Spine Check Takes Scoliosis Screening to School

Me: Kathy, thank you for taking the time to talk to us about scoliosis screenings and the new Spine Check program. What types of conditions can be found during a spinal screening?

Kathy: Spinal screening is designed to detect two major types of spinal deformities: scoliosis and kyphosis. Scoliosis is the abnormal lateral and rotational curvature of the spine, and although it can run in families, the cause is not known. Screening during the middle school years seems a natural way to identify this disease early. A normal spine looks like a straight "I." A spine with scoliosis looks more like an "S" or "C".

Kyphosis, or roundback, is an excessive forward curvature of the thoracic spine when viewed from the side. In relation to scoliosis, kyphosis is a much rarer finding, but will occasionally be identified during school screenings.

Me: It sounds like school screenings are a very important tool.

Kathy: Yes. Early detection is the key to controlling spinal deformities. The purpose of school screening is to detect scoliosis and kyphosis at an early stage when the curve is mild and may even go unnoticed. As a child matures and becomes more modest, parents may have few opportunities to view his or her back to notice a change.

Me: Is it easier to treat a child's scoliosis the earlier the condition is found?

Kathy: Absolutely. Scoliosis screenings, whether in the physician's office, nurse's clinics, or school environment, provide the opportunity to diagnose the condition and make referral for appropriate medical care. Brace treatment in children with significant scoliosis may avoid the need for surgical intervention. Those with deformities in need of surgery may be identified by screening at a time when operative intervention can be performed most effectively.

Me: What is the best age for screening students for scoliosis?

Kathy: Girls achieve skeletal maturity about two years before boys do and are afflicted with scoliosis that requires treatment three to four times more frequently than boys. Ideally, spinal screening should be conducted annually during the adolescent growth spurt (ages 9-15 years), but time and personnel constraints may prohibit yearly screenings. So if scoliosis screening is undertaken, the AAOS, SRS, POSNA, and AAP all agree that girls should be screened twice, at ages 10 and 12 years (Grades 5 and 7), and boys once, at age 13 or 14 years (Grades 8 or 9).

In the Adam's Forward Bend Test
shown above, you can see a normal
spine on the left and a scoliotic
spine on the right.

Me: That makes sense. How are the screenings performed?

Kathy: I have helped perform scoliosis screenings many times. It is easiest if students wear shorts and remove their shirts for the screening. Girls should wear a swimsuit top, sports bra, or other appropriate clothing to allow visualization of the spine. With the student facing toward the screener and then away from the screener, the torso is inspected in the standing position. I think all screening programs should include the Adam's Forward Bend Test.

Me: I know that scoliosis screening in schools can be the subject of controversy. Can you tell me more about that?

Kathy: Yes, you're right. Fewer than half of the states in the U.S. currently legislate school screening. Beginning in 1984, the American Academy of Orthopaedic Surgeons (AAOS) and the Scoliosis Research Society (SRS) formally endorsed the concept of school screening for the early detection of scoliosis in children whose deformities may have gone unnoticed. But then in 1996, the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to make a recommendation for, or against, screening. However, in 2004, the USPSTF changed their position and recommended against the routine screening of asymptomatic adolescents for idiopathic scoliosis. The AAOS, SRS, the Pediatric Orthopaedic Society of North America (POSNA), and the American Academy of Pediatrics (AAP) were concerned that this change in position by the USPSTF came in the absence of any significant change in the available literature, any change in position statements by the four societies, and any significant input from specialists who commonly care for children with scoliosis. Prevention of severe scoliosis is a major commitment of physicians caring for children with spinal deformities. For this reason, the AAOS, SRS, POSNA, and AAP do not support any recommendation against scoliosis screening, given the available literature, and convened a task force to examine issues related to scoliosis screening and to put forth an information statement. Although the AAOS, SRS, POSNA, and AAP recognize that support for scoliosis screening has limitations, the potential benefits that patients with idiopathic scoliosis receive from early treatment of their deformities can be substantial.

Me: One of the criticisms of school screening programs has been an unnecessary referral rate. Can you address that as well?

The images above show a normal
spine and a scoliotic spine being
measured with a scoliometer.

Kathy: Proper education on screening technique and the criteria for referrals would limit unnecessary referrals. To avoid unnecessary referrals, students with positive findings should be rescreened to determine if referral to a physician is necessary. The use of a scoliometer/ inclinometer is helpful to determine the amount of trunk rotation. I agree with referring students with a scoliometer reading of seven degrees or more. Schools should keep records of students who exhibit physical findings of asymmetry, but do not meet referral criteria. These students should be rescreened in approximately six months to determine if referral or continued observation is necessary. If a student meets the criteria for referral to a physician, a letter should be mailed to the parents because a letter sent home with the child may never reach them. If possible, a telephone call to explain the findings and give reassurance to the parents is a good idea. Treatment recommendations will be based on the severity of the curve and the age of the child. Many curves will simply require observation by the physician as the child grows and never need formal treatment.

Me: Let's talk about the Spine Check program for school nurses. I know you recently attended the National Association of School Nurses (NASN) conference in Albuquerque, New Mexico. What was their reaction to the Spine Check materials?

Kathy Blanke, RN demonstrates
the Adam's Forward Bend Test for
school nurses at the annual NASN
meeting.

Kathy: I enjoyed talking to school nurses from around the country at the NASN meeting. Whether they were new school nurses or they had performed scoliosis screenings for many years, they were very interested in a kit that would provide them additional tools. A couple of the nurses I talked to actually had scoliosis, and felt that if screenings had been done when they were in school, their condition could have been treated. But sadly, they went undiagnosed. There were some school nurses who do not conduct screenings because they are understaffed, and others don't do screenings because their state no longer requires it. In those cases, those of us at the convention shared an idea that can keep students from falling through the cracks. Even if your school does not conduct screenings, it would be great to use the school Web site or newsletter to remind parents to set aside some time to check their children. They can visit www.iscoliosis.com/nurses to view a demonstration of the screening technique and tips on what to look for.

Me: What are some ways to ease the burden on school nurses when it comes to scoliosis screenings?

Kathy: That's a good question. School nurses are busy, and they have a very tough job. An idea for easing the burden would be to get volunteers to help. Parents can make great volunteers. Another idea would be partner with a spinal surgeon in the local area whose staff could volunteer. That's something I've done a lot in the past. I work at a spinal surgery practice, but I used to volunteer to help out with screenings during my spare time.

Me: Kathy, thank you so much for speaking with me today. I really appreciate it.