Adolescent Idiopathic Scoliosis: Diagnosis and Management



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2014 Feb 1;89(3):193-198.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/scoliosis.html.

Adolescent idiopathic scoliosis is the most common form of scoliosis, affecting approximately 2% to 4% of adolescents. The incidence of scoliosis is about the same in males and females; however, females have up to a 10-fold greater risk of curve progression. Although most youths with scoliosis will not develop clinical symptoms, scoliosis can progress to rib deformity and respiratory compromise, and can cause significant cosmetic problems and emotional distress for some patients. For decades, scoliosis screenings were a routine part of school physical examinations in adolescents. The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend against routine scoliosis screening in asymptomatic adolescents, concluding that harm from screening outweighs the benefit because screenings expose many low-risk adolescents to unnecessary radiographs and referrals. In contrast, the Scoliosis Research Society, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, and Pediatric Orthopaedic Society of North America suggest that the potential benefit of detecting scoliosis early justifies screening programs, but greater care should be used in deciding which patients with positive screening results need further evaluation. The goal for primary care physicians is to identify patients who are at risk of developing problems from scoliosis, without overtesting or overreferring patients who are unlikely to have further problems. Physical examination with the Adam's forward bend test and a scoliometer measurement can guide judicious use of radiologic testing for Cobb angle measurement and orthopedic referrals. Treatment options include observation, braces, and surgery.

Scoliosis is a condition commonly encountered in the primary care setting, affecting roughly 2% to 4% of adolescents.14 Scoliosis is defined as a lateral curve to the spine that is greater than 10 degrees with vertebral rotation.15 It can be classified as congenital, neuromuscular, or idiopathic; approximately 85% of cases are idiopathic.13,6 Idiopathic scoliosis can be further classified by age of onset: infantile (birth to two years), juvenile (three to nine years), and adolescent (10 years and older).13,6 Adolescent idiopathic scoliosis is the most common form.13,6,7 Scoliosis usually does not cause problems, but sometimes leads to visible deformity, emotional distress, and respiratory impairment from rib deformity.1,35,79

Males and females are about equally likely to have minor scoliosis of approximately 10 degrees, but females are five to 10 times more likely to progress to more severe disease, possibly needing treatment.1,35,10,11 The goal for primary care physicians is to first determine which patients have significant spinal curvature, then decide which of these patients may need imaging or referral for treatment.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The U.S. Preventive Services Task Force and the American Academy of Family Physicians recommend against routine scoliosis screening in asymptomatic adolescents.

B

14, 15

A scoliometer measurement of less than 5 degrees likely does not require follow-up.

C

5, 8, 20

A scoliometer measurement of 10 degrees or greater requires radiologic evaluation for Cobb angle measurement.

C

5, 8, 20


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The U.S. Preventive Services Task Force and the American Academy of Family Physicians recommend against routine scoliosis screening in asymptomatic adolescents.

B

14, 15

A scoliometer measurement of less than 5 degrees likely does not require follow-up.

C

5, 8, 20

A scoliometer measurement of 10 degrees or greater requires radiologic evaluation for Cobb angle measurement.

C

5, 8, 20


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Etiology

The exact pathophysiologic mechanism for scoliosis is unknown. A genetic factor has been implicated in the development and progression of scoliosis.3,12 If both parents have idiopathic scoliosis, their children are 50 times more likely

The Authors

JOHN P. HORNE, MD, is a faculty member at the Latrobe (Pa.) Hospital Excela Health Family Medicine Residency. He also is a clinical assistant professor of family medicine at Thomas Jefferson University's Jefferson Medical College in Philadelphia, Pa., and he holds a certificate of added qualification in adolescent medicine.

ROBERT FLANNERY, MD, practices primary care sports medicine in Birmingham, Ala. At the time this article was written, he was a second-year resident at the Latrobe Hospital Excela Health Family Medicine Residency.

SAIF USMAN, MD, practices primary care sports medicine in Rockville and Gaithersburg, Md. At the time this article was written, he was a second-year resident at the Latrobe Hospital Excela Health Family Medicine Residency.

