Scoliosis - NCC Pediatrics Residency at Walter Reed

NCC Pediatrics Continuity Clinic Curriculum:Crooked Backs: Scoliosis for General PediatricsGoals & Objectives:1. Show how to physical screen for scoliosis2. Calculate a Cobb Angle and Risser Stage from an x-ray3. Tell your preceptor when to refer a patient with scoliosis.Pre-Meeting Preparation:• Read the 2 articleso Pediatrics In Review article on Scoliosiso Adolescent Idiopathic Scoliosis: Radiologic Decision-Making inthe AAFP (May 2002)• Complete the Scoliosis Crossword Puzzle.Conference Agenda:• Answer the questions as a group.• Demonstrate your technique for calculating Cobb Angles using the imagesprovidedExtra-Credit:• Use your computer based radiography software to calculate Cobb Angles on a patient• Find out something about the ‘Adams’ of the Adams Forward Bend Test or ‘Risser’• Answer the board questions© NCCPeds, 2012

How to Calculate a Cobb Angle-------------- cut here for a handy protractor to calculate your angles ---------------------------© NCCPeds, 2012

Calculate a Cobb Angle for the following images. Show your work.© NCCPeds, 2012

© NCCPeds, 2012

Scoliosis Crossword Puzzle© NCCPeds, 2012

in briefIn BriefScoliosisJacob J. Rosenberg, MD, FAAP, FRCPCVaughan Pediatric ClinicWoodbridge, Ontario, CanadaAuthor DisclosureDrs Rosenberg and Adam havedisclosed no financial relationshipsrelevant to this In Brief. Thiscommentary does not contain adiscussion of an unapproved/investigative use of a commercialproduct/device.Screening for Idiopathic Scoliosis inAdolescents. Richards S, Vitale M.J Bone Joint Surg Am. 2008;90:195–198Screening for Adolescent IdiopathicScoliosis. Policy Statement. US PreventiveServices Task Force. JAMA.1993;269:2664–2666Scoliosis is a lateral curvature of thespine. Although it can result from avariety of causes, more than 60% ofall cases are considered idiopathic.Eighty percent of idiopathic scoliosisoccurs in adolescents, while infantilescoliosis (ages 0 to 3 y) and juvenilescoliosis account for 1% and 12% to21% of cases, respectively. Nonidiopathicscoliosis, about one third ofall cases, is associated with underlyingneurologic disorders (cerebral palsy,myelomeningocele, tethered cord syndrome,spinal muscular atrophy, syringomyelia,muscular dystrophy, Friedrichataxia, Riley-Day syndrome), musculoskeletaldisorders (leg length discrepancy,developmental dysplasia of thehip, osteogenesis imperfecta, Klippel-Feil syndrome), and connective tissuedisorders (Marfan syndrome, Ehlers-Danlos syndrome, homocystinuria).The primary tasks for the clinicianwhen scoliosis is diagnosed are to:1) determine whether the condition isidiopathic or if there is an underlyingcause and 2) measure the curvature andascertain whether it is likely to worsen.The major factors influencing the progressionof the curve are sex, potentialfor future growth, and the magnitudeof the curve at the time of diagnosis.Mild curvature of the spine (10 to 30degrees) occurs equally in males andfemales, but 80% to 90% of patientswho have curves greater than 30 degreesare females. The more potentialfor growth, the greater is the risk thatthe curvature will worsen. Growth potentialcan be determined by assessingSexual Maturity Rating (SMR) on physicalexamination and Risser grading onradiography. Risser grading is a measurementof the ossification of the iliacapophysis: 0 is no ossification, grade 1is up to 25% ossification, grade 2 is 26%to 50% ossification, grade 3 is 51% to75% ossification, grade 4 is 76% to99% ossification, and grade 5 is completeossification. The lower the SMRstage and Risser grade, the greater isthe risk that the scoliosis will progress.The magnitude of the curve is measuredon radiograph by determining the Cobbangle: an angle derived from the positionsof the most tilted vertebrae aboveand below the apex of the curve. Thegreater the Cobb angle, the higher isthe risk of progression.The adverse effects of progressivescoliosis include cosmetic deformitywith its potential for social and psychologicalconsequences both during childhoodand adulthood; the financial costsof therapy; and although the associationis controversial before adulthood,the development of chronic back pain.With extreme curvatures (possibly 50degrees, certainly 75 degrees), scoliosiscan lead to respiratory compromiseas well. Because scoliosis often occurswithout symptoms, the concept of universalscreening during the adolescentyears has been advocated, both throughscreening in school and by routine examinationduring health supervisionvisits. School-based screening was begunin 1984 and endorsed by the AmericanAcademy of Orthopaedic Surgeons(AAOS), with the underlying convictionthat early detection of scoliosis whenthe deformity may have gone unnoticedcan lead to nonoperative treatmentthat can have a positive impact onlong-term outcome.The primary screening test is thephysical examination, which includesvisual inspection of the back with thepatient standing upright and the Adamsforward bending test. With this test,the patient stands with feet togetherand knees straight and slowly bendsforward from the waist, as if to touchthe toes, allowing the arms to hangwith palms touching. The examiner,with eyes level with the back, looks forasymmetry of one scapula or one sideof the rib cage or the paraspinousmuscles more prominent than the other.A scoliometer, which is a variation of acarpenter’s level, is useful for quantifyingthe degree of chest deformity, bothin the initial evaluation and in followingprogression of the curve. The degreemeasurements noted on the scoliometerare not equivalent to the degreesof the Cobb angle. Many clinicians usea scoliometer measurement of 6 to 7degrees or more as an indication forobtaining radiographs. If scoliosis isPediatrics in Review Vol.32 No.9 September 2011 397Downloaded from http://pedsinreview.aappublications.org/ at USUHS LRC on April 21, 2012

