or insurance status in determining access to bracing, though sex-specific analyses remain sparse (Table 3).

Table 3.

Access to conservative management and follow-up. Structural determinants affecting brace eligibility, orthotic receipt, and retention in care. Abbreviations: LTFU = loss to follow-up; COI = Childhood Opportunity Index; ADI = Area Deprivation Index

Exposure / Structural factor	Conservative-care outcome	Direction	Quantitative findings	Evidence base
Public insurance	Brace-eligible presentation	Decreased	OR 0.54 (95% CI 0.33–0.86)	Heffernan, 2022 [7]
Black race + public insurance	Brace eligibility	Markedly decreased	OR 0.33 (95% CI 0.13–0.83)	Heffernan, 2022 [7]
Underserved urban setting	Prior bracing	Decreased	~ 60% never braced	Diebo, 2019 [9]
Authorization delays	Brace initiation	Delayed	—	Arant, 2022 [28]; Sborov, 2023 [27]
Transportation barriers	Follow-up attendance	Reduced	—	Arant, 2022 [28]
Public insurance	LTFU	Increased	OR 1.55 (95% CI 1.09–2.21)	Goldstein, 2015 [13]
Black race	Registry retention	Reduced	Lower 2-yr follow-up	Todderud, 2024 [14]
Low COI	LTFU	Increased	COI predictive vs. ADI	Woodhams, 2025 [29]

Because brace effectiveness depends on early initiation and sustained follow-up, inequities in treatment access and patient retention represent a significant bottleneck. Public insurance, for example, seems to predict loss to follow-up (LTFU). Goldstein et al. reported higher odds of LTFU (OR 1.55, 95% CI 1.09–2.21) and premature discharge (OR 1.74, 95% CI 1.08–2.82) among publicly insured adolescents [13]. Linden [25] similarly reported lower one-year postoperative follow-up, while Todderud [14] demonstrated lower two-year registry follow-up among Black adolescents.

Neighborhood metrics may identify different high-risk groups. Woodhams et al. reported that COI, but not ADI or ICE, predicted LTFU, illustrating how metric selection shapes inferences [29]. Disparities in conservative-care access reflect delayed detection and referral [5, 7, 20], limited bracing before specialty evaluation in underserved settings [9], insurance- and transportation-related access barriers [27, 28], and differential LTFU by race and insurance [13, 14, 25, 29]. These processes are associated with higher operative utilization and cost [4, 30] and may bias registry-based estimates through selective attrition [14].

The Impact of Surgery, Cost, and Geographical Location

AIS surgical cohorts report attenuation of racial differences in major short-term complications such as postoperative pain and morphine consumption in sex- and race-controlled statistical analyses (Table 4) [10, 31]. Nonetheless, propensity-matched analyses identified higher odds of venous thromboembolism among Black patients, following adjustment for confounders [32]. Similarly, Medicaid patients have been found to have higher crude infection and hemorrhage rates and longer length of stay (LOS) [10]. Ferreri et al. found that public insurance patients consistently scored lower than private insurance patients across all Scoliosis Research Society 22r Questionnaire domains, despite similar preoperative and operative characteristics [8]. Nonetheless, patient-reported outcome research explicitly examining AIS disparities by sex or race is missing from the published literature.

Table 4.

Drivers of surgical utilization, cost, and geographical disparities in AIS. Abbreviations: LOS - length of stay; OR - Odds ratio

