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© 1997 The Journal of Bone and Joint Surgery, Inc. School-Screening for Scoliosis. A Prospective Epidemiological Study in Northwestern and Central Greece* , IOANNINA, GREECEInvestigation performed at the Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina
A two-year prospective study was done to assess the prevalence and distribution of various parameters associated with scoliosis in schoolchildren in northwestern and central Greece. A total of 82,901 children (41,939 boys and 40,962 girls) who were nine to fourteen years old were screened for scoliosis. Five thousand eight hundred and three children had clinical signs of scoliosis and, of these, 4185 were referred for posteroanterior radiographs (to be made with the patient standing) because they had a positive result on the forward-bending test (a difference of more than five millimeters between the two sides of the torso as measured in the thoracic or thoracolumbar region with use of a ruler and a level plane) at the time of a second screening. The prevalence of scoliosis (defined as a curve of 10 degrees or more) was 1.7 per cent (1436 of 82,901 children), and most of the curves (1255; prevalence, 1.5 per cent) were small (10 to 19 degrees). The ratio of boys to girls was 1:2.1 over-all but varied according to the magnitude of the curve (1:1.5 for curves of less than 10 degrees, 1:2.7 for curves of 10 to 19 degrees, 1:7.5 for curves of 20 to 29 degrees, 1:5.5 for curves of 30 to 39 degrees, and 1:1.2 for curves of 40 degrees or more). Thoracolumbar curves were the most common type of curve identified, followed by lumbar curves; specifically, of the 1436 children who had a curve of at least 10 degrees, 493 (34.3 per cent) had a thoracolumbar curve, 475 (33.1 per cent) had a lumbar curve, 261 (18.2 per cent) had a thoracic curve, and 207 (14.4 per cent) had a double curve. Although most (753) of these curves were to the left, the left:right ratio varied according to the location of the apex of the curve (1:3.1 for thoracic curves, 2.0:1 for thoracolumbar curves, and 3.2:1 for lumbar curves). The cost of the screening process was negligible (estimated at thirty cents per child); however, the decreased number of operative procedures performed in children from the geographical area of our University Hospital, the identification of a large number of previously undiagnosed curves (eleven of which were treated operatively and 170 of which were treated with a brace), and the identification of children who were at high risk for progression were considered important benefits of the school-screening program.
Although several procedures for operative and non-operative treatment of scoliosis have evolved, the most effective treatment is still based on early detection4,9,23. In this regard, school-screening is a powerful tool that can be used to identify children who may have scoliosis as well as those who may be at high risk for the disease; however, the screening procedure should not be considered a diagnostic test22. Several techniques have been described for the early detection of scoliosis, and the most widely used method is the forward-bending test developed by Adams11,15-17. The specific definition of scoliosis varies among reports, with the minimum size of the curve ranging from 5 to 10 degrees3,8,23. As a result, the prevalence reported in the literature varies greatly2,4,6,8-11,13,15-17,23,24. A two-year, prospective, epidemiological study was performed to assess the prevalence and distribution of various scoliotic parameters in schoolchildren in northwestern and central Greece. Between January 1993 and December 1994, members of The Spine Unit of the Department of Orthopaedic Surgery at the University of Ioannina School of Medicine screened a total of 82,901 children who were nine to fourteen years old for scoliosis. The present report describes the epidemiological findings according to the age and gender of the patient and the magnitude and type of the scoliotic curve.
As the prevalence of scoliosis is highest in preadolescents, the present study was restricted to schoolchildren who were nine to fourteen years old. After permission was obtained from the Greek Ministries of Education and Health, the administration of each school district was contacted and the schools and teachers were given a detailed explanation of the importance and methods of screening for scoliosis. Permission was obtained from the parents by means of a letter that described the intentions of the study, the details of the examination procedure, and the clinical importance of early detection. Once this phase was completed, scoliosis-screening teams, consisting of a senior orthopaedic surgeon and staff member, an orthopaedic resident, a nurse, and a medical student, were organized and trained in screening methods and childhood behavior. Before the screening, forms were forwarded to the schools and the children were instructed to fill in their biographical information. Children who had been diagnosed previously and who had been or were currently being managed for scoliosis were not examined at the initial screening at the schools, but they were included in all other aspects of the study. The screening took place during the physical education class, usually with the assistance of the physical education instructor. The boys and girls were examined separately. The boys wore shorts, and the girls wore shorts and a brassiere or a loose T-shirt that could be lifted during the examination. At this point in the screening process, the nurse was essential in assisting the younger children, and the women on the team eased the anxiety of the girls. Extreme caution with regard to the feelings of the children was of paramount importance to the success of this program and, as a result, all children were examined. For example, when a child wanted to refrain from the examination because, for example, his or her "throat hurt," it usually became clear that the child was embarrassed to show an unbecoming scar or a garment that the child believed was "too poor." In these situations, the child was put at ease and was examined discreetly.