in briefsuspected based on physical examinationfindings, a radiograph of the backshould be considered to measure thedegree of curvature (ie, the Cobb angle)and the Risser grade.Screening is not without its difficulties.Almost one third of patients whoare identified as having scoliosis byschool screening programs are found onfurther investigation to have no abnormality.In 1996, the United States PreventiveServices Task Force (USPSTF)concluded that evidence was insufficientto make a recommendation for oragainst screening. However, the USPSTFchanged its position in 2004, recommendingagainst routine screening ofasymptomatic adolescents for idiopathicscoliosis because of the low predictivevalue, the relatively small percentageof children whose curves progress, andthe possibility of screening leading tounnecessary treatment, including theuse of braces. This change in positionwas influenced by a study in the Netherlandsthat showed no significant reductionin the need for scoliosis surgeryattributable to screening. Patientsdetected by screening were significantlyyounger at diagnosis than patients whowere detected otherwise. Further, patientsdetected by routine screening hadadditional years of concern about theirscoliosis, and although they were morelikely to be treated with bracing, they didnot have better final outcomes.The USPSTF urges that instead ofroutine screening, clinicians shouldevaluate scoliosis when it presents as asymptom or is found incidentally. Ifscoliosis screening is undertaken, theAAOS, Scoliosis Research Society, PediatricOrthopaedic Society of NorthAmerica, and the American Academyof Pediatrics (AAP) agree that girlsshould be screened twice, at ages 10 and12 years, and boys once at 13 or 14 years.The AAP Bright Futures recommends examinationof the back at adolescenthealth supervision visits, which can includethe forward bend test.Treatment of scoliosis begins with afocused history and physical examination,looking for an underlying causeof the curvature. In cases of idiopathicscoliosis, intervention is aimed at preventing,or at least minimizing, cosmeticdeformity, respiratory compromise,and significant pain. Exercise therapyhas been advocated, but there is noevidence that it reverses or even slowsthe progression of curvature. Bracinguses mechanical force to straightenthe spine, but whether it can reliablyprevent progression of the curve isless certain. One of the major issueswith brace therapy is the difficulty thatadolescents have in adhering to theregimen, with one study showing only15% compliance and reporting thatmost patients wore their braces only65% of the recommended time. Ingeneral, bracing can be considered forcurves between 20 and 40 degrees inpatients who still have significantgrowth potential. With skeletal maturation,as evidenced by a high Rissergrading, such curves should not needintervention. For curves greater than40 degrees, surgery using spinal fusionand any of a variety of instrumentationtechniques is the generally recommendedtreatment.Comment: Two controversial questionsfor the pediatrician surroundingscoliosis are whether to screen routinely,and in a child complaining ofbackache who has a curve, how likelyis scoliosis an explanation for the pain.The problem with routine screening isthat it is poorly predictive of patientswho will ultimately benefit from intervention.Most children identified byroutine screening in early adolescenceeither do not have scoliosis or havecurves that require no treatment. Thesechildren will more than likely be irradiatedat least once, if not serially, andwill face anxiety over whether theywill become “deformed” or need surgery.The argument for routine screeningbecomes more difficult in the absenceof solid evidence that earlybracing really retards curve progression.If it does not, curves destined to warrantsurgery will progress despite earlyscreening.As for back pain and scoliosis, althoughlong-term follow-up studiessupport the association of scoliosis andchronic back pain in adulthood, theevidence among pediatric patients isless clear. When a child or adolescentwho has scoliosis complains of backpain, consideration should be given tothe possibility of the scoliosis not beingidiopathic, an underlying musculoskeletalor neurologic cause producingthe pain, or the back pain being unrelatedto the scoliosis. Who said practicingmedicine is easy?Henry M. Adam, MDEditor, In BriefParent Resources from the AAP at HealthyChildren.orgThe reader is likely to find material to share with parents that is relevant to this article byvisiting this link: http://www.healthychildren.org/english/health-issues/conditions/orthopedic/pages/scoliosis.aspx.398 Pediatrics in Review Vol.32 No.9 September 2011Downloaded from http://pedsinreview.aappublications.org/ at USUHS LRC on April 21, 2012

