Scoliosis is an abnormal curvature of the spine. There are several types. Some are associated with structural defects in the spinal vertebrae while others are the result of faulty muscle development. By far the most common is Adolescent Idiopathic Scoliosis (AIS). As the name implies it affects children around the age of puberty. Idiopathic means we don’t yet know the cause.
AIS affects 3% of the adolescent population. It is defined as a three-dimensional, structural curvature of the spine that measures more than 10 degrees. Only 3% of those with AIS require long-term close monitoring, brace treatment or surgery. Early detection of scoliosis via primary healthcare provider screening is generally accepted and cost effective.
The BRAIST study (Bracing in Adolescent Idiopathic Scoliosis Trial) in 2013 demonstrated the effectiveness of bracing in a selected cohort of patients with more than one year of growth remaining and a curve greater than 20 degrees.
Girls should be screened at ages 10 and 12 and boys once at age 13 or 14.5. Girls are considerably more at risk for significant curves requiring treatment; boys are at less risk but tend to have more rapid progression. Siblings and children of AIS-confirmed patients have higher prevalence rates of scoliosis and should be screened during their growth spurt. The Adams forward bend test (AFBT) can screen children. Although there are clear indications for imaging and for referral, simply identifying a positive AFBT is usually sufficient to warrant consultation.
Tips for Effectively Screening for AIS in Less than 2 Minutes
Treating scoliosis requires cooperation between the patient and the physician. Education is important and many doctors allow patients to take smart phone or tablet images of their own spinal x-rays to engage them in the management.
- The patient must be appropriately dressed to allow examination of the entire length of the spine.
- Observe the spine for the common features of AIS: right-sided upper thoracic curve, café au lait spots (light brown patches on the skin), asymmetrical flanks, uneven scapulae, rib-cage asymmetry and different shoulder levels.
- Ensure that the patient is barefoot. Palpate the height of the iliac crests to assess for leg length discrepancy.
- AFBT 1: Instruct the patient: “Hold your arms forward with your palms together, keep your head up and look straight ahead”. “Keep your knees straight and bend forward like you’re touching your toes”.
- AFBT 2: Observe the upper and lower back as the patient bends forward. Asymmetry of the rib cage in the upper thoracic region and asymmetric prominence in the lumbar spine are particularly important. Ribcage asymmetry warrants a spinal x-ray.
- With the patient standing erect, look for evidence of spinal dysraphism (incomplete development of the posterior spinal elements) along the spine.
- Parents or guardians are often disturbed by the extent of an existing deformity. Teens can be secretive about body changes during the adolescent growth spurt.
- Girls are frequently most concerned about the anterior ribcage asymmetry associated with spinal deformity and its effect on size and shape of the breast.
Evidence of Spinal Dysraphism
Most relevant abnormalities are seen in the midline at the base of the spine (See Figure 1). Findings that could indicate spinal dysraphism (a term denoting spina bifida or other incomplete development of the posterior spinal elements) include:
3. Hairy tufts.
4. Dimples or sinuses.
5. Cutaneous lesions.
6. A unilateral cavus foot*
* A significant rigid, high arch deformity of the foot, which can be congenital or occur spontaneously but which may be the most obvious physical manifestation of spinal dysraphism.
Published in the Journal of Current Clinical Care Volume 5, Issue 3, 2015