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Adolescent idiopathic scoliosis and back pain

Abstract

This broad narrative review addresses the relationship between adolescent idiopathic scoliosis (AIS) and back pain. AIS can be responsible for low back pain, particularly major cases. However, a linear relationship between back pain and the magnitude of the deformity cannot be expected for any individual patient. A large number of juvenile patients can remain pain-free. The long-term prognosis is rather benign for many cases and thus a tailored approach to the individual patient seems mandatory. The level of evidence available does not allow stringent recommendations for any of the disorders included in this review.

Background

Scoliosis is a frequent pathology in adolescents. Young patients and their families frequently blame (minor) deformities, considered to be the cause of back pain. In our opinion, the relationship between the two is not so clear based on scientific evidence. For this reason, we here review this topic in depth.

A high prevalence of low back pain (LBP) among children and adolescents has been identified in the last few decades. A recent systematic review and meta-analysis [1] has reported a figure of 39.9 % (95 % CI ranging from 34.2 to 45.9 %) for lifetime prevalence. In terms of aetiologies, a retrospective study of almost 2000 patients less than 21 years-old referred for a spine evaluation reported that when a pathology is identified, the most frequent diagnosis was scoliosis (1439/1953), followed by Scheuermann’s kyphosis (163/1953) and spondylolisthesis (154/1953) [2]. Other series of cases have also shown similar findings [3, 4]. However, the role of spinal deformities in LBP in the general population is not clear. For this reason, we here review the recent literature on the associations between pain and the most common adolescent spinal deformity, which is adolescent idiopathic scoliosis.

Trying to establish a causal relationship between deformities and back pain is not an easy task. Since Sir Austin Bradford Hill [5] published his important paper in 1965, the difficulties and limitations in drawing conclusions on the causal relationship between two variables have been the focus of several publications [69].

Our aim is to review the literature to evaluate the association in adolescents between back pain and idiopathic scoliosis, reported in studies done in different settings and/or with different perspectives.

Methodology

This paper is the product of the collaboration between 2 clinicians: an orthopaedic surgeon highly focused on deformities (FP) and a rheumatologist with a special interest in juvenile spinal disorders (FB). We have tried to find clinically relevant information that might answer some of the questions the practitioners have. Therefore this article does not aim to be a systematic review as we have not applied strict methodology as recommended, for example, by the Cochrane collaboration, for such reviews. We began with a bibliography search limited to MEDLINE and expanded this body of literature with a search of the publications cited in the selected articles. The search was done using several key words for back pain (backache OR back pain OR low back pain OR lumbar pain OR vertebral pain OR spinal pain) as well as for the age category of interest (adolescent OR teenager OR juvenile OR paediatric OR infant OR children). We then limited the search to meta-analyses and expanded it to include “systematic reviews”, and “cohort or longitudinal studies”, if the information gathered was too limited with the most stringent criteria. Our focus was on back pain and consequently the articles not including data on symptoms were excluded except for the Epidemiology section.

Adolescent idiopathic scoliosis (AIS) and back pain

According to the glossary of the Scoliosis Research Society (SRS) (http://www.srs.org/professionals/online-education-and-resources/glossary/revised-glossary-of-terms), idiopathic scoliosis can be defined radiographically as a lateral curvature of the spine greater than or equal to 10° Cobb with rotation, of unknown aetiology.

The possible relationship between scoliosis and back pain can be approached from different angles. Some examples may be:

  1. a)

    comparing the epidemiological data of the two diagnostic entities;

  2. b)

    examining the prevalence of back pain in adolescents with scoliosis or the prevalence of scoliosis among back pain sufferers;

  3. c)

    examining the prevalence of back pain over time in scoliosis left untreated; or

  4. d)

    examining the impact of treatment of the deformity on back pain.

Epidemiology

Prevalence of scoliosis

Adolescent idiopathic scoliosis is considered a quite common disorder, with a pooled referral rate for radiography of 5.0 %, according to a meta-analysis of 36 studies looking at the effectiveness of school scoliosis screening [10]. According to the definition used, the overall prevalence of AIS has been reported to range between 0.47 and 5.2 % in a recent review [11]. There are cases of scoliosis secondary to other pathologies, but those idiopathic (i.e. AIS) are by far the most frequent. In the series published by Rogala et al. [12], all but 9 of 1231 cases of structural scoliosis were idiopathic. We have limited this section of the review to adolescents or young adults with AIS.

There are other studies that have prospectively evaluated the epidemiology of scoliosis and its natural history in large samples of adolescents, but the most frequently referenced do not include any information on symptoms [1115]. Even the recent meta-analysis previously mentioned did not report data on back pain [10].

Scoliosis can be associated with other deviations from the normal spinal morphology. For example, in the series reported by Deacon et al. [16], 35 out of 50 adolescents were diagnosed with both Scheuermann’s disease and scoliotic curves. Overall, 43 curves were identified in these patients, which were divided in 2 types: 13 were apical at the same level as the kyphosis, and 30 occurred in regions of compensatory lordosis. Finally, in the small series reported by Blumenthal et al. [17], 4 out of 13 cases of lumbar Scheuermann’s also had scoliosis but none required treatment.

