EPIDEMIOLOGICAL PATTERNS OF ADOLESCENT IDIOPATHIC SCOLIOSIS IN A SPINAL CENTER IN CURITIBA

ABSTRACT Objective: Evaluation of the profile of the population with adolescent idiopathic scoliosis (AIS) treated at a center specializing in spine surgery in Curitiba-PR. Methods: Prospective multicenter study, being analyzed, at the moment, only data from the center in question. All patients referred from the basic health service for evaluation of deformity underwent panoramic radiography of the total spine to evaluate the curvature using the Cobb method, evaluation of skeletal maturity using the Risser classification, and the classification of scoliosis using the Lenke classification. Clinical photographs of all patients and an assessment of the quality of life using the SRS-30 questionnaire were also taken. Results: Thirty patients with scoliosis and a mean age of 14.63 ± 3 years were evaluated. Prevalence of female:male 1.5:1. Patients had a mean Cobb of 45.96°, and most were close to Risser 4 skeletal maturity (48.3%). 60% had a thoracic curve (Lenke 1), and 13.3% had a double curve (Lenke 3 or 6). 63.3% of cases had a delay in medical care, taking an average of 18 months between referral and consultation with a specialist. 60% of patients were referred for surgical treatment after the first appointment. Conclusion: The population sample of this center follows the literature. A Cobb >40° in the first consultation with a specialist and a high referral rate to surgery suggest the failure of early diagnosis and the need for public policies for better knowledge and assistance for adolescent idiopathic scoliosis. Level of Evidence IV; Descriptive Epidemiological Study.


INTRODUCTION
7][8] Studies estimate that up to 3% of pubescent adolescents will develop some degree of curvature of the spine, with progression to magnitudes that impact the cardiopulmonary system if left untreated. 9,10[10][11][12] In Brazil, studies on the epidemiology of scoliosis are rare, and no population screening policy exists. 6,13,14Therefore, the goal of this study is to evaluate the profile of scoliosis patients seen at our referral center and the main barriers encountered in the treatment of scoliosis to in the future create and implement ways to facilitate access to treatment for these adolescents.

METHODS
This multicenter prospective study was conducted in 17 centers specialized in spine surgery in Brazil, authorized by the ethics committee (CAAE 35250220.2.3009.0020).Our center is located in Curitiba, Paraná, and we collected the data between July 2021 and January 2023.
All patients under 18 years of age with adolescent idiopathic scoliosis were included.Those who had already had surgical procedures on the spine and other causes of deformity such as Scheuermann's kyphosis, neuromuscular or congenital scoliosis, isthmic and dysplastic spondylolisthesis were excluded from the study.
All patients underwent panoramic radiography of the total posteroanterior (PA) and lateral spine for deformity measurement using the Cobb method 5 (Figure 1), evaluation of skeletal maturity by Risser's classification 15 , and scoliosis classification by Lenke. 5,16uality of life was analyzed using the Scoliosis Research Society -30 (SRS-30) questionnaire, 17 , and clinical photos were taken (Figure 2) to evaluate shoulder height and symmetry, splint triangle, and the Adams test, according to the Spinal Deformity Study Group manual. 5atients with a curve above 40° or documented curve progression were referred for surgical deformity correction.
The patients' guardians followed all the consultation steps and signed the consent forms.

