School screening for scoliosis: the value of quantitative measurement

Segmental Rib Index and Spinal Deformity: Scoliogenic Implications

The aim of this report is to evaluate the segmental rib index (RI) from the T1 to T12 spinal levels in mild and moderate idiopathic scoliosis (IS) curves of thoracic, thoracolumbar and lumbar type by gender. The relationship of segmental RI to the frontal plane radiological deformity presented as the Cobb angle and to the posterior truncal surface deformity presented as the scoliometric readings of Angle of Trunk Rotation (ATR) in these patients is also assessed. Any statistically significant relationship between these parameters would be very important for biomechanical relations in rib cage (RC) deformity presented as rib hump deformity (RHD) and deformity in the spine, and would thus provide valuable information about scoliogeny. The segmental rib index (RI) is presented in 83 boys and girls with mild and moderate IS. The measurements include the scoliometric readings for truncal asymmetry (TA), the Cobb angle assessment and the segmental RI from T1-T12. The statistical package SPSS 23 was used for statistical analysis. The TA was documented and the Cobb angle is presented by gender and curve type. The segmental RI of thoracic, thoracolumbar and lumbar curves are presented for the first time. The correlations of the segmental RI to surface deformity presented as rib hump deformity (RHD) in all IS patients, and particularly in thoracic curves, to Cobb angle by gender and age and the comparison of the segmental RI index of asymmetric but not scoliotic children to the scoliotic peers by curve (in thoracic, thoracolumbar, lumbar curves) in boys and girls are presented. The findings emphasize the significant protagonistic role of thoracic asymmetry in relation to the spinal deformity, mainly in girls for the thoracic and in boys for the thoracolumbar curves. The cut-off point of age of the examined scoliotics was 14 years, which is when the RI shows a stronger correlation with spinal deformity, namely when thoracic deformity is decisively effective in the development of thoracic spinal deformity, in terms of Cobb angle. In summary, the results of this study may provide scoliogenic implications for IS, as far as the role of the thorax is concerned.

Why Is There Always a Remnant Rib Hump Deformity after Spinal Operations in Idiopathic Scoliosis: Aetiological Implications and Recognition of the Proper Rib Level for Costoplasty

The aim of this report is to review the literature dealing with the postoperative correction of rib hump (RH) after spinal operations for adolescent idiopathic scoliosis (AIS) and its aetiological implications of hump postoperative fate for IS. Recommendations related to RH deformity for the follow-up of younger asymmetric but not scoliotic children are provided, and the concept that clinical monitoring of the chest deformity is more important than merely an initially negative radiographic examination (curve less than 10°) is underlined. Additionally, guidelines are provided based on the segments T1-T12 rib index (RI) in the existing lateral preoperative radiographs for the optimal selection of the rib level for a successfully costoplasty. This review is based on the collected articles that used either the RI method, derived from the double rib contour sign (DRCS) at the lateral spinal radiographs, or alternative methods for the assessment of the RH deformity and presented the results of the operative treatment of the scoliotic spine on RH. A total of 19 relevant articles published from 1976 to 2022 were found in PubMed. Findings: All the above articles show that not only is the hump incompletely corrected, but it recurs and worsens during the follow-up and even more intensively in skeletally immature operated scoliosis children. Conclusions and Future Directions: Surgery straightens the spine, yet the RH is corrected approximately only as much as the spinal derotation. The only way to correct the RH more is with costoplasty, which, however, is not performed in most cases for many reasons. The key reason for this phenomenon is the fact that the RH deformity (RHD) is mainly due to the asymmetric development of the ribs and much less so due to the rotation of the vertebrae in the thoracic spine. Surgery on the spine cannot limit the asymmetry of the ribs or stop the mechanism that causes their asymmetrical growth. The results presented in all the reviewed articles support the important protagonistic role of RHD on scoliogenesis, which precedes the subsequent formed spinal deformity.

Correlation Between Hump Dimensions and Curve Severity in Idiopathic Scoliosis Before and After Conservative Treatment

STUDY DESIGN

Prospective study in 150 consecutive outpatients affected by adolescent idiopathic scoliosis (AIS).

OBJECTIVES

The purposes were to (1) identify a correlation between hump dimensions and the severity of scoliotic curve, and (2) evaluate how the treatment influenced the main parameters of scoliosis.