RADIOLOGIC DECISION-MAKINGAdolescent Idiopathic Scoliosis:Radiologic Decision-MakingK. ALLEN GREINER, M.D., M.P.H., University of Kansas Medical Center, Kansas City, KansasAdolescent onset of severe idiopathic scoliosis has traditionally been evaluatedusing standing posteroanterior radiographs of the full spine to assess lateral curvaturewith the Cobb method. The most tilted vertebral bodies above and belowthe apex of the spinal curve are used to create intersecting lines that give the curvedegree. This definition is controversial, and patients do not exhibit clinically significantrespiratory symptoms with idiopathic scoliosis until their curves are 60 to 100degrees. There is no difference in the prevalence of back pain or mortality betweenpatients with untreated adolescent idiopathic scoliosis and the general population.Therefore, many patients referred to physicians for evaluation of scoliosis do notneed radiographic evaluation, back examinations, or treatment. Consensus recommendationsfor population screening, evaluation, and treatment of this disorder bymedical organizations vary widely. Recent studies cast doubt on the clinical valueof school-based screening programs. (Am Fam Physician 2002;65:1817-22. Copyright©2002 American Academy of Family Physicians.)Coordinators of thisseries are Mark Meyer,M.D., University ofKansas School of Medicine,Kansas City, Kan.,and Walter Forred,M.D., University ofMissouri–Kansas CitySchool of Medicine,Kansas City, Mo.The editors of AFPwelcome the submissionof manuscriptsfor the RadiologicDecision-Making series.Send submissions toJay Siwek, M.D., followingthe guidelinesprovided in “Informationfor Authors.”Adolescent idiopathic scoliosisis lateral and rotational spinalcurvature in the absence ofassociated congenital or neurologicabnormalities. Longitudinalstudies 1,2 estimate the prevalence ofidiopathic scoliosis as 2 percent of the adolescentpopulation, using a definition of a spinalcurve greater than 10 degrees. 3 However, clinicallysignificant curves in the range of 40 to100 degrees are rare. Controversy surroundsclinical recommendations for evaluating andmanaging patients with a wide range of curvesizes. Recent debate has centered on the valueof school-based screening programs. 4School-Based ScreeningSchool-based scoliosis screening programsare currently mandated in 26 states, withmany other states having voluntary programs.Several studies 1,5,6 and the 1996 U.S.Preventive Services Task Force (USPSTF)Report 7 question the value and cost-effectivenessof these programs. Few children referredfor medical evaluation from these programsreceive any form of therapy. 8 Furthermore,the long-term health outcomes for treatedversus untreated patients with scoliosis havenot been well studied, making it difficult todetermine the health impact of these screeningprograms. Patients with severe curves arenot difficult to diagnose. Although someadvocates still recommend school-basedscreening of adolescents, there is no evidenceto support these programs. The AmericanAcademy of Pediatrics recommends screeningat physician visits. The USPSTF and theCanadian Task Force on the Periodic HealthExamination state that insufficient evidenceexists to support universal school-basedscreening. Radiographic decision-makingskills will help primary care physicians evaluatesevere scoliosis accurately.EtiologyThe etiology of adolescent idiopathic scoliosisis believed to be multifactorial, includinggenetic factors. One study 9 showed a 73 percentphenotypic concordance of scoliosis inmonozygotic twins. Eleven percent of firstdegreerelatives of patients with scoliosis areaffected. Inheritance of scoliosis varies, andno single pattern of genetic transmission hasbeen accepted. The physiologic causes of scoliosishave not been elucidated. Muscular,nervous system, hormonal, and connectivetissue defects have been noted in subgroupsof patients with scoliosis, but these abnor-MAY 15, 2002 / VOLUME 65, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1817

