To screen or not to screen? The role of school screening in the management of mild and moderate scoliosis curves (Concurrent)

Scoliosis is a three dimensional deformity that results in a lateral curvature of the spine combined with a rib-hump and an accompanying thoracic lordosis. Left untreated scoliosis can result in pain, decreased spinal mobility and level of physical activity, respiratory impairment as well as a number of psychological problems resulting from numerous back asymmetries. School Screening Programmes for this deformity are highly controversial with few countries having mandatory programmes. In the UK school screening was abolished in the 1980‘s when the British Scoliosis Society decided that it should no longer be national policy to screen for scoliosis. Since the abolition of screening the detection of a curvature in a child has tended to be haphazard and detected either by parents usually observing it on the beach whilst on holiday or by GP‘s observing asymmetries in the child’s back. Once diagnosed, current management procedures in the UK depend on the degree of severity of the curve when detected. Most children in the UK are “observed” at 3-6 monthly x-rays until the curve progresses to 40-45 degrees and then offered surgery. Occasionally when a child is still pre-pubertal and the curve is greater than 30 degrees a brace may be offered. Despite bracing being common in continental Europe however it is still uncommon in the UK. Furthermore although physiotherapy is offered as an option for curves ranging from 20 to 30 degrees in most countries in continental Europe, it is currently not offered as an option in the UK. This lack of screening in the UK has meant that many children at our centre are not detected till the curvature is 40 degrees or above and then the only option left for patients is surgery. Clinicians opposed to school screening have suggested a number of factors in support of their decisions. Obsolete assumptions, the low prevalence of IS, the high false positives and costs have all been quoted. The policy not to screen because of a lack of cost effectiveness is based on the obsolete assumption derived from a study dating back to 1941 that surgery is the only proven treatment option. However the study cited in this report does not scientifically justify the conclusion (SOSORT 2008). Today there is evidence that if detected early enough the signs and symptoms, as well as the rate of progression of scoliosis can be modified by the application of intensive scoliosis specific exercise programmes. Furthermore the numbers of patients referred for surgery can also be significantly decreased in countries where conservative treatment (physiotherapy and braces) is available to a high standard. This paper will discuss the scientific evidence in support of all of the above as well as specific evidence based recommendations for the improvement of school screening effectiveness and patient choice.