Scoliosis in Pediatrics: Comorbid Disorders and Scoliosis Screening

Patient Screening

History & Physical Examination

All skeletally immature patients should have a scoliosis examination as part of a well-child examination by the primary-care physician. As is often the case, a thorough history of physical examination is the most important screening tool. Patients will rarely complain of back pain as an initial symptom of scoliosis, but rather may mention a physical change, such as uneven shoulder heights, a thoracic prominence or rib hump, or uneven pelvis.^[1] Idiopathic scoliosis is typically nonpainful, with rates of low back pain approaching the same percentages encountered in similar patient populations without scoliosis.^[2] Up to a third of patients with idiopathic scoliosis report back pain with no clear etiology. Some will occasionally complain of subcapular pain over the rib hump that is of unknown etiology, but rarely require tertiary studies to follow-up these complaints. Persistent complaints of back pain, pain with activity or pain that wakes the patient at night are suspicious for other disorders, such as spondylolisthesis or, more rarely, a tumor or infection. Measures such as physical therapy for hamstring stretches or increasing physical activity are sometimes all that is required in the adolescent population to relieve intermittent back pain. Pain that is not relieved may warrant further work-up of the back pain with further radiographs and possibly an MRI if symptoms continue.

Upon physical examination, two elements are important, specifically for scoliosis: the neurologic examination and the spine examination. A complete neurologic examination of the extremities, including gait examination, is important to elucidate subtle findings of changes in tone, reflexes, weakness or balance. Any deviations from the normal, including asymmetry, should be noted. Cervical and lumbar motor and reflex examination should be performed through muscle testing of the C4-T1 and L1-S1 nerve roots.^[3] There is no easily applied motor examination for the thoracic spine; therefore, it is important to note the absence, presence or asymmetry of abdominal reflexes performed by lightly stroking the four quadrants of the abdomen around the umbilicus. A normal positive reflex involves the umbilicus slightly twitching toward the stroked quadrant.^[3] Absence of twitching is not necessarily pathologic, unless is it asymmetric. Asymmetry warrants attention in the setting of other physical findings, such as scoliosis, and the recommendation is for spinal MRI or neurologist evaluation.^[4,5,6]

The examination of the spine itself includes observing overall alignment of the spine as viewed from behind the patient. The spine should be exposed with the patient appropriately covered for modesty. Rib or lumbar prominences should be noted, as should a shift of the head to the left or right of the midline. A plumb line can be held at the base of the posterior occiput and dropped down vertically toward the gluteal cleft. Any lateral deviation from midline may indicate a trunk imbalance. Most commonly, scoliosis is observed as a right-sided curve with a balanced posture. This means that despite the size or shape of the curve, there is a physical compensation for it that centers the head over the pelvis. A curve that is left sided, especially in the setting of a young patient (<8 years of age) or a spine that is unbalanced with the trunk or head shifted away from midline warrants an MRI to evaluate for a neurologic cause of the scoliosis, such as a tumor or spinal cord syrinx. A curve may be directly visible if the patient is thin and the spinous processes are easily visualized; however, in obese patients, asymmetric skin folds may be the only indication of an underlying curve. Skin lesions, such as café-au-lait spots, may be a sign of neurofibromatosis and should be checked for in other areas of the body, including the axilla and groin. In the newborn or young patient, lumbar cutaneous findings, such as hairy patches or sacral dimpling, may be an indicator of spinal dysraphism and warrant further evaluation with imaging of the lumbar spine.

The Adams forward bend test should be performed after physical inspection of the spine. The patient is asked to bend forward at the waist with the knees straight and the arms passively hanging down. The examiner looks at the spine from behind and notes any thoracic or lumbar prominence indicating a rotational deformity of the spine. A scoliometer is a small calibrated level that can be used to assign a number to the amount of rotation to the spine, but most primary-care offices are not equipped with this device. Studies have demonstrated that this device can indicate which rotational deformities are associated with larger scoliotic curves and, therefore, which patients should be referred to a spine specialist.^[7]

A lumbar prominence can also be caused by a limb length discrepancy. While examining the extremities, any length discrepancy should be noted and a small corrective block placed under the shorter side will correct a lumbar prominence secondary to the discrepancy, as opposed to a scoliosis which will not correct.

No spinal examination is complete without an examination of the feet. A very high arch or cavus foot may be associated with a tethered spinal cord or spinal syrinx, especially if the cavus is unilateral and warrants an MRI of the spinal cord.^[8]

Suspicion of a scoliosis based on the above physical examination may warrant radiographs of the spine. Clinical experience may aid the examiner in deciding which curves appear to be small based on physical findings, and which may need radiographs and objective measures, such as the use of a scoliometer to aid in the decision. In general, radiographs are recommended for these physical findings. These should be performed on films that can include the entire spine in one radiograph and include both the lateral and posterior-anterior direction. The use of the posterior-anterior radiograph minimizes the exposure of the breasts and other organs to radiation and is the preferred method.^[9]

Positive neurologic findings in the setting of scoliosis warrant an MRI in addition to plain radiographs. Many practitioners may also suggest a referral to a neurologist to ensure there are no other pathologic causes of the findings that could be present outside of the spinal screening (e.g., brain lesion and peripheral nerve disorder).^[10,11]

School Screening

School screening programs were developed in the early 1980s as a way to identify scoliosis curves early. The basis of the program endorsement by the SRS and the American Academy of Orthopaedic Surgeons (AAOS) was that if a curve was found early, it could be followed and treatment initiated early in the hope of avoiding progression to surgery if the curve worsened. Children are screened at various ages with recommendations for girls to be screened between the ages of 10 and 12 years, and boys to be screened between the ages of 13 and 14 years. Over half of the states in the USA have screening programs; however, the idea was argued against in the early 1980s by the British Scoliosis Society for screening in the UK owing to concerns over excessive referrals and radiographs.^[1] A recent literature review yielded over 100 articles published on the topic of school screening for scoliosis. The US Preventative Services Task Force (USPSTF) had neither recommended for or against school screening owing to lack of evidence to support either argument. In 2004, USPSTF changed its long-standing position to recommend against school screening.^[12] Owing to this and other recent reports questioning the effectiveness of screening, the leadership of the SRS, AAOS and American Academy of Pediatrics issued a response recommending that the screening programs continue owing to insufficient evidence against their effectiveness. Evidently, the topic is under continued debate.^[13,14]

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