Abstract
Purpose
This study is a large-scale screening supported by government departments to investigate the prevalence of scoliosis in Shijiazhuang.
Methods
In this cross-sectional study, all students underwent body posture evaluation and the Adam’s forward flexure test to examine the back, and also underwent radiographic evaluation when scoliosis was suspected.
Results
In total, 181,935 students participated in the research, of which 289 students were diagnosed with scoliosis, with a prevalence of 2.5%, significantly higher in female (3.01%) than in male children (1.63%) (P < 0.001). Most of the patients (79.5%) had a Cobb angle from 10° to 19°.The mean Cobb angle of scoliosis was positively associated with age. The prevalence of a single curve (75.4%) was significantly higher than double curves (23.2%) and triple curves (1.38%). The percentage of scoliosis in which the thoracolumbar segment was involved (46.4%) was significantly higher than that of the single thoracic scoliosis (31.8%) and single lumbar scoliosis (21.8%).
Conclusions
The prevalence of adolescent idiopathic scoliosis in XXX was high (2.50%). It is necessary to strengthen the education of adolescent scoliosis, and improve the awareness and attention of social to scoliosis.
Level of Evidence
IV.
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Introduction
Scoliosis refers to the lateral curvature of the human spine in the coronal plane, which is generally accompanied by vertebral rotation and alteration of physiological curvature in the sagittal plane, and even rotation and tilting of ribs and pelvis, as well as abnormalities of the surrounding soft tissues. As the etiologies of approximately 90% of scoliosis are unclear, the disease is also termed as idiopathic scoliosis (IS). Based on the age of the patients, IS is further classified into infantile (0–2 years), juvenile (3–9 years), and adolescent (≥ 10 years) IS (AIS), of which AIS is the most common type [1]. AIS has reportedly become a major issue, following myopia and mental health, severely affecting the healthy growth of adolescents in China [2]. The school screening of AIS was first performed in the USA in 1960s [3] and was performed in various regions in China in 1990s, based on which the prevalence was reported. However, the screening could not be performed in most regions or performed in a small scale and limited patients due to the lack of support from relevant governments. The findings of screenings varied due to the differences in the regions, age groups, sample sizes, methods, and awareness of this disease in different regions. AIS screening has been included since 2018 in the routine health service in XXX, XX, China, thanks to the support from the XX provincial government, the XX Provincial Department of Education, the XX Provincial Health Commission, and the XX Provincial Sports Bureau. Since the outbreak of coronavirus disease 2019, online learning increased while physical activities reduced substantially in primary and secondary school students in mainland China, which further increased the spinal burden on children that was capable of inducing scoliosis [4]. This study aimed to screen this condition so as to explore the prevalence and features of AIS in XXX, XX, and provide timely interventions and accurate guidance to children with mild scoliosis.
Methods
Study design and participants
In this cross-sectional study, 181,935 students in 142 primary and secondary schools in XXX, XX, China, were screened for scoliosis. This study was supported by the XX provincial government, which facilitated communications with schools and the consequent screening. The XX Provincial Hospital of Traditional Chinese Medicine, which is also the First Affiliated Hospital of XX University of Chinese Medicine, through its sufficient medical staff, successfully carried out the medical strategies for screening students for scoliosis in this study. The screening was a medical examination for school students. The leaflets on the screening were dispatched to the schools by the concerned Education and Health Department, so that the parents could fully understand the protocols and aims of this screening. Then, the informed consent was obtained.
Screening
Screening personnel: The screening was performed by 12 teams, and each team comprised 1 professional orthopedist, 1 medical intern, and 1 nurse. All the medical workers received scoliosis screening training, and were allowed to participate in the screening after being qualified. All the screening teams went to the schools at the same time for screening, and the two doctors in each group performed the screening at the same time. The professional orthopedist conducted the surveillance to minimize the errors, while the nurse recorded the positive results in the first screening and dispatched reexamination notification for scoliosis.
