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What Factors Influence Delayed Referral to Spinal Surgeon in Adolescent Idiopathic Scoliosis?
Abstract
Study design:
Retrospective review with qualitative phone interview.
Objective:
This study aims to identify the factors leading to delayed diagnosis or referral to a spinal surgeon in patients who subsequently require surgery for adolescent idiopathic scoliosis (AIS).
Summary of background data:
AIS can be effectively treated with bracing to prevent curve progression in skeletally immature patients. Australia currently has in place a national self-detection screening program to diagnose AIS.
Methods:
A retrospective review was performed for patients who underwent surgery for scoliosis at Princess Margaret Hospital for Children and Royal Perth Hospital between June 1, 2010 and May 27, 2014. Data were retrieved from the digital medical record and a semistructured phone interview was used to determine path to diagnosis and referral.
Results:
Mean Cobb angle at first specialist review was 49.5° ± 14.0° for patients who subsequently required surgery for AIS. These patients experienced an average interval of 20.7 months from detection of symptoms to review in a specialist clinic.
Conclusion:
In a condition in which early detection and intervention may halt progression of disease, AIS is detected relatively late and there are specific delays to diagnosis and referral to specialist clinics.
Level of evidence:
4.
... [1][2][3] It can be classified as infantile (0 to 3 years old), juvenile (4 to 9 years old), and adolescent (10 to 18 years old). [3][4][5] The prevalence of AIS ranges from 1 to 13%, depending on the diagnostic criteria used, ethnicity, and access to the health care system. 1,[6][7][8] Studies estimate that up to 3% of pubescent adolescents will develop some degree of curvature of the spine, with progression to magnitudes that impact the cardiopulmonary system if left untreated. ...
... 9,10 With the studies proving that using the vest prevents the progression of the curve and reduces the need for surgical treatment, there has been a significant increase in interest in school screening, aiming for early diagnosis and treatment, thus ensuring faster access to specialized centers. 4,[8][9][10][11][12] In Brazil, studies on the epidemiology of scoliosis are rare, and no population screening policy exists. 6,13,14 Therefore, the goal of this study is to evaluate the profile of scoliosis patients seen at our referral center and the main barriers encountered in the treatment of scoliosis to in the future create and implement ways to facilitate access to treatment for these adolescents. ...
... Most studies show that when there is no school screening, the diagnosis of scoliosis is made late, usually by the caregivers' perception or the complaint of pain. 9,12,24,25 Kenner et al. 4 demonstrated that the lack of population screening in Australia generated a mean delay of 20.7 months between detecting the deformity and referral to a specialist, resulting in 78% of the adolescents with curves above 40° at the first clinical evaluation. Yaokreh et al. 23 found a 17.9-month delay for this first evaluation. ...
Objective
Evaluation of the profile of the population with adolescent idiopathic scoliosis (AIS) treated at a center specializing in spine surgery in Curitiba-PR.
Methods
Prospective multicenter study, being analyzed, at the moment, only data from the center in question. All patients referred from the basic health service for evaluation of deformity underwent panoramic radiography of the total spine to evaluate the curvature using the Cobb method, evaluation of skeletal maturity using the Risser classification, and the classification of scoliosis using the Lenke classification. Clinical photographs of all patients and an assessment of the quality of life using the SRS-30 questionnaire were also taken.
Results
Thirty patients with scoliosis and a mean age of 14.63 ± 3 years were evaluated. Prevalence of female:male 1.5:1. Patients had a mean Cobb of 45.96°, and most were close to Risser 4 skeletal maturity (48.3%). 60% had a thoracic curve (Lenke 1), and 13.3% had a double curve (Lenke 3 or 6). 63.3% of cases had a delay in medical care, taking an average of 18 months between referral and consultation with a specialist. 60% of patients were referred for surgical treatment after the first appointment.
Conclusion
The population sample of this center follows the literature. A Cobb >40° in the first consultation with a specialist and a high referral rate to surgery suggest the failure of early diagnosis and the need for public policies for better knowledge and assistance for adolescent idiopathic scoliosis. Level of Evidence IV; Descriptive Epidemiological Study.
Keywords:
Scoliosis; Epidemiology; Public Health; Prevalence; Spine
... Despite the rationale for preventing large curvatures, some countries ended their professional scoliosis screening [6][7][8][9]. In the absence of professional scoliosis screening, scoliosis has to be detected by untrained family or friends, and the proportion of patients pre-senting in an advanced stage to the orthopedic specialist has increased significantly [10][11][12][13][14]. Non-operative treatments are less effective in more advanced curvatures (>40 degrees), resulting in an increased frequency of patients who undergo corrective surgery [11,12]. ...
