Ten-year follow-up evaluation of a school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis?

Relation between Photogrammetry and Spinal Mouse for Lumbopelvic Assessment in Adolescents with Thoracic Kyphosis

The evaluation of the lumbopelvic region is a crucial point during postural assessment in childhood and adolescence. Photogrammetry (PG) and Spinal Mouse (SM) are two of the most debated tools to properly analyze postural alignment and avoid misleading data. This study aims to find out the best linear regression model that could relate the analytic measurements of the SM with one or more PG parameters in adolescents with kyphotic postures. Thirty-nine adolescents (female = 35.9%) with structural and non-structural kyphosis were analyzed (13.2 ± 1.8 years; 1.59 ± 0.12 m; 47.6 ± 11.8 kg) using the SM and PG on the sagittal plane in a standing and forward-bending position, allowing for the measurement of body vertical inclination, lumbar and pelvic alignment, trunk flexion, sacral inclination during bending, and hip position during bending. Lordosis lumbar angles (SM) were significantly (r = -0.379, r = -0.328) correlated with the SIPS-SIAS angle (PG) during upright standing, while in the bending position, the highest correlation appeared among the sacral-hip (SM) and the sacral tangent (ST_PG; r = -0.72) angles. The stepwise backward procedure was assessed to estimate the SM variability in the bending and standing positions. Only in the bending position did the linear regression model reach high goodness-of-fit values with two regressors (ST_PG η2=0.504, BMI η2=0.252; adjusted- R2 =0.558, p < 0.001, CCC = 0.972, r = 0.763). Despite gold-standard methods reducing error evaluation, physicians and kinesiologists may consider photogrammetry as a good method for spinal curve prediction.

Assessment of idiopathic scoliosis among adolescents and associated factors in Palestine

PURPOSE

This study aimed to investigate adolescent idiopathic scoliosis (AIS) and its related risk factors, including body mass index (BMI), physical activity (PA), gender, time of the first menstrual cycle, transportation, backpack weight and the way of carrying a backpack.

DESIGN AND METHOD

a cross-sectional quantitative design was utilized. A convenient sample of adolescent students in grades seven through ten was included in the study. A self-reported questionnaire with three sections: demographic data; physical data including height, weight and PA; and Adam's forward bend test to determine each student's spine's Cobb angle by measuring the angle of trunk rotation using a scoliometer. The data were analyzed using SPSS version 25, with confidence intervals of 95%.

RESULTS

A total of 820 schoolchildren participated in the study; 53.7% were female and 46.3% were male. Only 22% of these students engaged in vigorous exercise, compared to 36.7% who engaged in low PA; additionally, 10% of the adolescents had a low BMI. After the analysis, it was found that 5.4% of participants had AIS. Low PA (p = 0.001), being underweight (p = 0.038), and time of first menstrual period (p = 0.033) were significantly associated with AIS, while gender, backpack weight, and way of carrying were not statistically related to AIS. Binary logistic regression identified low PA as an independent predictor of AIS (OR = 7.22, 95%CI [1.64, 31.79]).

CONCLUSIONS

The frequency of AIS in Palestine was significant, which highlighted the importance of this issue at a national and global level. There was an association between AIS and BMI, PA, and the time of the first menstrual cycle, which signifies the importance of early detection of the problem to limit its burden later in life.

PRACTICE IMPLICATIONS

Teachers, teenagers, and their parents should be provided with programs that educate and clarify AIS, and a specific protocol should be established for scoliosis screening in schools.

Spinal Orthosis in Adolescent Idiopathic Scoliosis: An Overview of the Braces Provided by the National Health Service in Italy

Adolescent idiopathic scoliosis (AIS) is a lateral, rotated curvature of the spine. It is a 3-dimensional deformity that arises in otherwise healthy children at or around puberty. AIS is the most common form of scoliosis in the pediatric population. The etiology is multifactorial, including genetic and environmental factors. The incidence is roughly equal between males and females, while there is a higher risk of progression in females. Guidelines for AIS treatment identify three levels of treatment: observation, physiotherapy scoliosis-specific exercises, and braces. In this paper, we carried out a review of the scientific literature about the indication and success rates of the braces provided for free by the National Health Service in Italy (SSN). Despite a general consensus on the efficacy of rigid bracing treatment and its use in AIS, an important heterogeneity about the treatment is present in the scientific literature, demonstrating a high degree of variability. The overall success rate of the braces provided by the SSN is high, suggesting an important therapeutic role in the treatment of AIS. Robust guidelines are needed to ensure uniform and effective treatments.

Is Obstructive Sleep Apnea-Associated Adenoid Hypertrophy Linked to Scoliotic Attitudes in Children?

Introduction Scoliosis, a multifaceted spinal deformity commonly affecting pediatric and adolescent populations, has spurred extensive scientific inquiry to understand its origins and impacts. Early-onset scoliosis (EOS), characterized by spinal curvature exceeding 10° before the age of 10, presents a unique challenge necessitating a comprehensive understanding of its etiological factors. Within this context, the potential role of hypoxia-induced by adenoid hypertrophy in contributing to the pathogenesis of EOS has emerged as an intriguing avenue of investigation. Materials and methods This retrospective study was conducted focusing on radiological and clinical data pertaining to children below 10 years of age who underwent isolated adenoidectomy for adenoid hypertrophy. Preoperative posteroanterior standing chest radiographs were utilized for scoliosis assessment, with Cobb angles serving as the primary measurement metric. To ensure accuracy and reliability, Cobb angle measurements were independently performed by two experienced observers. Statistical analyses encompassed the Mann-Whitney U test, Spearman correlation analysis, and intraclass correlation coefficient calculations to evaluate interobserver agreement. Results Among the cohort of 218 pediatric adenoidectomy patients, 177 individuals had radiographs suitable for EOS evaluation. The mean age of the participants was 5.72±2 years, with a nearly equal distribution of 52.5% male and 47.5% female patients. Strikingly, the study identified a 10.2% prevalence of coronal plane curvatures exceeding the critical threshold of 10°, indicative of EOS. The robust interobserver reliability was demonstrated by a commendable mean interclass correlation coefficient (ICC) value of 0.926, affirming consistent and accurate Cobb angle measurements between the observers. Conclusion In light of the heightened prevalence of EOS observed in children undergoing adenoidectomy, this study provides a compelling impetus for exploring the potential interrelationship between adenoid hypertrophy, hypoxia, and the emergence of early-onset scoliosis. The study underscores the importance of prospective research to elucidate the complex mechanisms connecting these factors, offering insights into potential risk factors and underlying pathogenic pathways associated with the development of early-onset scoliosis.

A Novel Screening Method for Scoliosis Using a Bodysuit and 3-Dimensional Imaging

STUDY DESIGN

A single-center prospective observational study.

OBJECTIVE

To clarify the usefulness of a novel scoliosis screening method using a 3-dimensional (3D) human fitting application and a specific bodysuit.

SUMMARY OF BACKGROUND DATA

Several scoliosis screening methods, such as scoliometer and Moiré topography, are available for detecting scoliosis. In the present study, a novel screening method for scoliosis using a 3D human fitting application and a specific bodysuit was developed.

PATIENTS AND METHODS

Patients with scoliosis or suspected scoliosis, patients with non-scoliosis, and healthy volunteers were enrolled. They were divided into "non-scoliosis" and "scoliosis" groups. The scoliosis group was further subdivided into "mild," "moderate," and "severe-scoliosis" groups. Patients' characteristics and Z values, which were calculated by a 3D virtual human body model created by a 3D human fitting application and a specific bodysuit to evaluate trunk asymmetry caused by scoliosis, were compared between the non-scoliosis and scoliosis groups or among the non, mild, moderate and severe-scoliosis groups. Finally, the optimal cutoff of the Z value was determined to detect moderate to severe scoliosis using receiver operating characteristic curve analysis.