Screening method: The screening included school screening (first screening), hospital screening (second screening), and hospital confirmation (third screening). If the school screening reported scoliosis positive, the child was referred to the hospital and received further screening by a superior doctor and was assessed whether he/she met the referring criteria. If the child was found positive for scoliosis, he/she was again referred for an imaging examination.
Assessment criteria: The body posture evaluation was used in both school screening and hospital screening to assess whether the bilateral shoulders and anterior superior spines were at the same height, bilateral spealbone was symmetric, bilateral waist concaves were with equal depth, and the spinous process line was a straight line. Then, a scoliometer was used to measure the angle of trunk rotation (ATR) in the forward flexure test (FBT). Children with one or more abnormal measurements in body posture evaluation or ATR ≥ 5° were considered positive for scoliosis and regarded as suspected scoliosis. According to the Scoliosis Research Society (SRS) Criteria and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment 2008 Guidelines in Non-Operative Treatment of Idiopathic Scoliosis, scoliosis was defined as the Cobb angle of the spine of more than 10° in the coronal plane [5].Other types of non-idiopathic scoliosis were excluded, such as congenital, neuromuscular, neurofibromatosis, osteochondrodystrophy, and metabolic disorders. Idiopathic scoliosis was confirmed as the correct diagnosis by three senior spine surgeons.
Statistical analysis
The SPSS Statistics software (IBM SPSS Statistics for Windows, Version 22.0; IBM Corp., NY, USA) was used for data analysis. Quantitative data were described by \(\overline{x } \pm\) s s and quantitative data not in normal distribution were also described by M (Q1, Q3). Qualitative data were described by frequency and percentage. The inverse probability weight was calculated based on the propensity score modeling of general characteristics of children, and then the AIS prevalence in XXX was estimated. The Chisquare (χχ2) test was used to compare the prevalence between male and female children. The Spearman correlation test was used to explore the association between age group and corresponding average Cobb angle. The Kruskal–Wallis rank-sum test was used to compare the detection rate of scoliosis at different parts. A P value < 0.05 was considered a statistically significant difference.
Results
Screening outcomes
In total, 181,935 adolescents underwent school screening in this study, which included 94,403 male and 87,532 female children, and the male-to-female ratio was 1:0.93. Positive signs were found in 16,676 children (including 6466 male and 10,210 female children) in school screening. Then, 2054 children underwent hospital screening (including 789 male and 1265 female children), of which 1256 (including 456 male and 799 female children) were found with positive signs. Further, 705 children (including 243 male and 462 female children) underwent imaging examination, and finally 289 children (including 100 male and 189 female children) were confirmed with scoliosis. Of the 289 children with AIS, the detection rate in male children was 0.11%, and the estimated prevalence was 1.63%. The detection rate in female children was 0.22%, and the estimated prevalence was 3.01%. The male-to-female prevalence ratio was 1:1.85, and the direct detection rate and estimated prevalence were significantly higher in female than in male children (P < 0.001). Statistical analysis on the estimated prevalence between male and female children also showed statistically significant difference (P < 0.001) (Table 1).
Distribution of Cobb angle in the 289 children with AIS
Of the 289 children with AIS, the Cobb angle was 10°–19° in 228 children, 20°–29° in 46 children, 30°–39° in 10 children, and ≥ 40° in 5 children. The Cobb angle of children with AIS in XXX was mainly 10°–19°. The average Cobb angle of children aged 7–18 years was 13.4°, 14.2°, 14.6°, 15.9°, 15.8°, 18.7°, 16.9°, 17.4°, 19.7°, 24.2°, 33.3°, and 22.4°, respectively. The average Cobb angle in children with AIS tended to increase with age, and the statistical analysis showed relatively strong positive correlation between age and average Cobb angle (Spearman correlation coefficient: rs = 0.951, P < 0.001) (Table 2 and Figs. 1, 2).