Author disclosure: No relevant financial affiliations.

The authors thank Marilyn Daniels, MLS, Excela Health System library services, and Sarah Horne, MA, for their assistance with this article.

Address correspondence to John P. Horne, MD, Excela Health Latrobe, One Mellon Way, Latrobe, PA 15650 (e-mail: jhorne@excelahealth.org). Reprints are not available from the authors.

REFERENCES

1. Lonstein JE. Adolescent idiopathic scoliosis. Lancet. 1994;344(8934):1407–1412.

2. Smith JR, Sciubba DM, Samdani AF. Scoliosis: a straightforward approach to diagnosis and management. JAAPA. 2008;21(11):40–45.

3. Reamy BV, Slakey JB. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Physician. 2001;64(1):111–116.

4. Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30(3):353–365, vii–viii.

5. Bunnell WP. Selective screening for scoliosis. Clin Orthop Relat Res. 2005;(434):40–45.

6. Neinstein LS, Chorley JN. Scoliosis and kyphosis. Adolescent Health Care: A Practical Guide. 4th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2002:345–355.

7. O'Connor F. Pediatric Orthopedics for the Family Physician. Infant, Child & Adolescent Medicine. AAFP CME Program. 2007.

8. Weiss HR. Adolescent idiopathic scoliosis (AIS) – an indication for surgery? A systematic review of the literature. Disabil Rehabil. 2008;30(10):799–807.

9. Glassman SD, Carreon LY, Shaffrey CI, et al. The costs and benefits of nonoperative management for adult scoliosis. Spine (Phila Pa 1976). 2010;35(5):578–582.

10. Tan KJ, Moe MM, Vaithinathan R, Wong HK. Curve progression in idiopathic scoliosis: follow-up study to skeletal maturity. Spine (Phila Pa 1976). 2009;34(7):697–700.

11. Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am. 1984;66(7):1061–1071.

12. Ogilvie J. Adolescent idiopathic scoliosis and genetic testing. Curr Opin Pediatr. 2010;22(1):67–70.

13. Linker B. A dangerous curve: the role of history in America's scoliosis screening programs. Am J Public Health. 2012;102(4):606–616.

14. U.S. Preventive Services Task Force. Screening for idiopathic scoliosis in adolescents. Recommendation statement. June 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/scoliosis/scoliors.htm. Accessed August 8, 2013.

15. U.S. Preventive Services Task Force. Screening for idiopathic scoliosis in adolescents. Brief evidence update. June 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/scoliosis/scolioup.htm. Accessed August 8, 2013.

16. American Academy of Family Physicians. Clinical recommendations. Scoliosis, idiopathic in adolescents. 2004. http://www.aafp.org/patient-care/clinical-recommendations/all/scoliosis.html. Accessed August 8, 2013.

17. American Academy of Family Physicians. Choosing Wisely Scoliosis. http://www.aafp.org/about/initiatives/choosing-wisely.html. Accessed October 9, 2013.

18. Siwek J, Lin KW. Choosing Wisely: more good clinical recommendations to improve health care quality and reduce harm. Am Fam Physician. 2013;88(3):164–168. http://www.aafp.org/afp/choosingwisely. Accessed November 12, 2013.

19. Richards BS, Vitale M. SRS/AAOS position statement. School screening programs for the early detection of scoliosis. 2007. http://www.srs.org/professionals/advocacy_and_public_policy/SRS-AAOS_position_statement.htm. Accessed August 8, 2013.

20. Greene WB, ed. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill.: American Academy of Orthopaedic Surgeons; 2001:696–699.

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

22. Sanders JO, Khoury JG, Kishan S, et al. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am. 2008;90(3):540–553.

23. Negrini S, Minozzi S, Bettany-Saltikov J, et al. Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev. 2010;(1):CD006850.

24. Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013;369(16):1512–1521.

25. Carragee EJ, Lehman RA Jr. Spinal bracing in adolescent idiopathic scoliosis. N Engl J Med. 2013;369(16):1558–1560.

26. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ. Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA. 2003;289(5):559–567.


Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

More in Pubmed

Navigate this Article