The Canadian Scoliosis Screening Coalition
www.ScoliosisCanada.ca contact us by email: CSSC@scoliosiscanada.ca
Links to Articles and Published studies on the Conseqences of Not Screening for Adolescent Idiopathic Scoliosis (AIS), Delays to Surgery and Disparities in AIS Care pathway:
Added April 29, 2025. Revised: Sept 18, Dec 21, 2025, Jan 3, 12, Mar 24, 2026Curated list. These publications are directed at Public Health and Health Ministers. They are from countries, including Canada, that do not have Scoliosis Screening programs or previously had them and had recently stopped.
The publications reflect public health care neglect and undertreatment of vulnerable children and stress the need for screening for early-detection of Adolescent Idiopathic Scoliosis (AIS), shorter wait times for surgery and policy reform. One of the consequences of Not Screening for
Scoliosis (resulting in "late-referrals" and what is referred to as "late-presentation"3,4,6,7 patients) and delaying paediatric spine surgery for children with progressive spinal deformity (with dangerous long wait-times and lists) is increased interventions and the extremely invasive procedure
As well, Socioeconomic disparities, lack of health resources and infrastructure, exist as barriers in care pathways to preventative conservative non-operative care for children with AIS, with bracing not fully government funded in every province and territory, a Canada-wide lack of access to physiotherapists trained in scoliosis-specific methods and Certified Orthotists 1 with access to AIS care focused in large urban cities, all compounded by Canada's crisis of a family physician shortage.
There has been a lot of focus and attention in public health on the mental health crisis facing Canadian youth today due to concerted advocacy. Another consequence from not screening for AIS is potential harm to the mental health of youths with Scoliosis.
Allowing Scoliosis spinal curves to progress undetected to SEVERE degrees of deformity in Canadian youth due to the lack of
screening programs, public healthcare neglect, causes potential significant risk of harm to the mental health of these adolescents with
- Lebel A, Kline M, Boucher J, Carberry J, Adulovic N, Dermott JA.
Bracing and non-surgical management of scoliosis in Canada: Early detection, access inequities, and the need for interdisciplinary reform. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 9. https://doi.org/10.33137/cpoj.v8i2.46590
"Abstract: Bracing remains the cornerstone of non-surgical management for adolescent idiopathic scoliosis (AIS) with an aim to minimize the risk of progression and to avoid spine surgery. In Canada however, one third to half of patients present with curve magnitudes too severe for optimal brace treatment, resulting in higher than necessary surgical volumes.
High-cost spine surgeries are fully funded while non-surgical management is not. This Professional Opinion article highlights systemic barriers to early detection that limit opportunity for non-surgical management in Canada and ultimately drive up healthcare spending. In Canada, there is anurgent need for a coordinated national strategy to re-establish routine scoliosis screening, ensure equitable public funding for treatment and expand professional training in non-surgical spinal care ...." - Baez C, Ihnow S. Structural Drivers of Race and Sex Disparities in Adolescent Idiopathic Scoliosis Care: A Narrative Review. Curr Rev Musculoskelet Med. 2026 Mar 14;19(1):23. doi: 10.1007/s12178-026-10023-0. PMID: 41831094; PMCID: PMC12988917. "Abstract...Purpose Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity of adolescence and disproportionately affects females, with outcomes strongly dependent on curve magnitude and timing of detection. Increasing evidence demonstrates that structural and systemic factors influence multiple stages of the AIS care continuum and may be the primary drivers of disparities in care amongst this population.This narrative review synthesizes contemporary evidence on sex- and race-based inequities in AIS, emphasizing structural drivers rather than biologic explanations for these disparities and highlighting priorities for future research....Summary The available evidence indicates that structural and systemic factors, rather than biological factors, have a direct impact on disparate care in AIS. This impact is most noticeable at the initial stages of care, such as screening and diagnosis, where sociocultural and socioeconomic differences can affect patients’ access to timely non-operative care. However, it seems once the decision to treat with surgery has been made, the previously existing disparities do not affect surgical outcomes but can affect long-term follow-up." (NOte: this study is from the US)
- Nadler EB, Kim DJ, Lebel DE, Dermott JA.