RESULTS

A total of 101 patients were included. The non-scoliosis group consisted of 47 patients, and the scoliosis group included 54 patients, with 11, 31, and 12 patients in the mild, moderate, and severe-scoliosis groups, respectively. The scoliosis group showed a significantly higher Z value than the non-scoliosis group. The moderate or severe-scoliosis group had a significantly higher Z value than the non or mild-scoliosis group. The receiver operating characteristic curve analysis revealed that the optimal cutoff of the Z value was 19.9 mm (sensitivity, 95.3% and specificity, 58.6%).

CONCLUSION

A novel scoliosis screening method consisting of a 3D human fitting application and a specific bodysuit may be useful for detecting moderate to severe scoliosis.

Idiopathic short stature and scoliosis in children treated with growth hormone

The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial. We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study. A total of 2,053 children with idiopathic short stature and 4,106 age- and sex-matched (1:2) children without short stature with available whole-spine radiographs were enrolled in the cross-sectional study. Among them, 1,056 with idiopathic short stature and 790 controls who had radiographs more than twice were recruited to assess the development and progression of scoliosis, and the need for bracing and surgery. In the cross-sectional study, there was an unexpectedly higher prevalence of scoliosis (33.1% (681/2,053) vs 8.52% (350/4,106)) in children with idiopathic short stature compared with controls (odds ratio 3.722; p < 0.001), although most cases were mild. In the longitudinal study, children with idiopathic short stature had a higher risk of the development and progression of scoliosis than the controls. Among children with idiopathic short stature without scoliosis at baseline, treatment with growth hormone significantly increased the risk of developing scoliosis (p = 0.015) and the need for bracing (p < 0.001). Among those with idiopathic short stature and scoliosis at baseline, treatment with growth hormone did not increase the risk of progression of the scoliosis, the need for bracing, or surgery. The impact of treatment with growth hormone on scoliosis in children with idiopathic short stature was considered controllable. However, physicians should pay close attention to the assessment of spinal curves in these children.

The role of school medicine in the early detection and management of adolescent idiopathic scoliosis

Objective

To analyze the trends in scoliosis screenings over 10 years (2010 vs. 2020). To assess the management of schoolchildren with a preliminary diagnosis of adolescent idiopathic scoliosis by school medicine specialists.

Methods

Historical data were used for the year 2009/2010, and a cross-sectional study was conducted during the school year 2019/2020 on 18,216 pupils of 5th, 6th, and 8th elementary school grades. A forward bend test was used to detect clinical features of scoliosis and some positive findings were referred to orthopedists or physiatrists for further evaluation.

Results

In the analyzed 10-year period abnormal forward bend test findings increased from 4.9 to 5.8% (by 18.4%; P < 0.001). While its prevalence escalated markedly in girls (from 5.8 to 8.3%; P < 0.001), a modest but significant decrease, from 3.8 to 3.2% (P = 0.018), was noted in boys. Most pupils had low to moderate curves, and its prevalence was some 6.5 times higher in girls (P < 0.001). The forward bend test positive predictive value was 84.7%. Discrete forward bend test aberrations were managed by school medicine specialists only.

Conclusion

While actively promoting scoliosis screening in children, we have shown that forward bend test is an acceptable tool for early adolescent idiopathic scoliosis detection in school medicine. In collaboration with other specialists and using additional diagnostic methods, school medicine specialists can ensure early detection and appropriate interventions, avoiding the potential harms of radiation exposure.

Novel Screening Tool for Adolescent Idiopathic Scoliosis: A Reliability Study

OBJECTIVE

The aim of this study was to assess the agreement between a web-based scoliosis screening tool and a standard screening procedure.

METHODS

Sixty participants were selected (median age, 12 years; 75% were women) and separated into 2 groups: those with unknown spinal curvature status and those with confirmed scoliosis. Each participant was assessed by 2 blinded assessors, with one measuring the angle of trunk rotation using a scoliometer and the second using a web-based screening application. The app provided a relative risk score for having scoliosis based on a weighted algorithm. Those with an angle of trunk rotation ≥7° or risk score >2 were deemed as being at risk for having scoliosis.

RESULTS

There was fair agreement (kappa = 0.34; 95% confidence interval [CI], 0.14-0.55; P < .001) between the app and the scoliometer among the unconfirmed cases. The McNemar test indicated a difference in the proportion of positive tests (P = .001), whereby the screening app produced a significantly higher number of positive tests (15/53 = 28.3%) compared to the standard screening procedure (4/53 = 7.5%) for unconfirmed cases. Among the confirmed cases, the app correctly identified 5 out of 7 (sensitivity: 71%; 95% CI, 29%-96%) participants, whereas the scoliometer correctly identified 6 out of 7 (sensitivity: 86%; 95% CI, 42%-100%) participants.

CONCLUSION

These findings indicate fair agreement between the app and the scoliometer, though it was not possible to precisely estimate the sensitivity of the app in this study.

Screening for adolescent idiopathic scoliosis is more accurate when performed by healthcare professionals compared to untrained parents: a diagnostic accuracy study

BACKGROUND

Many countries ended their professional scoliosis screening due to ongoing controversies. Discontinuation resulted in a shift of screening responsibility from trained healthcare professionals to untrained parents.

PURPOSE

To compare the diagnostic accuracy of picture-based scoliosis screening between parents and healthcare professionals.

METHODS

In this cross-sectional diagnostic accuracy study, parents and healthcare professionals assessed pictures of 28 children (20 AIS & 8 non-scoliosis). Each child had two photographs (standing position & full-flexion during forward-bending test) that were presented simultaneously. Lumbar and thoracic curves were represented with a range in severity (10 to > 40°). The assessors had to answer whether they detected an abnormality that ought to be referred to a specialist. Measures of accuracy were calculated for both groups and various curve severities.

RESULTS

All pictures were assessed by 101 parents and 122 healthcare professionals. The sensitivity for detecting scoliosis was significantly lower in untrained parents (63.8%, [95% CI: 61.7-65.9%]) compared to healthcare professionals (73.4%, [95% CI: 71.6-75.2%]; p < 0.001), while the specificity was not significantly different (63.6%, [95% CI: 60.2-66.9%] vs. 65.3%, [95% CI: 62.2-68.3%]; p = 0.49). Healthcare professionals consistently recognized the gibbus as a warning sign when referring patients, while untrained parents highlighted various regions, including the spine, gibbus and scapula regions.

CONCLUSION

The sensitivity of screening for scoliosis was significantly lower when it was performed by parents, while the false-positive rate was similar to healthcare professionals. The window of opportunity for conservative treatment may be missed when parents rather than professionals are responsible for screening.

Study on the Reliability and Accuracy of Scolioscope, a New Digital Scoliometer

Early detection of scoliosis with school screening and quick, easy, and reliable assessment of its progress are of paramount importance in the management of patients. There have been several tools described, with the most common being the analog scoliometer. Most recently, smartphone applications have entered this area with and without the use of sleeves for the device. There is no research that has evaluated the accuracy of measurements both left and right in either digital or analog devices. In this study, we evaluated the reliability and validity of a new digital scoliometer called the Scolioscope. Thirty subjects were included for the intra-rater reliability study. ICC values >0.9 were calculated both for same-day and between-day measurements. The device was highly accurate with an average difference from the ones set on the sine bar of 0.03° for right-side measurements and 0.18° for the left. These measurements suggest a highly accurate and reliable tool.