SUMMARY OF BACKGROUND DATA

The existence of a relationship between clinical deformities and curve severity in AIS is still debated. Furthemore, only a few studies have investigated the effectiveness of conservative treatment for idiopathic scoliosis taking into account both clinical and radiologic factors.

METHODS

150 consecutive outpatients (mean age 12.8 ± 1.9 years) affected by AIS were subjected to conservative brace-based treatment. 134 participants completed the treatment protocol. Two parameters were considered to evaluate the treatment progress: the hump and the Cobb angle. Measurements were determined at the beginning and the end of treatment. Statistical analyses were performed in the whole sample and after dividing the study participants into 4 subgroups: patients with lumbar (n = 66) or thoracic curves (n = 68), patients ranging in age between 6 and 13 years (n = 89) and patients ≥ 14 years of age (n = 45).

RESULTS

A positive correlation was detected between the hump dimension and curve severity at the beginning and the end of treatment, except for lumbar curves at baseline. The deformity was effectively corrected by the orthotic treatment (Cobb angle: 29.4 ± 8.5° at baseline and 19.3 ± 9.8° at the end of treatment; hump severity: 11.6 ± 5.6 mm at baseline and 6.2 ± 4.6 mm at the end). In addition, our data indicate that the hump correction is more evident than that of the curve registered in Cobb degrees.

CONCLUSION

A significant correlation exists between the hump dimension and curve severity both at the beginning and the end of treatment, except for lumbar curves at baseline. The brace treatment confirmed its effectiveness in arresting the deformity progression and inducing a remodeling both of the scoliotic curve and the hump.

Systematic Review of School Scoliosis Screening

OBJECTIVES

The aim of this study was to review the literature on school screening and its reported effectiveness.

SUMMARY OF BACKGROUND DATA

There is no worldwide consensus concerning the mandating of school screening for scoliosis. This remains a controversial issue.

METHODS

The following databases were employed: Medline, Premedline, CINAHL, CENTRAL, AMED, Embase, SCOPUS, Ovid nursing, and Web of Science. These data were generated from the Forward Bend Test, the angle of trunk rotation and Moire topography. The first and second authors each independently screened titles and abstracts for potential studies. Fulltext papers of potential studies were also independently read by the first two authors to identify studies to be included based on strict inclusion/exclusion criteria. A heterogeneity test was performed by testing for the significance of the between-study variance. Publication bias was examined by a funnel plot.

RESULTS

We found 20 studies that met our inclusion criteria. The pooled estimate of prevalence of scoliosis curves in the population was 1.1% for curves greater than 10°, and 0.2% for curves greater than 20°. The pooled referral rate to radiography during the screening process was 6.6%. The pooled positive predictive values for detecting curves >10° and >20° were 32.3% and 6.5% respectively. Analysis of data demonstrated significant heterogeneity between studies but was not suggestive of the presence of publication bias.

CONCLUSIONS

We support the implementation of scoliosis screening as a means of detecting curves at an early treatable stage. The current available evidence in the literature for routine scoliosis screening is low to moderate. Challenges exist to the school scoliosis screening including a high referral rate to radiology.

Correlation between Topographic Parameters Obtained by Back Surface Topography Based on Structured Light and Radiographic Variables in the Assessment of Back Morphology in Young Patients with Idiopathic Scoliosis

Study Design

Optical cross-sectional study.

Purpose

To study the correlation between asymmetry of the back (measured by means of surface topography) and deformity of the spine (quantified by the Cobb angle).

Overview of Literature

The Cobb angle is considered the gold standard in diagnosis and follow-up of scoliosis but does not correctly characterize the three-dimensional deformity of scoliosis. Furthermore, the exposure to ionizing radiation may cause harmful effects particularly during the growth stage, including breast cancer and other tumors.

Methods

Patients aged 13.15±1.96 years (range, 7–17 years; n=88) with Cobb angle greater than 10° were evaluated with X-rays and our back surface topography method through three variables: axial plane (DHOPI), coronal plane (POTSI), and profile plane (PC). Pearson's correlation was applied to determine the correlation between topographic and radiographic variables. One-way analysis of variance and Bonferroni correction were used to compare groups with different grades of scoliosis. Significance was set at p<0.01 and, in some cases, at p<0.05.

