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Idopathic Scoliosis

Screening, diagnosis and treatment

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Primary care providers are committed to the early detection of idiopathic scoliosis so that an optimal treatment course can be implemented. Most screening for scoliosis occurs in schools, with confirmation of diagnosis in healthcare settings.1 Although the appropriateness of screening in schools is an ongoing subject of debate, several national health organizations continue to recommend the practice (Table 1).2

Background

Scoliosis is a spinal deformity characterized by a lateral curvature of more than 10 degrees.3 The primary deformity in scoliosis is lateral flexion plus rotation of the involved vertebrae around a vertical axis. Scoliosis is classified as nonstructural or structural according to magnitude, location, direction and cause. It may also be categorized by convexity and curvature:4 dextroscoliosis (convexity on the right side), levoscoliosis (convexity on the left side) and rotoscoliosis (both lateral and rotational spinal deviation).

The prevalence of scoliosis presenting with curvatures of less than 10% is between 0.3% and 15% in school-aged children.3 For curvatures greater than 10%, the range is 1.5% to 3%. For curvatures greater than 20%, the prevalence is 0.3% to 0.5%. Curvatures greater than 30% are the least common, with prevalence between 0.2% and 0.3%.5

The etiology of scoliosis is unknown, but it is believed to be a result of genetic, neuromuscular, hormonal and biomechanical abnormalities.3 Bone malformation during fetal development, asymmetric muscle weakness and abnormal postural control are possible sources. Scoliosis is more common in girls than boys.6,7

School-Based Screening

Screening for idiopathic scoliosis was introduced in the United States and many other countries in the 1970s.8 In 26 U.S. states, school-based screening is now mandatory.3,9 Eleven states recommend screening, and the remainder offer voluntary screening or have opted not to provide scoliosis screening in schools.10

Japan mandates scoliosis screening in schools, but local educational committees set the standards for compliance. In Great Britain, the British Orthopaedic Association and the British Scoliosis Society decided that it is not necessary to make school screening a national policy. The Netherlands screen an estimated 80% of children for scoliosis at least once.11

In the typical school-based screening in the United States, the assessment is made by a school nurse or someone hired by the school to perform screening. The student disrobes from the waist up, to allow for full visualization of the spine.12 He or she then bends over to attempt to touch the toes. The examiner assesses the hips and shoulders for symmetry and uses an inclinometer to measure any spinal curvature.12 Students with curves of 5º to 10º are rescreened in 6 months. Medical referral and x-ray are recommended for curvatures of 7º or more.2

Clinical Diagnosis

Idiopathic scoliosis typically develops after age 10. It is a lateral and rotational spinal curvature in the absence of associated congenital or neurologic abnormalities. Clinical diagnosis is made based on a spinal curvature of more than 10 degrees.13

The early detection of spinal deformities that appear in adolescence can improve long-term outcomes. Developmental delay or abnormal gait may be early signs of neuromuscular disease associated with scoliosis.14 Back pain, if present, should be assessed and documented. General inspection of the back, the prominence of the scapula, and measurement of shoulder levels and the alignment of the head over the sacrum are essential. Deviations may reflect a deformity.

A family friend may be the first to notice spinal deformity in an adolescent. Or, the adolescent may notice that clothes do not fit as they once did. For example, one pant leg may be shorter than the other.9

A primary care provider can detect several clues to a possible spinal deformity: an off-center appearance of the head; one hip or shoulder higher than the opposite side; rib cages of differing height; changes in the look or texture of skin overlying the spine (dimples, hairy patches, color changes).4                                                                                                                 

Diagnostic Tests

Table 2 outlines options for scoliosis screening.2 The Adam's forward bend test is the most commonly used screening tool in school settings. The gold standard for diagnosing spinal curvature greater than 10 degrees is a plain anteroposterior x-ray. This is used to assess the severity of the condition using the Cobb angle, an angle between the axes of the upper and the lower of the most inclined vertebra.10 Several other tools are available but used less commonly.