... The shifted responsibility of scoliosis detection from professional to untrained adult impacts the appropriateness of AIS referral [11][12][13][14]. Delayed referral to a physician may be due to a lack of knowledge and awareness among untrained adults. ...
... Due to the shifted responsibility of scoliosis detection, the characteristics of AIS patients in the orthopedic clinic have changed [10][11][12][13][14]. More patients visit the clinic in a later stage with larger curvatures. ...
(1) In countries where scoliosis screening programs ended, the responsibility for detection shifted from healthcare professionals to parents. Since recognizing scoliosis is difficult for parents, more patients are presenting late. Increased awareness of scoliosis may favor earlier detection. This study examines the effect of educating parents to recognize scoliosis. (2) In this cross-sectional study a consecutive group of parents completed a digital assessment. They had to complete two identical series of fourteen cases (eight with scoliosis and six without). Each case displayed two photographs of the child’s back; one in standing position and one during forward-bending. Based on visual inspection, parents had to indicate if the child had to be referred to a physician. After assessing the first series, information was given on how to detect scoliosis. Subsequently, parents assessed the second series of cases. Sensitivity and specificity were calculated before and after education. (3) A total of 100 parents completed the assessment. The sensitivity to detect scoliosis was slightly but significantly higher after education (68.8% versus 74.0%; p = 0.002), while specificity was not (74.0% versus 74.8%; p = 0.457). (4) This study showed that educating parents improved their ability to recognize scoliosis without increasing the false positive referral rate. Although written instructions can bridge the gap with professional screening programs, the overall sensitivity in this study remained low. Therefore, education can improve the awareness and ability to detect scoliosis, but will not replace screening by professionals.
... [1][2][3] Commonly used clinical screening methods for scoliosis include general visual inspection and the Adam's Forward Bending Test. 4 While the benefits of universal screening programs have been debated, 4-6 early detection of AIS is important so that appropriate management pathways can be initiated, especially those at highest risk for progression. 7 As summarized by the Scoliosis Research Society, risk of progression is higher in the in those who develop scoliosis at a young age, in the presence of skeletal immaturity, and when curve angle is ≥20 degrees at presentation. 8 Recent research has identified additional factors, such as spinal flexibility, that may be important to predict curve progression/successful outcomes with bracing 9,10 In addition to facilitating the initiation of bracing (when indicated 11 ), early identification allows for earlier introduction of other conservative approaches. ...
... 11 Barriers to early identification and referral for further management should be identified and addressed. 7 Several published studies have assessed the relationship between body mass index (BMI) and the magnitude of spinal curvature upon presentation to a specialized scoliosis clinic. [13][14][15] These retrospective studies examined the charts of 150-279 adolescents and concluded that adolescent patients with a higher BMI or higher adiposity are more likely to have a larger magnitude of curve when they are first diagnosed with scoliosis compared to adolescents with a lower BMI or adiposity. ...
Purpose
To evaluate the relationship between body mass index (BMI) and spinal curvature in patients presenting with idiopathic scoliosis at a major pediatric tertiary care centre.
Patients and Methods
Retrospective chart review (2015–2019). Data extracted from patient’s first visit included age, sex, height, weight, spinal curvature (magnitude, location), referral source, physical activity participation (yes/no), pain (yes/no). Demographics were analyzed descriptively. The relationship between BMI and spinal curve magnitude was analyzed using Spearman correlation coefficient. Linear regression was applied to determine the relationship between BMI, curve magnitude, and curve location. Exploratory univariate analyses were conducted for BMI and referral source, pain, and skeletal maturity, and physical activity and pain.
Results
A total of 206 patient charts were included (177 females, 29 males). Patients presented with double major (41.3%), thoracic (26.7%), thoracolumbar (22.8%), and lumbar (9.2%) curves. Mean (SD) BMI percentile was 48.3 (30.5). No relationship existed between BMI percentile and curve magnitude with curve locations combined. However, a test for interaction revealed a positive relationship between BMI percentile and curve magnitude for adolescents with double major curves, and a negative relationship for adolescents with thoracic curves. Exploratory analyses suggested a relationship between BMI percentile and presence of pain, and between referral source and curve magnitude. No relationship was observed between BMI and skeletal maturity, or physical activity and pain.
Conclusion
The relationship between BMI varied by curve location within this cohort, in which most patients presented with a BMI <85th percentile. Findings highlight the importance of sensitive history taking and careful physical examination for early detection of scoliosis.