A patient’s skeletal maturity can determine the risk of progressionof more severe scoliosis curves.23 4 51The Authormalities may be a result of the disorder ratherthan a cause. 10K. ALLEN GREINER, M.D., M.P.H., is assistant professor of family medicine at the Universityof Kansas Medical Center, Kansas City, where he also received his medicaldegree and masters of public health degree. He completed a residency in family medicineand a fellowship in primary care at the University of Kansas Medical Center.Address correspondence to K. Allen Greiner, M.D., M.P.H., Department of Family Medicine,University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS66160-7370 (e-mail: agreiner@kumc.edu). Reprints are not available from the author.RightLeftFIGURE 1. Ossification of the iliac apophysisstarts at the anterior superior iliac spine andprogresses posteromedially. The iliac crest isdivided into quadrants, and the stage ofmaturity is designated as the number of ossifiedquadrants. For example, 50 percent ossifiedis a Risser grade 2. On the anatomic left(right side of the figure), all quadrants areossified and the apophysis is fused to the iliaccrest, for a Risser grade 5.Natural HistoryStudies 11-13 of adolescent-onset scoliosishave demonstrated that patients with scoliosisshow minimal progression in the magnitudeof the curve in adulthood if the curve is lessthan 30 degrees at skeletal maturity. Althoughcurves in different regions of the spineprogress differently, curves measuring 40 to50 degrees at skeletal maturity progress anaverage of 10 to 15 degrees during a normallifetime, while curves measuring greater than50 degrees at skeletal maturity progress at arate of approximately 1 to 2 degrees per year. 11Because of the controversy surrounding idealtreatment strategies for patients with moderatecurves, estimation of curve progressioncan aid in clinical management and counselingpatients’ families about prognoses.Estimation of skeletal maturity can bedetermined by assessing the epiphyseal statuson wrist radiographs, the Risser sign, Tannerstages, progressive sitting and standing heightmeasurements, and age at menarche.Risser sign is defined by the amount of calcificationpresent in the iliac apophysis andmeasures the progressive ossification fromanterolaterally to posteromedially. A Rissergrade of 1 signifies up to 25 percent ossificationof the iliac apophysis, proceeding tograde 4, which signifies 100 percent ossification(Figure 1).A Risser grade of 5 means theiliac apophysis has fused to the iliac crest after100 percent ossification. Children usually progressfrom a Risser grade 1 to a grade 5 over atwo-year period. One study 8 found that immaturepatients (Risser grades 0 and 1) with aspinal curvature measuring 20 to 29 degreeshad a 68 percent probability of progression of6 degrees or more during remaining growth.Patients closer to maturity (Risser grades 2 to4) and with the same degree of scoliosis had a23 percent probability of progression. 8Curves measuring 5 to 19 degrees in immaturepatients had a 22 percent probability ofprogression, while small curves in maturepatients had only a 1.6 percent probability ofprogression. 8If other clinical markers of maturity suchas Tanner staging or age at menarche are notconsistent with the Risser grade, curve progressionmay proceed at a different rate. Thus,ILLUSTRATION BY RENEE L. CANNON1818 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 9 / MAY 15, 2002

