We have a role in screening and diagnosis of scoliosis in primary care, with the AAP recommending screening for teenagers between 12-14 years old. This week we will review this key orthopedic topic.
Materials for this week:
- Case discussion
- Idiopathic Scoliosis in Adolescents NEJM 2013
- US Preventive Services Task Force report, JAMA 2018 (gave screening an “i” for insufficient evidence, which moved it up from prior “D”); accompanying editorial and patient information
- Powerpoint summary shared by Dr. Abby Grant
Take-home points for this week:
- Epidemiology: Scoliosis is the most common abnormality of the spine. Idiopathic scoliosis is present in 2% of adolescents. There is a genetic basis with first-degree relatives at increased risk (10% prevalence).
- Definition: Scoliosis is defined as a lateral curvature of the spine that is 10 degrees or greater on a coronal radiographic image while the patient is in a standing position. It is measured by the Cobb angle.
- Types: Most cases are idiopathic and defined by age at recognized onset: before age 3 (infantile), age 3-10 (juvenile) and older than 10 (adolescent). There are also congenital forms due to malformations of the spine in utero that progress with age, and neuromuscular scoliosis associated with neuromuscular diseases.
- Screening: Classic findings of scoliosis on examination are shoulder and scapular asymmetry and rib prominence on forward flexion. We can use an inclinometer (scoliometer) tool to help assess the degree of asymmetry. Typically, referral is recommended if >= 7 degrees on inclinometer. Exam should also rule out hereditary connective-tissue disorders (e.g., Marfan’s syndrome), neurofibromatosis, or neurologic conditions. Obtain scoliosis spinal radiography in standing position and request measurement of the Cobb angle.
- Treatment: Most adolescents can be monitored in primary care for curves <20 degrees. If >20 degree curvature, we would refer to ortho for consideration of bracing. Data published from the BrAIST trial showed bracing reduced the likelihood of progression to curves >50 degrees yet there is still some concern that this was inconclusive (thus the USPSTF “I” recommendation). If >40-45 degree curvature, surgery is usually recommended. (MG note: if it were my child, I would want to have the option of bracing, with relatively few harms found in the trial, which was stopped early due to treatment success.)