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Malaysian Orthopaedic Journal 2017 Vol 11 No 3 Komang-Agung IS, et al

doi: http://dx.doi.org/10.5704/MOJ.1711.011

Prevalence Rate of Adolescent Idiopathic Scoliosis:

Results of School-based Screening in Surabaya,
Indonesia

Komang-Agung IS, PhD, Dwi-Purnomo SB, MD, Susilowati A*, MD

Department of Orthopaedics, Airlangga University, Surabaya, Indonesia
*Department of Public Health & Community Medicine, Airlangga University, Surabaya, Indonesia

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited

Date of submission: 14th May 2017

Date of acceptance: 5th October 2017

ABSTRACT INTRODUCTION
Introduction: Scoliosis is a lateral spinal deformity of 10 Idiopathic scoliosis is commonly found in children of age 10
degrees or more, resulting in a C-shaped or S-shaped curve years or older, most of the time not realized or noticed until
of the spine. Information about adolescent idiopathic too late2,3,4. The deformity could break one’s self-esteem
scoliosis (AIS) prevalence rate is important not only for especially in the adolescent age. There is no clear etiology of
paediatric health care planning strategy but also for parent's idiopathic scoliosis. Among the many theories, there are
awareness. This study aims to find the suitable inclination genetic factors, connective tissue and skeletal muscle
cut-off angle and the prevalence rate of AIS in Surabaya, abnormality, and biomechanical factors that may play roles
Indonesia. in its development. The clinical manifestation of AIS could
Materials and Methods: This is a descriptive cross- range from asymptomatic or minor complaints to major
sectional study conducted in 2010. We performed stratified cardiopulmonary and neurological symptoms3.
random sampling of 784 Elementary and Junior High School
students in Surabaya between 9-16 years of age. Scoliosis Early detection of AIS and proper management are the keys
screening was performed by the Adam's forward bending test to satisfactory results. Screening on school-age children is an
(FBT). The students with positive FBT were measured for effective way to detect scoliosis earlier. Thus, interventions
the inclination angle with scoliometer, and then subjected to either non-surgical (bracing or restoring the possible life
radiologic examination. Prevalence rate, gender ratio, and style which interfere the abnormal biomechanical factors) or
the cut-off point value of inclination angle were determined surgical, can be conducted earlier to prevent scoliosis
by a descriptive statistics analysis. progression1,2,5,6.
Results: Adam's forward bending test was positive in 50
students (6,37%). Among them, 23 students (2,93%) four In Indonesia, scoliosis management is often delayed due to a
males and 19 females had Cobb angle of ≥10°. The 5° cut- lack of awareness among patients and parents. There are
off point value of inclination angle had a 95.6% sensitivity, many ways to conduct the scoliosis screening such as:
an 18.5% specificity, a 50% positive predictive value (PPV), Adam’s forward bending test, plumb line test, or
and a 83.33% negative predictive value (NPV); while the 7° measurement using the scoliometer. The scoliometer is used
cut-off point had a 78.26% sensitivity, a 88.88% specificity, to measure the magnitude of vertebral rotation to its axis6,7,8.
a 85.7% PPV, and a 82.7% NPV. Some countries, like the USA and Hong Kong, report that the
Conclusion: The prevalence rate of AIS in Surabaya is school-based screening program is costly and inefficient;
2.93% and the 7° cut-off point of inclination angle is suitable that the effort to detect one case when surgery was indicated
for school-based screening. would require 450 student to be screened and around 20%
(90 students) to undergo radiological examination9.
Key Words:
school-based scoliosis screening, children, prevalence rate The prevalence rate varies worldwide according to country
and ethnicity. It also depends on the cut-off scoliosis criteria
in the screening protocol, which is 0.5 % (20° Cobb angle) -
7 % (10° Cobb angle) 8. Every country should determine its
Corresponding Author: Komang Agung Irianto S, Department of Orthopaedics, Medical Faculty, Airlangga University, Surabaya,
Indonesia
Email: komang168@yahoo.com

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Malaysian Orthopaedic Journal 2017 Vol 11 No 3 Komang-Agung IS, et al