School-Screening The parameters that were recorded included biographical information (the name, date of birth, age, and address of the patient; the age and occupation of the parents; and the number and gender of siblings), physical attributes (the color of the hair and eyes, the type of body frame [large, medium, or small], the age at menarche for the girls and a rough indication of the pubertal stage for the boys [as indicated by the degree of pubic and body hair], the weight of the patient, the height of the patient when standing and sitting, and the span of the upper extremities), and abnormalities involving the trunk or spine (such as humps in the rib or lumbar region, discrepancies between the shoulders or between the hips, and imbalance of the torso or spine).
Rescreening, Radiographic Evaluation, and Management Children in whom scoliosis was suspected were requested to return to the team the same afternoon for re-evaluation, at which time a second forward-bending test was performed. The examiner compared the two sides of the torso at both the thoracic and the thoracolumbar level. If any difference in height was noted, it was measured with use of a level plane and a ruler. A difference of more than five millimeters was considered to be a positive finding on the bending test. The child was referred for radiographic evaluation only if the examiner confirmed a positive result on the forward-bending test or noted any of the previously mentioned physical signs at the time of the re-evaluation. Posteroanterior radiographs were made (with the patient standing) at a local hospital or, in the case of children from Ioannina, at our University Hospital, and were assessed immediately. A curve of 10 degrees or more, as measured with the method of Cobb, was defined as structural scoliosis. The course of treatment for each child was based on the magnitude of the scoliotic curve.
Analysis of Data
A total of 82,901 children (41,939 boys and 40,962 girls) who were nine to fourteen years old were screened in northwestern and central Greece from January 1993 to December 1994. (Although some classrooms included children who were less than nine or more than fourteen years old, only those who were nine to fourteen years old were included in the analysis.) Five thousand eight hundred and three children (7.0 per cent; 2203 boys and 3600 girls) had at least one positive clinical sign at the initial screening and, of these, 4185 children (1405 boys and 2780 girls) were referred for radiographic evaluation. One thousand four hundred and two children (497 boys and 905 girls) had no radiographic evidence of a curve. One thousand three hundred and forty-seven children (547 boys and 800 girls) had a curve of 1 to 9 degrees as measured on the radiographs. A total of 1436 (1.7 per cent) of the 82,901 children (361 [0.9 per cent] of the 41,939 boys and 1075 [2.6 per cent] of the 40,962 girls) had radiographic evidence of structural scoliosis (a curve of 10 degrees or more). The average age of the 82,901 children was 12.4 years, and the average age at menarche was 12.0 years. Most of the children (3609 [62 per cent] of the 5803 children who had at least one positive sign) had a medium body frame: the average body weight by age-group ranged from 26.8 to 56.8 kilograms for the boys and from 27.5 to 53.4 kilograms for the girls, and the average standing height by age-group ranged from 134.2 to 167.0 centimeters for the boys and from 130.7 to 160.8 centimeters for the girls. The prevalence of scoliosis varied according to the age of the patient. Only fifty-eight (0.07 per cent) of the 82,901 children had scoliosis by the age of nine years, whereas 168 (0.2 per cent) of the 82,901 children had scoliosis by the age of ten years (Fig. 1). The greatest prevalence of scoliosis (338 children; 0.4 per cent) was observed among children who were fourteen years old. The prevalence of scoliosis also varied according to the magnitude of the curve. Specifically, 1255 (1.5 per cent) of the 82,901 children had a curve of 10 to 19 degrees, 144 (0.2 per cent) had a curve of 20 to 29 degrees, twenty-six (0.03 per cent) had a curve of 30 to 39 degrees, and eleven (0.01 per cent) had a curve of 40 degrees or more (Table I).
Of the 1255 children in whom the curve measured 10 to 19 degrees, 335 were boys and 920 were girls; of the 144 children in whom the curve measured 20 to 29 degrees, seventeen were boys and 127 were girls. Only twenty-six children (four boys and twenty-two girls) had a curve of 30 to 39 degrees, and eleven (five boys and six girls) had a curve of 40 degrees or more (Figs. 2 and 3). The boy:girl ratio varied with the magnitude of the curve (Table I). A substantial preponderance of girls was noted in association with all scoliotic curves except for those that were 40 degrees or more, for which the ratio approached 1:1.
Thoracolumbar and lumbar curves were the most common types of curves identified, and single curves occurred approximately six times more frequently than double curves. Over-all, of the 1436 curves, 261 (18.2 per cent; 197 right and sixty-four left) were thoracic, 493 (34.3 per cent; 166 right and 327 left) were thoracolumbar, 475 (33.1 per cent; 113 right and 362 left) were lumbar, and 207 (14.4 per cent) were double. There were 753 left curves (52.4 per cent) and 476 right curves (33.1 per cent), the ratio of which varied according to the anatomical location of the apex of the curve (Table II).
Of the 4185 children who were evaluated radiographically, the eleven who had a curve of more than 40 degrees were managed operatively and the 170 who had a curve of 20 to 39 degrees were managed with an orthosis. The parents of the 1255 children who had a curve of 10 to 19 degrees were advised that their child should have a clinical evaluation every four to six months, and those of the 1347 children who had a curve of 1 to 9 degrees were advised that their child should have such an evaluation every twelve months. Parents were informed that these periodic clinical examinations were particularly important for children who were considered to be in a high-risk group (for example, premenarchal girls). The 1402 children who had negative radiographic findings were excused. A follow-up study of the progression of the curves and the results of treatment is currently in progress.
