Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Paul J. Moroz, MD, MSc, FRCSC, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
Jessica Romeo, RN (EC), MN, BScN, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
Marcel Abouassaly, MD, FRCSC, Fellow in Pediatric Orthopedic Surgery at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

Abstract
Adolescent Idiopathic Scoliosis (AIS) is a condition requiring early detection for appropriate management. Bracing can be effective in preventing curve progression so failing to detect a small AIS curve in a growing child could result in losing the opportunity to avoid a major surgical procedure. Doubts about cost-effectiveness have ended most school screening programs and assessment is now provided mainly by primary care providers. The ability to conduct a quick effective scoliosis examination is important for the busy practitioner. This article illustrates the main features of the screening test, offers guides for imaging, and outlines appropriate tips for specialist referral.
Key Words: Adolescent Idiopathic Scoliosis (AIS), diagnosis, physical exam, Adams Forward Bend Test, primary care.

Introduction
Adolescent Idiopathic Scoliosis (AIS) affects 3% of the adolescent population. It is defined as a three-dimensional, structural curvature of the spine that measures more than 10 degrees on radiographs using the Cobb angle method.¹ Only 3% of those with AIS require long-term close monitoring, brace treatment or surgery. Early detection of scoliosis via primary healthcare provider screening is somewhat controversial but is generally accepted and believed to be cost effective.² The recent landmark BRAIST study demonstrated the effectiveness of bracing in a selected cohort of patients with more than one year of growth remaining and a curve greater than 20 degrees. The research emphasized the importance of early curve detection to increase effective brace use and reduce the frequency of surgery.³

In the 1980s and 1990s, based on the best evidence available at the time, the British, American and Canadian Preventive Task Forces did not recommend the use of school screening programs.⁴ Despite the ongoing support for screening by all major physician groups that actively manage scoliosis including the Paediatric Orthopedic Society of North America, the Scoliosis Research Society, the American Academy of Orthopedic Surgeons⁵ and the Canadian Paediatric Spine Society, some Canadian and US sources continue to cite insufficient evidence to recommend routine AIS screening.^6,7