What Factors Influence Delayed Referral to Spinal Surgeon in Adolescent Idiopathic Scoliosis?

Peter Kenner, MBBS, BSc (Phty); Stephen McGrath, MBBS, FRACS (Orth); Peter Woodland, FRACS, FAOrthA


Spine. 2019;44(22):1578-1584. 

In This Article

Abstract and Introduction


Study Design: Retrospective review with qualitative phone interview.

Objective: This study aims to identify the factors leading to delayed diagnosis or referral to a spinal surgeon in patients who subsequently require surgery for adolescent idiopathic scoliosis (AIS).

Summary of Background Data: AIS can be effectively treated with bracing to prevent curve progression in skeletally immature patients. Australia currently has in place a national self-detection screening program to diagnose AIS.

Methods: A retrospective review was performed for patients who underwent surgery for scoliosis at Princess Margaret Hospital for Children and Royal Perth Hospital between June 1, 2010 and May 27, 2014. Data were retrieved from the digital medical record and a semistructured phone interview was used to determine path to diagnosis and referral.

Results: Mean Cobb angle at first specialist review was 49.5° ± 14.0° for patients who subsequently required surgery for AIS. These patients experienced an average interval of 20.7 months from detection of symptoms to review in a specialist clinic.

Conclusion: In a condition in which early detection and intervention may halt progression of disease, AIS is detected relatively late and there are specific delays to diagnosis and referral to specialist clinics.

Level of Evidence: 4


Scoliosis is defined as a lateral curvature of the spine in the coronal plane of more than 10° (as measured by the Cobb angle). This lateral curvature is frequently accompanied by a rotatory component or exaggerated thoracic kyphosis.[1,2] In the younger population, 85% of cases of scoliosis are found to be idiopathic after excluding congenital, syndromic, or neuromuscular causes.[3–5] Idiopathic scoliosis has been classified by age into infantile (birth to 3 years), juvenile (4–9 years), and adolescent (10 years and older). Other authors have adopted the classification of early and late as defined by the age of 5. Adolescent idiopathic scoliosis (AIS) affects 2% to 4% of adolescents and is the most common spinal deformity seen by primary care physicians, pediatricians and spinal surgeons.[3,6–9]

The spinal asymmetry of AIS often presents with uneven shoulders, waist/pelvic asymmetry, or rib prominence. Back pain may also occur; however, this is usually mild and the vast majority patients are without pain.[10] AIS may also cause aesthetic or psychological morbidity. In rare cases with high degrees of curvature, cardiopulmonary compromise can occur.

The goal in treatment of AIS is to identify patients at risk of curve progression and offer treatment before complications occur. Western Australia introduced a school screening program for scoliosis in 1976; however, this program was abandoned in the early 1990s due to associated cost and lack of clinical data establishing the efficacy of treatment with bracing.[11] The school screening program was replaced by a national self-detection screening program, targeting girls aged 10 to 12. A fact sheet describing the outward signs of scoliosis is distributed through schools, and medical review is recommended if the child or parents are concerned scoliosis might be present.[12] Indications for referral for specialist management vary by region depending on resource availability and experience. Scoliosis Australia recommends primary care physicians perform 6-monthly observation through the growth phase (from early breast development at age 10–13 years) for curves less than 20°. Specialist referral is reserved for curves greater than 20°.[13]

A growing pool of research now exists demonstrating that treatment of AIS with bracing in skeletally immature patients reduces the risk of curve progression and requirement for surgery if patients are highly compliant with brace wear.[14–16] Of particular note is the landmark 2013 multicenter study by Weinstein et al,[17] which was terminated early due to the significant treatment benefit identified on interim analysis.

Canadian research has demonstrated a significant increase in delayed referrals for specialist management after the withdrawal of a school screening program.[18] The same pattern was seen in Norway, and an increased requirement for surgery was also demonstrated after cessation of screening in schools.[19] No Australian research exists to determine the typical path to AIS diagnosis or if delays in specialist referral are occurring in the absence of a school screening program. We hypothesize that a significant number of patients referred to the spinal clinic have delayed treatment due to delayed diagnosis or inappropriate observation and/or treatment by primary care physicians and other health professionals.