Scoliosis Screening

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Scoliosis Screening Detection

794 PEDIATRICS Vol. 61 No. 5 May 1978

The term “scoliosis” orginates from the Greek

word meaning crooked, and involves lateral

curvature and rotation of the spine. Although it

can span all age groups, the deformity is most

frequently seen in normal, rapidly growing,

preadolescent or adolescent children. Because

most of the serious consequences of scoliosis can

be prevented, it is a deformity particularly

amen-able to early diangosis and proper treatment. It is

therefore important that the health care

commu-nity and general public be knowledgeable about

the deformity; that screening programs be

promoted in every locality; and that pediatricians

focus particular attention on the spine during the

adolescent growth spurt.

Background

Scoliosis is a relatively common deformity of

the musculoskeletal system, with a prevalence

figure ranging from 0.5% to 2.0% in the general

population (for structural scoliosis).’3 There are

two fundamental types of scoliosis: nonstructural

(reversible) and structural (irreversible). While

70% to 85% of structural scoliosis is idiopathic, there is a definite familial tendency in occurrence

(20 times more frequent in immediate families of

scoliotic patients than in the general population),

and females require treatment five to eight times

more frequently than males.’5

The natural history of structural scoliosis

involves progression of the curve as long as the

potential for growth remains, or until skeletal

maturity is reached. (In the case of nonstructural

scoliosis, there may be no progression or even

spontaneous improvement in the degree of

curva-hire.6) Skeletal maturity is assessed by ossification

of vertebral ring and iliac apophyses, which

usually occurs between 13 and 16 years for girls

and 14 and 17 years for boys.3

If left untreated, scoliosis produces secondary

changes in vertebral bodies (rotation and

wedg-ing) and the rib cage (rotation), and ultimately

(curves

greater than 0) irreversibly impairs

cardiopulmonary function (vital capacity)

and

compromises life expectancy.”2’4’79 When the

deformity is allowed to progress to a severe

degree (greater than 50 to #{216}o), it is treatable only by surgical fusion of the spine, a complicated

and expensive major surgical procedure. If left

untreated at this stage, scoliosis will continue to

progress after skeletal maturity is reached, as

much as 1#{176}

per

year (average increase, 15#{176}).”

Why is it necessary to advocate screening

programs for scoliosis? Scoliosis continues to go

undetected during the early stages of progression

of the curve, and according to Tachdjian3 and W.

H.

Bunch (personal communication), 75% to 95%

of idiopathic scoliotic cases now requiring surgery

could have avoided surgical intervention through

early diagnosis and treatment. There are a

number of reasons why scoliosis continues to go

undetected: (1) lack of professional and public

awareness; (2) generally episodic, illness-related health visits during the adolescent period; (3) lack

of opportunity for the adolescent to view his own

back or for the adult to view the backs of often

modest adolescents; (4) lack of symptoms during

the slow, usually painless progression of the

deformity; (5) lack of attention on physical

exam-ination to signs of secondary changes resulting

from the primary spinal deformity; and (6) the

generally held opinion that all adolescents have

“poor posture.”

Screening

Beginning in 1975, scoliosis screening in the

Charlottesville-Albemarle public schools was

initiated through a cooperative effort of the

Charlottesville-Albemarle Health Department

and the Children’s Rehabilitation Center (CRC)

of the University of Virginia Medical Center. Our

experience has documented that screening can be

carried

out (1) with minimum instruction of

screening

personnel

(30 to 60 minutes inservice),

particularly with public health nurses and

physi-cat

education teachers; (2) with little disruption of

the normal school schedule if conducted during

physical education classes; (3) rapidly, requiring only 30 to 60 seconds

per

child; (4) without undue

anxiety

on the part of children and parents, if

adequate preparation has occurred prior to

screening (letters sent to parents; film

and

discus-sion in physical education classes); and (5) with

good acceptance and results, assuming

coopera-tion between the sponsoring agencies, the school

system, and local physicians in regard to referral and follow-up.

In

the Charlottesville-Albemarle protocol, it

was decided that sixth-

and

eight-grade children

would be screened, the rationale being that the

target population should be those children most

liable to develop scoliosis. Liability was

deter-mined by virtue of rapid growth (peak height

velocity: female, 12 years ± 1; male, 14 years ± 1)

and the likelthood of response to conservative

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TABLE I TABLE II

EXPERIENCE AND REASON 795

SELECTED FREQUENCIES AND PERCENTAGES OF ScoLlosls SCREENING DATA

1975-No.

1976,

(%)

1976-No.

1977,

(%)

Screened 2,608 2,440

Rescreened 343 (13.1) ...