Structural driver	Surgical / Economic outcome	Direction	Quantitative findings	Evidence base
Medicaid insurance	LOS; infection	Increased	Infection OR 1.76 (95% CI 1.08–2.85)	Cho, 2015 [10]
Black race	Venous thromboembolism risk	Increased	Persistent after matching	Kaushal, 2021 [32]
Hospital region	LOS; cost; complications	Highly variable	Northeast ↑ complications	Koo, 2020 [11]
Rural hospitals	Charges	Increased	—	Shaw, 2022 [33]
Late presentation	Surgical rate; lifetime cost	Increased	Surgery 47% vs. 12%; +$40k	Nadler, 2025 [4]
Surgical wait time	Complications; complexity	Increased	OR 1.81 per 90 days	Pontes, 2023 [30]
Hospital volume	Mortality; discharge	Improved at large centers	Lower mortality	Nuño, 2013 [12]
Rural residence (international)	Financial toxicity	Increased	Higher cost-to-income ratio	Wang, 2010 [34]

Cost and utilization disparities are more consistent. Delayed detection of AIS has significant economic implications. Nadler et al. demonstrated that adolescents presenting late with surgical-range curves incurred markedly higher costs than brace-eligible patients, with surgery rates of 47% versus 12% at five years and modeled per-patient cost differences exceeding $40,000 [4]. Eliminating late presentation was projected to save $2.3–2.9 million annually at a single tertiary center [4]. Comparably, Shaw et al. reported that Medicaid coverage and Hispanic race independently predicted higher costs [33]. Concomitantly, longer surgical wait times were associated with greater curve progression, higher operative complexity, increased costs, and adverse events per additional 90 days of wait time until surgery [30]. Notably, some of the characteristics tied to increased cost and utilization (i.e., Hispanic ethnicity and public insurance) are likely downstream effects of upstream structural disparities, as these are also associated with higher rates of delayed AIS diagnosis and decreased access to non-operative treatment.

Geographic location has a significant impact on the quality of AIS surgical care in the United States. Koo et al. identified substantial regional variation in complications, transfusion rates, LOS, discharge disposition, and costs across census regions, with the Northeast demonstrating the highest complication rates and the West the highest charges [11]. Regional cohorts also differed significantly in racial composition and Medicaid prevalence, suggesting that population-level social context contributes to the observed variation. Similarly, Achonu et al. showed that surgeries in New York State were disproportionately clustered in urban academic centers and that shifts toward medium-volume hospitals altered the regional distribution of care over time [35].

International cohorts show similar system effects: as AIS care progresses downstream, disparities shift from complication risk to economic burden. Adolescents from rural China experienced higher cost-to-income ratios despite similar outcomes [34]. Across multiple AIS surgical cohorts, racial differences in short-term complications often diminish after adjustment, whereas disparities in LOS, hospital charges, discharge disposition, and geographic distribution persist [10, 11, 32–35]. These patterns point to payer mix, regional capacity, and hospital-level resources as dominant drivers of inequity within surgical AIS care [12, 17, 36]. Structural features consistently stand out as the primary drivers of inequity.

What It Means, What To Do, And Where To Go

Across the AIS care continuum, a consistent pattern emerges: disparities by race, insurance status, and neighborhood context arise primarily at upstream stages rather than from intrinsic biologic differences in disease behavior. Screening policies, referral infrastructure, insurance coverage, and geographic access to pediatric spine centers repeatedly modify observed association [5, 7, 11, 20]. Once adolescents reach operative treatment within standardized systems, many short-term safety differences attenuate, while inequities in resource utilization and cost persist [10, 32, 33]. This trajectory supports a systems-of-care model in which structural barriers compound over time and disproportionately funnel disadvantaged patients into higher-risk, more costly treatment.

From a clinical standpoint, the literature points toward several actionable priorities. Adolescents from historically marginalized groups, including those with public insurance or residing in highly deprived neighborhoods, may benefit from lower referral thresholds by primary care providers and from proactive outreach strategies by local health promotion groups, particularly in regions without mandated school-based screening [5, 7]. Delays in brace initiation represent a critical inflection point in the cost of care. Qualitative and review-based analyses emphasize that prior-authorization requirements, fragmented orthotics networks, transportation limitations, and limited subspecialty access frequently impede timely nonoperative care [27, 28]. This leads to higher rates of surgical interventions in underserved populations [4], virtually inflating the cost for treatment by forcing these groups into surgical management due to a missed opportunity for bracing. Integrating early orthotist involvement and social-work support into AIS clinics may therefore preserve opportunities for conservative treatment.

