scoliosis

Are School Scoliosis Screening Examinations Necessary and Effective?

Lindsay Nakaishi, MD, MPH
Linda S. Nield, MD
Volume 14 - Issue 12 - December 2015

A Parent Asks

The school nurse will be performing scoliosis screenings, and my daughter is embarrassed to have this done at school. Is screening for scoliosis in school really necessary, and does it make a difference in the health of the child?

The Parent Coach Advises

Scoliosis, the most common spinal deformity, is a greater than 10° lateral curve (Cobb angle) in the coronal plane on a radiograph. Structurally, scoliosis is characterized by vertebral and trunk rotations that create a 3-dimensional, helically shaped spinal column.1,2

Scoliosis is divided into 3 primary classifications: congenital, neuromuscular, and idiopathic scoliosis.3

Congenital scoliosis is secondary to malformations of the vertebral bodies and/or the segmentation between vertebrae, which are present at birth but often are not evident until later in childhood.

Neuromuscular scoliosis results from inadequate muscular support surrounding the spinal column, and the age of onset depends on the type and severity of the underlying neuromuscular disease.3,4 Idiopathic scoliosis is the most common scoliosis form, comprising approximately 85% of cases. Idiopathic scoliosis is subdivided by age of onset: infantile (birth to 3 years), juvenile (3 to 9 years), and adolescent (10 to 18 years).2 Adolescent idiopathic scoliosis (AIS), the most common type of idiopathic scoliosis, affects approximately 2% to 4% of adolescents, has a milder clinical course, and is seen commonly in primary care.2-5

Scoliosis Screening Methods

Most patients with untreated AIS maintain normal function without increased morbidity or mortality.2,5-7 However, curve progression can lead to a visible deformity, emotional distress, intractable pain, and, rarely, organ dysfunction. Approximately 10% children with an AIS diagnosis require bracing, and approximately 0.25% require surgery.2,6,7

It has been known for decades that early diagnosis and nonsurgical treatments can mitigate negative health outcomes. Orthopedist G. Dean MacEwen, MD, first championed state school screening programs in Delaware in the early 1960s.8 The basic principle for all scoliosis screening techniques is to assess the surface topography, which is most often done with the Adams forward bending test and/or scoliometry.3,4,8,9

The Adams forward-bending test is the most sensitive and widely used qualitative clinical examination. The child bends forward at the waist, while the examiner observes from behind for shoulder and torso asymmetry, rib prominence, and/or paraspinal muscle prominence in the lumbar spine.3,4,9 Because no specialized equipment is required, the Adams test is used frequently during school screenings.

Quantitative evaluation is most often done with scoliometry, in which an inclinometer is used to measure the angle of trunk rotation while in the forward bend position.

Although scoliometry is simple and inexpensive, it requires equipment and additional training that is not feasible for every school screening program. Compared with the gold standard of scoliosis diagnosis—measurement of the Cobb angle on radiographs—the sensitivity, specificity, positive predictive values, and negative predictive values for both screening methods vary greatly depending on the examiner, location of the curve (ie, thoracic vs lumbar), severity of the Cobb angle, and number of curves in the spine.10-14 Both methods are used for school screenings, but neither is sufficient for diagnosis.

Screening Recommendations

AIS screening opponents include the United States Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians (AAFP). Although they do not address school-based screenings specifically, both groups recommend against routine screening for AIS in asymptomatic adolescents. In 2004, the USPSTF applied an updated methodology for rating the strength of evidence when reviewing scoliosis screening reports from 1994 through 2002. The task force found a lack of evidence that AIS was detected earlier in populations undergoing screenings compared with unscreened populations. It also found that only a small portion of AIS detected during early screenings resulted in decreased pain and disability, and that mandatory screening resulted in unnecessary interventions.2,15 However, the USPSTF evidence analysis included only a small number of studies, none of which were published after 2002. In addition, the USPSTF recommendation did not evaluate the methodologic quality of the papers in its review, calling into question the validity and reliability of the evidence used to support its recommendation against screenings.16

In 2007, the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics convened a task force supporting AIS screening in asymptomatic adolescents in clinical and school settings.2,17 After a systematic review of the literature, these societies concluded that there is a lack of definitive evidence for or against screening, and thus they emphasized the use of consensus expert opinion. They asserted that the potential benefits outweigh the harm, because AIS screening is inexpensive, the radiation exposure is significantly less than in the past, and earlier diagnosis allows for nonsurgical interventions (eg, bracing). Although their support for AIS screenings is fueled primarily by expert opinion rather than evidence, recent studies have demonstrated findings in support of screenings.

Research on Screening’s Effectiveness

In 2015, Fong and colleagues18 published a large population-based cohort study that included 306,144 Hong Kong students who were screened for scoliosis using the forward bending test with scoliometry. In screened students, the AIS prevalence was 3.5% (95% CI, 3.5%-3.6%), a rate that was significantly higher than that of unscreened students (P < .001), indicating that school-based scoliosis screening may help detect AIS. Until recently, data showing that there is an effective and reasonable treatment for AIS were limited.