Classification of AIS in the 289 children
Of the 289 children with AIS, 218 had a single curve, 67 had double curves, and 4 had triple curves. The prevalence of the single curve was significantly higher than the double and triple curves. The scoliosis involved the thoracolumbar segment in 134 children, and the percentage was significantly higher than those with single thoracic scoliosis (n = 92) and single lumbar scoliosis (n = 63). The comparison of different scoliosis types in different parts indicated statistically significant differences (P < 0.0001) (Table 3).
Discussion
The findings of this study showed that the AIS prevalence was 2.5% in XXX, XX, which was higher than the average AIS prevalence (1.23%) reported by a previous survey in China [6]. One possible cause of the difference in the prevalence could be that previous surveys did not consider reexamination rate and imaging rate of positive cases, and thus, relatively high report bias was found. In this study, the inverse probability weight was calculated based on the propensity score modeling of the general characteristics of children to adjust the prevalence. The IS prevalence varied substantially in countries other than China, ranging from 0.62 to 3.26% [7,8,9,10,11,12] (4.3% in Goiania, Brazil; 2.3% in Turkey; 3.1% in semiarid region of Brazil; 3.26% in Korea; 0.62% in Isfahan, Iran; 2.93% in Indonesia), which could be associated with the differences in regions, age of enrollment, methods of screening, and diagnostic criteria in the studies. The male-to-female prevalence ratio was 1:1.85, and the prevalence was higher in female than in male children, which was in agreement with the findings of previous studies [6]. The higher prevalence in female children could be associated with the early development in these children compared with their male counterparts, while their physical activities were less than male children, and their muscle strength was weak and incapable of supporting the trunk. Moreover, the higher prevalence in female children could also be associated with their dance training. Previous studies reported that the incidence of back and tendon injuries was relatively high in dancers with a younger age, and overstretching, especially back stretching, was not recommended in children under 10 years of age during dance training [13]. The IS prevalence in professional dancers was as high as 41.6% [14].
The findings of this study showed that the IS prevalence increased with age, which was in agreement with the results of a previous study that the IS prevalence was 0.1%, 0.3%, and 1.2% in children aged 6–8 years, 9–11 years, and 12–14 years, respectively [15]. The AIS prevalence was 1.19%, 1.04%, and 2.02% in children aged 7, 8, and 9 years, respectively, in this study. However, several other studies reported no IS in children aged 6–9 years and thus recommended no IS screening for children aged ≤ 10 years [16]. As the AIS prevalence in younger children was relatively low, the necessity of screening in this group still needed to be further evaluated. According to previous studies, the age of menarche in girls in China showed a long-term declining tendency, and is 11.8 ± 1 years currently [17]. The peri-menarche period is the peak stage of growth of girls, which is also the high-incidence stage of AIS. Therefore, IS screening should be performed in primary school as well, otherwise the best conservative treatment timing could be missed even if IS is screened.
The findings of this study showed that the percentage of mild IS (Cobb angle, 10°–19°) was 79.5% in XXX, XX, which was higher than the percentage reported in a western Istanbul study (42.8%) [18]. The findings of this study indicated that the AIS in XXX was mainly mild, while the essence of screening was to help early intervention on mild IS, prevent IS progression, and reduce the rate of surgery. The findings of this study also showed that the Cobb angle in children with AIS tended to worsen with age, which could be associated with the education mode in China. For instance, the pressure for learning was substantially higher in senior students than in junior students, and long-time sitting could also induce imbalance of trunk muscles, therefore increasing the risk of IS [19].
AIS could be further classified according to the number of spinal curves. In this study, most children with AIS were with single curve (75.4%), of which 46.4% were lateral thoracolumbar curve, consistent with the results reported by a Korean study (single curve accounted for 87.69%, and lateral thoracolumbar curve accounted for 53.6%) [10]. These findings indicated that the thoracolumbar segment of adolescents had poor stability and thus had a higher risk of IS.
