The decisional pathway of scoliosis

Key words: Scoliosis, Algorithm, Angle of trunk rotation (ATR)

Background - Adolescent scoliosis occurs in 2% of the young aged between 10 and 16; only 10% usually get worse and this poses the problem of an early identification of evolutive cases and of avoiding unnecessary treatment in the majority of cases. To recognize scoliosis the forward bending test is performed and the confirmation comes through X-rays. Cobb angle along with auxological data and curve pattern are the most important clinical clues for a therapeutic choice. This comprises observation up to 20°-25° Cobb, brace up to 45°-50°, and surgery over 50°.
Aim of the Study - To create an algorithm able to describe the clinical behaviour. To use the algorithm to analyze the results of a series of first visits to check the correctness of the referrals on one side and that of the therapeutic choice on the other, defined as congruent or not-congruent with the algorithm.
Materials and Methods - 623 consecutive first visits on adolescents aged 9-15 who were sent to the specialist for scoliosis have been analyzed. Every single case has been considered according to the algorithm, checking the result (discharge, control, brace, and surgery) and the coherence of the clinical decision.
Results - ATR of any degree was present in 92%; those without ATR were considered wrong referrals, the majority having leg length discrepancy. In 2/3 of the cases the ATR was low and the unique decision was observation. X-rays were prescribed in 20% whereas in 8% it was already available. A brace was prescribed in 10% of total cases. In 4 cases a surgical consultation was suggested. Among the 572 cases without previous X-ray, 462 (81%) resulted coherent with the algorithm. Among the 97 incoherent cases, for 39 (7%) the clinical decision was judged as imprudent, for 58 (10%) as invasive. Conclusions - The majority of the cases referred to the specialist had a small ATR, others had no rotation at all. Therefore, there is a problem of selection and to this aim the use of validated instruments (scoliometer, arcometer) as well as of shared objective criteria of selection is essential. 81% of prescriptions of the specialist resulted coherent with the algorithm. Imprudent behaviour usually regards borderline cases; an invasive behaviour can cause unnecessary concern and expenses to the families. The algorithm should be used for a comparison and not as a prescriptive tool.