The majority of patients detected with scoliosis in the absence of screening were skeletally mature and had curves that were not suitable for brace treatment. According to internationally accepted guidelines brace treatment is recommended in growing children with progressive curves >25°, who has at least one year growth potential . The mean chronological age at detection in the present study was 14 years, which is 2 years older than the ideal age [19, 55]. At the first presentation, 60% had Risser sign ≥3, and 78% of the girls were post menarche, indicating that most patients were detected late, and not suitable for brace treatment. A large proportion of patients also had curves ≥40° at first presentation which is beyond the international recommendation for initiation of brace treatment . The present results are in agreement with two previous studies that have assessed the impact of discontinuation of scoliosis program on detection, referral patterns and management. In a Canadian study, 32% of patients with AIS were referred too late with regard to brace treatment  and in a study conducted in London, United Kingdom, 56% of cases were detected when the primary curve was >40° and not suitable for brace treatment .
About 71% of cases were detected by non health care providers either by patients themselves, close family members or friends. It has been suggested that parents should be educated to perceive asymmetries of the back, shoulders, waistline, hips, and breast in their children as early signs of scoliosis and seek early and appropriate medical evaluation [42, 48]. In the present study, only 27% of cases were detected by healthcare providers. We found statistical differences in patient maturity, and treatment modalities between different originators of scoliosis detection. Close family members and friends detected patients with scoliosis at a younger age compared to scoliosis detected by the patients themselves. Since majority of curves were large at detection, we found no differences in the curve size according to the originator of detection.
Community health nurses and physical therapists detected patients with scoliosis that were suitable for brace treatment more than when the patients detect scoliosis themselves.
Two thirds of all patients were first observed by orthopedic surgeons at local hospitals on average 16 months before being referred and only 1/3 of patients were referred directly by primary physicians or physical therapists or community health nurses to the specialist clinic. Norway, with its public universal healthcare system, promotes referrals to specialized care and waiting times are generally at an acceptable level for a specialist’s evaluation of pediatric cases as shown in this study where the mean waiting time from referral to specialist evaluation was 4 months. A general guideline for primary physicians is to refer suspected cases of AIS to local orthopedic surgeons for diagnosis or refer directly to specialist evaluation of high risk patients for progression. Orthopedic surgeons at local clinics are authorized to diagnose and observe AIS patients for progression and to refer without unnecessary delay progressive curves >20° in immature patients to specialist clinics for evaluation. These orthopedic surgeons downstream the specialists’ clinics are however not authorized to prescribe brace treatment. There is either a late detection of AIS in the community in the absence of screening, or there is a delay in the referral practices of health care providers to specialist evaluation due to their non- awareness of existing guidelines, or failure of education on these guidelines. The result is that many patients with AIS in the present study were referred when mature, and with curves approaching the upper limit of brace treatment indications.
To ensure uniformity and quality of care for scoliosis patients, we suggest that persons involved in child health care like physical therapists community health nurses, chiropractors, sports instructors, primary physicians and orthopedic surgeons be better informed about guidelines for scoliosis detection. This includes the examination of asymmetries of the back in the routine examination of the child . Without objective screening test, proper training and clear guidelines for referrals, there is a risk of inappropriate referrals to the specialized care setting if one will suggest that community health nurses, physical therapists, chiropractors, sports instructors, refer patients directly to scoliosis specialist evaluation without first referring to local orthopedic surgeons. However, the magnitude of the eventual inappropriate referrals is not known. Local orthopedic surgeons still play important roles as gatekeepers while offering reassurances to the families and proper follow-up for mild cases. We emphasize therefore that in cases of confirmed scoliosis in immature patients, those involved in child health care should refer to specialized evaluation without unnecessary delay.
The majority of the patients were girls as reported before . The average angle of trunk rotation (ATR) is in agreement with a previous report . Family history of scoliosis is consistent with earlier studies [11, 12, 14–16]. Curve classification according to King-Moe compares well with the original publication reporting that type 2 curves were most common and type 5 were the least common . Neurological examination to eliminate underlying neurological pathology was normal in all patients except one patient who was subsequently referred for neurosurgical treatment before brace treatment commenced.
Scoliosis and back pain
Previous studies have reported slightly increased back pain in adolescents with idiopathic scoliosis compared to the normal population, but the pain is not usually disabling [58, 59]. These studies have not showed any association between back pain and curve size, gender, family history of scoliosis, or limb-length discrepancy, but significant association between back pain and mature age and skeletal maturity [58, 60]. A recent study showed an association between pain and maturity, overweight and larger proximal thoracic curves . In the present study most patients (59%) reported some, but not disabling back pain and only between 1-3% had back pain almost all the time. One previous study reported less postoperative pain in male patients with AIS . In the present study, we also found a significant association between back pain and girls compared with boys but no association between back pain, curve size, and BMI.
Comparison of treatment modalities during screening years versus non-screening years
The efficacy of scoliosis screening is under debate [40–44]. To justify screening, it should lead to early detection and initiation of brace treatment at the appropriate time to optimize its efficacy and reduce the option of surgery. Earlier studies suggest that screening may improve the outcome of bracing and either reduce the surgical rate or optimize timing for surgery [43, 45, 63, 64]. A recent case control study reported that screening does not reduce surgery in scoliosis patients . In the present study, we found that the average number of patients braced each year during the period of screening was significantly higher than in the period without screening. Authors clearly acknowledge the methodological weakness, when numbers of those operated were not retrieved from prospectively collected data, but from administrative count data (surgical protocols) over both periods. The Norwegian population has increased during the study years from an average of 4.1 million inhabitants during the screening years to 4.7 million during the non-screening periods, but the population segment of 10–19 year olds who represent the risk population in the study has remained relatively the same (634229 in 1976–1988 to 616715 during 2003–2011) . Within the relatively close periods in comparison, we assume that the prevalence, natural history, and the indications for idiopathic scoliosis treatment have not changed . The p-value in the chi-square statistics comparing the proportions of brace and surgical treatment was statistically significant. Our results therefore suggest that the absence of screening for scoliosis has resulted in less patients being treated with brace and more patients having surgery. However, technical advances in scoliosis surgery in recent years coupled with surgeon attitudes may also contribute to the observed change in treatment trends exhibited over the two periods. The Boston brace has remained the choice of brace type at our institution, but surgical treatment of scoliosis has evolved from the Harrington distraction rods to third generation instrumentation with segmental all pedicle screws construct in the course of the two periods. In addition, during the screening period bracing was administered by one spine surgeon, while different spine surgeons were involved in brace treatment during the period when there was no screening. The issue of non-uniform health care provision has the potential of introducing another bias in the comparison of treatment rates in the two periods.
Limitations of the study
Resident orthopaedic surgeons with variable experience in scoliosis management participated in the study. The inter-tester reliability was not tested. This variability in experience could influence evaluation of patient characteristics and the recommended treatment. The assessment of back pain applied has not been validated and recording by a surgeon may be less valid than self-assessment by patients. The estimation of surgical rates in the two treatment periods was based on surgical protocols and not on the registration chart at the outpatient clinic. There is an indication that, the number obtained from in the surgical protocol is a more valid estimate of the true number of actually operated than the recorded recommendations. It is also likely that some patients were not registered at the outpatient clinic. In view of the methodological weaknesses and other limitations which the authors clearly acknowledge in the manuscript, the results of the comparison of the rate of brace and surgery treatments during the two periods should be interpreted with caution.