Wednesday, May 20, 2015

Please Measure the Cobb's Angle

I believe radiologists here in Davao City should measure the Cobb's Angle before they remark that a patient has scoliosis! I posted this in my Facebook timeline yesterday: 

"In about 6 weeks, Ashley and I will be posting stuff about Scoliosis Awareness. As we have done in the last 2 years. Due to Amber's recent chest X-ray there is a need to shout out that a curve less than 10 degrees is NOT scoliosis!!! It should be noted that a curved to whatever direction has been observed. But a curve in the spine less than 10 degrees is not scoliosis!!!"

I also added this on my Facebook post: "Also if a curve has been observed ask for the Cobb's Angle. I think this makes sense since how will the orthopedic doctor know if the radiologist won't measure it? And how else can the radiologist know if he should just note it or call it scoliosis. "The term “Cobb Angle” is used worldwide to measure and quantify the magnitude of spinal deformities, especially in the case of scoliosis. The Cobb angle measurement is the “gold standard” of scoliosis evaluation endorsed by Scoliosis Research Society. It is used as the standard measurement to quantify and track the progression of scoliosis."
I got that here.

Here is another reason why you should ask for the Cobb's Angle. "It is important to realise that the accuracy of measurement of this angle is only to +/- 5 degrees and so a curve measured at 40 degrees could be between 35 and 45 degrees. "

When my second daughter was diagnosed with Adolescent Idiopatic Scoliosis, her Cobb's angle was 20 degrees as measured by our doctor, not the radiologist. We were asked to get another x-ray after 6 months in which her Cobb's Angle increased to 28 degrees. We went for a second opinion, and then a third and we were told, over and over again to wait and see since there is a margin of error of 2 to 5 degrees depending on who is measuring the angle. And each doctor made their own measurements with varying degrees. It seemed to me like the first x-ray was being dismissed on account of it not being measured by the radiologist! Again, the doctors were relaxed and kept saying that scoliosis is very common. Luckily, for my daughter because fo all the confusion and my doubts, I had taken her for a 2nd x-ray 4 weeks after her first one was taken and on that x-ray, the radiologist this time, measured the Cobb's angle 21 degrees. So, based on that measurement, her curve increase by 7 degrees in a span of 5 months!

As a parent, it is so unsettling to see and then be told by doctors that your child's spine is curving sideways and there seems to be nowhere to go. Compound that with an incomplete x-ray reading.

Why is it that here in Davao, the threshold for scoliosis seems to be any curve in the spine while for the rest of the world its at the very least 10 degrees before they say that a person has scoliosis? The two resident doctors I consulted for my eldest daughter's chest x-ray (one face to face on the day the x-ray was taken and the other yesterday afternoon on the phone) explained to me that based on their guidelines (both did not state where these guidelines came from) 8 to 10 degrees = mild scoliosis. Logic tells me that A LOT people who will get their x-rays at the said hospital will then be told that they have mild scoliosis. 

See here: 
From Australia: "Although scoliosis by definition (a curve of 10° or more) "
From the UK: "Curves measuring up to 11° are considered normal." and check out the chart here
From Europe: "Only 10% of adolescents with curves greater than 10ยบ require active treatment. Of these, 85–90% can be treated with non-surgical methods."" Again, below 10 degrees, then it is not called scoliosis.
From the US:  "The Scoliosis Research Society defines scoliosis as a curvature of the spine measuring 10 degrees or greater on x-ray."
From Asia:  Mild curve is stated to be at 10 to 20 degrees.

Here is what this radiology site have to say, "The angle may be plotted manually or digitally and scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more."

I am not upset that my eldest daughter was noted to have a curvature in her spine. But does she really have scoliosis? How can the radiologist write scoliosis and miss out writing the Cobb's Angle? Scoliosis can be accidentally discovered during chest X-ray or a patient will need an X-ray to figure out the severity of his or her condition to come up with a treatment plan. So, if the radiologist sees a curve during a chest xray shouldn't he or she measure it?

We had 5 doctors appointments in 2011 here in Davao City for our second daughter's scoliosis and none of the doctors used a scoliometer. We relied on x-ray readings/results! So it is very important that x-rays be complete. Patients rely on them! Both resident doctors I spoke to yesterday pointed to me that they write simply what they see. So why stop short at measuring what they see!??

What was upsetting about the x-ray experience with my eldest daughter last Monday,  are:
1. I had to ask for what should have been there and it was not comfortable.
 2. Instead of coming home with an X-ray result in hand we had to go back for it the next day!
3. The man I spoke wearing a radiology department uniform of the hospital acted like he couldn't care less. Thus making me feel uncomfortable. Unfortunately, I am taking his actions as a reflection of the standard and training that they have in the said hospital and the culture, at least of their radiology department.

Surprised that my eldest has scoliosis, I explained to this man that I wanted to speak to the radiologist and why I wanted the Cobb's Angle measured. He replied that I have to go see the orthopaedic doctor for that, not a radiologist. He also added that it is not a standard in that hospital to put the Cobb's angle because it is a chest x-ray and not a scoliosis screening!

I was not asking for a plan of action. I was simply stating that the revelations the radiologist made is lacking! The audacity to dismiss a valid request as if he had an orthopaedic doctor to recommend right there and then is astounding! Of course he does not know that four years ago, my husband and I along with our second daughter had to wait for 6 hours in that same hospital just to see this top orthopaedic doctor for one appointment. I called for that appointment four days before we went and even called to confirm the appointment a day before going! And in the end, we had to settle with another doctor after 6 hours of waiting! Now I understand the long line at the orthopaedic doctor's clinic.

How did all this end? We have a CD copy of my eldest daughter's chest xray and a long size bond paper that say stuff you would read in a normal chest X-ray concluding with,

Addendum created May/19/15:  "A 9 degree scoliosis is noted T8 -T12 with convexity to the right."

If we were living else where this would not be called scoliosis. But here in Davao City, Philippines it is called scoliosis! Why? What is the basis for this?

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