Pain associated with scoliosis

Regarding associated symptoms, a German study evaluated the data of more than 640,000 youths included in an insurance database. ICD diagnosis codes M40-43 would be relevant for the purpose of our review (M40: kyphosis and lordosis; M41: scoliosis; M42: spinal osteochondrosis; and M43: other deforming dorsopathies). For scoliosis, data from 2002 showed the following means in % (girls/boys) for prevalence at 0–14 years of age and at 15–24 years: M41: 2.31 (2.51/2.12) and 3.44 (3.80/3.07) [18]. Ramirez et al. [19] reported on more than 2400 subjects with AIS. Of these, 23 % reported back pain at the time of diagnosis. An additional 9 %, initially free of pain and managed with observation alone, developed pain during follow-up. A study from Japan including more than 30,000 adolescents concluded that the subgroup with scoliosis had an approximately 3 to 5 fold increased point and lifetime prevalence of backache in the upper and middle right part of the back [20]. In a prospective multicentre study, Lonner et al. [21] compared three groups of adolescents including 894 with AIS and 31 healthy controls. The pain scores on the specific subdomain of the SRS-22 questionnaire were 4.15 in the scoliosis group and 4.24 among the controls, which is not a significant difference.

A retrospective chart review of a random sample of 310 individuals (10–17 years) selected from all cases of AIS referred to a Canadian university hospital has been published recently [22]. The authors concluded that the prevalence of back pain was “moderately high” but the reported data on pain do not seem very homogeneous (gathered by the attending physicians, or reported by medical references, or by letters from the parents, narrative or through a pain score, with or without a specific topography of pain recorded, etc.). Of note, severe pain was documented in only 1 % of the charts [22].

A prospective multicentre study including 744 patients (621 females) surgically treated for AIS addressed the differences between genders in functional outcome. Before surgery, males were aged an average of 15.2 years and females 14.0 years (p < 0.001) with no significant differences in maximum Cobb angles (F: 53.3° and M: 55.9°) or Risser grades (F: 3.2 and M: 3.5) [23]. At baseline, the scores on the pain domain of the SRS-30 were 4.1 among girls and 4.3 in boys, below the statistical significance threshold [23].

A recent meta-analysis has been published comparing selective versus non-selective thoracic fusion in Lenke 1C curves [24]. Preoperative data on pain using the SRS-22 has shown slightly different scores between the two groups that is 4.13 (0.77) in the selective fusion group versus 3.92 (0.79) in those undergoing non-selective procedures. The difference is statistically significant (p = 0.038), but is at the limit of the minimum clinically important difference (MCID), reported to be 0.20 [21, 25, 26]. As any other tool, the questionnaires used to gather information on patients with scoliosis have some limitations. An American study evaluated SRS-22 performance in 450 healthy adolescents (mean age: 16 years; range: 9.3 to 21.8 years). Concerning specifically pain, the mean score was 4.3 ± 0.6 with males scoring a bit higher (actual figures by gender not reported but r = 0.103, p < 0.05) [27]. Moreover, ethnicity was also a significant factor with African Americans scoring significantly higher at 4.5 (i.e. less pain) than Hispanics (4.3). Other socio-demographic variables were significantly associated with different domains of the questionnaire [27].

Other studies have also shown that culture and ethnicity have an influence on outcomes with Caucasians reporting more pain than East Asians on the SRS-30 [28, 29]. Finally, in a Polish study, the living environment has also been reported to influence the results of the SRS-24 questionnaire, with rural patients reporting more pain than those from an urban environment [30].

The Pediatric Outcomes Data Collection Instrument (PODCI), a multidimensional tool developed in North America (also known as POSNA for Pediatric Orthopedic Society of North America) [31], was used to evaluate 102 patients with AIS (as well as other groups of patients with different pathologies) [32]. Scores of these patients were compared to those of a small group of 27 “healthy” adolescents evaluated in a different study [33]. Of these 102 patients, 95 (86 girls) filled in the patient questionnaire. The scores of the two groups for the comfort/pain scale were 86.7 ± 14.5 for the healthy group versus 75.2 ± 22.4 for the AIS group. Each dimension is scaled from 0 to 100, with 100 the most favourable outcome. The result is statistically significant at p < 0.05; however, the differences between the two groups do not seem clinically relevant when compared with the properties of the same tool described elsewhere [34].

Considering another perspective on the association between symptoms and scoliosis, a study carried out on 1743 men in the military (range: 18–30 years) found a prevalence of idiopathic scoliosis of 6.65 % among those with no symptoms and free of any lytic or olisthetic lesions [35]. Of note, none had a Cobb angle >20°. Prevalence ranged from 13.3 to 23.8 % in the symptomatic and asymptomatic subgroups with uni- or bilateral pars break and 18.3 % among those without any lesion of the posterior arch but reporting back pain.

Clark et al. [36] have just published the results of a prospective, population-based, birth cohort study with complete data on 3184 participants. Subjects were evaluated at age 15 for scoliosis using total-body dual-energy X-ray absorptiometry (DXA) and surveyed at age 18 for pain and function. A multivariable analysis shows a significant association between small spinal curves (≥6°) at age 15 and self-reported back pain at age 18. Spinal curvature is also associated with days off school and avoidance of activities.