RESULTS
This prospective multicenter study included 420 scoliosis sufferers in Brazil, and we are now presenting data from 30 patients from our specialized center in the city of Curitiba-PR.
The population of this study was made up mostly of girls (60%) post-menarche (88.9%), with a female:male prevalence of 1.5:1.The patients had a mean age of 14.63 ± 3 years.And 83% were white, 6.7% black, and 10% brown.
Ninety percent of the patients came to the specialized center by referral after primary care.Of these, approximately 56% received no treatment advice.Of the 30 patients, only seven (23.3%) had a previous orientation to wear a vest and had done so for at least six months.At the current visit, none of them was wearing an orthosis.A delay in assistance (consultation, treatment, or surgery) was found in 63.3% (19/30) of the patients, mainly due to the delay in entering the specialized center (84.2%); in our case, there was an average of 18 months waiting time between referral and consultation.
The search for assistance, in 80% of the cases, was due to the perception of the deformity by the parents, be it shoulder asymmetry, lateralization of the trunk, or gibbousness.In the SRS-30 questionnaire, 83.2% of the patients complained of constant but not limiting pain, and 10% had occasional pain.In addition, approximately half of the adolescents (51.2%) reported that the deformity bothered them to alter their social relationships with friends and family and affected their self-esteem.
After specialized consultation, 60% of the patients were referred to surgical treatment, with an average wait of 5 months, and none indicated using a brace.

DISCUSSION
9][20][21] Our study aimed to portray the population with adolescent idiopathic scoliosis seen at our specialized center.
In agreement with the published literature, [6][7][8]22 our population is composed predominantly (60%) of girls, in the age group between 11 and 17 years, with a mean age of 14 years.
Hurriyet et al. 18 , in their epidemiological study, found an incidence of AIS in Turkey of 2.3%, with a prevalence of female: male 2.1:1.Yaokreh et al. 23 showed a prevalence of 1.3F:1M, as well as Zhang et al. 22 in his meta-analysis of epidemiological studies from China found a 1.02% incidence of scoliosis in the school population with a sex prevalence of 1.5F:1M.data consistent with our population (1.5F:1M).
The search for care in our population was mainly (80%) due to the perception of the deformity by the parents.Most studies show that when there is no school screening, the diagnosis of scoliosis is made late, usually by the caregivers' perception or the complaint of pain. 9,12,24,25enner et al. 4 demonstrated that the lack of population screening in Australia generated a mean delay of 20.7 months between detecting the deformity and referral to a specialist, resulting in 78% of the adolescents with curves above 40° at the first clinical evaluation.Yaokreh et al. 23 found a 17.9-month delay for this first evaluation.Al-Arjani et al. 20 showed that most adolescents had curves above 40° at the initial consultation, and only 9% of the population diagnosed with scoliosis received any specific treatment before the specialist evaluation.These data are similar to the present study, which referred 60% of patients for surgical treatment at the first visit due to curvatures >45°.
Back pain, although not limiting daily activities, was one of the main complaints (83.2%) of the patients in this study.Although it is considered an asymptomatic pathology, recent studies have increasingly shown that the complaint of back pain is more frequent in scoliosis sufferers when compared to adolescents without scoliosis. 7,13,26,27Dantas et al. 13 found 63.7% of back pain in their study in Pernambuco.Teles et al. 27 demonstrated that 85.8% of patients have some degree of back pain and proved a statistical association between hypokyphosis and pain, concluding that pain in AIS is related to psychological factors and morphological factors of scoliosis.

Limitations
This study has some limitations, mainly the small number of participants that prevents the generalization of the data extracted here for Curitiba-PR.Another important factor is that the study occurred during the COVID-19 pandemic, directly influencing access to health care for non-emergency pathologies.

CONCLUSION
The prevalence and characteristics of AIS at the center evaluated are under the data in the literature.However, with most of the participants being referred for corrective surgery in the first evaluation, it suggests the failure of early diagnosis and the need to implement public policies to improve access to information and treatment of idiopathic scoliosis.

CONTRIBUTIONS OF THE AUTHORS:
Each author contributed individually and significantly to the development of this article.VEN: surgery and final paper approval; AAO: paper review and surgeries; GJBCR: data collection supervision and surgeries; PBMO: data collection, data analysis, and writing; BGT: data collection and paper review.

DefOrmitiesFigure 1 .
Figure 1.Measuring the curve by the Cobb method.

Figure 2 .
Figure 2. A -Clinical photo of the patient; B -Adams test.