own prevalence rate, and especially so in a multiracial conducted when FBT was positive. Students were then
country like Indonesia. To achieve this objective, we were radiologically examined to measure the Cobb angle. The
required to devise a good screening protocol. The aims of student was diagnosed with scoliosis when the Cobb angle
this study were to determine the AIS prevalence rate in was 10° or more.
Surabaya, Indonesia, the gender ratio and the cut-off point
value of inclination angle which suited our All radiological examinations were conducted in Surabaya
sociodemographic for an effective screening protocol. Orthopedic & Traumatology Hospital due to availability and
accessibility. The data results were statistically analyzed
using SPSS version 17.0 for Windows to determine the
MATeRIAlS AND MeThODS prevalence rate, the gender ratio, and the cut-off point of
inclination angle. The validity (sensitivity and specificity) of
This is a descriptive, cross sectional and population-based
Adam’s forward bending test and the minimum inclination
study, in collaboration with the regional Ministry of Health
degree by scoliometer was calculated upon the confirmed
and Ministry of Culture and Education, approved by the
diagnosis from radiologic examination as the gold standard
local orthopaedic research and ethics committee. According
(Cobb angle of ≥ 10°).
to the 2010 National Population Census, the population aged
5 to 19 years old in Surabaya City was 649,81610. The study
population was made up of students from elementary and
ReSUlTS
junior high schools in Surabaya in July 2010. Consent was
obtained from the students and their parents prior to the The total number of participants who went through scoliosis
screening. screening was 784 students from elementary and junior high
schools. The gender distribution were 315 male students
The sample was acquired using stratified random sampling (40.2%) and 469 female students (59.8%) (Table I). The
according to the proportion of the total elementary and junior ethnic denomination of the sample students was 770 Melayu,
high school students throughout Surabaya City, based on the ten Chinese, one Melanesian (Maluku origin), and three
data provided by the local Education Authority of Surabaya Weddoid (Papua origin). The age distribution of the scoliosis
in 2010. Surabaya is divided into five regions of North, West, screening participants was between 9 to 16 years old, with an
East, South, and Central. From each region, two districts average of 12.61 years and a median of ten years (24.1%).
were picked randomly, then the sampling of elementary and Fifty Melayu students were found to have asymmetrical back
junior high schools were conducted randomly according to (hump detected, resulting in a positive Adam’s forward
the proportion of schools in the district. One out of ten bending test (6.4%). The positive test was found in 14 males
elementary schools, and one out of five junior high schools (1.8%) and 36 females (4.6%). The age distribution of
were selected. The authorities in the chosen elementary and positive FBT was mostly (11 cases each) consisting of
junior high schools were asked to allow their students, aged students aged 10 years old, 14 years old, and 15 years old.
9 years or older, to participate in the scoliosis screening. The inclination degree (5°-7°) measured with scoliometer
was found in 23 students, whereas 21 students were
The sample size for this study was determined using measured with a ≥ 7° of inclination. Despite the 44 students
descriptive study sample size calculation formulated as measuring ≥ 5°; all 50 FBT positive students were further
follows: subjected to radiological examination and two candidates
were found to have Cobb angle 10° and 12° (false negative).
((Zα)^2 x P x Q)
n= Radiological examination for Cobb angle with ≥10° were
d2
found in 23 students (prevalence rate 2.93%); four males,
Zα = 1,96 P = 0,019 4

and 19 females (Table II). The ratio of male to female

d = 1% Q = 1-P = 0,981
scoliosis cases was 1: 4.7. Fifteen students (1.91%) had
Cobb angle of 10°-20°; five students (0.64%) had Cobb
(CI: 95%; Zα=1,96 and a proportion of P=0,019).
angle of 20°- 40° and three students (0.38%) had Cobb angle
of >40° (severe scoliosis); one student with > 50° and two
The proportion value was determined according to the results
students with >110°. All severe scoliosis cases were females
of the scoliosis prevalence rate study conducted by Shands
and 14 years of age.
and Eisberg in Delaware11. The precision rate was d=1%, the
minimum sample for the screening was 716 students.
The sensitivity test for the cut-off inclination angle of 5° was
91.3% sensitivity, 18.5% specificity, 71.4% negative
The Adam’s forward bending test (FBT) was applied for the
predictive value and 48.8% positive predictive value. The 7°
scoliosis screening. The test was considered positive when
cut-off point had 78.3% sensitivity, 88.9% specificity, 82.7%
back asymmetry (presence of hump) was detected. Further
NPV and 85.7% PPV (Table III).
measurement of inclination degree using scoliometer was

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Adolescent Idiopathic Scoliosis

Table I: Demographic profile of students

Age Gender Screening test results (FBT) Cobb angle >10°

Male Female Negative Positive
n % n % n %

9 5 7 11 1.4 1 0.13 0 0
10 90 100 179 22.83 11 1.4 3 0.38
11 41 54 91 11.61 4 0.51 3 0.38
12 29 25 51 6.5 3 0.38 0 0
13 28 58 83 10.58 3 0.38 2 0.26
14 77 111 177 22.58 11 1.4 5 0.06
15 40 75 104 13.27 11 1.4 8 0.10
16 5 39 38 4.85 6 0.77 2 0.02
Total 315 469 734 93.62 50 6.37 23 2.93

Table II: Gender proportion of students with scoliosis

Scoliosis (+) Prevalence

n (%)

Gender Male 4 0,51

Female 19 2,42
Total 23 2,93
Cobb Angle 10° - 19° 15 1,91
20°- 40° 5 0,64
>40° 3 0,38
Total 23 2,93

Table III: Validity test for different inclination cut-off angle

Inclination Cobb Angle ≥10° Cobb Angle ≥10° Total

(Scoliosis +) (Scoliosis -)

≥ 5° 21 22 43
< 5° 2 5 7
Total 23 27 50
Sensitivity 91.3%
Specificity 18.5%
PPV 48.8%
NPV 71.4%

≥ 7° 18 3 21
< 7° 5 24 29
Total 23 27 50
Sensitivity 78.3%
Specificity 88.9%
PPV 85.7%
NPV 82.7%

