Monday, January 13, 2020

Should schools screen for adolescent idiopathic scoliosis?

- Jennifer Middleton, MD, MPH

I still remember lining up with my female peers in junior high gym class, clad only in undergarments (quite the height of teenage mortification), to bend over and have our spines checked for scoliosis. Such school-based screenings remain commonplace across the US, though there is considerable debate regarding their benefit. The January 1 AFP review on "Adolescent Idiopathic Scoliosis: Common Questions and Answers" discusses the current United States Preventive Services Task Force "I" statement regarding screening and its rebuttal by several medical organizations including the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons. Although the evidence base leans away from screening, family physicians are still likely to encounter adolescents and their worried parents with positive screens in our offices.

Repeating the forward bend test in the office and looking for an abnormal appearance of the back or ribs is a reasonable first step. The AFP authors review a study that found the forward bend test has a 92-100% sensitivity for detecting a Cobb angle of at least 20 degrees. While the patient is bending over, clinicians may also use a scoliometer or a scoliometer app to quantify trunk rotation. Sensitivity to detect a Cobb angle of at least 10 degrees is highest with a scoliometer cutoff of 5%, but a cutoff of 7% has a better specificity (87% compared to 47%) with a small corresponding loss of sensitivity (down to 83%). Radiography can definitively make the diagnosis and quantify severity.

The AFP authors point out that evidence is lacking regarding the benefit of referring all but the most severe cases of scoliosis (Cobb angle of 40 degrees or greater) to an orthopedic surgeon. Family physicians should also discuss the prognosis for mild to moderate scoliosis with their patients and parents; the evidence review that informed the USPSTF's "I" decision found that:

Quality of life [measures]...were similar between observed and braced participants at adult followup, though braced participants felt their body appearance was more distorted than did untreated participants, and braced participants reported more negative treatment experiences than those treated surgically. No significant adult outcome differences were found between braced and surgically-treated participants on the Oswestry Disability Index, general well-being, or self-esteem and social activity. Pulmonary outcomes and childbearing and pregnancy outcomes were similar in braced and surgically-treated participants.

School-based nursing programs might more effectively target their efforts toward other disease processes (and their risk factors). In an era of school nursing shortages across the US, prioritizing school-based health efforts is more important than ever. The National Association of School Nurses does not include reference materials about scoliosis anywhere on their website, focusing instead on more prevalent and more impactful issues such as childhood obesity, drugs of abuse, mental health, and reproductive health.

There's an AFP By Topic on Musculoskeletal Care if you'd like to read more, and here is additional AFP content specifically regarding scoliosis as well.