Referred

Total 87 (3.3) 81 (3.3)

Male 30 (34.5) 20 (24.7)

Female 57 (65.5) 61 (75.3)

Referrals seen at CRC#{176}

Total 50 (57.5) 51 (63.0)

Initial 42 49

Subsequent 8 2

Disposition at CRC

No return 16 (32.0) 13 (25.5)

Follow-up 34 (68.0) 38 (74.5)

Type of follow-up at CRC

Return to clinic 26 (76.5) 29 (78.4)

Brace 8 (23.5) 7 (16.2)

Surge 0 (0.0) 2 (5.4)

#{176}Children’s Rehabilitation Center.

treatment.’#{176}” (It would be preferable in

commu-nities with greater manpower resources for

screening and/or more transient populations to

screen grades five or six through nine, rather than skipping grades.)

Children were screened wearing a minimum of

clothing (underwear or

gym

shorts) in indivudal

locker room shower stalls where available and

standing with their back toward the examiner.

We found it necessary to prompt the children on

how to stand, i.e., stand up straight with feet

together, shoulders back and hands hanging at

your sides, head up and looking straight ahead.

The examiner then checked for the following

signs of scoliosis: (1) asymmetry of shoulder

height; (2) asymmetry of scapulae; (3) asymmetry

of flanks; and (4) malalignment of spinous

processes. Elbow level may also be used as a sign:

with the arms bent at 9tJ0 the level of the elbows

should be horizontal. After looking at the back in

an upright position, the child was asked to bend

forward at the waist (90#{176},feet together, palms

together), and the thorax was checked for

asym-metry. It should be stressed that the

forward-bending test, to check for thoracic asymmetry

(whether scoliosis or kyphosis), is the single most

important screening technique.

Rescreening and Referral

Criteria for rescreening included any of the

CHucrERIsT1cs o PoPuiTloN REQUIRING FOLLOW-UP

IN SCOLIO5I5 SCREENING PROGRAM

1975-No.

1976,

(%)

1976-No.

1977,

(%)

Idiopathic scoliosis

Total 30 (1.1) 34 (1.3)

Return to clinic 25 (1.0) 27 (1.2)

Brace 5 (0.2) 6 (0.2)

Surgery 0 1 (0.04)

Nonidiopathic scoliosis

Total (postthoracotomy) 1 (0.04) 0 (0.0)

Brace 1 0

Kyphosis

Total 3 (0.1) 3 (0.1)

Return to clinic 1 2

Brace 2 1

Other deformity

Total 0 (0.0) 1 (0.04)

Foot surgery 0 1

aforementioned signs and/or other suspected

deformities, such as kyphosis, pelvic obliquity, or

leg length discrepancy. Children were rescreened

by pediatric nurse practitioners (PNPs). In our

experience, the best way to conduct rescreening

was to have the PNPs present during the initial

screening process, so that the child could be

rescreened immediately and referred as

neces-sary. Criteria for referral on rescreening included

presence of thoracic asymmetry (rib hump) on

forward-bending, presence of any two other signs

of scoliosis, or incidental physical findings.

if referral was indicated on rescreening, the

procedure was (1) to inform the child of the

physical finding; (2) to inform the child that a

letter would be sent to his/her parents, explaining

that a positive finding was suspected and

suggesting that the child be seen by his pediatri-cian, otherfamily physician, or at the CRC clinic;

(3) to make the PNP available for immediate

counseling if the child was particularly anxious or

asked for more information; and (4) to send letters

to the parents from school, accompanied by an

announcement that a special scoliosis follow-up

clinic would be conducted by orthopedic

surgeons at the CRC, in cooperation with the

Virginia State Bureau of Crippled Children.

Follow-up

In preparation for referrals to private

physi-cians and follow-up by the health department, the

medical director of the health department sent

letters to local physicians, describing the

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796 SCOLIOSIS SCREENiNG

Nuniber of patient visits and percent increase from 1974 to 1977 at Children’s Rehabilitation Center. Private scoliosis population not included in figures. Scoliosis screening in the

public schools began in September 1975.

ing program and requesting cooperation. As has

been the experience of other screening programs

for scoliosis, our emphasis was on detection,

education, and referral. However, because the

majority of the children referred were seen at the

CRC for initial or subsequent follow-up, we were

able to compile data regarding disposition on

those children. It should be noted that our

preva-lence figures for idiopathic structural scoliosis

(1.1% in 1975-1976 and 1.3% in 1976-1977) do not

reflect the actual prevalence in the population

screened, since 42.5% and 37.0%, respectively, of

the children referred in 1975-1976 and 1976-1977

were not seen at the CRC for follow-up (Tables I

and II).