DISCUSSION Surgeons has released a position statement that screening for

spinal deformity should be part of the medical home
In this study three out of 784 students were found to have
preventive services visit. The screening is considered
severe scoliosis, all female and in the age of 14 years. We
valuable in these domains: technical efficacy, clinical
could presume that if only this screening had been held three
program, and treatment effectiveness. It should be aimed at
years earlier, the disease might not have progressed to a more
identifying suspected cases of scoliosis to be considered as
severe condition which could only be treated by surgery.
positive cases and which would require to be referred for
Three cases out of 784 is quite significant and worthy of the
further evaluation14. A study in Guangdong, China,
screening effort compared to the Minnesota study (1 out of
suggested that it is important to screen schoolchildren in age
450 screened children)12. American Academy of Orthopaedic

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Malaysian Orthopaedic Journal 2017 Vol 11 No 3 Komang-Agung IS, et al

Fig. 1: Screening protocol of AIS in Surabaya, Indonesia. Fig. 2: Scoliosis screening age and sex distribution.

groups 12 to 13, 13 to 14, 14 to 15, and 15 to 16 years for a The meta-analysis study of the effectiveness of the screening
significantly high prevalence15. They believed that earlier program suggests that programs that used the FBT as the
identification will benefits the children and information only screening tool had a higher referral rate and a lower
should be extended to patients and parents, health care precision in detecting scoliotic curves18; hence, the
providers and policy makers. The value of school-based combination of FBT and scoliometer in the present study. We
scoliosis screening programs is well established despite therefore suggest making the combination of FBT and
some controversial issues, such as the relatively low scoliometer as a screening tool mandatory. The students
prevalence of significant curves in the general population, suspected to have scoliosis based on the screening would be
the lack of a definitive diagnostic screening test, as well as referred for further diagnostic evaluation to be ruled out or
the cost-effectiveness of the screening program. However, confirmed as having clinically significant scoliosis14.
the screening program are proven to be beneficial in the
study by Mukesh et al to identify children at risk for several In this study, the 5° cut-off point was sensitive though other
health problems related to scoliosis16. A study investigating indicator showed bad predictive value; confirmed by the bad
the clinical effectiveness of school screening program in correlation with the 10° Cobb angle (Table III). Only three
Malaysia showed a significant positive predictive value out of 22 positives > 5° that were confirmed to have Cobb
reflecting a significant amount of the percentage of students angle > 10°. While 18 out of 21 positives > 7° were
diagnosed with scoliosis amongst those positively screened confirmed for the >10° Cobb angle. Many centers used 5° or
using scoliometer. This meant that it was adequate to suggest 7° cut-off point considering many aspects, including using
that the screening program did play a role in early detection both cut-off; 7° for normal BMI and 5° for overweight
of scoliosis17. A cohort study conducted in Hong Kong also children9,17. The missed opportunity to be treated might
supported the program and recommended its own cohort further lead to disbelief in the screening test. The
study to continue9. unnecessary cost for further test and radiography exposure
also need to be considered. We decided to use 7° cut-off
The ideal test tool is one that has a high sensitivity and point for the inclination value based on these findings.
specificity, but the predictive factor is more susceptible for a
screening test since a false negative result will give worse The present study revealed a scoliosis prevalence of 2.93%
impact for the population. The person who had a false in school-age children between 9-16 years old in Surabaya,
negative result would lose the opportunity to be treated. which is high compared to other Asian country study (1.09%
False positive would invite stressful further examination. in Nepal; 2.22% in Singapore), and also when compared
Scoliometer was chosen as it is currently the best tool for with the Minnesota study in 1977 of 1.1%12. Adolescence
scoliosis screening14. As stated by the American Academy of Idiopathic Scoliosis (AIS) is common with an overall
Orthopaedic Surgeons (AAOS), the forward bend Adam’s prevalence of 0.47-5.2519. The AIS ratio of male to female in
test with the use of a scoliometer should be used for the this study was 1: 4.7. In the study in Chiba, Japan, the male
screening13, the same method as was used in this study. to female ratio was 1: 3.77. Based on these findings and what
the SRS International Task Force on Scoliosis Screening

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Adolescent Idiopathic Scoliosis

recommends, male students should be screened once at age CONClUSION

13 or 14, whereas females should be screened twice at age 10
The prevalence rate of adolescent idiopathic scoliosis in
or 1214.
school-age children between 9-16 years old in Surabaya,
Indonesia, is 2.93%, with male to female ratio of 1: 4,7. The
The authors noted some limitations of this study. The inter-
study also found that the inclination degree of 7° or greater
observer bias was possible when conducting the FBT and
is more acceptable compared to inclination degree of 5°.
measuring the inclination degree with scoliometer. The
sample size in this study was not large enough and did not
represent the wide variety of races in Indonesia; although all
CONFlICT OF INTeReST
results were comparable with studies in other countries. The
authors recommend regular screening of AIS not only in There was no conflict of interest in this study.
Surabaya but other parts of Indonesia to obtain national
figures. The data collected from a large population based
screening could be used to perform longitudinal study in
which bias could be minimized.

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