... However, the most common form of all scoliosis conditions is called 'idiopathic', which comprises 85% of all cases. The underlying cause of idiopathic scoliosis is not yet fully understood (Asher & Burton 2006;Kenner et al. 2019;Kruzel & Moramarco 2020). A functional tethering of the spinal cord as found by Deng et al. (2015) as a reason for the ventral overgrowth within the thoracic spine (Chu et al. 2006) currently seems the most promising concept explaining the aetiology of adolescent idiopathic scoliosis (AIS). ...
... Many AIS patients come for treatment at 12.8 ± 2.1 years old, with mean Cobb angles of 47.88° ± 14.28° at their first visit. The asymmetry is frequently noticed mostly by their mothers, when patients are in the shower, swimwear or wearing form-fitting clothes (Kenner et al. 2019). From our clinical experience we assume that in Indonesia, Muslims usually wear loose-fitting attire, and this might increase the likelihood of late detection of scoliosis. ...
Background: Lenke 5C (lumbar and or thoracolumbar) curve patterns lead to loss of lumbar lordosis which is associated with low back pain in later adulthood. We undertook our study to investigate if brace treatment may have an effect on low back pain and on improving the cosmetic appearance in late adolescents and adults.
Objectives: To estimate if conservative treatment may have an effect on pain in single lumbar curvatures in late adolescent and adult patients with Adolescent Idiopathic Scoliosis (AIS) using a Gensingen Brace by Weiss (GBW).
Method: We investigated AIS patients with Lenke 5C pattern who wore a GBW prospectively. The inclusion criteria of our study were age over 15 years, Cobb angle greater than 20° before treatment and Risser 4 or 5. A verbal pain rating scale was used (no pain, mild pain, moderate pain, severe pain, very severe pain).
Results: A total of 26 patients met the inclusion criteria. The average age was 17.7 years and the average Cobb angle was 41.5°. Nineteen patients (73.1%) experienced mild or moderate chronic low back pain before treatment and seven patients (26.9%) were asymptomatic but seeking treatment for cosmetic reasons. At follow-up, a 23% correction of the curve was achieved. All previously symptomatic patients reported that they no longer experienced low back pain after having worn the brace regularly.
Conclusion: High correction bracing seems to have a positive effect on the curve and on chronic low back pain in patients with a scoliosis and a Lenke 5C curve pattern.
Clinical implications: High correction, pattern specific bracing with a GBW may be applied aiming at reducing structural curves and chronic low back pain in late adolescent and adult patients with AIS and with a single lumbar curvature.
... The prevalence of AIS with a Cobb angle >10° is approximately 3 percent, but only 10 percent of adolescents with AIS require treatment. Patients with AIS usually come to medical attention as a result of truncal asymmetry noted by the patient or caregivers, as well as an incidental finding during physical examination or on chest radiograph or other imaging study [3,4] The Clinical Hisory and the physical examination are essential. Measurement of the patient's height and patient's arm span, assessment of Tanner stage, examination of the skin and a full neurologic examination should be performed. ...
Adolescent idiopathic scoliosis (AIS) is defined by lateral curvature of the spine with Cobb angle greater tan 10 degrees, age of onset older than 10 years, and no underlying etiology. The evaluation of this patology focuses on looking for an underlying etiology, evaluating the magnitude of the curve, and determining the risk of progression. In this article we present a case of rapidly evolving scoliosis that makes us question when MRI is indicated.
... Finally, the waiting list for AIS surgery does not seem to be the only problem in the treatment logistics of this spinal deformity. Delay in diagnosis and proper referral to specialized centers, and the presence or absence of health insurance also may justify the severity of deformities at the time of surgery [35][36][37][38][39]. ...
Purpose
To investigate, through a systematic review, the impact of the waiting time for Adolescent Idiopathic Scoliosis (AIS) surgical correction from the point of view of deformity evolution, treatment cost, and quality of life.
Methods
PubMed, Embase, LILACS, SciELO, Scopus, Web of Science, LIVIVO, and Cochrane Library databases were searched by two researchers to select the articles. The eligibility criteria were: Patients diagnosed with AIS with indication for surgical correction and submitted to waiting lists until treatment. The risks of bias were evaluated using the Risk Of Bias In Non-randomized Studies—Interventions (ROBINS-I) tool, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to classify the level of the evidence for each outcome. The summary of the available evidence is presented in a narrative synthesis.