It appears quite clear from comparing the prevalence of back pain and scoliosis that the latter cannot be the main explanation for LBP for a majority of adolescents reporting such symptoms, although scoliosis playing a role in some patients cannot be ruled out. However, comparing the results of different studies does not allow any firm conclusions to be drawn on the possible causal relationship between different variables. Nevertheless, the compelling and overwhelming predominance of girls in the adolescent cohorts with idiopathic scoliosis (up to almost 90 % in some series, such as that published by Théroux et al. [22]) casts doubt on the aetiological role of scoliosis on back pain in the general population, at least among boys. Another piece of information that suggests a limited role of scoliosis in back pain is the weak or even absent correlation between the magnitude of the curves measured by the Cobb angle and the presence of pain [22, 28, 37, 38].

The main references quoted in this section are summarized in Table 1.

Table 1 Summary of the main publications including data on pain presented in the order of citation in the manuscript

Effect of treatments on back pain

In this section, the effects of different treatments on the magnitude of scoliotic curves have not been included. Such an analysis, as well as the impact of treatment in cosmetic, psychological or other issues, would be beyond the scope of this review. Further, long-term follow-up studies in middle-age adults have also not been included, as the role of degenerative changes cannot be identified.

Conservative management

Numerous conservative techniques have been used to treat AIS, such as acupuncture, braces, electrical stimulation, exercises, foot orthosis, osteopathy, and yoga. The most recent systematic review on braces for AIS reported long-term stability in terms of back pain (very low quality evidence) in addition to a similar outcome for quality of life and psychological and cosmetic issues [39]. The authors highlighted that performing a meta-analysis was not possible due to differences among the studies.

In a systematic review by Maruyama et al. [40], bracing was compared to observation, other conservative treatments, and surgery. Considering the effect on QoL, the evidence was considered “conflicting” for each of the 3 comparisons. As such, the authors prudently concluded only that braces “may not have a negative impact on patients’ QOL”.

The authors of the most recent Cochrane review comparing surgical and conservative management of adolescent idiopathic scoliosis did not find any papers that would allow drawing conclusions regarding back pain [41]. Several other recent review articles have not specifically included information on back pain [4246].

Osteopathic manipulative treatments in children were reviewed by Posadzki et al. [45]. Only one study of the included references concerned the treatment of scoliosis. There is currently no evidence to support such an approach for the treatment of AIS.

In his recent review paper, Kim [47] found no evidence available for yoga, Pilates, foot orthosis or acupuncture. On the contrary, he found level I and II evidence for bracing and level II evidence in favour of scoliosis specific exercises (despite some concerns such as the difficulty of attributing all the benefit to exercises due to frequent associated bracing, the order of magnitude of the correction and some doubts concerning the level of evidence of the studies) and against electrical stimulation. Indeed, only one well-designed study published in 1995 is specifically quoted in Kim’s review. In their prospective controlled trial Nachemson et al. [48] compared 3 groups: 1 braced, 1 treated by electrical stimulation, 1 observed. The success rates were 74 % in braced, 33 % in electrical stimulation and 34 % in observed. Thus the conclusion was that electrical stimulation is comparable to natural history. Kim [47] highlights the fact that the concept of correcting scoliosis by stimulating to muscles has almost disappeared but animal studies are being done to evaluate the possibilities to influence asymmetric vertebral growth by means of electrical stimulation. Only one study cited by this review addressed the impact on pain, but this study assessed exclusively non-structural scoliosis with a mean Cobb angle < 8° [49].

A recent systematic review on the effects of exercise in patients with AIS concluded that exercises improve quality of life [50]. The data on pain is clearly reported in only two of the nine studies included in the review, of which both used the SR-22. In the RCT by Monticone et al. [51], at baseline, the scores in the pain dimension were 3.8 (0.4) in the exercise group and 3.9 (0.5) among the controls. At 1-year follow-up, the same values were 4.7 (0.2) and 4.2 (0.4), respectively. In the retrospective study by Noh et al. [52] (method of randomisation not clearly mentioned if any), the same scores were 4.5 (2.4) in the corrective spinal technique (combining the Schroth concepts and core stabilization techniques) and 3.8 (1.6) in the control group (conventional exercise) at the beginning of the trial and 4.9 (1) and 4.6 (2.4), respectively, at 3 months. Notably, both groups began with 16 patients each, but at follow-up, data were reported for only 8 subjects in the experimental group and 4 patients in the control group.

A recent trial compared an 8-week program of weekly-supervised spinal stabilisation exercises to unsupervised exercises [53]. Pain, evaluated by numerical rating scale, scored 5.4 on average in each group. After 8 weeks, the improvement was 3.9 (1.8) in the supervised group versus 2.2 (2.0) in the unsupervised group. The study has clear limitations, such as the small numbers and the dropout rate in the unsupervised group, as highlighted by the authors.

The beneficial effects of bracing in terms of pain are influenced by compliance with the SOSORT Brace Treatment Management Guidelines (SBTMG) [54].

Surgical treatment

A recent review of the literature with statistical analysis included 16 cohorts with data on pain. Of these, 81 % reported a statistically significant postoperative (2 years) improvement in pain, however, in only one study were the improvements clinically important [55]. Similarly, another systematic review concluded in favour of surgery to reduce the magnitude of spinal curves but stated that evidence supporting the correlation of this result with reduced pain is lacking [56].

A multicentre, prospective, consecutive clinical series reported on the prevalence and predictors of pain in AIS treated surgically [57]. Preoperative data from 1433 patients (80.4 % girls; mean curve: 56.7°) and changes in pain based on a subset of 295 cases with complete data and 2 years follow-up were reported. Pain was evaluated using the SRS-22 questionnaire. Preoperatively, 77.9 % of patients reported some back pain, mainly mild to severe. The prevalence of mild to severe pain in the past 6 months improved with surgery from 78.3 % of the subset (N = 295) preoperatively, to 68.8 % at 1 year and to 64.4 % at 2 years. Indeed, at follow-up, 40 % of the 295 patients reported a decrease in pain, 38.6 % no change and another 20.3 % reported an increase in pain. Of note, while reported pain decreased with treatment, analgesic use remained unchanged. Reduction in pain and absolute pain at 2 years were both correlated with patients’ perception of deformity, evaluated by means of the SAQ (Spinal Appearance Questionnaire). Such an association might be interpreted as decreasing the likelihood of a major biomechanical role of the deformity to explain pain.

The previously cited multicentre study that included 744 cases treated surgically reported outcomes at 2-years follow-up [23]. The SRS-30 pain scores improved to 4.3 in females and 4.5 among males, which was a significant difference (p = 0.003). Of note, although in absolute values the differences between genders were the same pre- and post-operatively (i.e. 0.2), the pre-operative difference was not statistically significantly [23].

Akazawa et al. [58] reported the results of a survey on health-related quality of life and LBP in a group of 80 patients with AIS (mean age at follow-up: 47.4 ± 6.8 years) and a matched control group (mean age: 46.7 ± 6.3 years). There was no statistical difference in terms of pain (4.3 ± 0.6 in the idiopathic scoliosis group versus 4.2 ± 0.5 in the controls on the SRS-22 pain score) and a small difference of 1 point on the Roland & Morris questionnaire (2.4 ± 4.1 in the scoliosis group versus 1.4 ± 3.1 in the control group), which is below the MCID [59].

A prospective registry based study (N = 584 patients) recently reported on the prevalence of postoperative pain and its relationship with preoperative pain [60]. Patients reporting postoperative pain had significantly worse preoperative pain scores (SRS-22) with a mean of 3.8 ± 0.8 versus 4.2 ± 0.7, which is both statistically (p < 0.001) and clinically significant.

Another multi-centred registry study of AIS patients treated surgically (n = 190 with 2-year follow-up and n = 77 with 5 years follow-up) reported on pain prevalence and trajectories after spinal fusion. Patients were evaluated by means of the SRS-30. Moderate to severe pain in the past month was reported by 35 % of patients preoperatively. The same figure was 11 % at 1-year follow-up and 15 % at 2- and 5-year follow-up. Curiously, medication usage did not change significantly: daily opioid use was reported by 1 % across all time points and weekly or less frequent use of non-opioid medication also remained stable (23 % preoperatively, 25 % at 2-year follow-up and 25 % at 5-year follow-up) [61].

A longitudinal cohort of 745 patients with AIS treated surgically was followed for 2 years and the results of the pre- and postoperative SRS-22 compared [62]. The pre- and postoperative pain scores were 4.16 ± 0.71 and 4.31 ± 0.72, respectively. The difference is statistically significant (P < 0.0001) but below the MCID. At 2 years, the correlation of the reported pain with the satisfaction score was 0.260, slightly lower than for appearance (0.280) and for the total SRS-22 score (0.398) but higher than for activity (0.172) or mental (0.202) scores.

We have identified two further studies comparing the effects of bracing and surgery for the treatment of AIS. A short-term study using the SRS-22 questionnaire evaluated the outcome at age 16.3 ± 1.6 years of 109 Dutch adolescents with AIS treated either by brace, surgery, or brace followed by surgery [63]. The group treated by brace only reported significantly less pain at follow-up than the two groups that received surgery (4.5 vs 4.1). Moreover, there was no interaction between pain and the time passed since the end of treatment (i.e. interval at which the questionnaire was completed) for any of the groups [63]. A Danish group had reported on the outcome at 10 years of 181 patients with AIS treated either by brace or surgery [64]. Pain was assessed by means of 6 questions using VAS. The intensity of back and leg pain was mild, with values of 2.5 (0–10 scale) for the most severe back pain within the last 2 weeks for the braced patients and 2.1 in those operated. The scores of the SF-36 were compared with a Danish control cohort. The bodily pain scores were 74.6 (95 % CI.: 68.7–80.5) in the braced subjects, and 71.4 (66.1–76.8) in the surgical cohort, which is not a significant difference. However, both values were significantly below the scores for the reference population (79.8 (77.6–82.0)) [64]. The authors of the Ste-Justine cohort did not find any major difference in self-reported pain based on preoperative characteristics, the degree of surgical correction or the distal level of fusion [65].

A recent study has shown that both the SRS-22 and SRS-24 questionnaires are able to discriminate between AIS patients with preoperative curves >80° and those <45°. Specifically concerning pain, evaluated by the SRS-22 tool, the scores were 4.2 ± 0.7 for small curves versus 3.8 ± 0.9 for large (p = 0.003). The corresponding values obtained with the SRS-24 were 3.8 ± 0.6 and 3.5 ± 0.7 (p = 0.002). Postoperatively, the same questionnaires did not show any significant difference in pain according to neither the percent correction (<40 % Vs ≥80 %) nor when stratifying into post-operative curves <11° or ≥29° [66].

A relationship between scoliosis and pain might be mediated by variables other than the curve itself. It has been shown that compared with asymptomatic volunteers, baseline data on lumbar stiffness evaluated by means of Lumbar Stiffness Disability Index (LSDI) correlates with pain (Pearson correlation “r” LSDI versus SRS-22 Pain: −0–749) and functional limitations (LSDI vs SRS-22 Function: −0.760) in patients with spinal deformity [67].

Untreated scoliosis

The literature comparing untreated AIS with normal controls was recently reviewed and statistically analysed [68]. Twenty-one cohort studies were included that used different questionnaires (SRS-24/23/22/22r/30). Of these, 81 % reported statistically worse pain than unaffected adolescents; however, in only 5 % of cohorts was the difference clinically important. In comparison, in patients’ self-image, almost three-quarters of the studies with a statistically significant difference were also clinically significant.

A few studies on the conservative management of adolescents with idiopathic scoliosis have included control groups not braced. In the series reported by Pham et al. [69], a subgroup of 32 patients (30 girls, age 12.5 ± 1.4 years) with Cobb’s angles 26.5° ± 2.4° was left non braced until the next follow-up visit at least 3 months later and compared with patients wearing a specific brace (Chênau brace) full-time or during the night (weaning period). No differences in terms of pain were found.

Another study compared 78 patients with AIS being braced with 136 patients being observed. The two groups were very similar except for the magnitude of the curves (24.6° for the observed subjects and 34.5° for those being braced, p < 0.0001). The authors used the parents’ forms for the Child Health Questionnaire (CHQ) and the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). National normative values were available for the CHQ but not for the second instrument. No significant differences between the two groups of patients (observed vs braced) were reported for any of the pain dimensions of the two questionnaires. Moreover, when compared with the scores of healthy children, those with AIS showed similar scores on the bodily pain domain of the CHQ [70].

The main references quoted in this section are summarized in Table 2.

Table 2 Summary of the main publications including data on the effect on pain of different treatments presented in the order of citation in the manuscript

Conclusions

Back pain in adolescents is quite common, especially in girls. There is no doubt that some AIS patients are back pain sufferers; however, pain does not seem to be a major problem for the vast majority of adolescents with an idiopathic form of this type of deformity. Some elements from the literature suggest that the link between pain and scoliosis is not strongly linked with a biomechanical problem. In most studies, pain has not shown a strong correlation with the Cobb angle, untreated cases fare reasonably well from the perspective of back pain, there is a much greater difference between genders in the incidence of scoliosis compared with the epidemiological data on back pain, and patients’ self-perception of their image correlates with pain. All these findings argue against a major aetiological role of the idiopathic scoliotic deformity of adolescents on back pain. However, the impact of pain in adults’ scoliosis is entirely different [71, 72] and out of the scope of this review.

Abbreviations

AIS:

Adolescent idiopathic scoliosis

BP:

Back pain

CHQ:

Child health questionnaire

ICD:

International classification of diseases

LBP:

Low back pain

LSDI:

Lumbar Stiffness Disability Index

MCID:

Minimal clinically important difference

PODCI:

Pediatric Outcomes Data Collection Instrument

POSNA:

Pediatric Orthopedic Society of North America

QOL:

Quality of Life

SAQ:

Spinal Appearance Questionnaire

SRS:

Scoliosis Research Society

VAS:

Visual analogue scale

References

  1. 1.

    Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013;13:14.

  2. 2.

    Dimar 2nd JR, Glassman SD, Carreon LY. Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging. Spine J. 2007;7:332–7.

  3. 3.

    Combs JA, Caskey PM. Back pain in children and adolescents: a retrospective review of 648 patients. South Med J. 1997;90:789–92.

  4. 4.

    Gennari JM, Themar-Noel C, Panuel M, Bensamoun B, Deslandre C, Linglart A, et al. Adolescent spinal pain: the pediatric orthopedist’s point of view. Orthop Traumatol Surg Res. 2015;101(6 Suppl):S247–50.

  5. 5.

    Hill AB. The environment and disease: association or causation? Proc R Soc Med. 1965;58:295–300.

  6. 6.

    Evans DW, Lucas N, Kerry R. Time, space and form: necessary for causation in health, disease and intervention? Med Health Care Philos. 2016;19:207–13.

  7. 7.

    Phillips CV, Goodman KJ. The missed lessons of Sir Austin Bradford Hill. Epidemiol Perspect Innov. 2004;1:3.

  8. 8.

