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Scoliosis screening: the ISICO study on artificial intelligence in the running for the SOSORT Award

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Developing a new tool for scoliosis screening in a tertiary specialist setting using artificial intelligence: a retrospective study on 10,813 patients is one of the ISICO studies due to be presented at the next SOSORT conference, which will take place in Melbourne, Australia. The fact that the study is also a candidate for the SOSORT Award consolidates the standing of ISICO, which in recent years has not only participated with its research but also been awarded this prestigious prize on several occasions. 

In recent years, we have seen an increasing body of evidence supporting the efficacy of conservative treatment (e.g., exercises, soft and rigid braces) for adolescent idiopathic scoliosis (AIS), because treating a skeletally immature spine conservatively is certainly more effective and gives better results. The use of the conservative approach, however, has to be based on accurate and sensitive early screening for the condition, which often involves the use of X-rays.

What can be done to continue screening patients while at the same time making less use of X-rays? “Although technological improvements have, in recent years, made it possible to reduce the radiation dose in radiographic examinations, it is not possible to completely eliminate the long-term risk of cancer due to the stochastic effect of even low doses of radiation,” explains Dr Francesco Negrini, ISICO physiatrist and author of the research. “This is why we set out to analyse whether adding other rapid and reliable clinical parameters to the angle of trunk rotation (ATR°) might improve scoliosis screening in terms of sensitivity and specificity, making it possible to limit the use of X-rays to cases in which it is indispensable.”

How was the research conducted? The researchers looked at 10,813 patients between the ages of 4 and 18 who underwent clinical and radiological evaluation for scoliosis at a tertiary clinic specialising in spinal deformities. After excluding patients who wore a brace, had secondary scoliosis, or had no hump, 7,378 cases remained and were included in the analysis. In these cases, the following information was collected: ATR°, hump (mm), visible asymmetry of the waist, scapulae and shoulders, family history, sex, BMI, age, menarche (yes/no), and location of the curve. “At this point, we applied advanced analysis methods involving the use of artificial intelligence to try and create a model that would allow us to accurately select the cases needing to be X-rayed,” Dr Negrini goes on, “and we identified ATR°, hump (mm) and visible waist asymmetry as the clinical parameters best able to accurately classify Cobb angle measurements.”

On the basis of this conclusion, the researchers were able to affirm that classification models obtained through artificial intelligence may effectively improve non-invasive screening for AIS, thereby making it possible to reduce the X-ray exposure of healthy young individuals. “On the basis of the positive results obtained in the study, we may, in the near future, be able to develop a very flexible and user-friendly tool” says Dr Negrini. “This would allow doctors working in this specialised field to decide to prescribe radiographic imaging only when it is strictly necessary.”

https://en.isico.it/isico/ricerca/pdf/ID00665.pdf

Scoliosis: why prevention matters

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About spinal disorders like scoliosis, it is often said that prevention is just as important as treatment.

Before we go any further, let’s clarify a few things, starting with the definitions of screening and scoliosis. Screening is an activity involving rapid tests, examinations or other procedures, and its purpose is to detect the possible presence of a disease or defect that the patient didn’t know they had.

Scoliosis, on the other hand, is a three-dimensional spine deformity.There are different forms, depending on the age at which it was first diagnosed: infantile (diagnosed between 0 and 3 years), juvenile (between 3 years of age and puberty), adolescent (between puberty and the completion of bone growth), and adult-onset. Scoliosis affects 3% of the population, prevalently females; 80% of cases are diagnosed in adolescence.

Two aspects in particular make scoliosis an insidious disease: first, it causes no symptoms of any kind during childhood and adolescence, which makes it difficult to identify young people who are at increased risk of developing spinal deformities; second, in most cases, it is idiopathic, which means we don’t know what causes it. 

Therefore, early diagnosis of scoliosis, i.e., at an age when there is a considerable risk of the condition progressing, allows the patient to receive adequate, less invasive and more effective treatment. This, as far as possible, will prevent it from worsening to the point of causing, in adulthood, pain, progressive deformity and sometimes cardiorespiratory problems that will negatively impact their quality of life.  

Screening: when and by whom?

Scoliosis screening’s importance is widely recognised, also by the scientific community (ref. Screening for adolescent idiopathic scoliosis: an information statement by the Scoliosis Research Society international task force). 

Scoliosis screening should target all girls in their last year of primary school/first year of secondary school and all boys in their second year of secondary education. This is the age at which they reach puberty and are therefore most at risk of progression of scoliosis, if affected by the disease. 

Youngsters should be screened by a spine expert who, through specific tests, can identify those at risk of a spinal deformity.

Screening results are given to the patient directly so that they can decide how to proceed with their doctor. In this way, if necessary, a diagnostic-therapeutic pathway can be planned.

What does Screening involve?

The first thing to do when evaluating whether or not a youngster may have scoliosis is to observe their bare back. The presence of more or less obvious asymmetries at trunk level, such as a difference in the height of the shoulders, or the hips, or a difference between the two shoulder blades, is the first sign of a possible case of scoliosis.

Then, the Adams test is performed, which is crucial: standing with their knees straight, the patient has to bend their trunk forwards, keeping their head down and letting their arms hang limply. This position has the effect of emphasising any hump due to scoliosis. If a hump is observed, it will be measured at the point where the height difference between the two sides of the patient’s back is greatest.

This measurement is taken using the Bunnell method, using a scoliometer to determine the angle of trunk rotation. If this angle measures 5° +/- 2° or more, it is advisable to have a specialist consultation. 

A patient with an angle of 3° or more should be checked every six months if they are approaching or have entered puberty, otherwise at yearly intervals. If a patient’s measurement is below this threshold (between 0 and 2°), but they have one hip or one shoulder higher than the other, or a protruding shoulder blade, then they need to be seen after six months and referred to a specialist if the asymmetries persist; otherwise, they can be referred back to their general practitioner/paediatrician.

How to screen a child online

Visit https://screening.isico.it to carry out a rapid screening for scoliosis or a curved spine, free of charge.
After watching the brief explanatory video, follow the steps and carry out the assessment. This will involve taking a few measurements. Depending on the data you provide us, we can tell you whether it would be a good idea to consult a spine specialist or whether there is currently no reason for concern.

Message in a bottle: an Isico research

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Isico’s study, “Torsion bottle, a very simple, reliable, and cheap tool for a basic scoliosis screening“, published by Scoliosis and Spinal Disorders, demonstrates how and why scoliosis can be identified using a bottle of water. 

“One of the reasons that make scoliosis a disease that scares so much the parents, is its specific characteristic of being difficult to detect on its onset – explains Michele Romano, director of physiotherapists in Isico – A scoliometer is a professional medical instrument used by specialists such as doctors and physiotherapists to detect the pathology. In the absence of this instrument, is there a simple test for scoliosis that we can do in our own homes? Yes, the Torsion Bottle. Our paper aimed to check the possible usefulness of a simple tool (the Torsion Bottle) developed to offer an instrument for home-use by parents but also for screening purposes in low-income countries”.

The study was divided into two parts. The main purpose was to compare the measurements collected with the torsion bottle and the same measurements collected with the scoliometer in a population of patients accessing our clinic for the rehabilitation treatment following Isico standard evaluation protocols.

The secondary aim was to verify the reliability of blinded inter-operator assessments, performed with the torsion bottle on the same patients by two physiotherapists. These double-blinded measurements were taken periodically for a short-time-interval in our clinic to verify measurement accuracy in the everyday clinical activities.

The conclusion? The torsion bottle is useful to perform a pre-investigation of the presence of a prominence, permitting a simplified assessment of its value, thus referring to a specialist for a medical assessment.

We remind you that you can perform a quick and simple assessment/check for scoliosis or curved back on the website screening.isico.it,where you are simply asked to take some measurements with easily procurable tools like a ruler and others again to be detected with the help of a simple bottle of water, the Torsion Bottle. 

My kid is always slouching: bad posture or a medical problem?

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In today’s digital age, the incredible exponential curves of technological growth and innovation are increasingly reflected in curves of another kind, namely those affecting our spines, as we assume various odd and unnatural positions when using our electronic devices.  

Parents are the first to notice their youngsters’ tendency to adopt these awkward and unattractive positions. The most frequent is the hunched back position, where the upper spine, shoulders and head are bent forward in relation to the rest of the body.
Consequently, we now see countless humps like that of Quasimodo, the famous “Hunchback of Notre Dame”.