Results
Six observational studies were included. In a Canadian study, the primary outcome was the need for additional spine surgery in patients who had to wait more than three months due to spine deformity progression. American researchers presented a sample of premenarcheal and skeletally immature patients with AIS showing increased Cobb angle and attributed this to a six-month waiting for the surgical treatment. Another study included 177 patients with AIS with a mean waiting time of 225.7 days. There was a worsening average of 7.7° ± 8.6° in Cobb angle, and there was a change in surgical plan in 28 patients, which increased surgical time. Studies that evaluated the treatment cost showed significantly higher mean costs in those who waited longer than six months. Regarding the quality of life, while waiting for surgery, a retrospective study found that patients who underwent surgery earlier showed better results in a questionnaire that assessed their quality of life compared to those who were still waiting.
Conclusion
Observational studies show that, in individuals who are on waiting lists for AIS surgery, there is a worsening of the spinal deformity (substantial evidence), an increasing cost of treatment (moderate evidence) and it may negatively impact patients' quality of life (insufficient evidence). Performing better methodological quality studies to investigate these outcomes can violate good research practices since randomized clinical trials on this subject have ethical limitations to be carried out.
Trial registration
The authors declare that the systematic review protocol was registered at the international prospective register of systematic reviews (PROSPERO), CRD42020212134, and it was accepted for publication.
... The upper limit (75th percentile) of the curve magnitude IQR is higher and the large magnitude outliers are more extreme On-line learning and lock down measures, including activity cancellations, have further limited opportunities for early diagnosis. Although scoliosis referrals are ultimately made by PCPs, it is not uncommon for a curvature to first be noted by an individual that is not a health-care professional [8,22]. Opportunities for curve recognition include social activities and organized sport. ...
Study designRetrospective comparative review.Objective
The aim of this study was to determine the short-term impact of the COVID-19 pandemic on the demographic and clinical profile of new idiopathic scoliosis (IS) patients, with a particular focus on treatment and late referral.Summary of background dataThe COVID-19 pandemic has limited health-care services and public access and, as a result, the diagnosis and management of non-COVID-19 health conditions have been compromised. Delayed diagnosis of IS may limit conservative treatment options and subsequently, increase a patient’s risk of requiring surgical intervention.Methods
The volume of spine referrals received and new IS clinic visits were compared between March 15–October 15, 2019 and the same period in 2020. A chart and radiographic review detailed the patient profile at initial presentation. Descriptive statistics and comparative analyses examined the referral source, curve magnitude, skeletal maturity, and prescribed treatment. Late referrals were those with a curve magnitude ≥ 50°, or > 40° and Risser 2 or less.ResultsDuring the 2020 study period, the referral volume decreased 76% and clinic visits 55%. The 2019 cohort was similar in age (13.7 ± 2.1 years vs 13.3 ± 2.3 years, p = 0.08), Risser score distribution (p = 0.32), menarchal status (0.07), and curve magnitude (37.1° ± 3.8° vs 39.0° ± 16.0°, p = 0.22). During the pandemic, there was an increased proportion of referrals made by pediatricians (41 to 54%, p = 0.01). The proportion of brace prescriptions increased from 30 to 42% (p = 0.01). The proportion of surgical bookings and late referrals were increased but did not reach significance.Conclusion
Despite no significant increase in the magnitude of the curve at initial presentation or the proportion of late referrals, there was a marked decrease in referral volume, over the first 7 months of the COVID-19 pandemic. This suggests that the majority of expected new IS patients remain undiagnosed. A future increase in late referrals should be anticipated.Level of evidenceIII.
... Studies have shown that cases of adolescent idiopathic scoliosis (AIS) that are undiagnosed could lead to major debilitating trunk deformity, pain in adulthood, pulmonary complications and, in extreme cases, mortality (Kenner, McGrath & Woodland 2019). Physiotherapists who are often the first contact clinicians, and who implement physiotherapeutic scoliosis-specific exercises (PSSE) in the management of patients with scoliosis, can have a positive influence on the course of scoliosis. ...
Background:
Idiopathic scoliosis (IS) is a common musculoskeletal condition with a multi-factorial aetiology characterised by a three-dimensional torsional deformity of the spine.
Objectives:
To ascertain the current level of knowledge on IS among registered practising physiotherapists who expressed an interest in orthopaedic, muscular, manual and manipulative therapy in South Africa (SA).
Method:
An online survey was used to collect the data. The questions were based on an existing questionnaire, validated by a South African panel of experts in the field of musculoskeletal physiotherapy and updated based on the 2016 Society of Scoliosis Orthopaedic Rehabilitation Treatment (SOSORT) guidelines for the assessment and management of IS.