Results

We detected a positive, statistically significant correlation between Cobb angle with DHOPI (r=0.810) and POTSI (r=0.629) and between PC variables with thoracic kyphosis angle (r=0.453) and lordosis lumbar angle (r=0.275). In addition, we found statistically significant differences for DHOPI and POTSI variables according to the grade of scoliosis.

Conclusions

Although the back surface topography method cannot substitute for radiographs in the diagnosis of scoliosis, correlations between radiographic and topographic parameters suggest that it offers additional quantitative data that may complement radiologic study.

Clinical application of back surface topography by means of structured light in the screening of idiopathic scoliosis

We present the results of the clinical validity in the screening of idiopathic scoliosis with a nonharming method of back surface topography by means of structured light projection. A total of 155 patients were evaluated (mean age 13.3 years). They were divided into two groups: pathologic patients (scoliosis) and nonpathologic patients (control and asymmetries). An analytical case-control study was carried out. Our topographic method obtained 92% sensitivity and 74% specificity as a screening test in identifying patients with scoliosis (P=0.05). We could quantify the vertebral deformity of scoliosis in the three spatial planes by means of three topographic variables, Horizontal Plane Deformity Index, Posterior Trunk Symmetry Index and Columnar Profile, and to elaborate a combined screening algorithm with good reliability parameters.

To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature

OBJECTIVES

Over the years, there has been much debate about the desirability and efficacy of screening for adolescent idiopathic scoliosis. To analyse the current evidence from a public health point of view a renewed evaluation of the literature was performed.

STUDY DESIGN

Literature review.

METHODS

We performed two literature searches: from January 2000 to April 2015 for systematic reviews or guidelines on screening for adolescent idiopathic scoliosis and from January 2009 to April 2015 for all studies on adolescent idiopathic scoliosis and screening methods. We evaluated if screening for adolescent idiopathic scoliosis fulfils the criteria of the UK National Screenings Committee for appraising a screening programme.

RESULTS

Adolescent idiopathic scoliosis is a condition with an unpredictable natural history. The optimal age and frequency of screening are unknown; it is not possible to predict which patients will need (conservative or surgical) treatment. The Forward Bending Test has a positive predictive value of 2.6% and a sensitivity of 56% (95% CI 23-88%) for (conservative or surgical) treatment, and is therefore not valid enough for use in a screening programme. There seems to be sufficient evidence that brace treatment is effective for preventing progression of adolescent idiopathic scoliosis. It is not clear if screening is cost effective.

CONCLUSIONS

Despite evidence that brace treatment is effective for preventing progression of adolescent idiopathic scoliosis, the benefits from the screening programme do not outweigh the harms. From a Public Health point of view, there is not enough evidence to support a screening programme for adolescent idiopathic scoliosis.

Evaluation of the iPhone with an acrylic sleeve versus the Scoliometer for rib hump measurement in scoliosis

Background

Vertebral rotation found in structural scoliosis contributes to trunkal asymmetry which is commonly measured with a simple Scoliometer device on a patient's thorax in the forward flexed position. The new generation of mobile 'smartphones' have an integrated accelerometer, making accurate angle measurement possible, which provides a potentially useful clinical tool for assessing rib hump deformity. This study aimed to compare rib hump angle measurements performed using a Smartphone and traditional Scoliometer on a set of plaster torsos representing the range of torsional deformities seen in clinical practice.

Methods

Nine observers measured the rib hump found on eight plaster torsos moulded from scoliosis patients with both a Scoliometer and an Apple iPhone on separate occasions. Each observer repeated the measurements at least a week after the original measurements, and were blinded to previous results. Intra-observer reliability and inter-observer reliability were analysed using the method of Bland and Altman and 95% confidence intervals were calculated. The Intra-Class Correlation Coefficients (ICC) were calculated for repeated measurements of each of the eight plaster torso moulds by the nine observers.

Results

Mean absolute difference between pairs of iPhone/Scoliometer measurements was 2.1 degrees, with a small (1 degrees) bias toward higher rib hump angles with the iPhone. 95% confidence intervals for intra-observer variability were +/- 1.8 degrees (Scoliometer) and +/- 3.2 degrees (iPhone). 95% confidence intervals for inter-observer variability were +/- 4.9 degrees (iPhone) and +/- 3.8 degrees (Scoliometer). The measurement errors and confidence intervals found were similar to or better than the range of previously published thoracic rib hump measurement studies.