In 2013, Weinstein and colleagues19 published a randomized, multicenter, prospective cohort study to determine the effectiveness of bracing in preventing the progression of the spinal curve to more than 50°, which is a common indication for surgery. The primary analysis, which included 242 adolescents with high-risk AIS (ie, curves greater than 50°), found that bracing significantly decreased the progression of curves to the threshold for surgery; however, bracing did not improve quality of life. Additionally, the authors noted that the rates of treatment success depended on the number of hours the brace was worn, with a recommended minimum of 18 hours per day. Wearing a rigid thoracolumbosacral orthosis for 18 hours per day, including during school hours, can be emotionally distressing for adolescents.

A paucity of evidence exists demonstrating that school AIS screenings result in improved patient-oriented outcomes, including improved quality of life. Any positive AIS screening warrants additional evaluation by a primary care physician in consultation with an orthopedic surgeon before the initiation of bracing.

The Take-Home Message

AIS affects 2% to 4% of 10- to 18-year-olds. Most of these adolescents maintain normal function; nevertheless, unrecognized AIS can result in poor physical and emotional outcomes that could be mitigated with early detection and management of the condition.2-7 Early detection through school-based AIS screening programs is highly controversial because of the conflicting evidence and recommendations about the efficacy of school screenings.6,16,20,21 Consequently, only some states mandate school screenings.

The current USPSTF recommendation against school screenings is based on outdated and limited data, and therefore it may not provide the validity and reliability necessary to make an informed, evidence-based decision for or against screenings. Recent work by Fong and colleagues18 demonstrated that the forward bend test with scoliometry is an easily accessible and reasonable method of detecting AIS in asymptomatic children. 

To date, no evidence exists to support AIS screenings that use the forward bend test alone, which commonly is the only screening method used in schools. 

Weinstein and colleagues19 found a positive association between brace wearing and treatment success, suggesting that if AIS is identified early, bracing is a readily available and a potentially curative intervention.19,22 

Based on the best current evidence available, it is reasonable to recommend that adolescents participate in school-based screenings if the forward bend test with scoliometry is employed. If a child is embarrassed to be examined in a school setting, the child’s health care provider should screen for scoliosis at the next scheduled well child visit.

Lindsay Nakaishi, MD, MPH, is a family medicine physician at the University of Pittsburgh Medical Center Shadyside Family Health Center in Pittsburgh, Pennsylvania.

Linda S. Nield, MD—Series Editor, is a professor of pediatrics and medical education at the West Virginia University School of Medicine in Morgantown, West Virginia.

References

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  3. Hresko MT. Clinical practice: idiopathic scoliosis in adolescents. N Engl J Med. 2013;368(9):834-841.
  4. El-Hawary R, Chukwunyerenwa C. Update on evaluation and treatment of scoliosis. Pediatr Clin North Am. 2014;61(6):1223-1241.
  5. 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.
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  13. Viviani GR, Budgell L, Dok C, Tugwell P. Assessment of accuracy of the scoliosis school screening examination. Am J Public Health. 1984;74(5):497-498.
  14. Amendt LE, Ause-Ellias KL, Lundahl Eybers J, Wadsworth CT, Nielsen DH, Weinstein SL. Validity and reliability testing of the Scoliometer. Phys Ther. 1990;70(2):108-117.
  15. US Preventive Services Task Force. Screening for idiopathic scoliosis in adolescents: recommendation statement. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/idiopathic-scoliosis-in-adolescents-screening?ds=1&s=scoliosis screening. Updated July 2015. Accessed November 9, 2015.
  16. Płaszewski M1, Bettany-Saltikov J. Are current scoliosis school screening recommendations evidence-based and up to date? A best evidence synthesis umbrella review. Eur Spine J. 2014;23(12):2572-2585.
  17. Richards BS, Vitale MG. Screening for idiopathic scoliosis in adolescents. J Bone Joint Surg Am. 2008;90:195-198.
  18. Fong DYT, Cheung KMC, Wong Y-W, et al. A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening. Spine J. 2015;15(5):825-833.
  19. Weinstein DL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013;369(16):1512-1521.
  20. Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician. 2002;65(9):1817-1822.
  21. Dickson RA, Weinstein SL. Bracing (and screening)—yes or no? J Bone Joint Surg Br. 1999;81(2):193-198.
  22. Herman C. What makes a screening exam “good”? Virtual Mentor. 2006;8(1):34-37.

Acknowledgement

The authors acknowledge the assistance of Mathew D. Lively, DO, professor of pediatrics, internal medicine, and exercise physiology at the West Virginia University School of Medicine in Morgantown, West Virginia, as well as the assitance of Madeline Simasek, MD, director of newborn and pediatric services in the University of Pittsburgh Medical Center Shadyside family medicine residency program in Pittsburgh, Pennsylvania.