Scoliosismultiple measures of maturity are importantto the clinical assessment of these patients.Although a recent study 14 showed anincreased incidence of precocious puberty, theaverage female reaches a Tanner stage 1 at 11years of age, the beginning of the growth spurtat 11.5 years of age, a Risser grade 1 at 12 yearsof age, and has an onset of menarche between12 and 13 years of age. A female patient whomatures consistent with these averages will havea relatively higher risk of curve progressionbefore 12 years of age and a relatively lower riskof curve progression after 12.5 years of age. 15A scoliotic curve is more likely to progressin females, and thoracic curves or curves witha higher apex vertebral level are more likely toprogress than other types of curves. 8,14 Severecurves or moderate curves expected to progressbeyond 100 degrees can lead to restrictivepulmonary disease and a possible reductionof life expectancy. 11 Curves of thismagnitude usually have an infantile or juvenileonset rather than an adolescent onset.Studies 16,17 show an equal incidence of backpain and mortality in the general populationand patients with adolescent idiopathic scoliosis.There are few recent studies 18-20 that evaluatethe long-term cosmetic and psychosocialconsequences of progressive spinal curvesfrom the perspective of patients with scoliosis.Clinical Presentation and EvaluationFamily physicians may need to examine childrenfor scoliosis who have been referred fromschool-based screening programs. Becausediastematomyelia (congenital splitting of thespinal cord), syringomyelia (cavity in the spinalcord), a tethered cord, or a spinal tumor cancause spinal curvature, physicians should askthe patient questions concerning neurologicsymptoms. Neurofibromatosis can be associatedwith scoliosis, and a unilateral cavus footcan be a manifestation of intraspinal pathology.Magnetic resonance imaging should beobtained in patients with an onset of scoliosisbefore eight years of age, rapid curve progressionof more than 1 degree per month, anMagnetic resonance imaging should be obtained in patientswith an onset of scoliosis before eight years of age, rapidcurve progression, an unusual curve pattern, neurologicdeficit, or pain.unusual curve pattern such as left thoraciccurve, neurologic deficit, or pain. Spineabnormalities may present during routineexaminations of 10- to 19-year-olds. Manyexamination techniques are used to evaluatepatients presenting with spinal curvatures.Traditionally, the Adam’s test with level planeand ruler or a scoliometer evaluation of thepatient while bending forward was used toguide clinical decision-making. 19 These measurementsare difficult to standardize andshould only be obtained when they will affectmanagement decisions for an individualpatient or to reassure the patient and family. 6Height measurements of the patient sittingand standing should be taken in the physician’soffice every three to four months. Documentingrapid height increases helps the physiciandetermine the onset of the adolescent growthspurt and gauge the risk of rapid progressionof the spinal curve. Sitting heights can be measuredwith the patient sitting in a standardchair and the height of the seat subtractedfrom the total height. Changes in sitting heightcan be less than changes in standing height andgive a better estimate of truncal growth rate.Any examination data must be combinedwith a thorough history to assess skeletal andsexual maturation. 21If an examination of the back is conducted,the physician should begin with a survey ofthe back while the patient is standing. Physiciansmay be misled by scapular or shoulderasymmetry and should focus on waist creaseasymmetry or spine deviation during theupright examination. When measuring waistcrease asymmetry, subtract perpendicularheight from the iliac crests on each side. Radiographsshould only be considered when aMAY 15, 2002 / VOLUME 65, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1819