Using Ultrasound to Screen for Scoliosis to Reduce Unnecessary Radiographic Radiation: A Prospective Diagnostic Accuracy Study on 442 Schoolchildren

Scoliosis screening is important for timely initiation of brace treatment to mitigate curve progression in skeletally immature children and adolescents. School scoliosis screening programs in Hong Kong follow the protocol of referring children screened positive with a scoliometer and Moiré topography for confirmatory standard radiography. Despite being highly sensitive (88%) in detecting those who require specialist referral, the screening program was found to have a false-positive rate >50%, which could lead to unnecessary X-ray radiation. Radiation-free ultrasound has been reported to be valid and reliable for quantitative assessment of curve severity in scoliosis patients. The aim of this prospective diagnostic accuracy study was to determine the accuracy of ultrasound in determining the threshold of referral that requires X-ray for children screened positive with the scoliometer and Moiré topography. Our study recruited 442 schoolchildren with a mean Cobb angle of 14.0 ± 6.6°. The sensitivity and specificity of ultrasound in predicting the correct referral status, confirmed by X-ray, were 92.3% and 51.6%, with positive and negative predictive values of 29.0% and 96.9%, respectively. Receiver operating characteristic curve analysis revealed area under the curve values of 0.735 for ultrasound alone and 0.832 for ultrasound in combination with measurement of angle of trunk rotation. The finding supports the accuracy of using ultrasound to determine referral status, which could result in a >50% reduction of unnecessary radiation for children undergoing scoliosis screening.

Spinal Deformities in the Adolescent Athlete

Idiopathic scoliosis will be noted in 2% to 3% of typically developing athletes. Sports physicals are an opportunity to screen for spinal deformity and to promote healthy involvement in activities. Bracing is effective at limiting further progression if a curve progresses beyond 20°. If spinal fusion is performed, most surgeons allow return to noncontact and contact sports by 6 to 12 months. There are many other conditions associated with scoliosis that require a more nuanced approach and assessment of the entire patient. Patients with Down syndrome should be examined for myelopathy before participation and a lateral radiograph obtained if concerned for instability.

Scoliosis Screening

The national recommendations for school screening programs for scoliosis in the United States have undergone a shift in perspective over the past two decades. In 2004, the United States Preventive Services Task Force recommended against screening programs but changed its recommendation to be inconclusive in 2018. Early diagnosis of scoliosis can allow for close monitoring of the deformity and early initiation of bracing treatment when appropriate, with the goal of preventing costly and invasive surgical intervention. Several different diagnostic tools are available, including Adam's forward bending test alone, Adam's forward bending test with scoliometry, the humpometer, and Moiré topography, each with varying degrees of sensitivity and specificity. Controversy prevails over the cost efficacy of screening programs and possible unnecessary exposure of adolescents to radiation for confirmatory radiographs after a positive screening test. However, the recent definitive evidence of bracing treatment efficacy in slowing the progression of scoliotic curves and preventing the need for surgery indicates that school screening programs may still have a role in allowing early diagnosis.

Evaluation of Late Postural Complications in Breast Cancer Patients Undergoing Breast-Conserving Therapy in Relation to the Type of Axillary Intervention-Cross-Sectional Study

Purpose: The aim of the study was to evaluate posture in patients undergoing breast-conserving therapy (BCT) in relation to the type of surgical intervention to the axilla. Methods: The study was conducted on patients who had undergone breast-conserving surgical treatment for breast cancer 5–6 years earlier. In 54 patients, BCT+ALND (axillary lymph node dissection) was performed, while 63 patients were subjected to BCT+SLND (sentinel lymph node dissection). The control group consisted of 54 females. The study was conducted using digital postural assessment. Results: No statistically significant differences were observed with respect to the parameters between the BCT+SLNB and BCT+ALND groups (p > 0.05). However, the differences were highly significant between the CG (control group) and the studied groups (BCT+ALND, BCT+SLNB) for the following parameters: BETA angle of thoracolumbar spine inclination (p = 0.002), GAMMA angle of thoracic spine inclination (p = 0.0044), TKA (thoracic kyphosis angle) (p < 0.0001) and shoulder level inclination (p = 0.0004). The BCT+ALND patients were characterized by higher dependency of raised shoulder (p = 0.0028) and inferior angle of the scapula (p = 0.00018) on the operated side compared to BCT+SLNB patients. Conclusions: Postural imbalance occurs independent of the type of axillary intervention. Disturbances within the upper torso (abnormal position of shoulders and inferior angles of scapulae) are more pronounced in patients after ALND.

Reliability of a New Smartphone Accessory for Scoliosis Measurements

BACKGROUND: Idiopathic scoliosis is the most common pathology of the children’s spine, identified as spine lateral curvature with Cobb angle greater than 10°. The rapid development of technology allows, even mobile devices, to perform a quick and cheap diagnosis ensuring an accuracy similar to the Bunnell scoliometer.

OBJECTIVE: The study aimed to validate the accuracy of a newly developed accessory for measuring the angle of trunk rotation (ATR) using mobile devices.

METHODS: ATR measurements were carried out on a group of 30 adults using 3 diagnostic tools: the Bunnell scoliometer, Scolioscreen, and mScolio designed by the authors. Scolioscreen and mScolio were used together with a smartphone and the Clinometer app. Three measurements were performed using each of the methods.

RESULTS: The greatest data discrepancy was obtained between the Bunnell scoliometer and Scolioscreen (-3.7°÷4.4°) and was twice larger than between the Bunnell scoliometer and mScolio (-1.8°÷2.1°). The excellent agreement was obtained for the mScolio device, where the concordance correlation coefficient was 0.9381 (95% CI of 0.9076÷0.9588) and the interclass correlation coefficient was 0.9501 (95% CI of 0.9242÷0.9671).

CONCLUSIONS: Tests showed excellent reliability and validity of ATR using the mScolio solution. Obtained results show excellent consistency between mScolio and the Brunnell scoliometer measurements.

Predicting Adolescent Idiopathic Scoliosis among Chinese Children and Adolescents

Objective

Adolescent idiopathic scoliosis (AIS) affects 1%-4% of adolescents in the early stages of puberty, but there is still no effective prediction method. This study aimed to establish a prediction model and validated the accuracy and efficacy of this model in predicting the occurrence of AIS.

Methods

Data was collected from a population-based school scoliosis screening program for AIS in China. A sample of 884 children and adolescents with the radiological lateral Cobb angle ≥ 10° was classified as an AIS case, and 895 non-AIS subjects with a Cobb angle < 10° were randomly selected from the screening system. All selected subjects were screened by visual inspection of clinical signs, the Adam's forward-bending test (FBT), and the measurement of angle of trunk rotation (ATR). LR and receiver operating characteristic (ROC) curves were used to preliminarily screen the influential factors, and LR models with different adjusted weights were established to predict the occurrence of AIS.

Results

Multivariate LR and ROC curves indicated that angle of thoracic rotation (adjusted odds ratios (AOR) = 5.18 − 10.06), angle of thoracolumbar rotation (AOR = 4.67 − 7.22), angle of lumbar rotation (AOR = 6.97 − 8.09), scapular tilt (area under the curve (AUC) = 0.77, 95% CI: 0.75-0.80), shoulder-height difference, lumbar concave, and pelvic tilt were the risk predictors for AIS. LR models with different adjusted weights (by AOR, AUC, and AOR+AUC) performed similarly in predicting the occurrence of AIS compared with multivariate LR. The sensitivity (82.55%-83.27%), specificity (82.59%-83.33%), Youden's index (0.65-0.67), positive predictive value (82.85%-83.58%), negative predictive value (82.29%-83.03%), and total accuracy (82.57%-83.30%) manifested that LR could accurately identify patients with AIS.

