© NCCPeds, 2012

NCC Pediatrics Continuity Clinic Curriculum: Crooked Backs: Scoliosis for General Pediatrics

Goals & Objectives:

1. Show how to physical screen for scoliosis

2. Calculate a Cobb Angle and Risser Stage from an x-ray

3. Tell your preceptor when to refer a patient with scoliosis.

Pre-Meeting Preparation:

• Read the 2 articles o Pediatrics In Review article on Scoliosis o Adolescent Idiopathic Scoliosis: Radiologic Decision-Making in

the 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 images

provided

Extra-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

© NCCPeds, 2012

Scoliosis Crossword Puzzle

In BriefScoliosisJacob J. Rosenberg, MD, FAAP, FRCPCVaughan Pediatric ClinicWoodbridge, Ontario, Canada

Author Disclosure

Drs Rosenberg and Adam have

disclosed no financial relationships

relevant to this In Brief. This

commentary does not contain a

discussion of an unapproved/

investigative use of a commercial

product/device.

Screening for Idiopathic Scoliosis inAdolescents. Richards S, Vitale M.J Bone Joint Surg Am. 2008;90:195–198

Screening for Adolescent IdiopathicScoliosis. Policy Statement. US Pre-ventive Services Task Force. JAMA.1993;269:2664–2666

Scoliosis 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. Nonidio-pathic scoliosis, about one third ofall cases, is associated with underlyingneurologic disorders (cerebral palsy,myelomeningocele, tethered cord syn-drome, spinal muscular atrophy, syrin-gomyelia, muscular dystrophy, Friedrichataxia, Riley-Day syndrome), musculo-skeletal disorders (leg length discrep-ancy, developmental dysplasia of thehip, osteogenesis imperfecta, Klippel-Feil syndrome), and connective tissue

disorders (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 pro-gression of 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 de-grees are females. The more potentialfor growth, the greater is the risk thatthe curvature will worsen. Growth po-tential can be determined by assessingSexual Maturity Rating (SMR) on phys-ical examination and Risser grading onradiography. Risser grading is a mea-surement of 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 com-plete ossification. 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 posi-tions of 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 psycho-logical consequences both during child-hood and adulthood; the financial costsof therapy; and although the associa-

tion is controversial before adulthood,the development of chronic back pain.With extreme curvatures (possibly �50degrees, certainly �75 degrees), scoli-osis can lead to respiratory compromiseas well. Because scoliosis often occurswithout symptoms, the concept of uni-versal screening during the adolescentyears has been advocated, both throughscreening in school and by routine ex-amination during health supervisionvisits. School-based screening was be-gun in 1984 and endorsed by the Amer-ican Academy 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 quantify-ing the degree of chest deformity, bothin the initial evaluation and in follow-ing progression of the curve. The degreemeasurements noted on the scoliom-eter are 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 is

in brief

Pediatrics in Review Vol.32 No.9 September 2011 397 at USUHS LRC on April 21, 2012http://pedsinreview.aappublications.org/Downloaded from

suspected based on physical examina-tion findings, 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 difficul-ties. Almost one third of patients whoare identified as having scoliosis byschool screening programs are found onfurther investigation to have no abnor-mality. In 1996, the United States Pre-ventive Services Task Force (USPSTF)concluded that evidence was insuffi-cient to make a recommendation for oragainst screening. However, the USPSTFchanged its position in 2004, recom-mending against 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 Neth-erlands that showed no significant re-duction in the need for scoliosis sur-gery attributable to screening. Patientsdetected by screening were significantlyyounger at diagnosis than patients whowere detected otherwise. Further, pa-tients detected 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, Pedi-

atric Orthopaedic 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 ex-amination of the back at adolescenthealth supervision visits, which can in-clude the forward bend test.

Treatment of scoliosis begins with afocused history and physical examina-tion, looking for an underlying causeof the curvature. In cases of idiopathicscoliosis, intervention is aimed at pre-venting, or at least minimizing, cos-metic deformity, 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 matu-ration, 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 recom-mended treatment.

Comment: Two controversial ques-tions for the pediatrician surroundingscoliosis are whether to screen rou-tinely, 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 inter-vention. Most children identified byroutine screening in early adolescenceeither do not have scoliosis or havecurves that require no treatment. Thesechildren will more than likely be irradi-ated at least once, if not serially, andwill face anxiety over whether theywill become “deformed” or need sur-gery. The argument for routine screen-ing becomes more difficult in the ab-sence of solid evidence that earlybracing really retards curve progression.If it does not, curves destined to war-rant surgery will progress despite earlyscreening.

