Scoliosis referral depends on knowing Cobb angle

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All of the relevant professional organizations recommend that children be screened for scoliosis sometime around adolescence.

Shriners Hospitals for Children — Northern California can help.

When should you screen?

The American Academy of Pediatrics, the American Association of Orthopedic Surgeons and the Pediatric Orthopedic Society of North America suggest that boys should be screened for scoliosis once, at around age 13 or 14 years and girls should be screened twice, at age 10 and then again at age 12. Girls are five to 10 times more likely to have a scoliosis curve that is minor to begin with but will progressively get worse.

How should you screen?

When screening a patient, physicians should look to see if the pelvis is level, if the waist is symmetric, if the shoulders are level and perform an Adams forward bending test. If the patient has asymmetry, of the rib cage, the scapulas, the hips, etc., while bending forward with the torso parallel to the ground, the asymmetry can be measured with an inclinometer or a scoliometer. Shriners Hospitals for Children offers a mobile app, SpineScreen, which works like a scoliometer. SpineScreen walks users through the steps of how to appropriately screen for scoliosis at home and when they should consult their doctor. It also has links to Shriners Hospitals for Children resources. (bit.ly/Apple_SpineScreen)

Who gets follow-up?

In general, if the inclinometer shows an angle, but that angle is less than 7 degrees, the child can be followed up in 6-12 months, depending on their growth potential. If the inclinometer shows more than 7 degrees, recommendations suggest more evaluation, with a standing x-ray, taken as a posterioanterior view, from C7 to the iliac crest, to determine the Cobb angle. (NEJM2013;368:834-41.)

When should you refer?

Scoliosis generally is defined as a Cobb angle greater than 10 degrees. A Cobb angle greater than 20 degrees is large enough to reasonably warrant referral to a scoliosis specialist. And a Cobb angle of about 25 degrees is at the threshold where one might consider prescribing a brace for the child.

At 45 degrees to 50 degrees, surgery becomes an appropriate consideration. Forty-five degrees is considered a threshold because a curve that progresses to 40-50 degrees in a skeletally immature person likely will continue to progress through adulthood, at a rate of about 1 degree per year. (J Child Orthop 2013;7:37-41.)

In 2003, a study following up on 117 patients whose idiopathic scoliosis was never treated, found that 66% had back pain and more than 80% of those with big curves had impairment of their breathing. That is an average of 51 years after their initial diagnosis. (JAMA2003;289:559-567.)

For more specific recommendations for management of different degrees of curvature and different ages, see NEJM 2013:368:834-41.

Does bracing work?

Bracing is not intended to correct spine curvature. Rather, children with scoliosis are braced in an attempt to halt progression. Study shows that bracing does work, but, for it to work, patients must wear the brace for up to 23 hours per day. When it is worn for only seven hours a day average, as is not uncommon, it is not effective.  (Cochrane Database Syst Rev 2015 Jun 18 (6):CD006850.)

Scoliosis Care at Shriners Hospitals for Children — Northern California

Children being examined and treated for scoliosis often get repeat X-rays throughout their care. The Northern California Shriners Hospital has a low-radiation X-ray machine, specifically for its scoliosis patients. The EOS machine uses anywhere from 70% less radiation than a normal x-ray to just a 50th of the radiation, depending on the image needed. The Spine program at Shriners Hospitals for Children — Northern California, focuses on early detection and fusionless treatments for the growing spine, as well as minimally invasive (nonfusion) to advanced surgical techniques in children who require spinal fusions.

The position statement of the relevant pediatric orthopedic associations can be found at: https://www.srs.org/about-srs/news-and-announcements/position-statement—screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents