28 The Asian Experience
Asia is the world’s largest and most populous continent, located in the eastern and northern hemispheres of the planet. It covers 30% of the planet’s land area and is home to approximately 4.3 billion people, or 60% of the world’s current human population. Because of its size and diversity, Asia is a “cultural concept,” incorporating diverse regions and heterogeneous peoples, cultures, and environments.
Asian economic growth in the past 30 years has been centered in the nations of the Pacific Rim, most of which have now achieved the status of developed countries; some have the highest numbers for gross domestic product per capita in Asia. East Asia also has the highest overall human development index (HDI), which has doubled over the past 40 years, whereas areas like Afghanistan are rated low. As such, there cannot be a uniform “Asian experience.” Certain geographic regions of Asia—for example, Japan, Hong Kong, Korea, Taiwan, Singapore, and major cities in India, Malaysia, Thailand, and the Philippines—have scoliosis treatment facilities comparable with those in Europe and North America.
Definition of early onset scoliosis. Early onset scoliosis is best described as a coronal spinal deformity larger than 10 degrees that starts to develop before the age of 10 years. One cannot exclude the combination of a coronal (scoliotic) deformity and a sagittal (kyphotic) component—kyphoscoliosis—because the two problems frequently occur together. The study of early onset scoliosis is still an expanding area in which new knowledge is added continuously, and presently, the level of evidence worldwide does not allow a standard “best protocol / guideline” of treatment to be implemented across the board. However, most Asian centers rely on their past clinical experience and results from other world centers as guides to treatment.
28.1 Prevalence and Magnitude of the Problem
No study has reported the exact prevalence of early onset scoliosis in Asia, and data can only be inferred from the available published literature on idiopathic scoliosis, which has been well studied. The prevalence of idiopathic scoliosis has been consistently estimated at about 2 to 3% in screened schoolchildren at the peripubertal age of 12 years. 1 In a study conducted in Singapore, the prevalence rates of idiopathic scoliosis among 9-, 10-, 11-, 12-, and 13-year-old female students were 0.27%, 0.64%, 1.58%, 2.22%, and 2.49%, respectively. 2 Another Singapore study demonstrated a prevalence of 0.12% in the 6- and 7-year-old school population. A Korean school screening program in 2000–2008 reported a prevalence of 3.26%, with the highest prevalence seen in the 10- to 12-year-old age group. A Taiwanese study group reported prevalence rates of 6.58% (curve of 5 degrees) and 2.4% (curve of 10 degrees). A large Hong Kong school screening study group demonstrated a 2.8% referral rate for radiography. This study also demonstrated school screening to be predictive and highly sensitive, with low referral rates for radiography, and remains a strong validation for school screening programs. Interestingly, a study in Patiala, India, of a school screening program reported an incidence of scoliosis of 0.13%, and the majority of cases (43.7%) were paralytic curves due to poliomyelitis. A study from Ahwaz, Iran, reported a prevalence of 42.9% in a screened school population of 12-year-olds in 2004.
28.2 Screening for Early Onset Scoliosis: Is It Possible? A Case for Asia
Screening for scoliosis is conducted solely to identify children who are at risk for curve progression and may require referral to a specialist center for treatment. 3 Although some public health authorities consider screening programs not to be cost-effective, there are some very effective programs in Asia. Examples of excellent screening programs for adolescent girls and boys are those in the city state of Singapore 4 and in Hong Kong. These school programs are well placed to detect affected children 10 years of age and older. The programs do not identify early onset scoliosis in those younger than 10 years of age who may already have progressive curves and the attendant pulmonary problems that ensue. Although it is well understood that the prevalence of idiopathic scoliosis is much lower in children younger than 10 years old, the failure to identify a developing curve (of any etiology) may prevent a child from receiving treatment with simple measures, such as bracing. A higher proportion of patients in this group have spinal deformities with congenital, syndromic, or infective causes, which may require early attention. The only way to capture children younger than 10 is to identify them during “grassroots” evaluations conducted by child health care programs when childhood vaccination and nutritional programs are being implemented, usually between the ages of 4 and 5 years. In most nationwide implemented child health programs, anthropometric data are routinely collected to assess nutrition and growth. The Village Health Promoter Programmes implemented in the Borneo States of Malaysia are an example. 5 The simple incorporation of a back examination, neurologic examination, or Adam forward bend test as part of each child’s health record is sufficient at least to identify those who are at risk and require referral to a treatment center.
28.3 Public Resource Allocation and Accessibility of the Referral System
The allocation of public resources is a major issue for nations already suffering from overburdened and limited resources. Scoliosis treatment and screening programs may even be considered a luxury in these nations because infectious and communicable diseases still cause high rates of morbidity and mortality in children younger than 5 years of age. 6 Poverty and conflict, although not major concerns in East Asia and South Asia, remain major concerns in West Asia. 7 Integrated “grassroots” public health programs (with the ability to identify children who need assessment) providing direct referral to regional scoliosis treatment centers are best suited to tackle this issue. Such programs are already working in most, if not all, regions in Asia. 5
28.4 Cultural Attitudes and Compliance
The “acceptability” of treatment can be an issue. It is a challenge to educate the parents and guardians of children who need treatment. Barriers must be overcome, such as views that Western / allopathic medicine is unacceptable and reliance on traditional or shaman treatment methods. Even now, there are parents who distrust the efficacy of modern treatment methods, such as bracing and surgery, and prefer to rely on alternative or complementary methods of massage, osteopathy, and manual manipulation.