Results:
Two hundred and twenty-three physiotherapists spread across the nine provinces of SA met the inclusion criteria and were included in our study. Our findings showed that about one-third (33.6%) of the physiotherapists could answer more than 50% of these questions correctly, and 16.5% could answer 70% of the questions correctly in relation to the widely accepted guidelines on IS management.
Conclusion:
The participants had a poor understanding of the diagnosis and treatment involved in managing patients with IS and a lack of knowledge regarding the methods of conservative treatment for scoliosis. Future studies should be aimed at assessing intervention strategies to improve the knowledge of IS in physiotherapists in SA, especially regarding diagnosis and identifying appropriate management strategies.
Clinical implications:
Physiotherapists are often the first contact practitioners for patients presenting with scoliosis and therefore need to have the necessary clinical knowledge on the assessment and management of IS. Our study can improve the awareness among the South African physiotherapists regarding IS and its complex presentation and management.
Adolescent idiopathic scoliosis (AIS) is the most characteristic disorder of the adolescent spine. It is a three-dimensional (3D) disorder that occurs from 10 years of age and comprises 90% of all idiopathic scolioses. Imaging plays a central role in the diagnosis and follow-up of patients with AIS. Modern imaging offers 3D assessment of scoliosis with less radiation exposure. Imaging helps rule out occult conditions that cause spinal deformity. Various imaging methods are also used to assess skeletal maturity in patients with AIS, thus determining the growth spurt and risk of progression of scoliosis. This article provides a brief overview of the pathophysiology, biomechanics, clinical features, and modern imaging of AIS relevant to radiologists in clinical settings.
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.
Background
The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. Methods
We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). ResultsThe trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). Conclusions
Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.)
Unlabelled:
Background:
Early diagnosis of idiopathic scoliosis allows for observation and timely initiation of brace treatment in order to halt progression. School scoliosis screening programs were abolished in Norway in 1994 for lack of evidence that the programs improved outcome and for the costs involved. The consequences of this decision are discussed.
Objectives:
To describe the detection, patient characteristics, referral patterns and treatment of idiopathic scoliosis at a scoliosis clinic during the period 2003-2011, when there was no screening and to compare treatment modalities to the period 1976-1988 when screening was performed.
Methods:
Patient demographics, age at detection, family history, clinical and radiological charts of consecutive patients referred for scoliosis evaluation during the period 2003-2011, were prospectively registered. Patients were recruited from a catchment area of about 500000 teenagers. Maturity was estimated according to Risser sign and menarcheal status. Severity of pain was recorded by a verbal 5-point scale from no pain to pain at all times. Physical and neurological examinations were conducted. The detector and patient characteristics were recorded. Referral patterns of orthopedic surgeons at local hospitals and other health care providers were recorded. Patient data was obtained by spine surgeons. Treatment modalities in the current period were compared to the period 1976-1988.
Results:
We registered 752 patients with late onset juvenile and adolescent idiopathic scoliosis from 2003-2011. There were 644 (86%) girls and 108 (14%) boys. Mean age at detection was 14.6 (7-19) years. Sixty percent had Risser sign ≥ 3, whilst 74% were post menarche with a mean age at menarche of 13.2 years. Thirty-one percent had a family history of scoliosis. The mean major curve at first consultation at our clinic was 38° (10°-95°). About 40% had a major curve >40°. Seventy-one percent were detected by patients, close relatives, and friends. Orthopaedic surgeons referred 61% of the patients. The mean duration from detection to the first consultation was 20(0-27) months. The proportion of the average number of patients braced each year was 68% during the period with screening compared to 38% in the period without screening, while the proportion for those operated was 32% and 62%, respectively ( p=0.002, OR 3.5, (95%CI 1.6 to 7.5).
Conclusion:
In the absence of scoliosis screening, lay persons most often detect scoliosis. Many patients presented with a mean Cobb angle approaching the upper limit for brace treatment indications. The frequency of brace treatment has been reduced and surgery is increased during the recent period without screening compared with the period in the past when screening was still conducted.
The efficacy of brace treatment for patients with adolescent idiopathic scoliosis remains controversial, and effectiveness remains unproven. We accurately measured the number of hours of brace wear for patients with this condition to determine if increased wear correlated with lack of curve progression.
Of 126 patients with adolescent idiopathic scoliosis curves measuring between 25 degrees and 45 degrees , 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured the exact number of hours of brace wear. Orthopaedic teams prescribed either sixteen or twenty-three hours of brace wear and were blinded to the wear data. At the completion of treatment, the number of hours of brace wear were compared with the frequency of curve progression of > or =6 degrees and with curve progression requiring surgery.