Improving longitudinal engagement is equally essential. Public insurance, Black race, and neighborhood deprivation consistently predict LTFU after initial evaluation and surgery [13, 14, 25]. Interventions such as patient navigation programs, telehealth follow-up, appointment reminders, transportation assistance, and flexible clinic scheduling have been proposed in pediatric orthopaedic equity reviews and in AIS cohorts as strategies to mitigate LTFU, particularly among publicly insured and racially marginalized populations [13, 14, 25, 27, 28]. Beyond their clinical importance, such strategies are necessary to mitigate attrition bias in AIS registries and long-term outcome studies, which currently underrepresent socially disadvantaged adolescents (Table 5) [14].

Table 5.

Sources of heterogeneity in AIS disparities research. Methodologic factors that limit cross-study comparability, including socioeconomic metrics, screening context, and data sources. Abbreviations: SES - Socioecomonic Status

Methodological issue	Effect on interpretation	Example sources
Different SES indices	Can reverse associations	Nezwek, 2021 [15]; Orellana, 2024 [23]
Screening context	Modifies race effects	Thomas, 2018 [20]
Registry attrition	Underestimates inequity	Todderud, 2024 [14]
Administrative data limits	Misses causal pathways	Cho, 2015 [10]
Lack of interaction modeling	Masks compounded risk	Heffernan, 2022 [7]

Standardization of perioperative pathways represents another potential equity lever. Although racial differences in short-term complications are generally attenuated after adjustment, payer- and region-associated variation in LOS and hospital charges persist [10, 11, 33]. Enhanced recovery-after-surgery protocols, transfusion guidelines, and coordinated discharge planning may reduce unwarranted utilization differences while maintaining safety. Continued surveillance for uncommon but persistent associations (i.e., elevated venous thromboembolism risk in Black adolescents) remains warranted [32].

The evidence base also highlights urgent research and policy priorities. Most existing AIS disparity studies are retrospective and rely on administrative datasets that lack granular clinical variables, including skeletal maturity, screening exposure, bracing history, and patient-reported outcomes [10–12]. Prospective multicenter cohorts capable of capturing these features would strengthen causal inference. Intersectional analytic approaches that formally test interactions among race, insurance status, sex, and neighborhood deprivation are critical given the emerging evidence of compounded risk [3, 7].

Finally, harmonization of socioeconomic measurement is essential for cross-study synthesis. Multiple neighborhood indices identify overlapping but distinct populations and are not interchangeable in their application or interpretation [15, 16, 23, 29]. Standardized reporting of geographic scale and race/ethnicity, alongside deliberate efforts to improve registry enrollment and retention, will be necessary to build an evidence base that accurately reflects the populations at risk.

Conclusions

AIS disparities most consistently reflect modifiable system-level factors (i.e., screening exposure, referral pathways, bracing access, and follow-up infrastructure) rather than intrinsic biologic differences. Sex remains central to progression biology, but race- and SES-associated inequities primarily arise through structural mechanisms that operate before definitive treatment. Addressing these gaps will require coordinated redesign of detection systems, conservative care pathways, and retention strategies, alongside rigorous, equity-focused research.

Key References

• Nadler EB, Kim DJ, Lebel DE, Dermott JA. The True Cost of Late Presentation in Adolescent Idiopathic Scoliosis: A 5-Year Follow-up Study. J Pediatr Orthop. 2025;45:e531–7.