The prevalence of scoliosis in children from northwestern and central Greece who were nine to fourteen years old was 1.7 per cent, with most of the curves being seen in children who were thirteen or fourteen years old. The findings of the present study indicate that small scoliotic curves (10 to 19 degrees) are the most common (prevalence, 1.5 per cent). Although these findings are compatible with those of most previous reports1,4,6,8-18,23,24, the differences that we noted indirectly support the hypothesis of a genetically related variation in the prevalence of scoliosis and the apex of the curve for different populations. Specifically, the most common types of scoliotic curves in our series were thoracolumbar and lumbar. This finding differs from those described in reports from Norway and Sweden, where the proportion of single thoracic curves greatly outweighed that of all others19,23. In contrast, the prevalence of thoracolumbar curves reported by Brooks et al.4 for California (75 per cent of 624 curves) was greater than that reported in the present study (34.3 per cent of 1436 scoliotic curves). The findings of most studies4,19,23 are in agreement with those of the present study in that double curves constitute less than 20 per cent of the curves observed. Although the total number of left curves was greater than the total number of right curves, the left:right ratio varied according to the location of the apex of the curve. Most of the thoracic curves were to the right (left:right ratio, 1:3.1), while most of the thoracolumbar and lumbar curves were to the left (left:right ratio, 2.0:1 and 3.2:1, respectively). The ratio of boys to girls in the present study is intermediate to those reported for Sweden (107 boys and 367 girls)23 and California (263 boys and 361 girls)4. Although previous studies4,9,10,16,17,23 have indicated that the preponderance of girls increases noticeably with increasing magnitude of the scoliotic curve, in the more than 82,000 school children whom we screened the preponderance of girls increased with the degree of curvature only to a certain point. We found that the prevalences of large curves (those of 40 degrees or more) in boys and girls were approximately equal; however, the numbers are small. The criteria for referral for treatment in the present study were the presence of at least one physical sign and a Cobb angle of 10 degrees or more. The percentage of children referred for re-evaluation (7.0 per cent; 5803 of 82,901) is within the range of 3 to 10 per cent reported for other countries (3.4 per cent of a quarter million11, 6.5 per cent [1744] of 26,94717, 9.7 per cent [790] of 816515, and 10 per cent [362] of 349420). Although it has been suggested that the lack of an objective screening criterion and inappropriate screening techniques in some early studies led to over-referral of a large number of children, we found that the re-evaluation of children in whom scoliosis was suspected before radiographs were made reduced the number of false-positive findings. The cost of the actual screening process was negligible, with the primary expense being associated with transportation of the screening teams to the various sites. The cost for the entire screening program was approximately $25,000, or about thirty cents per child. However, as Ashworth et al. stated: "All costs and benefits of screening cannot be measured in terms of dollars ... subjective benefits must be balanced against objective costs." In this regard, the aim of screening is early diagnosis and application of an appropriate orthotic device in order to decrease the need for an operation. Thus, the effectiveness of a screening program is reflected mainly by a decrease in the number of children who need operative intervention. Although we are unable to state definitively whether non-operative treatment prevented progression of the curve and reduced the number of spinal arthrodeses in our study group, preliminary findings indicate that the number of operative procedures performed in the geographical area of the hospital of the University of Ioannina decreased from twelve in the three-year period immediately preceding the screening program to four in the subsequent three-year period. This decrease in the number of operations is compatible with the findings described in previous reports16,21. In addition, the identification of eleven patients who subsequently had an operation and 170 who subsequently were managed with a brace was considered a noteworthy outcome of the screening program. The fact that all thirty-seven patients who had a scoliotic curve of 30 degrees or more were unaware of their medical problem underscores the importance of screening these children. It has been suggested that the purpose of a screening program is to identify children who are at high risk for the disease and not to diagnose the disease2. On the basis of previous reports on the risk of progression16, we estimate that there was a 20 to 70 per cent risk of progression in the group of seventy-six children who were managed with a brace before menarche or the development of secondary sex characteristics. Of the 1255 children who had a curve of 10 to 19 degrees, approximately 815 (those in whom the curve was detected before menarche) were identified as being at high risk for progression. Over-all, screening children for scoliosis with use of a simple test appears to be an effective means for the early detection and non-operative treatment of scoliosis and other spinal deformities. Furthermore, school-screening programs generate invaluable data regarding not only the prevalence but also the natural history of spinal deformities. Such data are fundamental to an understanding of the development of scoliosis and, ultimately, its treatment.
NOTE: The authors express their sincere gratitude to the residents, staff, and nurses of the Department of Orthopaedic Surgery at the University of Ioannina for making this study possible. The authors thank the school administrations and the children for their cooperation, as well as the directors of the local orthopaedic clinics for invaluable assistance. They also thank the Archdiocese of Ioannina for its support.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were Mr. A. Averoff of the Papastratos Foundation Agrinion, and a grant from the Greek Ministry of State, Palinostoundon Foundation, Athens.
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