90°.Most tiltedvertebraabove apex.Cobb angle.Apex90°.Most tiltedvertebrabelow apexFIGURE 2. To use the Cobb method of measuringthe degree of scoliosis, choose the mosttilted vertebrae above and below the apex ofthe curve. The angle between intersectinglines drawn perpendicular to the top of thetop vertebrae and the bottom of the bottomvertebrae is the Cobb angle.patient has a curve that might require treatmentor could progress to a stage requiringtreatment (usually 40 to 100 degrees). 22Radiologic Evaluation and ClassificationThe standard radiologic evaluation of adolescentidiopathic scoliosis consists of standingposteroanterior radiographs of the fullspine. Follow-up is necessary in those patientswith severe curves who are at risk for significantcurve progression or require some formof treatment. Any discrepancy in leg lengthshould be corrected with a block placed underthe patient’s shorter leg when radiographs aretaken. One study 23 has shown that long-termmanagement of scoliosis poses no radiograph-relatedrisks to patients, but posteroanteriorviews assure maximal safety by minimizingradiation to the breasts. The Cobbmethod is used to measure the degree of scoliosison the posteroanterior radiograph (Figure2).In addition to curve degree, physiciansshould describe curves as “right” or “left,”based on their curve convexity. Standard measurementerror is 3 to 5 degrees for the sameFIGURE 3. Posteroanterior radiograph of thespine in a patient with a thoracic spinal curve.Right thoracic curve, T6-11 (most tilted vertebraeabove apex of curve T6, most tilted vertebraebelow apex of curve T11). The degreeof curvature is 65.observer and 5 to 7 degrees for differentobservers when the same end vertebrae areused for measurements. 24,25 Thus, physiciansshould use the same end vertebrae for subsequentmeasurements and assume that somemeasurement change may be caused by errorrather than true curve progression.Posteroanterior radiographs should beviewed in reverse to normal chest radiographswith the patient’s right side on the physician’sright side. Curves are named for the locationof the apex vertebrae, and may be described asthoracic (Figure 3), lumbar, thoracolumbar,cervical, or double major (two curves in differentspinal regions). A thoracolumbar curve(Figure 4) has an apex vertebrae at T12 or L1.Thoracic and lumbar curves have apex vertebraein the middle of the thoracic and lumbarregions, respectively. A double curve (Figure 5)has a major and a minor curve (based on sizeand flexibility) and a primary and secondarycurve (based on respective development). Acompensatory curve is nonstructural and1820 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 9 / MAY 15, 2002

ScoliosisFIGURE 5. Posteroanterior radiograph of thespine in a patient with a double spinal curve.Double curve: right thoracic curve, T5-12 with adegree of curvature of 45; left lumbar curve,T12-L4 with a degree of curvature of 35.FIGURE 4. Posteroanterior radiograph of thespine in a patient with a thoracolumbar spinalcurve. Left thoracolumbar curve, T10-L3 (mosttilted vertebrae above apex of curve T10,most tilted vertebrae below apex of curve L3).The degree of curvature is 56.develops to balance out a primary curve. Anonstructural curve differs from a structuralcurve because it can correct on lateral bending,distraction, or sitting.Management and Follow-upThe primary goal of treating adolescentidiopathic scoliosis is preventing progressionof the curve magnitude. Curves less than 10 to15 degrees require no active treatment andcan be monitored, unless the patient’s bonesare very immature and progression is likely.Moderate curves between 25 and 45 degrees inpatients lacking skeletal maturity used to betreated with bracing, but this treatment hasnever been proven to prevent curve progression.Poor compliance with wearing a braceobviates any potential usefulness of the therapy.26 Much controversy surrounds braceindications, and trends over the past 20 yearshave moved toward no bracing or bracingonly the more significant curves (20 to50 degrees). Evidence 27-29 showing the lowsymptomatic burden of patients with curvesless than 60 degrees has influenced this trendaway from treatment with bracing.Most patients with adolescent idiopathicscoliosis who require treatment with a bracemay use a thoracolumbar-sacral orthosis(TLSO) or a cervicothoracolumbar-sacralBracing and surgery are reserved for patients with severescoliosis curves.MAY 15, 2002 / VOLUME 65, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1821