As for back pain and scoliosis, al-though long-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 be-ing idiopathic, an underlying musculo-skeletal or neurologic cause producingthe pain, or the back pain being unre-lated to the scoliosis. Who said practic-ing medicine is easy?

Henry M. Adam, MDEditor, In Brief

Parent 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.

in brief

398 Pediatrics in Review Vol.32 No.9 September 2011

at USUHS LRC on April 21, 2012http://pedsinreview.aappublications.org/Downloaded from

MAY 15, 2002 / VOLUME 65, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1817

determine the health impact of these screen-ing programs. 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 screen-ing at 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 evalu-ate severe scoliosis accurately.

EtiologyThe etiology of adolescent idiopathic scol-

iosis is believed to be multifactorial, includinggenetic factors. One study9 showed a 73 per-cent phenotypic concordance of scoliosis inmonozygotic twins. Eleven percent of first-degree relatives of patients with scoliosis areaffected. Inheritance of scoliosis varies, andno single pattern of genetic transmission hasbeen accepted. The physiologic causes of sco-liosis have not been elucidated. Muscular,nervous system, hormonal, and connectivetissue defects have been noted in subgroupsof patients with scoliosis, but these abnor-

Adolescent idiopathic scoliosisis lateral and rotational spinalcurvature in the absence ofassociated congenital or neu-rologic abnormalities. Longi-

tudinal studies1,2 estimate the prevalence ofidiopathic scoliosis as 2 percent of the adoles-cent population, using a definition of a spinalcurve greater than 10 degrees.3 However, clin-ically significant 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.4

School-Based ScreeningSchool-based scoliosis screening programs

are currently mandated in 26 states, withmany other states having voluntary pro-grams. Several studies1,5,6 and the 1996 U.S.Preventive Services Task Force (USPSTF)Report7 question the value and cost-effective-ness of 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 to

Adolescent onset of severe idiopathic scoliosis has traditionally been evaluatedusing standing posteroanterior radiographs of the full spine to assess lateral cur-vature with 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 signif-icant respiratory 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 recom-mendations for 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. Copy-right© 2002 American Academy of Family Physicians.)

Adolescent Idiopathic Scoliosis:Radiologic Decision-MakingK. ALLEN GREINER, M.D., M.P.H., University of Kansas Medical Center, Kansas City, Kansas

RADIOLOGIC DECISION-MAKING

Coordinators of thisseries are Mark Meyer,M.D., University ofKansas School of Medi-cine, Kansas City, Kan.,and Walter Forred,M.D., University ofMissouri–Kansas CitySchool of Medicine,Kansas City, Mo.

The editors of AFPwelcome the submis-sion of manuscripts for the Radiologic Decision-Making series.Send submissions toJay Siwek, M.D., fol-lowing the guidelinesprovided in “Informa-tion for Authors.”

malities may be a result of the disorder ratherthan a cause.10

Natural HistoryStudies11-13 of adolescent-onset scoliosis

have 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.11

Because of the controversy surrounding idealtreatment strategies for patients with moder-ate curves, estimation of curve progressioncan aid in clinical management and counsel-ing patients’ 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 cal-cification present in the iliac apophysis andmeasures the progressive ossification fromanterolaterally to posteromedially. A Rissergrade of 1 signifies up to 25 percent ossifica-

tion of the iliac apophysis, proceeding tograde 4, which signifies 100 percent ossifica-tion (Figure 1). A Risser grade of 5 means theiliac apophysis has fused to the iliac crest after100 percent ossification. Children usually pro-gress from a Risser grade 1 to a grade 5 over atwo-year period. One study8 found that im-mature patients (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 a 23 percent probability of progression.8

Curves measuring 5 to 19 degrees in imma-ture patients had a 22 percent probability ofprogression, while small curves in maturepatients had only a 1.6 percent probability ofprogression.8

If other clinical markers of maturity suchas Tanner staging or age at menarche are notconsistent with the Risser grade, curve pro-gression may proceed at a different rate. Thus,

1818 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 9 / MAY 15, 2002

FIGURE 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 ossi-fied quadrants. For example, 50 percent ossi-fied is 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.