Conclusions

LR model is a relatively high accurate and feasible method for predicting AIS. Increased performance of LR models using clinically relevant variables offers the potential to early identify high-risk groups of AIS.

Evaluating the validity of diagnostic methods for scoliotic posture of primary school children

Primary school children are exposed to asymmetric loads that lead to an imbalance of postural muscles and a violation of the body relative symmetry. Mass screening examinations in schools for scoliotic posture and scoliosis are conducted primarily through the Adams test. It has low reproducibility and a high frequency of false negative results. In practice, various methods for diagnosing posture disorders are also used. Some methods are based on the evaluation of postural muscles static endurance, elasticity and proportionality of their functional capabilities. Others are based on a comprehensive assessment of the ability to maintain an upright posture rationally. The third ones are based on the analysis of the tonic vibration and H-reflex of skeletal muscles on both sides of the vertebral column. All the above mentioned methods definitely have diagnostic potential. Therefore it was decided to determine the validity of some common methods for diagnosing posture disorders based on the analysis of their mutual congruence. Based on the results of the experiment, a reliable correlation between the studied parameters was established. It in turn allows us to judge the congruence of the considered diagnostic methods and, accordingly, the high probability of their validity.

Development and validation of deep learning algorithms for scoliosis screening using back images

Adolescent idiopathic scoliosis is the most common spinal disorder in adolescents with a prevalence of 0.5-5.2% worldwide. The traditional methods for scoliosis screening are easily accessible but require unnecessary referrals and radiography exposure due to their low positive predictive values. The application of deep learning algorithms has the potential to reduce unnecessary referrals and costs in scoliosis screening. Here, we developed and validated deep learning algorithms for automated scoliosis screening using unclothed back images. The accuracies of the algorithms were superior to those of human specialists in detecting scoliosis, detecting cases with a curve ≥20°, and severity grading for both binary classifications and the four-class classification. Our approach can be potentially applied in routine scoliosis screening and periodic follow-ups of pretreatment cases without radiation exposure.

Current status of scoliosis school screening: targeted screening of underserved populations may be the solution

OBJECTIVES

The growing body of evidence documenting the effectiveness of brace treatment for scoliosis has renewed interest in potential benefits of early detection through school screening. We aimed to assess the prevalence and identify barriers of screening. We hypothesized that school screening is more frequent in schools that have a nurse on staff compared to schools without nurse on staff.

STUDY DESIGN

A questionnaire survey.

METHODS

All schools located in four counties in Louisiana, United States of America comprising the New Orleans metropolitan area between September 2015 and January 2016 were contacted by phone to assess rates of scoliosis screening, report the availability of a school nurse, and specify barriers if screening was not performed.

RESULTS

Two hundred and ninety-one schools responded to the survey including 152 public, 30 charter, and 109 private schools (101 had religious affiliation). A staff nurse was available in 180 schools (61.8%). Only 21 schools (7.2%) performed scoliosis screening. The majority were charter schools (11 schools), while six were private and four were public (P < 0.0001). Of these 21 schools, 16 (76.2%) had a nurse on staff while five schools did not (P = 0.16). Lack of a referral pathway in the event of a positive screen was the most common barrier to performing scoliosis screening.

CONCLUSION

Scoliosis screening is infrequent in the examined school districts. Efforts to support school screening can facilitate clear referral pathways for schools in the event of a positive screen. These findings suggest a potential need for different pathway of scoliosis screening. Pediatricians and family physicians can assist with scoliosis screening during the annual visit. While universal screening is overburdensome and likely unnecessary, targeted screening of underserved populations may prove to be beneficial. Further investigation should include assessment of the economic viability of targeted screening programs.

LEVEL OF EVIDENCE

IV.

Association between physical activity and scoliosis: a prospective cohort study

BACKGROUND

Little is understood about the causes of adolescent onset idiopathic scoliosis (AIS). No prospective studies assessing the association between physical activity and idiopathic adolescent scoliosis have been carried out. We aimed to carry out the first prospective population-based study of this association.

METHODS

The Avon Longitudinal Study of Parents and Children (ALSPAC) collected self-reported measures of physical ability/activity at ages 18 months and 10 years. Objective measures of physical activity were collected by accelerometry at age 11 years. scoliosis was identified using the dxa scoliosis Method at age 15 years. Participants with scoliosis at age 10 years were excluded.

RESULTS

Of 4640 participants at age 15 years who had DXA scans, 267 (5.8%) had scoliosis. At age 18 months, those infants who were able to stand up without being supported were 66% less likely to have developed scoliosis by age 15 (P = 0.030) compared with infants who could not. Those children whose mothers reported they did most vigorous physical activity at age 10 years were 53% less likely to develop scoliosis (P = 0.027). Those children who did more objectively measured moderate/vigorous physical activity at age 11 were 30% less likely to have developed scoliosis (P < 0.001). Results were not affected by adjustment for age, gender, lean mass, fat mass or back pain.

CONCLUSIONS

We report reduced physical ability and activity as early as age 18 months in those who go on to develop scoliosis by age 15 years. Further research is justified to examine the mechanisms underlying this association.

Effectiveness of school scoliosis screening and the importance of this method in measures to reduce morbidity in an Italian territory

Although several procedures for treating scoliosis have been developed, the most effective treatment is still based on early detection. For early diagnosis of idiopathic scoliosis, many authors have proposed methods of school screening; however, there is still no standardized screening program. The aim of this study was to evaluate a school screening method and the prevalence and distribution of scoliosis in Italian school children, aged 9-14 years, and to determine if the screening method can reduce morbidity in an Italian territory. The screening program consisted of three steps: the first step was a clinical examination carried out by the school physician and two specialists. In the second step, doubtful cases (presence of a hump between the two sides of the torso, in the thoracic or thoracolumbar region, measured using a hump meter) were evaluated by an orthopedic specialist and subsequently controlled every 6 months either clinically or by radiographic examination. The third step was the classification of the scoliosis and procedures for treatment. All patients were scheduled for a follow-up program and were evaluated during the subsequent 3 years. Statistical analyses were performed with GraphPad Prism 6. A total of 8995 children were screened for scoliosis. Of these, 487 showed clinical signs of scoliosis, and 181 were referred for anteroposterior radiographs because of a positive result on the forward-bending test (hump>5 mm). No significant statistical difference was observed by the three clinical examiners. Of the 181 patients who were referred, 69 were radiographed, and the clinical diagnosis was confirmed in 94.2% of the cases. The prevalence of scoliosis (defined as a curve of ≥10°) was 0.76% (65 of 8995 children), and most of the curves (44; prevalence 67.69%) were small (<20°). The overall ratio of boys to girls was 1 : 3.3, but varied according to the magnitude of the curve (1 : 3 for curves of <20°, 1 : 3.25 for curves of 20-29°, and 1 : 4 for curves of ≥30°). Double curves were the most common type identified, followed by thoracolumbar curves; specifically, of the 65 children who had a curve, 21 (32.30%) had a double curve, 18 (27.6%) had a thoracolumbar curve, 17 (26.1%) had a lumbar curve, and nine (13.84%) had a thoracic curve. In the following 3 years, only four patients were found to have curves more than 20° and none more than 30°. Our results show that the school screening program was accurate and repeatable. Moreover, screening children for scoliosis using a simple test appears to be an effective means of early detection. Above all, the screening process effectively decreased morbidity in the territory at a negligible cost.