Treatment

When scoliosis is suspected, the child should be

referred to an orthopedic surgeon, where a

standing anteroposterior roentgenogram of the

spine will confirm the diagnosis. The degree of

curvature is generally determined by the Cobb

method of measurement: after determining the

end vetebrae (the proximal and distal vertebrae

that tilt maximally into the concavity of the

curve), a line is drawn parallel to the superior

cortical plate of the proximal end vertebra and

inferior cortical plate of the distal end vertebra, a

perpendicular is erected to each line, and the

angle of intersection of the perpendiculars is the

angle of the curve.12

Depending on the degree, flexibility, and

loca-tion of the curve, the attitude of the child and

parents, and the preference of the physician,

treatment recommendations will be made. The

following are general guidelines: (1) less than 15#{176} to 20#{176},the child may be followed up closely every

three to six months with roentgenograms and

photographs; (2) between 20#{176}and 40#{176},the child is

usually fitted

with

a

Milwaukee brace; (3)

between 40#{176}and 50#{176},depending on the

afore-mentioned variables, the recommendation may

be for a trial period of bracing or surgery; and (4) greater than 50#{176},spinal fusion is usually indi-cated.

Conclusion

Idiopathic scoliosis is a common

musculoskele-tal

deformity frequently seen in preadolescent or

adolescent girls, and is usually responsive to early

diagnosis and conservative treatment.

Pediatri-cians and other health care professionals have a

real opportunity to assist in preventing the serious

consequences of scoliosis by disseminating

infor-mation to parents, children, and the general

public; by encouraging routine health visits

during the periods of rapid growth; and by

promoting

and

cooperating in screening

pro-grams in their locality. As a result of the visibility

of the Charlottesville-Albemarle experience, the

community has become more knowledgeable

about this deformity and more children are being

referred earlier (Figure). In addition, statewide

screening for scoliosis was begun in January 1977,

with the endorsement of the Virginia State

Bureau of Crippled Children and the Virginia

State Orthopedic Society.

Biuui H. DUNN, R.N., M.S.N., P.N.P.

MICHAEL W. HAKALA, M.D. Children’s Rehabilitation Center, University of Virginia

Medical Center

MARY E. MCGEE, R.N., M.S.N.

Thomas Jefferson Health District,

Charlottesville-Albemarle Health Department Charlottesville, Virginia

Ms. Dunn is now with the Pediatric Nurse Practitioner Program, Virginia Commonwealth University, Medical College of Virginia, Richmond.

ADDRESS FOR REPRINTS: (B.H.D.) Box 875, MCV Station, Richmond, VA 23298.

REFERENCES

1. Cailliet R: Scoliosis: Diagnosis and Management. Phil-adelphia, FA Davis Co, 1975.

2. Salter B: Textbook of Disorders and Injuries of the Mu.sculoskeletal System. Baltimore, Williams & Wilkins Co, 1970, pp 296-297.

3. Tachdjian M: Pediatric Orthopedics. Philadelphia, WB Saunders Co, 1972, vol 2, pp 1190-1208.

4. Roberts R: Scoliosis Gun Syznp 24:6, 23, 26, 1972.

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PEDIATRICS Vol. 61 No. 5 May 1978 797

5. James JIP: The aetiology of scoliosis, in Zorab PA (ed):

Scoliosis and Musck. Philadelphia, JB Lippincott Co, 1974, p 176.

6. Brooks HL, Azen SP, Gerberg E, et al: Scoliosis: A

prospective epidemiological study. I Bone Joint Surg 57A:968, 1975.

7. Collis D, Ponseti I: Long-term follow-up of patients with idiopathic scoliosis not treated surgically. I

Bone Joint Surg 51A:443, 1969.

8. Westgate H: Pulmonary function in thoracic scoliosis.

Minnesota Med 53:847, 1970.

9. Winter RB, Moe JH: Idiopathic scoliosis: Current concepts in treatment. Minnesota Med 53:531, 1972.

10. Duthrie RB: Growth and its relation to bone

deformi-ties, in Zorab PA (ed): Scoliosis and Growth.

Balti-more, Williams & Wilkins Co, 1971, p 35.

11. Tanner JM: Some main features of normal growth in

children, in Zorab PA (ed): Scoliosis and Growth.

Baltimore, Williams & Wilkins Co, 1971, p 20. 12. Goldstein LA, Waugh TR: Classification and

termino-logy of scoliosis. Clin Orthop 93:10, 1973.

BIBLIOGRAPHY

Blount W: Early recognition and evaluation of spinal

defor-mity. WLs Med J 68:245, 1969.