    Phillips CV, Goodman KJ. Causal criteria and counterfactuals; nothing more (or less) than scientific common sense. Emerg Themes Epidemiol. 2006;3:5.

  9. 9.

    Schunemann H, Hill S, Guyatt G, Akl EA, Ahmed F. The GRADE approach and Bradford Hill’s criteria for causation. J Epidemiol Community Health. 2011;65:392–5.

  10. 10.

    Fong DY, Lee CF, Cheung KM, Cheng JC, Ng BK, Lam TP, et al. A meta-analysis of the clinical effectiveness of school scoliosis screening. Spine (Phila Pa 1976). 2010;35:1061–71.

  11. 11.

    Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. J Child Orthop. 2013;7:3–9.

  12. 12.

    Rogala EJ, Drummond DS, Scoliosis GJ. incidence and natural history. A prospective epidemiological study. J Bone Joint Surg Am. 1978;60:173–6.

  13. 13.

    Luk KD, Lee CF, Cheung KM, Cheng JC, Ng BK, Lam TP, et al. Clinical effectiveness of school screening for adolescent idiopathic scoliosis: a large population-based retrospective cohort study. Spine (Phila Pa 1976). 2010;35:1607–14.

  14. 14.

    Montgomery F, Willner S. The natural history of idiopathic scoliosis. A study of the incidence of treatment. Spine (Phila Pa 1976). 1988;13:401–4.

  15. 15.

    Weinstein SL. Idiopathic scoliosis. Natural history. Spine (Phila Pa 1976). 1986;11:780–3.

  16. 16.

    Deacon P, Berkin CR, Dickson RA. Combined idiopathic kyphosis and scoliosis. An analysis of the lateral spinal curvatures associated with Scheuermann’s disease. J Bone Joint Surg (Br). 1985;67:189–92.

  17. 17.

    Blumenthal SL, Roach J, Herring JA. Lumbar Scheuermann’s. A clinical series and classification. Spine (Phila Pa 1976). 1987;12:929–32.

  18. 18.

    Ochsmann EB, Escobar Pinzon CL, Letzel S, Kraus T, Michaelis M, Muenster E. Prevalence of diagnosis and direct treatment costs of back disorders in 644,773 children and youths in Germany. BMC Musculoskelet Disord. 2010;11:193.

  19. 19.

    Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:364–8.

  20. 20.

    Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, et al. Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City. Japan Eur Spine J. 2011;20:274–9.

  21. 21.

    Lonner B, Yoo A, Terran JS, Sponseller P, Samdani A, Betz R, et al. Effect of spinal deformity on adolescent quality of life: comparison of operative scheuermann kyphosis, adolescent idiopathic scoliosis, and normal controls. Spine (Phila Pa 1976). 2013;38:1049–55.

  22. 22.

    Theroux J, Le May S, Fortin C, Labelle H. Prevalence and management of back pain in adolescent idiopathic scoliosis patients: a retrospective study. Pain Res Manag. 2015;20:153–7.

  23. 23.

    Roberts DW, Savage JW, Schwartz DG, Carreon LY, Sucato DJ, Sanders JO, et al. Male-female differences in Scoliosis Research Society-30 scores in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36:E53–9.

  24. 24.

    Boniello AJ, Hasan S, Yang S, Jalai CM, Worley N, Passias PG. Selective versus nonselective thoracic fusion in Lenke 1C curves: a meta-analysis of baseline characteristics and postoperative outcomes. J Neurosurg Spine. 2015;23:721–30.

  25. 25.

    Bago J, Perez-Grueso FJ, Les E, Hernandez P, Pellise F. Minimal important differences of the SRS-22 Patient Questionnaire following surgical treatment of idiopathic scoliosis. Eur Spine J. 2009;18:1898–904.

  26. 26.

    Carreon LY, Sanders JO, Diab M, Sucato DJ, Sturm PF, Glassman SD. The minimum clinically important difference in Scoliosis Research Society-22 appearance, activity, and pain domains after surgical correction of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2010;35:2079–83.

  27. 27.

    Verma K, Lonner B, Hoashi JS, Lafage V, Dean L, Engel I, et al. Demographic factors affect Scoliosis Research Society-22 performance in healthy adolescents: a comparative baseline for adolescents with idiopathic scoliosis. Spine (Phila Pa 1976). 2010;35:2134–9.

  28. 28.

    Morse LJ, Kawakami N, Lenke LG, Sucato DJ, Sanders JO, Diab M. Culture and ethnicity influence outcomes of the Scoliosis Research Society Instrument in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2012;37:1072–6.

  29. 29.

    Watanabe K, Lenke LG, Bridwell KH, Hasegawa K, Hirano T, Endo N, et al. Cross-cultural comparison of the Scoliosis Research Society outcomes instrument between American and Japanese idiopathic scoliosis patients: are there differences? Spine (Phila Pa 1976). 2007;32:2711–4.

  30. 30.

    Misterska E, Glowacki M, Panek S, Ignys-O’Byrne A, Glowacki J, Ignys I, et al. Effects of living environment on the postoperative Scoliosis Research Society-24 results in females with adolescent idiopathic scoliosis. Med Sci Monit. 2012;18:CR523–31.