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 respiratory function and spine and thorax deformity in children with mild scoliosis

Idiopathic scoliosis (IS) is the most common 3-dimensional deformation abnormality of the spine with direct effects on the thoracic cage and can potentially affect respiratory function.The purpose of the present study was to recognize whether the 3-dimensional displacement of the spine and trunk as a consequence of IS directly influences and diminishes respiratory function in children with mild IS.The study involved 68 children aged 10 to 12 years with mild thoracic or thoracolumbar IS who were the outpatients of the local Center for Corrective Gymnastics. The study consisted of 2 interrelated parts: the body posture examination using a Moiré topography and the spirometric examination including measurements of basic ventilatory parameters (vital capacity [VC], forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], and FEV1/FVC).For the majority of subjects, the results of VC were within the normal range and did not confirm the existence of features characteristic for ventilatory functional restriction. The VC does not depend on the curvature angle value or the degree of rotation of vertebral bodies. It was observed that VC in children with mild IS of 20 to 30 degree depended on thoracic kyphosis, that is, length, depth, and the thoracic kyphosis length/depth indicator.The results of performed study showed that in children with mild IS the lung volumes are reduced not only by an increased angle of the lateral curvature but also by the degree of loss of normal thoracic kyphosis. The regular respiratory function testing and back-shape analysis are advisable in children with thoracic and thoracolumbar mild IS.

Postural habits and weight of backpacks of Portuguese adolescents: Are they associated with scoliosis and low back pain?

BACKGROUND

The adoption of incorrect postures or carrying overweight backpacks may contribute to the development of musculoskeletal disorders in school children.

OBJECTIVE

This study evaluated the weight of backpacks and the postural habits adopted in schools by Portuguese adolescents, and their association with scoliosis and low back pain (LBP).

METHOD

The sample comprised 966 Portuguese students, aged between 10 and 16 years. The instruments included a questionnaire to characterize the presence of LBP and the postural habits adopted by students, the weighing of backpacks and a scoliometer to evaluate scoliosis.

RESULTS

No association was observed between assuming incorrect postures and carrying overweight backpacks, in students with scoliosis. Students who adopted incorrect sitting postures had 1.77 times the risk (95% CI: 1.32-2.36; p < 0.001) of developing LBP; those positioned incorrectly whilst watching TV and playing games had 1.44 times the risk (95% CI: 1.08-1.90; p = 0.012) of developing LBP; and those standing incorrectly had 2.39 the risk (95% CI: 1.52-3.78; p < 0.001) of developing LBP.

CONCLUSIONS

The results revealed that students who sat with the spine positioned wrongly, as well as those who were standing incorrectly, were more likely to present with LBP.

Presentation of Adolescent Idiopathic Scoliosis: The Bigger the Kid, the Bigger the Curve

BACKGROUND

It is our clinical suspicion that children with higher body mass index (BMIs) who are diagnosed with scoliosis tend to have larger curves on presentation. The purpose of this study was to determine the effect of BMI on severity of curve at initial presentation of adolescent idiopathic scoliosis.

METHODS

This is a retrospective, descriptive cohort study of consecutive patients age 10 or greater referred to a single large tertiary care center with concern for spinal asymmetry. Patients were separated into 3 BMI categories as measured on the presenting visit: normal weight-≥5th and <85th percentile, overweight-≥85th and <95th percentile, and obese-≥95th percentile. In addition to demographic information, data collected included BMI, curve magnitude, curve location, Risser stage, and where or by whom spinal asymmetry was noted.

RESULTS

A total of 150 patients, 50 in each the normal weight, overweight, and obese categories, were included in this study. Average curve at presentation for normal weight patients was 18.1 degrees, for overweight patients 23.9 degrees (P=0.02), and for obese patients 24.5 degrees (P=0.02). As compared with the normal weight group, odds ratio of presenting with a curve of 40 degrees or above was 10.8 for the overweight group (95% confidence interval, 1.3-88.5, P=0.03) and 12.2 for the obese group (95% confidence interval, 1.5-99.8, P=0.02). Assuming a cut-off of 45 degrees as surgical range, no normal weight patients presented in surgical range (0%), but 7/50 (14%, P=0.01) overweight and 8/50 (16%, P<0.01) obese patients did. Moreover, higher BMI patients were significantly more likely to present at a higher degree of skeletally maturity, with an average Risser of 1.8 for normal weight patients, 2.7 (P=0.01) for overweight patients, and 2.9 (P=0.01) for obese patients.

CONCLUSIONS

Overweight and obese patients with adolescent idiopathic scoliosis present at significantly larger curve magnitudes and significantly higher degrees of skeletal maturity. Moreover, these patients were significantly more likely to present with very large curves and, in our study, all patients presenting with a surgical range curve were either overweight or obese.

LEVEL OF EVIDENCE

Level III-Retrospective case-control.

The Impact of Small Spinal Curves in Adolescents Who Have Not Presented to Secondary Care: A Population-Based Cohort Study

STUDY DESIGN

A prospective, population-based, birth cohort study.

OBJECTIVE

The aim of this study was to identify whether there is any hidden burden of disease associated with smaller spinal curves.

SUMMARY OF BACKGROUND DATA

Adolescent idiopathic scoliosis is present in 3% to 5% of the general population. Large curves are associated with increased pain and reduced quality of life. However, no information is available on the impact of smaller curves, many of which do not reach secondary care.

METHODS

The Avon Longitudinal Study of Parents and Children (ALSPAC) recruited over 14,000 pregnant women from the Bristol area of South-West England between 1991 and 1992 and has followed up their offspring regularly. At age 15, presence or absence of spinal curvature ≥6 degrees in the offspring was identified using the validated dual-energy X-ray absorptiometry Scoliosis Measure on 5299 participants. At age 18, a structured pain questionnaire was administered to 4083 participants. Logistic regression was used to investigate any association between presence of a spinal curve at age 15 and self-reported outcomes at age 18 years.

RESULTS

Full data were available for 3184 participants. Two hundred two (6.3%) had a spinal curve ≥6 degrees and 125 (3.9%) had a curve ≥10 degrees (median curve size of 11 degrees). About 46.3% reported aches and pains that lasted for a day or longer in the previous month. About 16.3% reported back pain. Those with spinal curves were 42% more likely to report back pain than those without (odds ratio 1.42, 95% confidence interval 1.00-2.02, P = 0.047). Those with spinal curves had more days off school and were more likely to avoid activities that caused their pain.

CONCLUSION

Our results highlight that small scoliotic curves may be less benign than previously thought. Teenagers with small curves may not present to secondary care, but are nonetheless reporting increased pain, more days off school, and avoidance of activities. These data suggest that we should reconsider current scoliosis screening and treatment practices.

LEVEL OF EVIDENCE

2.

Pathways of healthcare utilisation in patients with suspected adolescent idiopathic scoliosis: a cross-sectional study

Background

School screening programs for adolescent idiopathic scoliosis (AIS) have been discontinued in Canada and elsewhere because they were not considered cost-effective. In communities lacking such programs, we expect a significant variety of healthcare pathways and timeframes for patient referrals to orthopaedics.

The objectives of this study were: 1) to characterise the healthcare pathways of young children with suspected AIS in a population without school screening; and 2) to investigate the relationships between these healthcare pathways and the appropriateness of referrals to specialised orthopaedic clinics.

