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. 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.