  31. 31.

    Christakou A, Laiou A. Comparing the psychometric properties of the pediatric outcomes data collection instrument and the activities scales for kids: a review. J Child Health Care. 2014;18:207–14.

  32. 32.

    Lerman JA, Sullivan E, Haynes RJ. The Pediatric Outcomes Data Collection Instrument (PODCI) and functional assessment in patients with adolescent or juvenile idiopathic scoliosis and congenital scoliosis or kyphosis. Spine (Phila Pa 1976). 2002;27:2052–7. discussion 7–8.

  33. 33.

    Haynes RJ, Sullivan E. The Pediatric Orthopaedic Society of North America pediatric orthopaedic functional health questionnaire: an analysis of normals. J Pediatr Orthop. 2001;21:619–21.

  34. 34.

    Daltroy LH, Liang MH, Fossel AH, Goldberg MJ. The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America. J Pediatr Orthop. 1998;18:561–71.

  35. 35.

    Libson E, Bloom RA, Shapiro Y. Scoliosis in young men with spondylolysis or spondylolisthesis. A comparative study in symptomatic and asymptomatic subjects. Spine (Phila Pa 1976). 1984;9:445–7.

  36. 36.

    Clark EM, Tobias JH, Fairbank J. The impact of small spinal curves in adolescents who have not presented to secondary care: a population-based cohort study. Spine (Phila Pa 1976). 2016;41:E611–7.

  37. 37.

    Pellegrino LN, Avanzi O. Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery. J Spinal Disord Tech. 2014;27(8):409–14.

  38. 38.

    Weiss HR, Goodall D. The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence. A systematic review. Eur J Phys Rehabil Med. 2008;44(2):177–93.

  39. 39.

    Negrini S, Minozzi S, Bettany-Saltikov J, Chockalingam N, Grivas TB, Kotwicki T, et al. Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev. 2015;6:CD006850.

  40. 40.

    Maruyama T, Grivas TB, Kaspiris A. Effectiveness and outcomes of brace treatment: a systematic review. Physiother Theory Pract. 2011;27:26–42.

  41. 41.

    Bettany-Saltikov J, Weiss HR, Chockalingam N, Taranu R, Srinivas S, Hogg J, et al. Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis. Cochrane Database Syst Rev. 2015;4:CD010663.

  42. 42.

    Mordecai SC, Dabke HV. Efficacy of exercise therapy for the treatment of adolescent idiopathic scoliosis: a review of the literature. Eur Spine J. 2012;21:382–9.

  43. 43.

    Negrini S, De Mauroy JC, Grivas TB, Knott P, Kotwicki T, Maruyama T, et al. Actual evidence in the medical approach to adolescents with idiopathic scoliosis. Eur J Phys Rehabil Med. 2014;50:87–92.

  44. 44.

    Noshchenko A, Hoffecker L, Lindley EM, Burger EL, Cain CM, Patel VV, et al. Predictors of spine deformity progression in adolescent idiopathic scoliosis: A systematic review with meta-analysis. World J Orthop. 2015;6:537–58.

  45. 45.

    Posadzki P, Lee MS, Ernst E. Osteopathic manipulative treatment for pediatric conditions: a systematic review. Pediatrics. 2013;132:140–52.

  46. 46.

    Romano M, Minozzi S, Zaina F, Saltikov JB, Chockalingam N, Kotwicki T, et al. Exercises for adolescent idiopathic scoliosis: a Cochrane systematic review. Spine (Phila Pa 1976). 2013;38:E883–93.

  47. 47.

    Kim HS. Evidence-based of nonoperative treatment in adolescent idiopathic scoliosis. Asian Spine J. 2014;8:695–702.

  48. 48.

    Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77:815–22.

  49. 49.

    Alves de Araujo ME, Bezerra da Silva E, Bragade Mello D, Cader SA, Shiguemi Inoue Salgado A, Dantas EH. The effectiveness of the Pilates method: reducing the degree of non-structural scoliosis, and improving flexibility and pain in female college students. J Bodyw Mov Ther. 2012;16:191–8.

  50. 50.

    Anwer S, Alghadir A, Abu Shaphe M, Anwar D. Effects of exercise on spinal deformities and quality of life in patients with adolescent idiopathic scoliosis. Biomed Res Int. 2015;2015:123848.

  51. 51.

    Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Ferrante S. Active self-correction and task-oriented exercises reduce spinal deformity and improve quality of life in subjects with mild adolescent idiopathic scoliosis. Results of a randomised controlled trial. Eur Spine J. 2014;23:1204–14.

  52. 52.

    Noh DK, You JS, Koh JH, Kim H, Kim D, Ko SM, et al. Effects of novel corrective spinal technique on adolescent idiopathic scoliosis as assessed by radiographic imaging. J Back Musculoskelet Rehabil. 2014;27:331–8.

  53. 53.

    Zapata KA, Wang-Price SS, Sucato DJ, Thompson M, Trudelle-Jackson E, Lovelace-Chandler V. Spinal stabilization exercise effectiveness for low back pain in adolescent idiopathic scoliosis: a randomized trial. Pediatr Phys Ther. 2015;27:396–402.

  54. 54.