Right

1

23 4 5

Left

ILLU

STR

ATI

ON

BY

REN

EE L

. CA

NN

ON

The Author

K. ALLEN GREINER, M.D., M.P.H., is assistant professor of family medicine at the Uni-versity of Kansas Medical Center, Kansas City, where he also received his medicaldegree and masters of public health degree. He completed a residency in family med-icine and 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 Med-icine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS66160-7370 (e-mail: agreiner@kumc.edu). Reprints are not available from the author.

A patient’s skeletal maturity can determine the risk of pro-gression of more severe scoliosis curves.

multiple measures of maturity are importantto the clinical assessment of these patients.

Although a recent study14 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.15

A 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 pro-gress beyond 100 degrees can lead to restric-tive pulmonary disease and a possible reduc-tion of life expectancy.11 Curves of thismagnitude usually have an infantile or juve-nile onset rather than an adolescent onset.

Studies16,17 show an equal incidence of backpain and mortality in the general populationand patients with adolescent idiopathic scoli-osis. There are few recent studies18-20 that eval-uate the long-term cosmetic and psychosocialconsequences of progressive spinal curvesfrom the perspective of patients with scoliosis.

Clinical Presentation and EvaluationFamily physicians may need to examine chil-

dren for 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 associ-ated with 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 progres-sion of more than 1 degree per month, an

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 mea-surements are difficult to standardize andshould only be obtained when they will affectmanagement decisions for an individualpatient or to reassure the patient and family.6

Height measurements of the patient sittingand standing should be taken in the physician’soffice every three to four months. Document-ing rapid 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 mea-sured with 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.21

If an examination of the back is conducted,the physician should begin with a survey ofthe back while the patient is standing. Physi-cians may 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. Radi-ographs should only be considered when a

Scoliosis

MAY 15, 2002 / VOLUME 65, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1819

Magnetic 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.

patient has a curve that might require treat-ment or could progress to a stage requiringtreatment (usually 40 to 100 degrees).22

Radiologic Evaluation and ClassificationThe standard radiologic evaluation of ado-

lescent idiopathic scoliosis consists of stand-ing posteroanterior radiographs of the fullspine. Follow-up is necessary in those patientswith severe curves who are at risk for signifi-cant curve 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 study23 has shown that long-termmanagement of scoliosis poses no radio-graph-related risks to patients, but posteroan-terior views assure maximal safety by mini-mizing radiation to the breasts. The Cobbmethod is used to measure the degree of scol-iosis on the posteroanterior radiograph (Fig-ure 2). In addition to curve degree, physiciansshould describe curves as “right” or “left,”based on their curve convexity. Standard mea-surement error is 3 to 5 degrees for the same

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 subse-quent measurements 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 dif-ferent spinal regions). A thoracolumbar curve(Figure 4) has an apex vertebrae at T12 or L1.Thoracic and lumbar curves have apex verte-brae in 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 and

1820 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 9 / MAY 15, 2002

FIGURE 2. To use the Cobb method of measur-ing the 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.

90°

Cobb angle

90°

Most tilted vertebra above apex

Apex

Most tilted vertebrabelow apex

.

. .

.

FIGURE 3. Posteroanterior radiograph of thespine in a patient with a thoracic spinal curve.Right thoracic curve, T6-11 (most tilted verte-brae above apex of curve T6, most tilted ver-tebrae below apex of curve T11). The degreeof curvature is 65.

develops to balance out a primary curve. Anonstructural curve differs from a structuralcurve because it can correct on lateral bend-ing, distraction, or sitting.

Management and Follow-up The primary goal of treating adolescent

idiopathic 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 has

never been proven to prevent curve progres-sion. Poor compliance with wearing a braceobviates any potential usefulness of the ther-apy.26 Much controversy surrounds braceindications, and trends over the past 20 yearshave moved toward no bracing or bracingonly the more significant curves (20 to 50 degrees). Evidence27-29 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-sacral

Scoliosis

MAY 15, 2002 / VOLUME 65, NUMBER 9 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1821

Bracing and surgery are reserved for patients with severescoliosis curves.

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.

FIGURE 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.

Scoliosis

orthosis (CTLSO). Recommendations for opti-mal use 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 con-flicts of interest. Sources of funding: none reported.