Methods

This study concerned all children, ages 10 to 18, referred for an initial visit for suspected AIS to any of the five out-patient paediatric orthopaedic clinics of south-western Quebec (Canada). For the 831 participants, referrals to orthopaedics were characterised as appropriate, late, or inappropriate, based on known risk factors for AIS progression and on treatment indications. Parents documented the circumstances of healthcare use prior to the orthopaedic consultation. Relevant predisposing, enabling, and need variables derived from Andersen’s Behavioral Model of Health Services Use were also documented. Healthcare pathways were characterised by developing a taxonomy using multiple correspondence analysis prior to hierarchical classification. Associations between the healthcare pathways and appropriateness of referral were assessed using multinomial regression analyses.

Results

We constructed a taxonomy of five distinct healthcare pathways: 1) Lay/regular source of care interrelation, 2) Other professionals, 3) Lay/consultation discontinuity, 4) Other medical doctor, and 5) Regular source of care continuity. Laypersons played an important role in AIS suspicion (53 % of cases), but did not prevent late referrals. Continuity of care, as opposed to numerous uncoordinated consultations, was an effective strategy to prevent late referrals (OR = 0.32 [0.17–0.59]), but was related to increased probability of inappropriate referrals.

Conclusions

We identified two cardinal characteristics that distinguished the healthcare pathways and related significantly to appropriateness of referral status, namely the role of laypersons and the involvement of the regular source of care. This suggests directions for intervention such as advocating for access to a regular source of care, increasing awareness of the disease to medical practitioners’ and improving their knowledge of AIS detection and referral criteria.

Idiopathic Scoliosis Prevalence Is 5 Times Less in Roma Than Greek Children and Adolescents

STUDY DESIGN

Serial screening of Roma children for idiopathic scoliosis.

OBJECTIVE

To confirm or reject the observation that the prevalence of scoliosis is reduced in the Roma population and possibly to explain it.

MATERIALS AND METHODS

The authors conducted serial screening for idiopathic scoliosis of 1,034 indigenous Roma children (542 boys and 492 girls), aged 4-18 years (857 children were aged 8-18 years) from 1997 to 2011. Age, height, weight, body mass index, years of schooling, and menarche for girls were recorded. Children were clinically examined for body asymmetries and a standing posteroanterior spinal radiograph was obtained in selected cases.

RESULTS

Sixty Roma children (6%) had clinical humps. Single humps, according to location, were mostly benign and not related to progressive scoliotic curves. In children with right thoracic humps a left lumbar component could be overlooked. Of 60 children, only 4 (3 girls and 1 boy) with right thoracic and left lumbar or thoracolumbar humps had true progressive scoliotic curves with greater than 10° Cobb angle (prevalence rate, 0.35%). This is 5 times less than the rate of 1.5% in Greek children. One of these 4 children was young and had possible congenital scoliosis; the other 3 were early adolescents.

CONCLUSIONS

A substantial difference in the prevalence of scoliosis between Roma and Greek children was documented. The usual percentage of adolescent scoliosis found in the Greek population (approximately 15-17 cases/1,000 children) was not seen in this sample of Roma children.

A health economic evaluation of screening and treatment in patients with adolescent idiopathic scoliosis

SUMMARY OF BACKGROUND DATA

Adolescent idiopathic scoliosis can progress and affect the health related quality of life of the patients. Research shows that screening is effective in early detection, which allows for bracing and reduced surgical rates, and may save costs, but is still controversial from a health economic perspective.

STUDY DESIGN

Model based cost minimisation analysis using hospital's costs, administrative data, and market prices to estimate costs in screening, bracing and surgical treatment. Uncertainty was characterised by deterministic and probabilistic sensitivity analyses. Time horizon was 6 years from first screening at 11 years of age.

OBJECTIVE

To compare estimated costs in screening and non-screening scenarios (reduced treatment rates of 90%, 80%, 70% of screening, and non-screening Norway 2012).

METHODS

Data was based on screening and treatment costs in primary health care and in hospital care settings. Participants were 4000, 12-year old children screened in Norway, 115190 children screened in Hong Kong and 112 children treated for scoliosis in Norway in 2012. We assumed equivalent outcome of health related quality of life, and compared only relative costs in screening and non-screening settings. Incremental cost was defined as positive when a non-screening scenario was more expensive relative to screening.

RESULTS

Screening per child was € 8.4 (95% CrI 6.6 to10.6), € 10350 (8690 to 12180) per patient braced, and € 45880 (39040 to 55400) per child operated. Incremental cost per child in non-screening scenario of 90% treatment rate was € 13.3 (1 to 27), increasing from € 1.3 (-8 to 11) to € 27.6 (14 to 44) as surgical rates relative to bracing increased from 40% to 80%. For the 80% treatment rate non-screening scenario, incremental cost was € 5.5 (-6 to 18) when screening all, and € 11.3 (2 to 22) when screening girls only. For the non-screening Norwegian scenario, incremental cost per child was € -0.1(-14 to 16). Bracing and surgery were the main cost drivers and contributed most to uncertainty.

CONCLUSIONS

With the assumptions applied in the present study, screening is cost saving when performed in girls only, and when it leads to reduced treatment rates. Cost of surgery was dominating in non-screening whilst cost of bracing was dominating in screening. The economic gain of screening increases when it leads to higher rates of bracing and reduced surgical rates.

Bilateral reconstructive costoplasty for razorback deformity correction in adolescent idiopathic scoliosis

BACKGROUND

Correcting the chest wall deformity is an important goal of scoliosis surgery. A prominent rib hump deformity may not be adequately addressed by scoliosis correction alone. It has been shown that costoplasty in conjugation with scoliosis correction and instrumented spinal fusion is superior to spinal fusion alone in addressing the chest wall deformity. In cases of severe rib hump deformity unilateral convex side costoplasty alone might not adequately restore thoracic cage symmetry necessitating for additional concave side rib cage reconstruction.

CASE REPORT

A 16-year-old male with adolescent idiopathic scoliosis and a sharp, cosmetically unacceptable, prominent rib hump (razorback deformity) underwent scoliosis correction with posterior spinal fusion and bilateral costoplasty. The convex-sided ribs were resected and used for concave-sided rib reconstruction. The rib hump height was reduced from 70 mm before the procedure to 10 mm after the procedure and the apical trunk rotation was reduced from 36° to 5°, respectively. Solid spinal fusion and ribs union was achieved. The patient remained very satisfied with no loss of correction at 2-year postoperative follow-up.

CONCLUSION

Bilateral costoplasty in conjugation with scoliosis correction may provide a safe and effective method for the treatment of severe rib cage deformities associated with thoracic scoliosis. It should be considered in the presence of prominent rib hump deformity, where scoliosis correction alone or with unilateral costoplasty is unlikely to provide adequate correction.

Does school scoliosis screening make the grade?

School nurses have provided routine health screenings of school-age children for decades. During the 1970s, recommendations for school scoliosis screening, which were based upon poor access to health care, led state boards of education to mandate that school nurses screen for scoliosis. The history of mandated scoliosis screening in U.S. schools is reviewed, and current school nurse practices for scoliosis screening are presented. Elevated referral rates for repeat scoliosis examination following school scoliosis screenings have led to questions of efficacy. Further controversy exists regarding school nurses screening for scoliosis due to a lack of evidence indicating a decreased need for scoliosis surgery. This article contains evidence-based recommendations for discontinuing school scoliosis screening to help school nurses refocus their efforts on complex health needs and preventive health issues more likely to impact the majority of their students.