    Tavernaro M, Pellegrini A, Tessadri F, Zaina F, Zonta A, Negrini S. Team care to cure adolescents with braces (avoiding low quality of life, pain and bad compliance): a case-control retrospective study. 2011 SOSORT Award winner. Scoliosis. 2012;7:17.

  55. 55.

    Rushton PR, Grevitt MP. What is the effect of surgery on the quality of life of the adolescent with adolescent idiopathic scoliosis? A review and statistical analysis of the literature. Spine (Phila Pa 1976). 2013;38:786–94.

  56. 56.

    Hawes MC, O’Brien JP. A century of spine surgery: what can patients expect? Disabil Rehabil. 2008;30:808–17.

  57. 57.

    Landman Z, Oswald T, Sanders J, Diab M. Prevalence and predictors of pain in surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36:825–9.

  58. 58.

    Akazawa T, Minami S, Kotani T, Nemoto T, Koshi T, Takahashi K. Health-related quality of life and low back pain of patients surgically treated for scoliosis after 21 years or more of follow-up: comparison among nonidiopathic scoliosis, idiopathic scoliosis, and healthy subjects. Spine (Phila Pa 1976). 2012;37:1899–903.

  59. 59.

    Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J. 2010;19:1484–94.

  60. 60.

    Bastrom TP, Marks MC, Yaszay B, Newton PO. Prevalence of postoperative pain in adolescent idiopathic scoliosis and the association with preoperative pain. Spine (Phila Pa 1976). 2013;38:1848–52.

  61. 61.

    Sieberg CB, Simons LE, Edelstein MR, DeAngelis MR, Pielech M, Sethna N, et al. Pain prevalence and trajectories following pediatric spinal fusion surgery. J Pain. 2013;14:1694–702.

  62. 62.

    Carreon LY, Sanders JO, Diab M, Sturm PF, Sucato DJ. Patient satisfaction after surgical correction of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36:965–8.

  63. 63.

    Bunge EM, Juttmann RE, de Kleuver M, van Biezen FC, de Koning HJ. Health-related quality of life in patients with adolescent idiopathic scoliosis after treatment: short-term effects after brace or surgical treatment. Eur Spine J. 2007;16:83–9.

  64. 64.

    Andersen MO, Christensen SB, Thomsen K. Outcome at 10 years after treatment for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2006;31:350–4.

  65. 65.

    Poitras B, Mayo NE, Goldberg MS, Scott S, Hanley J. The Ste-Justine adolescent idiopathic scoliosis cohort study. Part IV: surgical correction and back pain. Spine (Phila Pa 1976). 1994;19:1582–8.

  66. 66.

    Bastrom TP, Bartley C, Marks MC, Yaszay B, Newton PO. Post-operative perfection: ceiling effects and lack of discrimination with both SRS-22 and 24 outcomes instruments in adolescent idiopathic scoliosis patients. Spine (Phila Pa 1976). 2015;40:E1323–9.

  67. 67.

    Daniels AH, Smith JS, Hiratzka J, Ames CP, Bess S, Shaffrey CI, et al. Functional limitations due to lumbar stiffness in adults with and without spinal deformity. Spine (Phila Pa 1976). 2015;40:1599–604.

  68. 68.

    Rushton PR, Grevitt MP. Comparison of untreated adolescent idiopathic scoliosis with normal controls: a review and statistical analysis of the literature. Spine (Phila Pa 1976). 2013;38:778–85.

  69. 69.

    Pham VM, Houlliez A, Carpentier A, Herbaux B, Schill A, Thevenon A. Determination of the influence of the Cheneau brace on quality of life for adolescent with idiopathic scoliosis. Ann Readapt Med Phys. 2008;51:3–8. 9–15.

  70. 70.

    Ugwonali OF, Lomas G, Choe JC, Hyman JE, Lee FY, Vitale MG, et al. Effect of bracing on the quality of life of adolescents with idiopathic scoliosis. Spine J. 2004;4:254–60.

  71. 71.

    Bess S, Line B, Fu KM, McCarthy I, Lafage V, Schwab F, et al. The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases. Spine (Phila Pa 1976). 2016;41:224–33.

  72. 72.

    Pellise F, Vila-Casademunt A, Ferrer M, Domingo-Sabat M, Bago J, Perez-Grueso FJ, et al. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24:3–11.

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Acknowledgements

The authors thank Ms Patricia Gongal (UK) for the linguistic support.

Authors’ contributions

FB and FB decided together on the structure of the manuscript and the literature search strategies. FB produced a first draft of the review and tables that were critically read and double-checked by FP. Both authors read and approved the final manuscript.

Competing interests

The authors have no financial competing interests and the manuscript has not received any economic support. Moreover, the authors declare that they have no other competing interests (non-financial) in relation to this manuscript.

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Correspondence to Federico Balagué or Ferran Pellisé.

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Balagué, F., Pellisé, F. Adolescent idiopathic scoliosis and back pain. Scoliosis 11, 27 (2016). https://doi.org/10.1186/s13013-016-0086-7

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Keywords

  • Adolescent idiopathic scoliosis
  • Back pain
  • Conservative management
  • Surgical treatment
  • Natural history