Conclusions

The iPhone is a clinically equivalent rib hump measurement tool to the Scoliometer in spinal deformity patients. The novel use of plaster torsos as rib hump models avoids the variables of patient fatigue and discomfort, inconsistent positioning and deformity progression using human subjects in a single or multiple measurement sessions.

School screening and point prevalence of adolescent idiopathic scoliosis in 4000 Norwegian children aged 12 years

BACKGROUND

School screening for adolescent idiopathic scoliosis (AIS) is discussed. The aim of the present study was to describe the point prevalence of AIS and to evaluate the effectiveness of school screening in 12-year- old children.

METHODS

Community nurses and physical therapists in the Southern Health region of Norway including about 12000 school children aged 12 years were invited to participate. All participating community nurses and physical therapists fulfilled an educational course to improve their knowledge about AIS and learn the screening procedure including the Adam Forward Bending Test and measurement of gibbus using a scoliometer.

RESULTS

Sub-regions including 4000 school children participated. The prevalence of idiopathic scoliosis defined as a positive Adam Forward Bending Test, gibbus > 7° and primary major curve on radiographs > 10°, was 0.55%. Five children (0.13%) had a major curve > 20°. Bracing was not indicated in any child; all children were post menarche; four had Risser sign of 4, and one with Risser 1 did not have curve progression > 5° at later follow-up. In one of these 5 children however, the major curve progressed to 45° within 7 months after screening and the girl was operated.

CONCLUSION

The point prevalence of AIS in 12- year old children is in agreement or slightly lower than previous studies. The screening model employed demonstrates acceptable sensitivity and specificity and low referral rates. Screening at the age of 12 years only was not effective for detecting patients with indication for brace treatment.

Referral criteria for school scoliosis screening: assessment and recommendations based on a large longitudinally followed cohort

STUDY DESIGN

This study was a retrospective cohort study.

OBJECTIVE

To examine the criteria recommended in the literature for the school-based scoliosis screening program in Hong Kong.

SUMMARY OF BACKGROUND DATA

School-based screening for scoliosis has been a controversy. Objectors to the policy were concerned about the high over-referral and false-positive rates. Recommendations were then made for improvement, but the feasibility of these recommendations has not been studied.

METHODS

The cohort consisted of students in Grade 5 in 1995/1996 or 1996/1997 who underwent scoliosis screening in Hong Kong. Participants who had an angle of trunk rotation (ATR) ≥15°, 2 or more moiré lines, or presented significant clinical signs were referred for radiography. Screening histories and radiography records before the age of 19 years were extracted. The accuracy measures for different combinations of screening tests were examined.

RESULTS

There were 115,178 students in the cohort, of which 3228 (2.8%) were referred for radiography. Among the 1406 students who displayed a curve ≥20° during screening, 257 (18.3%) were boys and 336 (23.9%) were identified as 16 years or older, ruling out the suggestion of screening only 10-year-old girls. The sensitivity and positive predictive value for the current referral criteria were 88.1% and 43.6%, respectively. The sensitivity would drop substantially if the use of moiré topography (39.8%) or clinical signs (55.5%) were discarded. With the inclusion of these 2 tests, the clinical effectiveness measures were robust to the cutoff for ATR, unless it was set below 10°.

CONCLUSION

Selectively screening only premenarche girls was not feasible, as this screen would have missed a significant proportion of children with significant curvature. No refinement of the current protocol was necessary, although boys could be screened beginning at 12 years of age. The tandem use of ATR, moiré topography, and clinical signs was recommended for future studies.

Selective screening for scoliosis

Scoliosis screening has been practiced for nearly 50 years and has provided valuable knowledge about the prevalence and natural history of scoliosis. Early diagnosis allows for nonoperative treatment, like wearing an orthosis that has been shown to be effective by numerous outcome studies. Challenges in scoliosis screening include the low prevalence rate of clinically significant scoliosis, the inverse relationship of sensitivity and specificity in the screening process because of the poor correlation of clinical deformity and radiographic abnormality, and the inflated cost of these programs because of overreferral. Recommendations for improvement include redefinition of what actually constitutes a "significant" scoliosis for screening, diagnostic, and outcome purposes; selective screening of only immature females; the use of objective referral criteria; and re-screening patients rather than referring those who have borderline cases.