Adam’s FBT is still the extensively acknowledged effective method for IS screening. Previous studies demonstrated that ATR correlated with the Cobb angle of IS (r = 0.7) [20], and ATR ≥ 5° could be used as the criterion for referral. However, this criterion had the risk of over-referral, and the false positive rate was 35.7–61.1% [7, 10, 21] (35.7% in Goiania, Brazil; 53.6% in Korea; and 61.1% in Chongming Island, China). However, when using ATR ≥ 7° as the criterion for referral, the false positive rate decreased, but still approximately 25% of positive cases had no IS, while the false negative rate increased [22]. The difference in the false positive rate could be associated with the age of patients receiving the screening. Previous studies demonstrated that ATR was not associated with the Cobb angle in children < 9 years, and the association decreased gradually with the increase in the curvature. Therefore, the best cutoff value of ATR for referral is still not decided [23]. Both ATR ≥ 5° and trunk asymmetry abnormality were included as criteria to identify more children suspected with AIS in this screening, which could be a cause of the substantial higher positive rate in the school screening in this study (9.16%) than the average prevalence of 4.4% reported in previous studies [6]. Second screening by superior doctors was performed for positive children identified during the school screening to reduce the unnecessary imaging examinations due to high false positive rate; the final diagnosis rate was 41.0% and the false positive rate was 59.0%.
This study had several limitations. First, the awareness of students and parents on this disease was insufficient, and thus, the rate of second screening and imaging examination was relatively low, which was 12.3% and 41.0%, respectively. The school–family–hospital communications were to be strengthened to gradually improve the recognition and attention of students, teachers, and parents on AIS. Second, some positive children might also have visited to other hospitals for reexamination. In the future, communications and cooperation with other hospitals in XXX should be strengthened, and clinical studies on large data from multiple platforms should be conducted for better and effective outcomes. The AIS prevalence was estimated based on the reexamination rate, imaging examination rate, and weights of children in different age groups and sexes, in order to exclude the interference of aforementioned factors on the data analysis of AIS in children in XXX, XX. Thirdly, a detailed examination of leg length discrepancy was not conducted for lateral bends less than 20, so it was not clear whether the LLD and the curve really have apical torsion, and need to be further clarified in the later stage.
The findings of this study showed that the AIS prevalence in primary and secondary school students in XXX, XX, was relatively high, indicating the need to pay more attention to AIS to achieve early screening, prevention, and treatment. Moreover, a number of images showed that AIS is often accompanied by straightening of cervical curvature, straightening of lumbar curvature, collapse of thoracic spine, and thoracic kyphosis. Previous studies showed that spinal abnormality in the sagittal plane was a risk factor for IS [24]. Therefore, we need to enhance the overall screening and data analysis of spines in adolescents in the future for an in-depth epidemiological investigation to improve prevention and treatment strategies in patients with IS.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
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Funding
This study was supported by the Scientific Research Project of Hebei Administration of Traditional Chinese Medicine (No. 2021015), the Special TCM Innovation Project of Hebei Provincial Department of Science and Technology (Approval No. 223777130D), the Special TCM Innovation Project of Hebei Provincial Department of Science and Technology (Approval No. 223777125D), and Scientific research project of Hebei Province Administration of Traditional Chinese Medicine (2024215).
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LL, XW, and SD conceived and designed the study. WS and CY helped with the study. LL and WX wrote and revised the manuscript. All authors edited and approved the manuscript.
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The study was based on the Declaration of Helsinki. This study was approved by the ethics committee of the Hebei Provincial Hospital of Traditional Chinese Medicine (HBZY2021-KY-004-01). Informed consents were obtained from the parents of the students participating in the study.
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Liu, L., Wang, X., Du, S. et al. Prevalence of adolescent idiopathic scoliosis in Shijiazhuang, Hebei, China: a cross-sectional study. Eur Spine J 33, 673–679 (2024). https://doi.org/10.1007/s00586-023-08030-7
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DOI: https://doi.org/10.1007/s00586-023-08030-7