Magnetic resonance imaging should be obtained in patients with an onset of scoliosis before age 8 years, with a rapid curve progression of more than 1 degree per month, an unusual curve pattern, a neurologic deficit, or pain.9                     

Therapeutic Intervention

Treatment for idiopathic scoliosis aims to prevent the progression of the magnitude of spinal curve. Progression depends on severity as well as skeletal maturity.3 Spinal curvatures of less than 10 to 15 degrees do not require treatment. These can simply be monitored every 3 to 4 months or once a year, after a baseline x-ray. Mild scoliosis typically does not progress and in many cases causes few physical problems.13

Curves of 25 to 45 degrees are considered moderate and can be treated with bracing. Some braces are worn 18 to 23 hours a day.15 Factors contributing to the success of brace treatment include: sufficient time in brace daily, weight loss, flexibility gain or loss, and appropriate, comfortable fit. Table 3 lists the types of braces used to treat scoliosis.15

Curvatures greater than 50 degrees require surgery and rod placement, and bone grafting may be necessary to achieve partial or complete correction.9 The image accompanying this article shows a left-standing radiographic view of postsurgical rod placement.

Other indications for surgery include progressive axial rotation leading to severe back pain, cardiopulmonary compromise, progressive cosmetic deformities, social and emotional problems, and possible subsequent morbidity and mortality.2

Education Essential

Patients with scoliosis require education about proper posture when sitting and standing, strategies to prevent back pain, and adherence to treatment. Socialization can be especially difficult, and counseling or other assistance may be helpful. Early family support and the encouragement of independence can help ensure that adolescent patients achieve maximal adult function.                        

School-based screening for scoliosis should use tests that are easily reproducible and have low false-positive and false-negative rates.16 The Adam's forward bending test used in conjunction with the scoliometer should not attempt to predict the degree of curvature; that determination is best made by the patient's healthcare provider.     

Patients with severe spinal curves are not difficult to diagnose.9 So why are some adolescents with pronounced scoliosis not identified earlier? Modesty and privacy concerns often lead these teens to wear loose clothing, preventing visualization of deformity. To increase early recognition, NPs and PAs should encourage parents to periodically inspect the backs of their adolescent children.        

References

1. Fong DY, et al. A meta-analysis of the clinical effectiveness of school scoliosis screening. Spine. 2010;35(10):1061-1071.

2. Minnesota Department of Health Community & Family Health Division, Maternal-Child Health Section. Adolescent School Screening for Scoliosis in Minnesota Review of Literature and Current Practice Recommendations. St. Paul, MN: Minnesota Department of Health; 2008: 1-31. http://www.health.state.mn.us/divs/fh/mch/scoliosis/litreview.pdf

3. Mirtz TA, et al. Adolescent idiopathic scoliosis screening for school, community, and clinical health promotion practice utilizing the  PRECEDE-PROCEED model. Chiropr Osteopat. 2005;13:25.

4. International Spine Association. Scoliosis. http://www.spinephysicians.org

5. Wajchenberg M, et al. Genetic aspects of adolescent idiopathic scoliosis in a family with multiple affected members: a research article. Scoliosis. 2010;5:7.

6. Trobisch P, et al. Idiopathic scoliosis. Dtsch Arztebl Int. 2010;107(49):875-884.

7. Sharma S, et al. Genome-wide association studies of adolescent idiopathic scoliosis suggest candidate susceptibility genes. Hum Mol Genet.    2011;20(7):1456-1466.

8. Bunge EM, et al. NESCIO Group. Screening for scoliosis: do we have indications for effectiveness? J Med Screen. 2006;13(1):29-33.

9. Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician. 2002;65(9):1817-1822.

10. Grivas TB, et al. SOSORT consensus, paper: school screening for scoliosis. Where are we today? Scoliosis. 2007;2:17.

11. Bunge EM, et al. Estimating the effectiveness of screening for scoliosis: a case-control study. Pediatrics. 2008;121(1):9-14.

12. Eck JC. Scoliosis. http://www.medicinenet.com/scoliosis/article.htm  

13. Ovadia D, et al. Radiation-free quantitative assessment of scoliosis: a multi center prospective study. Eur Spine J. 2007;16(1):97-105.

14. Taft E, Francis R. Evaluation and management of scoliosis. J Pediatr Health Care. 2003;17(1):42-22.

15. Fayssoux RS, et al. A history of bracing for idiopathic scoliosis in North America. Clin Orthoped Relat Res. 2010;468(3):654-664.

16. Grivas TB, et al. The direct cost of "Thriasio" school screening program. Scoliosis. 2007;2:7.

Andrea M. Patterson is a family nurse practitioner at Baptist Primary Care in Jacksonville, Fla. She has completed a disclosure statement and reports no relationships related to this article.




     

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