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THE VIEW OF THE PATIENT ABOUT AESTHETICS AND HIS/HER EXPECTATIONS ABOUT THE TREATMENT.
Martha Hawes, PhD

aesthetics:
1. The branch of philosophy that provides a theory of the beautiful and the fine art;
2. The theories and descriptions of the psychological responses to beauty and artistic experiences;
3. In the philosophy of Kant, the branch of metaphysics concerned with the laws of perception. (Oxford English Dictionary)
The view of the patient about aesthetics and his/her expectations about the treatment Shands et al (1941) deduced that individuals with scoliosis seek treatment in response to concerns about appearance, not because patients complained about appearance but because they did not complain of other symptoms. Over the years this conclusion increasingly has been transformed into the presumption by physicians that patients seek spinal fusion as cosmetic surgery, even when patients express no such sentiments. Thus according to van Dam [1988], 'Although not expressed, cosmesis may be of primary concern to the patient' and Weinstein [1999] suggests that adults may become 'mentally disabled' by distress over their deformity. Lonstein [1995] has said, "It is becoming more and more obvious that cosmesis is one of the main factors that motivate patients to seek treatment. Many will not openly discuss this aspect of their scoliosis but once the subject of cosmesis is raised most patients show interest in improving their body image." It is well known that individuals with scoliosis do not always complain of symptoms even when clinical tests reveal significant deficiencies in pulmonary function, for example (Drummond 1985; Weinstein et al., 1981].
In my own case, by the time I was diagnosed in 1964 I had long been aware of pulmonary, pain and balance problems that interfered with school and other activities. But I only learned these might be related to my scoliosis when I initiated a literature search at our medical library in 1999 and read that pulmonary, pain and balance problems often are associated with spinal deformities. This was also the first I heard about 'cosmesis' being an issue. Conversations with other patients have revealed that as a group, we have diverse opinions even about the definition of what 'aesthetic appearance' means in terms of a spinal deformity, let alone its significance. The definition of 'aesthetics' (above) is a good reminder that subjectivity among doctors with regard to whether or not a back is aesthetically pleasing, is as problematical as in their patients. Several surveys have revealed major discrepancies between the judgements of doctors vs their patients [reviewed in Hawes 2007]. When patients were asked their reasons for choosing spine surgery, indeed, they reported the primary concern as long-term disability, not appearance [Bridwell et al. 2000]. Whether a patient is concealing his or her feelings about the aesthetics of having a spinal deformity, is difficult to evaluate. What is clear is that, whether the primary concern is aesthetics, disability, or both, the best solution is to prevent the progression of mild curvatures into conditions involving irreversible torso deformity, asymmetric gait and reduced respiratory function. My latest update of the scoliosis literature provides encouraging evidence for change (Table 1). With nearly 1000 new papers emerging in the last two years, articles describing surgery methods, complications and outcomes continue to predominate. But for the first time, a significant number of studies report outcome, diagnostic methods and principles of nonsurgical approaches with interpretable illustrations, that patients will be able to use to work with their doctors to judge their own problems and goals. Several recent reviews now have concluded that research into strategies for early intervention and prevention are needed.

References
Drummond DS (1985) in Bradford and Hensinger The Pediatric Spine, p. 171
Bridwell KH, Shufflebarger HL, Lenke LG, et al.(2000) Parents and patients preferences and concerns in AIS. A cross-sectional preoperative analysis. Spine, 25: 2392-2399.
Hawes M (2006) Impact of spine surgery on signs and symptoms of spinal deformity. Pediatr Rehabil 9: 318-39.
Lonstein JE (1995) IS. pp 219-256 in Moe's Textbook of Scoliosis and Other Spinal Deformities, Third Edition, Lonstein J, Bradford D, Winter R, Ogilvie J, WB Saunders, Philadelphia.
Shands AR, Barr JS, Colonna PC, Noall L (1941) End-result study of the treatment of idiopathic scoliosis. Report of the Research Committee of the American Orthopedic Association. J Bone Jt Surg 23: 963-977
VanDam B (1988) Nonoperative treatment in adult scoliosis. Orthopedic Clinics of N Amer 19: 347.
Weinstein SL (1999) Natural history. Spine 24: 2592-2600.
Weinstein SL, Zavala DC, Ponseti IV (1981) Idiopathic scoliosis: long term follow-up and prognosis in untreated patients. J Bone Jt Surg 63-A:702-712.