Scoliosisorthosis (CTLSO). Recommendations for optimaluse of braces vary from eight to 24 hours aday depending on the style of brace chosen.In patients with a curve severe enough torequire surgery (greater than 45 degrees inadolescents and greater than 50 degrees inadults), rod placement and bone grafting maybe necessary to achieve partial or completecorrection. Patient preference is essential indeciding on a surgical treatment, and primarycare physicians should work closely withpatients and their families to reach optimalindividual outcomes.The author thanks Marc Asher, M.D., for editorialassistance, and Anne D. Walling, M.D., for review ofthe manuscript.The author indicates that he does not have any conflictsof interest. Sources of funding: none reported.REFERENCES1. Yawn BP, Yawn RA, Hodge D, Kurland M, ShaughnessyWJ, Ilstrup D, et al. A population-based studyof school scoliosis screening. JAMA 1999;282:1427-32.2. Soucacos PN, Soucacos PK, Zacharis KC, Beris AE,Xenakis TA. School-screening for scoliosis: aprospective epidemiological study in northwesternand central Greece. J Bone Joint Surg Am 1997;79:1498-503.3. Kane WJ. Scoliosis prevalence: a call for a statementof terms. Clin Orthop 1977;126:43-6.4. Higginson G. Political considerations for changingmedical screening programs. JAMA 1999;282:1472-4.5. Morais T, Bernier M, Turcotte F. Age- and sex-specificprevalence of scoliosis and the value of schoolscreening programs. Am J Public Health 1985;75:1377-80.6. Grossman TW, Mazur JM, Cummings RJ. An evaluationof the Adams forward bend test and the scoliometerin a scoliosis school screening setting.J Pediatr Orthop 1995;15:535-8.7. U.S. Preventive Services Task Force. Guide to clinicalpreventive services. 2d ed. Baltimore: Williams& Wilkins, 1996:517-29.8. Lonstein JE, Carlson JM. The prediction of curveprogression in untreated idiopathic scoliosis duringgrowth. J Bone Joint Surg Am 1984;66:1061-71.9. Carr AJ. Adolescent idiopathic scoliosis in identicaltwins. J Bone Joint Surg Br 1990;72:1077.10. Miller NH. Cause and natural history of adolescentidiopathic scoliosis. Orthop Clin North Am 1999;30:343-52.11. Weinstein SL, Ponseti IV. Curve progression in idiopathicscoliosis. J Bone Joint Surg Am 1983;65:447-55.12. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis:long-term follow-up and prognosis inuntreated patients. J Bone Joint Surg Am 1981;63:702-12.13. Weinstein SL. Natural history. Spine 1999;24:2592-600.14. Peterson LE, Nachemson AL. Prediction of progressionof the curve in girls who have adolescent idiopathicscoliosis of moderate severity. Logisticregression analysis based on data from The BraceStudy of the Scoliosis Research Society. J Bone JointSurg Am 1995;77:823-7.15. Nachemson A. A long term follow-up study ofnon-treated scoliosis. Acta Orthop Scand 1968;39:466-76.16. Branthwaite MA. Cardiorespiratory consequencesof unfused idiopathic scoliosis. Br J Dis Chest 1986;80:360-9.17. Cordover AM, Betz RR, Clements DH, Bosacco SJ.Natural history of adolescent thoracolumbar andlumbar idiopathic scoliosis into adulthood. J SpinalDisord 1997;10:193-6.18. Raso VJ, Lou E, Hill DL, Mahood JK, Moreau MJ,Durdle NG. Trunk distortion in adolescent idiopathicscoliosis. J Pediatr Orthop 1998;18:222-6.19. Bengtsson G, Fallstrom K, Jansson B, NachemsonA. A psychological and psychiatric investigation ofthe adjustment of female scoliosis patients. ActaPsychiatr Scand 1974;50(1):50-9.20. White SF, Asher MA, Lai SM, Burton DC. Patients’ perceptionsof overall function, pain, and appearanceafter primary posterior instrumentation and fusion foridiopathic scoliosis. Spine 1999;24:1693-700.21. Amendt LE, Ause-Ellias KL, Eybers JL, Wadsworth CT,Nielsen DH, Weinstein SL. Validity and reliability testingof the Scoliometer. Phys Ther 1990;70:108-17.22. Bunnell WP. Outcome of spinal screening. Spine1993;18:1572-80.23. Drummond D, Ranallo F, Lonstein J, Brooks HL,Cameron J. Radiation hazards in scoliosis management.Spine 1983;8:741-8.24. Morrissy RT, Goldsmith GS, Hall EC, Kehl D, CowieGH. Measurement of the Cobb angle on radiographsof patients who have scoliosis. Evaluation of intrinsicerror. J Bone Joint Surg Am 1990;72:320-7.25. Pruijs JE, Hageman MA, Keessen W, van der Meer R,van Wieringen JC. Variation in Cobb angle measurementsin scoliosis. Skeletal Radiol 1994;23:517-20.26. DiRaimondo CV, Green NE. Brace-wear compliancein patients with adolescent idiopathic scoliosis.J Pediatr Orthop 1988;8:143-6.27. Roach JW. Adolescent idiopathic scoliosis. OrthopClin North Am 1999;30:353-65.28. Karachalios T, Roidis N, Papagelopoulos PJ,Karachalios GG. The efficacy of school screeningfor scoliosis. Orthopedics 2000;23:386-91.29. Dickson RA. Spinal deformity—adolescent idiopathicscoliosis. Nonoperative treatment. Spine1999;24:2601-6.1822 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 9 / MAY 15, 2002