The total number of hours of brace wear correlated with the lack of curve progression. This effect was most significant in patients who were at Risser stage 0 (p = 0.0003) or Risser stage 1 (p = 0.07) at the beginning of treatment and in patients with an open triradiate cartilage at the beginning of treatment. Logistic regression analyses showed a "dose-response" curve in which the greater number of hours of brace wear correlated with lack of curve progression. Brace wear to school and immediately afterward was most successful. Curves did not progress in 82% of patients who wore the brace more than twelve hours per day, compared with only 31% of those who wore the brace fewer than seven hours per day (p = 0.0005). The number of hours of brace wear also correlated inversely with the need for surgical treatment (p = 0.0005). The number of hours of wear were similar for the patients who were advised to wear the brace sixteen or twenty-three hours daily.
The Boston brace is an effective means of controlling curve progression in patients with adolescent idiopathic scoliosis when worn for more than twelve hours per day.
A prevalence study of idiopathic scoliosis was conducted among 29,195 children of a community health district in the province of Quebec. The study was designed to determine whether a permanent screening program for idiopathic scoliosis was justified. The prevalence of the condition among school children aged 8 to 15 years was 42.0 per 1,000 in the screened population, 51.9 per 1,000 among girls, and 32.0 per 1,000 among boys. The positive predictive value of the bending test is estimated as 42.8 per cent for scolioses of 5 degrees or more; it is only 6.4 per cent when curves of 15 degrees or more are considered. The average cost of finding one child with a scoliosis of 5 degrees or more is $194. Mass screening for idiopathic scoliosis does not seem to be justified in the present state of knowledge of the disease.
The aim of our study was to evaluate the current methods of detection of adolescent idiopathic scoliosis. Data were collected from 100 consecutive patients with adolescent idiopathic scoliosis referred to the Scoliosis clinic in 2000. The age of the patient, the Cobb angle at presentation and the person who first noticed the deformity were recorded. Sixty three percent of the cases were detected by family or friends. The number of cases being detected at school had dropped considerably to 8%. Fifty six percent of all cases presented with a Cobb angle of more than 40 degrees. Our study shows that the most common method of detection was by family and friends. Seventy percent of these cases were detected when the deformity was advanced with Cobb angles of more than 40 degrees. There was a drop in the number of cases detected at school when most of the curves are at an earlier stage. We believe that greater awareness is needed in the community, for earlier recognition of idiopathic scoliosis.
A retrospective study of 2442 patients who had idiopathic scoliosis was performed to determine the prevalence of back pain and its association with an underlying pathological condition. Five hundred and sixty (23 per cent) of the 2442 patients had back pain at the time of presentation, and an additional 210 (9 per cent) had back pain during the period of observation. There was a significant association between back pain and an age of more than fifteen years, skeletal maturity (a Risser sign of 2 or more), post-menarchal status, and a history of injury. There was no association with gender, family history of scoliosis, limb-length discrepancy, magnitude or type of curve, or spinal alignment. At the latest follow-up evaluation, 324 (58 per cent) of the 560 patients who had had back pain at presentation had no additional symptoms. Forty-eight (9 per cent) of the 560 patients who had back pain had an underlying pathological condition: twenty-nine patients had spondylolysis or spondylolisthesis, nine had Scheurmann kyphosis, five had a syrinx, two had a herniated disc, one had hydromyelia, one had a tethered cord, and one had an intraspinal tumor. A painful left thoracic curve or an abnormal neurological finding was most predictive of an underlying pathological condition, although only eight of the thirty-three patients who had such findings were found to have such a condition. When a patient with scoliosis has back pain, a careful history should be recorded, a thorough physical examination should be performed, and good-quality plain radiographs should be made. If this initial evaluation reveals normal findings, a diagnosis of idiopathic scoliosis can be made, the scoliosis can be treated appropriately, and non-operative treatment can be initiated for the back pain. It is not necessary to perform extensive diagnostic studies to evaluate every patient who has scoliosis and back pain.
This paper summarizes the results of research into the scoliosis screening programme undertaken in Western Australian schools over a three-year period from October 1976 to October 1979. It represents the follow-up operating in the spinal deformities clinics chiefly at the Princess Margaret Hospital for Children and also at the Royal Perth (Rehabilitation) Hospital giving details of numbers seen, sex and age relationship, necessity for review visits and active treatment required. The various treatments are outlined briefly. The optimum school levels at which screening should be carried out have emerged and the programme has been altered accordingly as from the beginning of 1980. This paper concludes that school screening for scoliosis is a worthwhile exercise in preventive medicine.
