Referrals from Scoliosis Screenings
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Am Fam Physician. 2001 Jul 1;64(1):32-34.
School screening programs for scoliosis remain the subject of considerable controversy.1–7 A recent epidemiologic study7 reported that some children with scoliosis who were identified through screening received treatment but, because screenings have a low positive predictive value (0.05 percent), many children were referred who did not require treatment. In 1993, the U.S. Preventive Services Task Force concluded that, “There is insufficient evidence for or against routine screening of asymptomatic adolescents for idiopathic scoliosis.”1 That conclusion was based, in part, on the lack of studies documenting improved outcomes from early identification and treatment of children with scoliosis. While subsequent reports8–10 have both supported and questioned the effectiveness of brace treatment for scoliosis, no randomized, prospective studies have clarified the efficacy of brace treatment. The benefits of scoliosis screening include increased public awareness of and knowledge about the epidemiology and natural history of scoliosis.
The American Academy of Orthopedic Surgeons (AAOS) and the Scoliosis Research Society (SRS) support school-based screening for scoliosis.11 A joint position statement on School Screening Programs for the Early Detection of Scoliosis by the AAOS and the SRS states that the optimal age for screening has not been established with certainty, but a reasonable approach is to screen girls twice, at about 10 and 12 years of age (grades five and seven), and boys once, at 13 or 14 years of age.11
The best means of assessing patients for scoliosis also has been debated. The most commonly performed test in school screening is the Adams forward-bending test, yet its effectiveness in school screening has been questioned.12–14 In the Adams forward-bending test, the patient bends forward at the waist with knees straight and arms together and hanging toward the floor, and the back parallel to the floor. The examiner looks along the axis of the spine for rotatory asymmetry of the trunk. A difference of 8 mm in height between sides is considered abnormal.11
The degree of rotatory asymmetry in the Adams position relative to the horizontal position can be measured with a scoliometer. A measurement of 7 degrees is generally used as the cut-off point for referral for evaluation of scoliosis.11,15 A 7 degree measurement by scoliometer correlates with a Cobb angle of 20 degrees.15
Controversy notwithstanding, school screening for scoliosis is commonly performed, and physicians are likely to have patients who have been referred for evaluation for possible scoliosis. Therefore, some practical recommendations are warranted. I consider the Adams forward-bending test, as described earlier, to be quite useful on physical examination. With the patient standing before me, I can observe the unclothed back for asymmetry in the shoulders, waist and pelvis, as well as leg length and space between the arms and the body (I find the last factor easiest to appreciate).
As touched on by Reamy and Slakey in their review of scoliosis in this issue of American Family Physician,16 perhaps the most important aspect of a physician's evaluation of a patient referred because of a positive scoliosis screening result is to rule out any underlying pathology that might be causing scoliosis (see Table 1 in Reamy and Slakey's article).16 A history of unusual back pain, radiating limb pain, sensory or motor changes, and bowel and bladder problems should be obtained. A brief neurologic examination should consist of testing the patient's reflexes, asking the patient to jump up and down on each leg and walk on the heels, observation of the popliteal angle (to assess hamstring tightness), as well as tests of sensitivity of the lower extremities to light touch.
The AAOS and the SRS maintain that not all children who are referred because of a positive screening result require radiography. By design, school screening will refer some children who do not have scoliosis in an effort not to miss referring children with scoliosis.11 The question of when to obtain radiography cannot be answered on the basis of available scientific data. In my practice, I am likely to obtain radiography in children who have (1) a large, unambiguous curve on physical examination, (2) asymmetry on examination in skeletally immature children (the risk of curve progression is greatest during growth), (3) asymmetry on examination and a family history of scoliosis, and (4) asymmetry and neurologic signs or symptoms.
A patient with scoliosis and neurologic signs or symptoms warrants referral and, most likely, a magnetic resonance imaging study of the entire spine. The two most important predictors of curve progression are the size of the curve and the amount of growth remaining. Based on these risk factors, skeletally immature children with curves greater than 20 degrees Cobb angle or fully mature adolescents with curves greater than 40 degrees Cobb angle should be considered for referral to an orthopedic surgeon.
David L. Skaggs, M.D., is an assistant professor of orthopedic surgery at the University of Southern California-Keck School of Medicine, Los Angeles.
Address correspondence to David L. Skaggs, M.D., University of Southern California-Keck School of Medicine, 4650 Sunset Blvd., Mail Stop #69, Los Angeles, CA 90027.
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2. Dickson RA, Weinstein SL. Bracing (and screening)—yes or no? J Bone Joint Surg [Br]. 1999;81:193–8.
3. Goldberg CJ, Dowling FE, Fogarty EE, Moore DP. School scoliosis screening and the United States Preventive Services Task Force. An examination of long-term results. Spine. 1995;20:1368–74.
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5. Montgomery F, Willner S. Screening for idiopathic scoliosis. Comparison of 90 cases shows less surgery by early diagnosis. Acta Orthop Scand. 1993;64:456–8.
6. Winter RB, Lonstein JE. To brace or not to brace: the true value of school screening [Editorial]. Spine. 1997;22:1283–4.
7. Yawn BP, Yawn RA, Hodge D, Kurland M, Shaughnessy WJ, Ilstrup D, et al. A population-based study of school scoliosis screening. JAMA. 1999;282:1427–32.
8. Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg [Am]. 1995;77:815–22.
9. Noonan KJ, Weinstein SL, Jacobson WC, Dolan LA. Use of the Milwaukee brace for progressive idiopathic scoliosis. J Bone Joint Surg [Am]. 1996;78:557–67.
10. Skaggs DL. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society [Letter]. J Bone Joint Surg [Am]. 1996;78(1):151.
11. American Academy of Orthopaedic Surgeons. School screening programs for the early detection of scoliosis: a position statement. Rosemont, Ill.: American Academy of Orthopaedic Surgeons, 1992.
12. Huang SC. Cut-off point of the scoliometer in school scoliosis screening. Spine. 1997;22:1985–9.
13. Karachalios T, Sofianos J, Roidis N, Sapkas G, Korres D, Nikolopoulos K. 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? Spine. 1999;24:2318–24.
14. Grossman TW, Mazur JM, Cummings RJ. An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting. J Pediatr Orthop. 1995;15:535–8.
15. Bunnell WP. An objective criterion for scoliosis screening. J Bone Joint Surg [Am]. 1984;66:1381–7.
16. Reamy BV, Slakey JB. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Physician. 2001;64:111–6.
Copyright © 2001 by the American Academy of Family Physicians.
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