Scoliosis

You probably remember being evaluated for #scoliosis as a kid, whether at your primary care provider's office or by the school nurse. Maybe you even remember a kid in school who had to wear a back brace. My best friend in my early high school years was one of those unfortunate youths. We were in band together, marching band even, and she was our drum major. Imagine mastering all the fancy footwork in time, while commanding a bunch of teenagers, under the blistering sun while sweating under the hard and unforgiving plastic brace strapped around your torso. She did this and ended up having to have surgery to correct the curve in her spine anyway.

Approximately 2% to 4% of adolescents are diagnosed with scoliosis which is a lateral curve to the spine greater than 10 degrees with vertebral rotation. My son visited the chiropractor when he was a young teenager and then missed treatment for a while. About a year later he returned to start again and the chiropractor showed him an X-ray he used in his office as an example of scoliosis and it ended up being his, funny enough. He did continue with chiropractic care and it resolved. His scoliosis was significant, impressive even, but related to nearly two feet of growth in just about a year.

Scoliosis can present at birth, which is congenital, or it may be related to neuromuscular issues or even idiopathic. Most all are the latter, which can occur at anytime in childhood. This typically doesn't cause a lot of problems, but sometimes can lead to visible deformity, emotional distress, and respiratory impairment from rib deformity. This occurs equally between boys and girls, although girls are far more likely to progress towards more severe disease. Our goal as the primary care provider is to identify the issue, then decide if imaging is appropriate and ultimately treatment.

Although screening was super popular in the 80s and 90s with the school nurse, into the early 2000s screening was no longer recommended as the U.S. Preventive Services Task Force (USPSTF) found screening was actually more harmful than helpful. Interesting since this is a seemingly benign evaluation, right? However, the screenings themselves aren't super consistent so radiologic screenings, which have significant risk, are performed more often and even when scoliosis is identified, almost never do these result in need for treatment and surgery. Those that do are apparent, symptomatic and can be addressed. Admittedly, in all my years in practice, I've never seen a #scoliometer in practice, which is the tool that measures the degree of curvature to determine when radiologic screening is appropriate.

There are professional groups though that argue this, stating that screenings are low cost and radiologic screening isn't as significant as it once was, and brace treatment and earlier recognition could maybe prevent severe deformities requiring surgery. The challenge then for the primary care provider is discerning which cases are more significant and which ones can be observed without intervention. The USPSTF suggests those that are significant, really will be identified without routine screening as visible curvature of the spine is not likely to go unnoticed by provider or adolescent.

What You Need to Know

Here are a few interesting points though, you might keep in mind. Almost all scoliosis curves lead to the right, so the spinal curve is convex to the right. Those that lean more left are more often associated with additional pathology such as a tumor or a neuromuscular disorder, or an Arnold-Chiari malformation or occult syrinx. Rarely does scoliosis cause pain, so pain in itself should prompt timely evaluation. And midline hairy patches or cafe au lait spots are indication for further investigation, as are any neurologic deficits or findings.

References

Horne, J. P., Flannery, R., & Usman, S. (2014). Adolescent idiopathic scoliosis: Diagnosis and management. American Family Physician, 89(3), 193-198.