Wednesday, June 9, 2010

Wake County Physician's Magazine Article

By Lloyd A. Hey, MD, MS*

Consultant’s Corner


It is late on a Friday afternoon, and an
anxious call comes into Hey Clinic
from a pediatrician that she had an
urgent spine consult for a young man with
an apparent rapidly growing spinal tumor
growing out of his lower back. My staff
made arrangements to get this young man
and his mom into see me right away. The
adolescent indeed had a fairly large hump
on his left lower back. X-Ray revealed a
very large thoracolumbar scoliosis as the
cause of the hump. The mom was actually
quite upset to the point of tears: “Why
wasn’t this picked up earlier? Don’t they
screen for this?”

Many of us adults remember being
screened as a middle schooler in gym class
or by our school nurse. Gym teachers
or school nurses often would have large
groups of children bend forward, examining
the upper and lower back for asymmetries
(humps) that would then result
in a letter going home with the child to
have them seek further evaluation and an
X-Ray. It seemed like a good idea from a
public health standpoint: early diagnosis
could lead to earlier treatment with molded
scoliosis braces, and the possible avoidance
of surgery.

Dr. Ralph Coonrad, cared for thousands
of children and adolescents with scoliosis
from all over Durham, Orange and Wake
Counties for over thirty years. Back in the
1970s, Dr. Coonrad along with other physicians,
nurses and school administrators who
helped develop and implement the scoliosis
screening programs in the Triangle area and
even around other areas of North Carolina.
Most, if not all of the local school districts
had some form of screening program in
place by the end of the 1970s. Similar
screening programs were implemented
across the United States.

While scoliosis screening was done
consistently during the 1970s and
1980s, many school districts moved
away from scoliosis screening during
the 1990s in part because of the United
States Preventive Services Task Force
(USPSTF) began to raise questions
regarding the effectiveness of such
screening. In their 1996 report, it was
their belief that there was insufficient
evidence to warrant the costs associated
with widespread scoliosis screening in

As a result, many school districts
began to discontinue their scoliosis screening
programs during the 1990’s, including
most school districts in North Carolina. By
2004, this same organization updated its
opinion to state that scoliosis screening was
considered “Grade D: Not recommended,
with fair evidence that the screening was
ineffective or harms outweigh benefits.”

Many States used this document to eliminate
the requirement for scoliosis screenings
in their schools, and as a result, school
scoliosis screenings have become quite
variable nationwide. As a result of this
dramatic drop in school screenings, overall
awareness of scoliosis among families and
even some physicians has dropped.
Now that school scoliosis screenings have
been largely eliminated, what role, if any,
does the pediatrician, family physician, OB/
GYN and orthopaedic surgeon play in the
detection of scoliosis? Many are choosing
to include scoliosis screening as a part of
their usual physical examination for children,
adolescents and adults. Many are also
using the Scoliometer, which is a tilt gauge
tool that helps define paraspinal asymmetries
that are large enough to warrant an
X-Ray evaluation. In my discussions with
many Wake County pediatricians, they have
found that the Scoliometer has been very
helpful to help add an objective high tech
measure to their documentation to show that
they checked for scoliosis. It also gives our
well-educated Wake County population,
(who also like objective measures) some visual
proof that we checked their child/teenager
thoroughly and that nothing is being
overlooked or missed: they will remember
that you put a device on their child’s back,
whereas they may not remember that you
eye-balled them for potential rib hump.
Screening for scoliosis is becoming even
more difficult as obesity becomes more
prevalent in the adolescent and adult population.
Very large, well-balanced curves
can be nearly completely invisible. As
shown below, two young ladies have similarly
appearing backs on clinical exam, with
possible slight curve. The one on the left
actually has an 80 degree scoliosis, twice
as large as the young lady on the right who
has a single 40 degree curve. The scoliometer
has proven to be helpful in this obese
population as well.

*Hey Clinic for Scoliosis and Spine
Raleigh, North Carolina

1 comment:

Jessie said...

Dr. Hey,

Thank you for advocating for such an important issue. My scoliosis was found during such a routine screening, and was braced and began physical therapy shortly thereafter. Although my curvature did eventually increase, leading me to your door, I am grateful to have caught this early and better inform both me and my family of next steps. It would be a shame to lose such an important process.

Kind regards,
Jessie Rountree
(spinal fusion December 2005)