Association between components of body composition and scoliosis: a prospective cohort study reporting differences identifiable before the onset of scoliosis

There is an increasing body of research suggesting that low body weight is associated with scoliosis, but this is based on case-control studies, which are prone to bias. No studies have investigated the components of body weight: fat and lean mass. We have therefore carried out the first population-based prospective study of the association between fat and lean mass at age 10 years assessed by dual-energy X-ray absorptiometry (DXA), with presence of scoliosis at age 15 years using the Avon Longitudinal Study of Parents and Children (ALSPAC). All children with scoliosis at age 10 years were excluded. Of 5299 children at age 15 years, 312 (5.9%) had scoliosis. Our results show a negative association between body mass index (BMI)/body weight at age 10 years and scoliosis at age 15 years, with a 20% reduced risk of scoliosis per SD increase in BMI (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.70-0.92; p = 0.001). This association with BMI/body weight reflects associations with both fat mass and lean mass. After adjustment for age, gender, leg length, and fat mass per SD increase in lean mass, there was a 20% reduced risk of scoliosis (OR, 0.80; 95% CI, 0.65-0.97) and per SD increase in fat mass there was a 13% reduced risk of scoliosis (OR, 0.87; 95% CI, 0.74-1.03). In terms of adipocyte function, an inverse association was seen between leptin at age 10 years and scoliosis (OR for scoliosis per SD increase in leptin of 0.78; 95% CI, 0.63-0.99), and a positive association between adiponectin at age 10 years and scoliosis (OR for scoliosis per SD increase in adiponectin of 1.44; 95% CI, 0.99-2.10). This is the first study to address the association between the individual components of body weight and scoliosis in a prospective cohort study, and shows altered body composition that is present before the onset of clinically detected scoliosis.

The prevalence of idiopathic scoliosis in eleven year-old Korean adolescents: a 3 year epidemiological study

PURPOSE

School screening allows for early detection and early treatment of scoliosis, with the purpose of reducing the number of patients requiring surgical treatment. Children between 10 and 14 years old are considered as good candidates for school screening tests of scoliosis. The purpose of the present study was to assess the epidemiological findings of idiopathic scoliosis in 11-year-old Korean adolescents.

MATERIALS AND METHODS

A total of 37856 11-year-old adolescents were screened for scoliosis. There were 17110 girls and 20746 boys. Adolescents who were abnormal by Moire topography were subsequently assessed by standardized clinical and radiological examinations. A scoliotic curve was defined as 10° or more.

RESULTS

The prevalence of scoliosis was 0.19% and most of the curves were small (10° to 19°). The ratio of boys to girls was 1:5.5 overall. Sixty adolescents (84.5%) exhibited single curvature. Thoracolumbar curves were the most common type of curve identified, followed by thoracic and lumbar curves.

CONCLUSION

The prevalence of idiopathic scoliosis among 11-year-old Korean adolescents was 0.19%.

Epidemiology of adolescent idiopathic scoliosis in students of the public schools in Goiânia-GO

OBJECTIVE:

To investigate the prevalence of adolescent idiopathic scoliosis in school children from 10 to 14 years in public schools in Goiânia, GO, Brazil.

METHODS:

In a cross-sectional study, 476 students were randomly selected from 5 public schools, from a total of 33,343 students distributed in 162 schools. These subjects received the informed consent prior, which was returned after being signed by parents on physical examination day. We evaluated the symmetry of the shoulders, the scapulae, the triangle-cut, the hip evenness and the Adams test. In suspected cases, students were referred to panoramic radiographs of the spine.

RESULTS:

418 students participated in the study (adjusted sampling error of 3.2%). Of this total, 31 students were suspected of scoliosis (17 males and 14 females). Twenty-eight students took radiographs, of which 18 were diagnosed with adolescent idiopathic scoliosis (11 female and 7 male), determining the prevalence of 4.3%. The chi-square test suggested no statistical difference in prevalence between the sexes. One student had congenital scoliosis.

CONCLUSION:

The prevalence of adolescent idiopathic scoliosis in the public schools of Goiânia is 4.3%. Level of Evidence III, Study of Nonconsecutive Patients.

Identifying scoliosis in population-based cohorts: development and validation of a novel method based on total-body dual-energy x-ray absorptiometric scans

The purpose of this study was to develop and validate a novel method of identifying scoliosis on total-body dual energy X-ray absorptiometric (DXA) scans. Scoliosis was identified on total-body DXA scans by triaging to distinguish true curves from positioning errors, followed by a modified Ferguson method to measure angles. Precision was assessed on 174 children from the Avon Longitudinal Study of Parents and Children (ALSPAC), who underwent repeat DXA scans at age 15, 2-6 weeks apart. In addition, precision of angle estimation was evaluated on 20 scans measured five times. To evaluate accuracy, angle size was compared to spinal radiographs in 13 individuals with known scoliosis. Subsequently, this method was applied to estimate scoliosis prevalence rates and curve patterns from DXA scans previously obtained in 7,298 ALSPAC participants at age 9 and 5,122 at age 15. There was substantial agreement in identifying those with scoliosis on repeat DXA scans taken 2-6 weeks apart (kappa 0.74, 95 % CI 0.59-0.89). Of repeat angle measures, 95 % were within 5°. Angle size was underestimated by approximately 40 %. Prevalence of scoliosis ≥10° in the ALSPAC was 0.3 % at age 9 and 3.5 % at age 15 and was higher in girls at both time points. The mean ± SD curve size was 12 ± 4° at age 9 years and 15 ± 7° at age 15. We have developed and validated a novel method for identifying scoliosis from DXA scans. Comparison with prevalence data using more established techniques suggests our method provides valid estimates of scoliosis prevalence in population-based cohorts.

Association between common variants near LBX1 and adolescent idiopathic scoliosis replicated in the Chinese Han population

Background

Adolescent idiopathic scoliosis (AIS) is one of the most common spinal deformities found in adolescent populations. Recently, a genome-wide association study (GWAS) in a Japanese population indicated that three single nucleotide polymorphisms (SNPs), rs11190870, rs625039 and rs11598564, all located near the LBX1 gene, may be associated with AIS susceptibility [1]. This study suggests a novel AIS predisposition candidate gene and supports the hypothesis that somatosensory functional disorders could contribute to the pathogenesis of AIS. These findings warrant replication in other populations.

Methodology/Principal Findings

First, we conducted a case-control study consisting of 953 Chinese Han individuals from southern China (513 patients and 440 healthy controls), and the three SNPs were all found to be associated with AIS predisposition. The ORs were observed as 1.49 (95% CI 1.23–1.80, P = 5.09E-5), 1.70 (95% CI 1.42–2.04, P = 1.17E-8) and 1.52 (95% CI 1.27–1.83, P = 5.54E-6) for rs625039, rs11190870 and rs11598564, respectively. Second, a case-only study including a subgroup of AIS patients (N = 234) was performed to determine the effects of these variants on the severity of the condition. However, we did not find any association between these variants and the severity of curvature.

Conclusion

This study shows that the genetic variants near the LBX1 gene are associated with AIS susceptibility in Chinese Han population. It successfully replicates the results of the GWAS, which was performed in a Japanese population.

Hip internal rotation is correlated to radiographic findings of cam femoroacetabular impingement in collegiate football players

PURPOSE

The objective of this study was to determine whether physical examinations (flexion-abduction-external rotation [FABER], impingement, range-of-motion profiles) could be used to detect the bony abnormalities of femoroacetabular impingement (FAI) in an athletic population.

METHODS

We performed a prospective study of 65 male collegiate football players. Both hips were evaluated by 2 orthopaedic surgeons for radiographic signs of FAI. The alpha angle and head-neck offset were measured on frog-leg lateral films. The center-edge angle, acetabular index, crossover sign, and alpha angle were measured on anteroposterior films. Measurements were averaged for both observers. Maximum hip range of motion in flexion (supine) and internal/external rotation (supine, sitting, and prone) was measured with a goniometer. Pain provoked by the impingement and FABER tests was also recorded. Examinations were completed at 2 of 4 stations (2 duplicates), each staffed by 2 clinicians (1 examined and 1 measured). The relation between each range-of-motion and radiographic measure was determined. Data from each station were assessed separately. Only those regressions significant (P < .05) for paired stations were considered clinically significant.