Although the efficacy of bracing for adolescent idiopathic scoliosis has been debated, recent evidence indicates a strong dose-response effect with respect to preventing curve progression of ≥6°. The purpose of this study was to investigate whether bracing, prescribed with use of current criteria, prevents surgery and how many patients must be treated with bracing to prevent one surgery.
Of 126 patients with adolescent idiopathic scoliosis measuring between 25° and 45° and with a Risser sign of ≤2, 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured brace wear. Noncompliant patients were compared both with highly compliant patients and with the entire cohort, with the end point of progression to surgery. The absolute risk reduction (ARR) was calculated and used to calculate the number needed to treat (NNT) to prevent one surgery.
Bracing was not effective in preventing surgery unless the patient was highly compliant with brace wear. For patients who were considered to be highly compliant, based on the hours per day that they wore the brace, the NNT was 3 (95% confidence interval [CI], 2 to 7).
Within the limitations of a nonrandomized prospective study design, bracing for adolescent idiopathic scoliosis was found to substantially decrease the risk of curve progression to a range requiring surgery when patients were highly compliant with brace wear. Since many patients avoid surgery without wearing a brace, current indications appear to lead to marked overtreatment. Bracing appears to decrease the risk of curve progression to a magnitude requiring surgery, but current bracing indications include many curves that would not have progressed to a magnitude requiring surgery even if the patient had not worn the brace, and overall compliance with brace wear is low. Identifying these lower-risk patients and improving the compliance of those likely to have curve progression could substantially improve bracing results.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Scoliosis should be no more intimidating to manage than acute otitis media. This article reviews how to treat patients with the condition before and after referral to a specialist.
Recently published prevalence studies of scoliosis reveal a disconcerting variability, largely due to the use of different diagnostic "cutting points", which are frequently unstated. A statistical analysis of the prevalence of moderate and severe scoliotic curves shows that the distribution of scoliotic curves conforms best to a log normal distribution. Using this analysis, and using 10 degrees as the "cutting point" for the diagnosis, the adolescent scoliosis population consists of approximately 25 per 1,000.
The natural history presented in this chapter applies only to AIS. Other types of scoliosis have their own natural history and associated problems that may significantly affect the ability of the patient to meet the demands of daily life. Increased public awareness and screening clinics have resulted in an increased number of children referred for orthopaedic opinion, less severe curve magnitude at initial detection, and earlier institution of treatment. Treatment of each patient must be individualized, taking into consideration the probability of curve progression based on curve magnitude, skeletal maturity, sexual maturity, and age (Table 6-7). Overdiagnosis and unnecessary treatment must be avoided. As our knowledge of the natural history of AIS expands, treatment decisions can be based on objective rather than subjective data. Any proposed treatment of this condition must have a reasonable chance of altering the natural history in a positive way. The information available on natural history has been accumulated on relatively small groups of patients and the conclusions presented represent generalities. There are probably many "natural histories" for AIS, especially with reference to curve progression; therefore, treatment decisions must be individualized. Long-term results of various treatments for scoliosis must take into consideration the natural history of the disorder.
A prospective study was carried out in a cohort of 6873 children to determine diagnosis and treatment rates for adolescent
idiopathic scoliosis (AIS) and to establish the distribution of parameters related to bracing. The follow-up completion rate
was 85%, and prevalence rates were adjusted accordingly.
The prevalence of AIS of 6° or more at time of diagnosis was 8.1%. The female to male ratio for curves of 6° or more was 1.07:1
with an increase to 6:1 for curves greater than 21°. The rate of brace treatment was 2.8 per 1000. Deterioration, defined
as progression of a scoliosis curve to the point where a brace was prescribed, was found in 3.7% of the scoliosis group. Fifteen
children were prescribed braces: eight did not follow the treatment plan adequately (non-compliers), and five among these
abandoned the follow-up programme. However, none of the non-compliers deteriorated to the point where spinal fusion was required.
From 1973 to 1977, 7,642 girls and 751 boys were screened for spinal deformity in a Wisconsin County with a population of approximately 100,000. Of 243 girls and 30 boys found to have scoliosis, 155 girls and 13 boys had curves 10 degrees or greater. The most common location and curve direction was right thoracic; 98% of those with scoliosis were classified as idiopathic. Eighteen girls required treatment when initially seen: ten with a Milwaukee brace and eight with spine fusion. Of those not treated and followed for six months or longer, 24 girls and one boy had a decrease in their curve of at least 5 degrees, and 21 girls and one boy had an increase in their curve of at least 5 degrees. Determination of which curves would progress was unpredictable and identification of progression was possible only by repeated examinations.