The tendency to slouch or adopt slumped postures is prevalent among the young. Youngsters (and adults too) often assume incorrect postures simply because it is easier and requires less effort.
As a result, they allow the force of gravity to take its toll on their backs without trying to counteract it. 
Some situations, however, require careful assessment, as incorrect postures can sometimes indicate a spinal disorder.

Initially, it is up to parents to check their children’s backs, and if they have any doubts at all, they should seek the opinion of expert medical spine specialists.

How do you tell the difference between incorrect posture and a spinal disorder?

If you have the youngster stand in front of you with his/her back exposed and look at him/her sideways on, you should immediately notice the classic shape of the back, created by two natural and opposing curves; starting from the base of the spine and moving upwards, you will see the first, lower curve.
Known as lumbar lordosis, this is a physiological curve in which the lumbar spine appears more anteriorly positioned and concave. Immediately above it, you will see that the dorsal spine instead shows a posterior convex curve.

In normal conditions, these two curves are harmonious and not too pronounced. However, if, on observing the youngster, you notice that one curve is more pronounced or protruding or that both are marked, then this could be a sign of a spinal disorder. In such cases, screening by a qualified professional or a consultation with a specialist spine doctor is strongly recommended.

In the same way, you might notice that the youngster’s back appears flat, with the physiological curves barely visible or not visible at all. This profile, too, can indicate the presence of a spinal disorder.

The spinal disorder most commonly associated with the rounded back or hunchback posture is hyperkyphosis, i.e. excessive curvature of the thoracic spine, evident on clinical examination as posterior protrusion of a section of the thoracic spine, often with the protruding vertebrae clearly visible under the skin.  

But how can a parent distinguish between incorrect posture and hyperkyphosis, a fairly frequent condition among youngsters?
Incorrect posture is always easily remedied simply by reminding the youngster to stand up straight: indeed, in this case, this action is enough to straighten his/her back completely.
In the presence of a spinal disorder, on the other hand, he/she will show more or less marked stiffness: even when he/she tries to stand up straight, part of the spine will remain curved due to the disease having stiffened his/her back.

Long kyphosis is another frequent vertebral alteration. In this case, the thoracic convexity extends down as far as the lumbar vertebrae, invading the space normally occupied by the upper part of the lumbar lordotic curve: the back, therefore, presents with a long convexity that reaches down to the base of the back.

Dorsal hyperkyphosis and long kyphosis are sometimes caused by Scheuermann disease, which is characterised by a wedge-shaped deformity of the vertebral bodies with anterior thinning of the vertebrae.
This makes it difficult and sometimes impossible for affected youngsters to hold their back straight: as a result, they become curled up like hedgehogs, and unfortunately, their growth exacerbates the vertebral deformity.

Conclusion

Like scoliosis, spinal deformities in the sagittal plane must be diagnosed early to allow timely and effective treatment. Families have the important task of trying to spot spinal disorders instead of simple cases of poor posture. Whenever they are in any doubt, they should always contact a specialist spine doctor for a proper diagnosis and necessary treatment. 

Now screening comes online!

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Isico launches online screening. Just connect to the dedicated screening website and you can perform a quick and simple assessment and check whether, with respect to pathologies such as scoliosis or curved back, it is appropriate to carry out a specialist medical visit that investigates further.
The idea, which has been in the works for some time, has had a further stimulus thanks to the departure of Telemedicine during the Covid-19 emergency period. We know how essential an early screening is to set up adequate rehabilitation therapy in case of vertebral deformities.
At Isico, screening has always been done, free of charge for the siblings of our patients. Now the novelty is given by an additional online tool that everyone can access as well in several languages; in addition to Italian and English, the German version is now available as well. 
How does the site work?
After viewing a short explanatory video of Michele Romano, head of physiotherapy in Isico, the evaluation begins either for scoliosis or for the curved back. 
The process is always guided by an introductory video given by Michele Romano. He explains how to make a part of these evaluations through observation only, others where you are asked to take measurements with a ruler and others again to be detected with the help of a simple bottle of water, the Torsion Bottle. 
On the basis of the data entered, it will be possible to know if it is appropriate to contact the evaluation of an expert in vertebral pathology or if there is nothing at the moment to worry about.


The next steps?
Translating the site into other languages ​​so that more people can use it easily. In this regard, we will be pleased to accept those who want to collaborate with us for the translation into other languages, in case you contact the email: isico@isico.it