As a pediatric orthopedic surgeon who specializes in spinal deformity, I see many young patients who are referred for evaluation of scoliosis. Scoliosis is very common, occurring in around 1 in 100 teenagers, and about 10 percent of those may have more severe scoliosis that requires treatment. Boys and girls seem to get scoliosis at the same rate, but girls are about five times more likely to have severe scoliosis.
What Is Scoliosis?
Scoliosis is defined as a curvature of the spine in the frontal plane of more than 10 degrees on a standing radiograph (X-ray) and, especially in the early stages, can be very difficult to diagnose with physical examination alone. Sometimes the shoulders or hips may be uneven, sometimes the chest and trunk may look shifted or the scapula (wing bone) may be more prominent on one side. The most commonly used clinical test is the Adam’s forward bend test, where the child is asked to bend forward at the waist as if touching his or her toes. You may remember this test from a visit to your doctor or school nurse as a way to detect scoliosis.
While the forward bending test is very sensitive for scoliosis (meaning that it is able to detect most severe cases) it can sometimes be falsely positive, making children and parents believe they may have scoliosis when in fact they do not. This can be very upsetting for families and can result in unnecessary visits to the doctor and testing, like X-rays. I see this frequently in my practice, and I think there are a few reasons to explain these false positives.
[See: 10 Seemingly Innocent Symptoms You Shouldn’t Ignore.]
What Is “Normal”?
First, many people have subtle or not-so-subtle asymmetries in their trunk or chest, and this may be interpreted as scoliosis. Second, when children are asked to bend forward, they often bend one or both knees, and this can make the back look different than if they kept their knees straight. Additionally, many nurses or doctors would prefer to be “on the safe side” and send kids for further evaluation when they are not sure of the diagnosis. All of these are understandable and justifiable reasons, but they can result in unnecessary cost and worry for parents and kids.
[See: What Your Doctors Wish You Knew.]
The Screening Debate
A few years ago, the U.S. Preventive Services Task Force examined the medical evidence around school screening and determined that it was not a cost-effective method of finding scoliosis. Too many kids were being evaluated and getting X-rays unnecessarily and, ironically, kids with more severe scoliosis sometimes got missed. Across the nation there is wide variability in the number of schools that have screening programs and with good reason, some schools don’t even have a dedicated school nurse — and the ones that do often need to care for very sick kids, which often results in scoliosis screening going by the wayside.
My colleagues in the orthopedic and pediatric fields understand this, and generally agree that school screening may not be the most clinically effective or budget-friendly way to detect scoliosis in young children. That doesn’t mean, however, that it’s not important for pediatricians and other health care professionals to continue checking kids’ spines. A thorough back exam may alert your doctor to more serious medical conditions such as neuromuscular or genetic syndromes. And even if they “only” detect scoliosis, doing so at an early stage may allow kids to receive treatment that could help delay surgery or avoid it all together.
Debate exists on the exact reason why most children get scoliosis but genetics definitely play a big role, so if a relative has scoliosis you have increased chances of having it too. Our first goal, as health care professionals, is to prevent curves from becoming large enough to warrant surgery, and the most effective way to do this is to detect it early and initiate proper treatment. For children with mild curve, this treatment may only be observation, coming to the doctor every few months for a clinical exam and sometimes an X-ray. At the Children’s Hospital at Montefiore, we’re investigating a new body mapping device that may help us check children’s spines more accurately, without the need for X-rays.
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
Brace Yourself
For curves that are getting bigger and in children who are still growing, the most effective treatment is a scoliosis brace. There are many kinds and none have been proven superior, but it’s important to work with a surgeon and orthotist (brace maker) who can help select the best brace for your curve and make it specifically for your body. While it may not be fun to wear a brace, the more you do, the more likely it is to prevent the curve from getting bigger. Generally, children and adolescents tolerate the brace very well and most sleep in it to get even more corrective time.
When curves become very large, generally more than 40 to 50 degrees, many people feel that surgery is the best option to prevent further curvature and straighten the spine, but this is a very individual conversation that families have with their doctors, and some people with severe scoliosis never have surgery. While scoliosis surgery continues to get safer, there are definitely significant risks, and it should not be taken lightly. Many different types of surgery exist depending on the age of the child, the amount of growth he or she has left and the pattern, size and flexibility of the curve. Parents often ask about exercises to help improve their child’s scoliosis. While exercises are beneficial for general health and back pain when done safely, I always emphasize that wearing a well-fitted scoliosis brace has the best evidence behind it and should be the mainstay of treatment. At CHAM, we are currently investigating different exercises and comparing them to brace therapy to see if they may be helpful for certain children.
I always tell my patients that scoliosis is not a fatal illness, but it can have a significant impact on health, well-being and function. Early screening remains important and, together with the professional societies in pediatrics and scoliosis surgery, we continue to strongly recommend regular back screening for all children.
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Scoliosis Screening: Should it Be Universal? originally appeared on usnews.com