In a prospective study by the Scoliosis Research Society, 286 girls who had adolescent idiopathic scoliosis, a thoracic or thoracolumbar curve of 25 to 35 degrees, and a mean age of twelve years and seven months (range, ten to fifteen years) were followed to determine the effect of treatment with observation only (129 patients), an underarm plastic brace (111 patients), and nighttime surface electrical stimulation (forty-six patients). Thirty-nine patients were lost to follow-up, leaving 247 (86 per cent) who were followed until maturity or who were dropped from the study because of failure of the assigned treatment. The end point of failure of treatment was defined as an increase in the curve of at least 6 degrees, from the time of the first roentgenogram, on two consecutive roentgenograms. As determined with use of this end point, treatment with a brace failed in seventeen of the 111 patients; observation only, in fifty-eight of the 129 patients; and electrical stimulation, in twenty-two of the forty-six patients. According to survivorship analysis, treatment with a brace was associated with a success rate of 74 per cent (95 per cent confidence interval, 52 to 84) at four years; observation only, with a success rate of 34 per cent (95 per cent confidence interval, 16 to 49); and electrical stimulation, with a success rate of 33 per cent (95 per cent confidence interval, 12 to 60).(ABSTRACT TRUNCATED AT 250 WORDS)
Because of the relatively recent understanding of the untreated natural history of idiopathic scoliosis, many patients do not require treatment and are simply observed. Immature patients whose curves are between 25 degrees and 40 degrees are at high risk for further progression and should be treated with a brace. Seventy percent to 80% of the time, the patient can expect that the brace will prevent further progression. Curves in growing children greater than 40 degrees require a spinal fusion. Modern scoliosis surgery provides excellent correction of deformity and allows immediate ambulation without a cast or brace. This article reviews the diagnosis, cause, and treatment recommendations for adolescent idiopathic scoliosis.
Adolescent idiopathic scoliosis is a highly prevalent disorder of the spine, occurring in phenotypically normal individuals for unknown reasons. The role of genetic factors in this condition has been widely documented through clinical observations and population studies. Multiple areas of research, including connective tissue, neuromotor mechanisms, hormonal system, and biomechanics, have been explored for a potential relationship to the cause of idiopathic scoliosis; however, no clear evidence supports any one area as a etiologic factor of this disorder. The main difficulty of most investigations is to determine whether the observed abnormalities are primary or secondary features in the scoliotic deformity. It is hoped that continued research efforts will aid in the understanding of this disorder in an effort to improve the ability to assign a more specific prognosis.
Adolescent idiopathic scoliosis is present in 2 to 4 percent of children between 10 and 16 years of age. It is defined as a lateral curvature of the spine greater than 10 degrees accompanied by vertebral rotation. It is thought to be a multigene dominant condition with variable phenotypic expression. Scoliosis can be identified by the Adam's forward bend test during physical examination. Severe pain, a left thoracic curve or an abnormal neurologic examination are red flags that point to a secondary cause for spinal deformity. Specialty consultation and magnetic resonance imaging are needed if red flags are present. Of adolescents diagnosed with scoliosis, only 10 percent have curves that progress and require medical intervention. The main risk factors for curve progression are a large curve magnitude, skeletal immaturity and female gender. The likelihood of curve progression can be estimated by measuring the curve magnitude using the Cobb method on radiographs and by assessing skeletal growth potential using Tanner staging and Risser grading.
A cross-sectional study was conducted of all patients referred for an initial visit to the orthopedic outpatient clinic of a metropolitan pediatric hospital in Canada for suspected adolescent idiopathic scoliosis (AIS).
To document the appropriateness of current referral patterns for AIS in comparison to those that were prevailing before discontinuation of school screening in Canada.
The consequences of the discontinuation of school scoliosis screening programs on the referral patterns of AIS patients remain unknown.
The clinical and radiologic charts of the 636 consecutive patients referred for scoliosis evaluation over a 1-year period were reviewed. Patients were classified according to defined criteria of appropriateness of referral based on skeletal maturity and curve magnitude.
Of the 489 suspected cases of AIS, 206 (42%) had no significant deformity (Cobb angle <10 degrees ) and could be considered as inappropriate referrals. In subjects with confirmed AIS, 91 patients (32%) were classified as late referrals with regards to brace treatment indications.
These findings suggest that current referral mechanisms for AIS are leading to a suboptimal case-mix in orthopedics in terms of appropriateness of referral.