Hungerford D: Spinal deformity in adolescence. Med Clin

North Am 59:1517, 1975.

Kane WJ, Moe J: A scoliosis prevalence study in Minnesota.

Clin Orthop 69:216, 1970.

Lonstein JL, Winter RB, Moe JH, et al: School screening for the early detection of spine deformities. Minnesota Med

59:51, 1976.

MacEwen GD, Shands AR: Scoliosis: A deforming childhood

problem. Clin Pediatr 6:210, 1967.

Sells C, May E: Scoliosis screening in public schools. Am I

Nurs 74(1):60, 1974.

Shands AR, Eisberg HB: Incidence of scoliosis in the state of

Delaware. J Bone Joint Surg 37A:1243, 1955.

Weiler D: Scoliosis screening. I School Health 44(10):563,

1974.

Winter R, Moe J: A plea for the routine school examination

of children for spinal deformity. Minnesota Med 57:419, 1974.

Zuege R, Blount W, Dicus W: Indications for operative

treatment of spinal deformities. Wis Med I 74:33, 1975.

ACKNOWLEDGMENT

The authors wish to express their appreciation to Ms.

Rebecca Parks and Ms. Sharon Wright for their assistance with compilation of data, and to Wilton Bunch, M.D., for his assistance with manuscript revisions.

Persistent MUllerian Duct Syndrome

in Male Identical Twins

Male pseudohermaphroditism, characterized

by the persistence of M#{252}llerian duct structures

with

otherwise normal differentiation, is a rare

disorder that appears to be caused by an

abnor-mality in the activity of M#{252}llenan inhibiting

factor.1 Patients

with

this syndrome are

pheno-typically normal males who usually present with

inguinal hernia and cryptorchidism. This

condi-tion has also been called hernia uteri inguinalis,

persistent M#{252}llenan duct syndrome, and male

internal pseudohermaphroditism. It has recently

been suggested that hysterectomy may not be

indicated in most of these patients because of

possible injury to the vas deferens.2

The condition appears to be genetic, since

familial incidence occurs. Brook et al.3 reported

four affected pairs of brothers in unrelated

fami-lies. David et al.,4 Guell-Gonzalez et al.,5 and

Sloan and Walsh2 have each reported

two

broth-ers with

this condition. We wish to report the

occurrence of this condition in identical twins. To

our knowledge there are no previous reports of

the occurrence of this syndrome in identical

twins.

CASE REPORTS

At the age of 7 months, male twins who were apparently

identical underwent surgery for presumed simple right

inguinal hernias. The hernial sac of each child revealed a

uterus and two fallopian tubes. The contents were placed in

the abdomen. The children were later transferred to the

University of illinois Hospital for further investigation.

Family history revealed two older normal brothers and

five older normal sisters. A year after surgery another normal

sister was born. Three siblings died in early infancy from

“pneumonia” according to the mother.

Physical examination revealed both patients to be pheno-typically normal males in the 50th percentile for height and

weight. The penis of each child was of normal size,

circum-cised, and without hypospadias. No testes were palpable in twin 1. Twin 2 had a 1 X 0.5 X 2 cm nontransilluminable, easily reducible mass in the right upper portion of the

scrotum.

Buccal smear on each child was sex chromatin-negative.

Kaiyotypes on both brothers prepared from peripheral blood

lymphocytes were 46,XY. Seventeen ketosteroid and preg-nanetriol determinations on 24-hour urine specimens from

each twin were normal. Blood type was identical for each

twin, being group A, Rh genotype was cDE/ce, NN, positive

for P,S,K (Kell), F (Duffy), k (Cellano), Lea (Lewis a) and

Jb An excretory urogram of each child was normal, and

bone age of each was compatible with chronological age. Exploratory laparotomy of twin 1 revealed an infantile

uterus rising from the pelvis. Two fallopian tubes were present. A hysterectomy was performed. Embedded in the posterior wall of the uterine specimen were two vasa

deferentia with a posteriorly located central fallopian tube

(Fig. 1). The left gonad was 15 x 9 x 12 mm and the right gonad was 20 x 10 x 8 mm. A biopsy specimen from each of the gonads revealed testicular tissue normal for age. The

testes could not be brought into the scrotum and were left in

the abdomen.

At the time of exploratory laparotomy of twin 2, a testis

was found in each broad ligament with long vascular

pedicles, especially on the left. These long pedicles enabled

the testes to be secured in the scrotum. A uterus and

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1978;61;794

Pediatrics

Barbara H. Dunn, Michael W. Hakala and Mary E. McGee