  • ○ This Canada-based, single-center, retrospective study aimed to determine the cost differences between AIS patients diagnosed early enough to initiate brace treatment and those who initially presented with curves beyond the bracing range. This reference was chosen for its high-level methodology for cost analysis and for being one of the few publications examining the direct economic impacts of early AIS detection and surgery avoidance. Although its generalizability may be limited because the analysis is based on a universal healthcare system, it provides tangible data on the direct impact of late AIS diagnosis on both the patient and the healthcare system.
• Woodhams W, Benvenuti MA, Warren J, Thomas G, Anderson JT, Schwend RM, et al. Health disparity indices in the assessment of adolescent idiopathic scoliosis: are all indices similar? J Pediatr Orthop Soc N Am. 2025;13:100254.

  • ○ This single-center, retrospective study compared multiple SES indices (i.e., COI, ADI, ICE) to determine whether different disparity metrics similarly identify AIS patients at risk for severe curvature at presentation or loss to follow-up after surgery. This study was chosen for its ability to reflect the actual effects and applicability of these SES indices in AIS care. Although many indices have been developed to quantify the impact of socioeconomic status on patient care, this paper highlights that different metrics differ in their ability to predict clinical outcomes. Most importantly, it shows that awareness of the outcome of interest is the primary driver of which SES metric to use. Unsurprisingly, these metrics all measure SES in different ways and should not be used interchangeably.
• Covell NB, Chari T, Hendren S, Poehlein E, Green CL, Catanzano AA. A Framework for Studying Healthcare Equity in Adolescent Idiopathic Scoliosis: Scoping Review and Meta-Analysis of Existing Literature. J Am Acad Orthop Surg. 2024;32:e452–65.

  • ○ This scoping review and meta-analysis aimed to synthesize United States evidence associating race/ethnicity, insurance status, and socioeconomic status with Cobb angle at presentation for AIS patients. This study was selected due to its well-structured methodology and proposed AIS research framework. The authors provide a reliable interpretation of existing disparities in AIS care in the U.S., highlighting that, for disparities to be adequately investigated, we must first reach consensus on how we will categorize variables (e.g., race, ethnicity, public vs. private insurance). They also propose a basic framework for future researchers to ensure systematic data collection that supports between-study comparisons based on the data quality obtained.
• Garcia SM, Niknam K, Sumandea F, Swarup I. Socioeconomic differences in access to scoliosis care in the pediatric population. Spine Deform. 2024;12:1667–73.

  • ○ This retrospective database study assessed whether geographic residence (i.e., rural vs. urban) and socioeconomic characteristics (i.e., race/ethnicity, insurance type, and household income) influence postoperative outcomes after posterior spinal fusion in AIS. This study was selected for its large sample size (15,318 patients) and its adequate methodology. This study’s findings of non-significant effects of geographic residence and socioeconomic characteristics on postoperative outcomes for AIS underscore the message of this narrative review: disparities in AIS care are not biological and tend to have a diminished impact on surgical outcomes, as the main effect of these disparities seems to affect early detection and access to non-operative care.
• Heffernan MJ, Younis M, Song B, Fontenot B, Dewitz R, Brooks JT, et al. Disparities in pediatric scoliosis: the impact of race and insurance type on access to nonoperative treatment for adolescent idiopathic scoliosis. J Pediatr Orthop. 2022;42:427–31.

  • ○ This single-center, retrospective study assessed whether race (i.e., White vs. Black), insurance type (i.e., public vs. private), area deprivation index, or body mass index predict curve magnitude at presentation and likelihood of meeting brace indications (i.e., Cobb angle ≤40°). The authors reported covariate-controlled results showing that Black patients with public insurance had lower odds of presenting with a braceable curve. This study was selected for its reliable methodology and for its analysis of an under-reported effect of structural limitations to care: access to non-operative treatment. Most studies on AIS management focus on surgical cohorts or outcomes, leaving a gap in the literature on non-operative scoliosis treatment.

Author contributions

C.B. and S.I. researched, planned, and wrote the main manuscript text. C.B. prepared all tables. All authors reviewed and contributed to the manuscript equally.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Financial interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Competing interests

The authors declare no competing interests.