Scoliosis Questions1. The resident who has most recently participated in the orthopedicsrotation should answer this question: What part of the skeleton isassessed during Risser Staging?2. The resident who has most recently been on a ship, boat, or otherwaterborne craft should tell the group what percent of scoliosis is dueto a secondary condition.3. The residents with the 3 shortest last names should each name aunique cause of non-idiopathic (secondary) scoliosis, and 1 additionalfact about that condition.4. The youngest resident in the group should tell the group therelationship between gender and scoliosis.5. The resident with the last name alphabetically in the group should tellthe group the relationship between Risser Stage, Tanner Stage, andscoliosis progression.6. The resident who was born furthest from your current location shouldtell the group at what Cobb Angles would respiratory compromise beexpected with scoliosis.7. The resident should tell the group the angle on the scoliometer thatshould prompt ordering of scoliosis films, and should do so in theirbest Southern drawl.© NCCPeds, 2012

Scoliosis Board Review1. A 14-year-old girl comes to your office because her mother is concerned about scoliosis. The mother had mildscoliosis as an adolescent, but she did not require treatment. The girl is previously healthy and participates in sportsat school. She denies back pain, weakness, or abnormal sensations. On physical examination, lumbar asymmetry isapparent when she bends forward with her arms hanging down. There are no cutaneous findings, and her neurologicexamination results are normal. You order posteroanterior and lateral radiographs of the spine to evaluate the degreeof scoliosis.Of the following, the radiographic finding that is MOST suggestive of a nonidiopathic cause for this girl’s scoliosisis aA. Cobb angle of 30 degreesB. lack of thoracic kyphosisC. lumbar curve to the leftD. thoracic curve to the rightE. widening of the pedicles2. While examining a newborn, you note a persistent curve in the spine regardless of the baby’s position. You orderspine radiographs, which reveal multiple vertebral malformations and segmentation defects.Of the following, the MOST appropriate studies to guide further management areA. chromosome analysis and renal ultrasonographyB. echocardiography and chromosome analysisC. echocardiography and renal ultrasonographyD. head ultrasonography and ophthalmology consultationE. renal and head ultrasonography3. You work as a voluntary attending pediatrician in the resident continuity clinic at your local hospital. You areprecepting a resident, who tells you that she has just evaluated a 16-year-old varsity volleyball player. The girl’sheight is 71 inches, weight is 125 lb, and blood pressure is 115/74 mm Hg. The resident is concerned about scoliosisand a 3/6 holosystolic murmur heard at the cardiac apex with radiation to the left axilla.Of the following, the MOST likely diagnosis for this patient isA. Ehlers—Danlos syndromeB. infective endocarditisC. Marfan syndromeD. rheumatic heart diseaseE. Williams syndrome4. A 7-year-old boy who is new to your practice comes in for evaluation of developmental delay and poor schoolperformance. He began speaking in sentences at age 4. He repeated kindergarten and is struggling in first grade. Onphysical examination, you note that he has fair hair and light skin compared with his brown-haired, olive-skinnedyounger brother and mother. He is wearing thick glasses, and his mother says that he was diagnosed as being nearsightedwhen he was 2 years old. He has a lanky build with long fingers, and on forward bending, there is a curve inthe thoracolumbar spine.Of the following, the condition that is MOST consistent with this presentation isA. alkaptonuriaB. homocystinuriaC. nonketotic hyperglycinemiaD. oculocutaneous tyrosinemiaE. phenylketonuria© NCCPeds, 2012