Case Study

MP is a 16-year-old male who presents to your office for his annual health assessment and sports physical. During the course of his examination, you note a mild convexity in the thoracic region of his spine with forward flexion at the hips. Based on your clinical examination, you estimate a lateral spinal curvature of about 5 degrees. You note these findings to the patient and then to his mother.

Questions

1. Which one of the following procedures should be implemented next?

   A. Recommend a back-strengthening program.

   B. Refuse to permit participation in contact sports.

   C. Order a radiograph of the back to quantify the curvature (e.g., Cobb angle).

   D. Monitor the patient's condition.

   E. Refer for orthopedic consultation.

2. Because you have recently agreed to serve as school physician in the district where your office is located, you wonder what scoliosis screening programs are in place and who has been examining these school children for scoliosis. Which one of the following procedures should you implement?

   A. Arrange scoliosis screening for all students between 10 and 16 years of age.

   B. Arrange scoliosis screening for all students 10, 12, 14 and 16 years of age.

   C. Contact the school nurse and review skills for scoliosis screening procedures.

   D. Visually inspect for severe curves only when the back is examined for other reasons.

   E. Screen girls for scoliosis at 11 and 13 years of age and boys at 13 and 15 years of age.

3. Which of the following statement(s) about treatment for adolescent scoliosis is/are correct?

   A. Exercise therapy has been shown to be an effective treatment for preventing progression of scoliosis.

   B. Spinal surgery for scoliosis is not supported by studies showing improvements in clinical outcomes, such as decreased back pain and increased functional status.

   C. Lateral electrical surface stimulation for eight hours nightly can limit progression of spinal curvature.

   B. Back bracing (e.g., orthoses) reduces symptoms of low back pain.

Answers

1. The answer is D: monitor the patient's condition. Scoliosis is defined as the presence of a lateral spinal curvature of 11 degrees or more.^1,2 Its prevalence during adolescence is estimated to be between 2 and 3 percent. Curvatures greater than 100 degrees can contribute to restrictive pulmonary disease^2,3; however, deviations of this magnitude are extremely rare. Curvatures greater than 20 degrees are observed in fewer than one in 200 adolescents.⁴ The likelihood that a curve will progress is dependent on a patient's age, gender and skeletal maturity, as well as the current degree of curvature, with progression less likely among adolescents with greater skeletal maturity and smaller curves.^5–7 Progression of curvatures less than 19 degrees has been reported among 10 percent of girls between 13 to 15 years of age and among 4 percent of those more than 15 years of age.^5,8

2. The answer is D: visually inspect for severe curves only when the back is examined for other reasons. Although scoliosis screening is mandated by law in several states, the U.S. Preventive Services Task Force (USPSTF) and the Canadian Task Force on Periodic Health Examination⁹ have determined that there is insufficient evidence to recommend for or against routine scoliosis screening among asymptomatic adolescents. Because adolescents with more severe curvatures (greater than 40 to 50 degrees) may be candidates for surgery, it is reasonable to visually inspect for marked spinal curves while examining the back for other reasons. Sensitivity and specificity for scoliosis screening are dependent on the degree of curvature being assessed, the prevalence of scoliosis in the screened population and the skills of the examiner. In all situations, the positive predictive value of screening is limited because of the low prevalence of adolescent scoliosis.^10,11 No controlled studies supporting the effectiveness of screening for scoliosis have been published.

3. The answer is B: treatment of patients with adolescent scoliosis with exercise therapy is not supported by scientific evidence. Curve progression is not prevented by exercise alone.^12,13 Although bracing provides immediate correction of spinal curvature, its effects on progression of scoliosis, or on the long-term outcomes such as back pain, have not been demonstrated in properly controlled studies. Moreover, the success of back bracing can be limited by patient noncompliance with the recommendation that a brace be worn for 23 hours per day.^14,15 Only 15 percent of adolescents were found to be highly compliant, with most patients wearing back braces for only 65 percent of the prescribed time.¹⁶

   A significant proportion (between 18 and 56 percent) of patients treated with lateral electrical surface stimulation demonstrated progression of their spinal curvature by more than 10 degrees.^17,18 Although surgery for scoliosis is generally not recommended without marked curvature, well-conducted outcomes studies with patients who have had surgery have not been completed. Symptoms of back pain do not appear to correlate with magnitude of surgical correction.¹⁹