Even in regions where excellent public health systems are integrated with regional scoliosis centers, there are children whose parents and guardians choose not to have them undergo treatment. In an audit of the public hospital scoliosis service in Kuala Lumpur, Malaysia, between 1985 and 2000, of the 89 patients who presented with a primary curve larger than 50 degrees and who were advised to have surgery, only 45% underwent surgery; 3.5% elected for brace treatment instead, and 51.5% decided against surgery or any treatment, preferring to be observed. 8 In the same study, of the 75 children who presented with a curve between 30 and 50 degrees, 73.4% declined brace treatment, whereas 17.3% complied with bracing. The rate of acceptance of bracing and surgery, when these are indicated, is less than 50%. 8 Interestingly, those families who were likely to agree to surgical treatment were from urban, middle class backgrounds. The availability of excellent treatment facilities does not mean that treatment will be accepted. Only public and parental education policy can remedy this attitude.
28.5 Population Differences
Are the physical data similar in different population groups? To answer this question, pedigree population groups should be compared. The populations of Malaysia and Singapore, which historically are diverse, comprising three major Asian ethnic groups (Han Chinese, South Indian, and Malay), present a unique opportunity to make such a comparison.
28.5.1 Menarche
Age at menarche is an important prognostic factor in idiopathic scoliosis. A later mean age at menarche is associated with a higher prevalence of idiopathic scoliosis. This finding is attributed to the longer period during which the spine can undergo rapid growth. 9 The mean age at menarche was 12.35 years in Malay, 12.43 years in Chinese, and 13.00 years in Indian patients who presented at the scoliosis service in Malaysia. 3 Although these differences were not significant, the prevalence of scoliosis was seen to be marginally higher in the Chinese populations of Malaysia and Singapore.
28.5.2 Progression of Untreated Curves
In the cohort of patients with untreated idiopathic scoliosis, the mean premenarchal progression rate was 5.66 degrees per year, and the mean postmenarchal progression rate was 2.94 degrees per year. No significant difference was found between the ethnic groups. 3 When the data were analyzed with respect to curve size at presentation, curves larger than 50 degrees progressed fastest in Chinese patients, at a rate of 14.7 degrees per year, and most slowly in Malay patients, at 8.4 degrees per year. Rates of progression for curves of 30 to 50 degrees at presentation were the same for all groups, as were the rates for curves of less than 30 degrees at presentation. 8 , 10
28.5.3 Ethnic Differences in Quality of Life in Adolescents
A very interesting study from Singapore has demonstrated significant differences in adolescent quality of life among Chinese, Malays, and Indians. These differences were independent of socioeconomic and health status, suggesting important cultural differences. Such cultural differences may be important in efforts to develop quality-of-life assessments for patients who have early onset scoliosis. 11
28.6 Etiology of Curves at Presentation to the Scoliosis Service
In Malaysia, idiopathic scoliosis was the most common type, accounting for 68.1% of all cases; neuromuscular scoliosis accounted for 10.4% of cases, and congenital scoliosis for 14.8%. In the remaining 6.7%, scoliosis was due to neurofibromatosis, Marfan syndrome, infection, and other miscellaneous causes. 8 Data from a Saudi scoliosis service reported that 59% of curves were idiopathic, 17% were congenital, and 7% were due to poliomyelitis. 12
28.6.1 Curves at Presentation
In the Malaysian study, irrespective of the diagnostic group, the curve size at presentation for treatment was consistently between 37 and 42 degrees. 8 This is probably the size at which curves become clinically apparent to family members. When age at presentation was considered, patients with idiopathic scoliosis were seen at a mean age of 16.3 years, those with neuromuscular scoliosis at a mean age of 13.3 years, and those with congenital scoliosis at a mean age of 9 years. 8 The Saudi study reported that although the curves were first detected at a mean age of 12.5 years, the patients presented to the scoliosis service at a mean age of 16 years. 12 In both study populations, most patients at presentation were past the optimal stage for successful treatment, despite the availability of excellent public health surveillance and scoliosis services.
28.7 Diagnostic Groups
28.7.1 Idiopathic Curves
Goal of Treatment
The goal of treatment in idiopathic early onset scoliosis is to achieve a spine with normal coronal and sagittal alignment at skeletal maturity. The earlier a curve begins, the more likely it is to progress, and the more likely it is that surgical treatment will be required. The chance that curves of more than 30 degrees during the premenarchal period will progress is 100%, with the need for surgery. Evaluation of the patient requires magnetic resonance imaging of the whole spine because the incidence of neuroaxial anomalies in idiopathic scoliosis has been reported to be between 5.9% and 16% in two Indian studies and 3.8% in a Japanese study. The other major factor that is deemed important is that the treatment must be acceptable culturally and socially, so that the utilization of treatment will be maximized.
Observation
Although observation as a method of surveillance / treatment is reserved for curves of less than 30 degrees that present in the postmenarchal period, observation is sometimes used for patients with larger curves who present before 10 years of age and do not want bracing or surgery. This is suboptimal, but at least intervention can be offered when necessary. The risk for the progression of juvenile curves of more than 30 degrees is 100%, 13 and surgery can be offered whenever the patient or parents opt for it.
Rib Hump
Observation is also used to monitor rib humps. The cause of rib humps is still not well understood. They are seen in patients with idiopathic, neuromuscular, and syndromic curves. It is not uncommon to see a significant rib hump in a patient with a “smallish” curve of 20 degrees (Fig. 28.1 , Fig. 28.2 , Fig. 28.3) and, conversely, to see a patient with a large curve and no or a minimal rib hump. Rib humps are integrally related to vertebral rotation and pulmonary function, although no large study has evaluated the exact relationship between rib humps and pulmonary outcome.
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