REFERENCES

1. Yawn BP, Yawn RA, Hodge D, Kurland M, Shaugh-nessy WJ, 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 state-ment of 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-spe-cific prevalence of scoliosis and the value of schoolscreening programs. Am J Public Health 1985;75:1377-80.

6. Grossman TW, Mazur JM, Cummings RJ. An evalu-ation of the Adams forward bend test and the sco-liometer in a scoliosis school screening setting.J Pediatr Orthop 1995;15:535-8.

7. U.S. Preventive Services Task Force. Guide to clini-cal preventive 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 idio-pathic scoliosis. J Bone Joint Surg Am 1983;65:447-55.

12. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic sco-liosis: 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 progres-sion of the curve in girls who have adolescent idio-pathic scoliosis 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 idio-pathic scoliosis. 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’ per-ceptions of 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 test-ing of 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 manage-ment. 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 measure-ments in 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 idio-pathic scoliosis. Nonoperative treatment. Spine1999;24:2601-6.

1822 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 9 / MAY 15, 2002

© NCCPeds, 2012

Scoliosis Questions

1. The resident who has most recently participated in the orthopedics rotation should answer this question: What part of the skeleton is assessed during Risser Staging?

2. The resident who has most recently been on a ship, boat, or other waterborne craft should tell the group what percent of scoliosis is due to a secondary condition.

3. The residents with the 3 shortest last names should each name a unique cause of non-idiopathic (secondary) scoliosis, and 1 additional fact about that condition.

4. The youngest resident in the group should tell the group the

relationship between gender and scoliosis.

5. The resident with the last name alphabetically in the group should tell the group the relationship between Risser Stage, Tanner Stage, and scoliosis progression.

6. The resident who was born furthest from your current location should tell the group at what Cobb Angles would respiratory compromise be expected with scoliosis.

7. The resident should tell the group the angle on the scoliometer that should prompt ordering of scoliosis films, and should do so in their best Southern drawl.

© NCCPeds, 2012

Scoliosis Board Review 1. A 14-year-old girl comes to your office because her mother is concerned about scoliosis. The mother had mild

scoliosis as an adolescent, but she did not require treatment. The girl is previously healthy and participates in sports

at school. She denies back pain, weakness, or abnormal sensations. On physical examination, lumbar asymmetry is

apparent when she bends forward with her arms hanging down. There are no cutaneous findings, and her neurologic

examination results are normal. You order posteroanterior and lateral radiographs of the spine to evaluate the degree

of scoliosis.

Of the following, the radiographic finding that is MOST suggestive of a nonidiopathic cause for this girl’s scoliosis

is a

A. Cobb angle of 30 degrees

B. lack of thoracic kyphosis

C. lumbar curve to the left

D. thoracic curve to the right

E. widening of the pedicles

2. While examining a newborn, you note a persistent curve in the spine regardless of the baby’s position. You order

spine radiographs, which reveal multiple vertebral malformations and segmentation defects.

Of the following, the MOST appropriate studies to guide further management are

A. chromosome analysis and renal ultrasonography

B. echocardiography and chromosome analysis

C. echocardiography and renal ultrasonography

D. head ultrasonography and ophthalmology consultation

E. renal and head ultrasonography

3. You work as a voluntary attending pediatrician in the resident continuity clinic at your local hospital. You are

precepting a resident, who tells you that she has just evaluated a 16-year-old varsity volleyball player. The girl’s

height is 71 inches, weight is 125 lb, and blood pressure is 115/74 mm Hg. The resident is concerned about scoliosis

and 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 is

A. Ehlers—Danlos syndrome

B. infective endocarditis

C. Marfan syndrome

D. rheumatic heart disease

E. Williams syndrome

4. A 7-year-old boy who is new to your practice comes in for evaluation of developmental delay and poor school

performance. He began speaking in sentences at age 4. He repeated kindergarten and is struggling in first grade. On

physical examination, you note that he has fair hair and light skin compared with his brown-haired, olive-skinned

younger brother and mother. He is wearing thick glasses, and his mother says that he was diagnosed as being near-

sighted when he was 2 years old. He has a lanky build with long fingers, and on forward bending, there is a curve in

the thoracolumbar spine.

Of the following, the condition that is MOST consistent with this presentation is

A. alkaptonuria

B. homocystinuria

C. nonketotic hyperglycinemia

D. oculocutaneous tyrosinemia

E. phenylketonuria