RESULTS

The alpha angle and head-neck offset measured on the frog-leg lateral films were significantly correlated (all P < .01) to supine, sitting, and prone internal rotation for all stations. Correlation coefficients ranged from -0.59 to -0.35 for alpha angle and 0.42 to 0.57 for head-neck offset. Although 95% of the hips had at least 1 radiographic sign of FAI, pain was reported in only 8.5% and 2.3% during the impingement and FABER tests, respectively.

CONCLUSIONS

Internal rotation correlates to radiographic measures of cam FAI in this cohort of collegiate football players. Football players with diminished internal rotation in whom hip pain develops should be evaluated for underlying cam FAI abnormalities.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

[Prevalence of idiopathic scoliosis and associated variables in schoolchildren of elementary public schools in Cuiabá, state of Mato Grosso, 2002]

OBJECTIVE

To estimate the prevalence of idiopathic scoliosis and its associated factors in schoolchildren of elementary public schools.

METHODS

Cross sectional two-phase study, the first of which in classrooms. Those considered Adams positive were invited for the second phase, which consisted of an interview for associated factors and a scoliosis exam. Those with a confirmed test in the second phase were submitted to x-rays for scoliosis and other factors. To estimate the prevalence, curves with > 5 and > 10 Cobb degrees were used as cut off.

RESULTS

In the first phase, 382 students were counted as Adams positive; of these 210 came for the second phase, 142 of which with a confirmed test. Using a chi-square test to compare the variables age, sex and color of the lost group (n = 172) to the group that accepted the invitation (n = 210), no statistical significance was observed, allowing statistical inference for the sample studied (n = 3,105). The estimated prevalence of scoliosis in the sample studied was 5.3% for curves > 5 Cobb degrees and 2.2% for curves > 10 Cobb degrees. Thoracic curves were observed in 44.8%, Risser grade 1 in 97.4%, and vertebral rotation degree I in 3.2%. Statistical significance was observed (p < 0.05) for the association of scoliosis with: physical activity, hump, and flexibility of the spine to the right.

CONCLUSION

The estimated prevalence of scoliosis in our study is comparable to those from other studies. However, its diagnosis and follow-up are important to health promotion and to the prevention of more severe disorders.

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.

A 5-year epidemiological study on the prevalence rate of idiopathic scoliosis in Tokyo: school screening of more than 250,000 children

BACKGROUND

School screening for scoliosis is a powerful tool that can be used to identify children who may have scoliosis. There have been no reports on the recent prevalence of idiopathic scoliosis in Japan since 1988.

METHODS

A 5-year epidemiologic study was performed to determined the prevalence of idiopathic scoliosis, the curve magnitude, the distribution of this magnitude, and the sex ratio in school children. Between 2003 and 2007, a total of 255,875 children aged 11-14 years were screened.

RESULTS

A total of 3,424 children were found to be positive as a result of Moiré topography. With radiographic examination, 2,225 (65.0%) children with a Cobb angle of 10° or more were detected. The overall prevalence rate in schoolchildren 11-14 years of age with Cobb angles of 10° or more was 0.87%. The prevalence rate in girls increased from 0.78% at the age of 11-12 years to 2.51% at the age of 13-14 years. For boys, the prevalence rates were 0.04% at the age of 11-12 years and 0.25% at the age of 13-14 years. The overall ratio of girls to boys with scoliosis was 11:1. The ratio of girls to boys was 17:1 at the age of 11-12 years and 10:1 at the age of 13-14 years.

CONCLUSIONS

The majority of the curves fell in the range of 10°-19°. There was a slight increase in the prevalence rates of children with a curve of high magnitude (≥20°) as compared to the prevalence rate in 1988. We suggest that school screening for scoliosis is effective for early detection; however, it is first necessary to review and optimize the target groups.

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.

A meta-analysis of the clinical effectiveness of school scoliosis screening

STUDY DESIGN

A meta-analysis that systematically reviewed the evaluation studies of a scoliosis screening program reported in the literature.

OBJECTIVE

To evaluate the best current evidence on the clinical effectiveness of school screening for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The use of school scoliosis screening is controversial, and its clinical effectiveness has been diversely reported.

METHODS

Data sources included 3 databases, namely, PubMed, Google scholar, CINAHL database, and the references from identified reviews and studies. Studies were included if: (1) they adopted a retrospective cohort design; (2) were screened using either the forward bending test (FBT), angle of trunk rotation, or Moiré topography; (3) reported results of screening tests and radiographic assessments; (4) screened adolescents only; (5) reported the incidence of curves with a minimum Cobb angle of 10 degrees or greater; and (6) reported the number of referrals for radiography. Reviews, comments, case studies, and editorials were excluded.

RESULTS

Thirty-six studies, including 34 from the 775 initially identified studies and 2 from the references, met the selection criteria. The pooled referral rate for radiography was 5.0%, and the pooled positive predictive values for detecting curves > or =10 degrees , curves > or =20 degrees , and treatment were 28.0%, 5.6%, and 2.6%, respectively. There was substantial heterogeneity across studies. Meta-regression showed that programs using the FBT alone reported a higher referral rate (odds ratio [OR] = 2.91) and lower positive predictive values for curves > or =10 degrees (OR = 0.49) and curves > or =20 degrees (OR = 0.34) than programs using other tests. Only one small study followed students until skeletal maturity and reported the sensitivity of screening; however, the specificity was not reported. No severe publication bias was noted.

CONCLUSION

The use of the FBT alone in school scoliosis screening is insufficient. We need large, retrospective cohort studies with sufficient follow-up to properly assess the clinical effectiveness of school scoliosis screening.

Spinal postural alignment variance according to sex and age in 7- and 8-year-old children

PURPOSE

Children's postural alignment undergoes many adjustments due to the changes in body proportions during the stages of growth. The objective of this study was to quantitatively characterize and analyze spinal postural standards in 7- and 8-year-old children to verify which of the differences found were correlated to age and sex.

METHODS

Two hundred thirty public school students (Amparo, São Paulo, Brazil) aged 7 to 8 years were divided into groups according to postural alignment, which were further subdivided by sex and age, for comparison. Digital photos of upright subjects were analyzed to evaluate posture. Lumbar and thoracic curvature, pelvic inclination, head posture, and lateral spine deviation were measured using CorelDraw (Ottawa, Canada) software guidelines and bone landmarks. Descriptive statistics and analysis of variance data analysis were utilized to verify differences among the groups. This was a cross-sectional, descriptive study.

RESULTS

Mean values for the variables analyzed were calculated. For lumbar lordosis, 7-year-old boys showed 38.49 degrees +/- 15.32 degrees in comparison to all other groups (42.29 degrees +/- 7.13 degrees ). For thoracic kyphosis, the 7-year-old children presented 28.07 degrees +/- 7.73 degrees , and the 8-year-olds 30.32 degrees +/- 7.73 degrees . Pelvic inclination presented a mean value of 15.82 degrees +/- 5.46 degrees and single lateral spine deviation mean value of 3.48 degrees +/- 2.12 degrees .

CONCLUSION

For the sample studied, differences based on sex and age were found for some of the body segments analyzed. The values found in this study may contribute to improved physiotherapeutic treatment when associated with other aspects of the clinical assessment and symptomatology.