The True
Cost of Late Presentation in Adolescent Idiopathic Scoliosis: A 5-Year Follow-up Study. J Pediatr
Orthop. 2025 Feb 28. doi: 10.1097/BPO.0000000000002937. Epub ahead of print. PMID: 40019300.
“Each patient who was prescribed a brace and avoided progression to the surgical range saved
$23,000 in treatment costs.
Eliminating late presentation of AIS would save at least $2 to $3 million per year at a single institution . ...This study provides financial impetus for early AIS detection, decreasing the number of avoidable surgeries. Scoliosis screening recommendations in primary care should be re-examined, alongside the development of educational tools, equipping primary care providers, and youth and their caregivers with appropriate knowledge on how to identify AIS.” Level of evidence: Level III-retrospective comparative study. (Sickkids, Toronto, Ontario, Canada) -
Jennifer A. Dermott, Liisa Jaakkimainen, Teresa To, Maryse Bouchard, Andrew Howard, David E. Lebel.
Late referral of adolescent idiopathic scoliosis: the impact of socioeconomic status and health care utilization Canadian Journal of Surgery Vol. 67 (6 Suppl 1) November 13, 2024
doi: 10.1503/cjs.011424,
CPSS-03. Abstract ID 164. The Hospital for Sick Children, Toronto, Ont.; the University of Toronto, Toronto, Ont.; ICES, Toronto, Ont.; the Sunnybrook Research Institute, Toronto, Ont.; the
SickKids Research Institute, Toronto, Ont "...Results: In total, 2732 patients with
AIS (2236 [82%] female) were seen in the study period. The average age (± standard deviation) was 14.1 (± 1.7) years (range
10.0–17.9 yr), mean Cobb angle 37.6° (± 14.4°) (range 10°–95°) and mean BMI 20.4 (± 5.2) (range 12.2–54.5). The percentage of
late referrals was 27% (n = 728). Late referral was associated with younger age at presentation (13.8 yr v. 14.2 yr), less mature Risser stage and fewer physician outpatient visits (16.2 v. 18.7). The probability of being referred late increased with lower income (Q1 = 0.32 v. Q5 = 0.23) and higher level of material deprivation
(Q5 = 0.3 4 v. Q1 = 0.22), and decreased when a pediatrician was the primary care provider (0.13 v. 0.35) or with regular annual
health examinations (0.11 v. 0.32). Conclusion:
Both lower SES and health care utilization increased the probability of late AIS referral, particularly when care was not provided by a pediatrician or when annual health examinations were infrequent" - Jessica Romeo, Holly Livock, Kevin Smit, James Jarvis, Andrew Tice.
Postoperative suicide risk is elevated in patients under going
posterior spinal instrumentation and fusion.Canadian Journal of Surgery Vol. 67 (6 Suppl 1) November 13, 2024
doi: 10.1503/cjs.011424, CPSS-09 Abstract ID 96,
The Children’s Hospital of Eastern Ontario, Ottawa, Ont,
"...The
Ask Suicide-Screening Questions (ASQ) tool is an instrument to identify at-risk youth. It has been implemented at our institu
tion since 2019 in patients over age 12 years admitted for any reason. The study objective was to determine the incidence and
risk factors of positive ASQ screening findings in patients undergoing posterior spinal fusion (PSF)...Methods:
Participants were retrospectively collected from a single-centre tertiary hospital. Patients diagnosed with a spine condition who
had had PSF between 2019 and 2023, were aged 12–20 years and had completed the ASQ postoperatively were included... Conclusion:
Twenty one percent of patients undergoing PSF had a positive ASQ screen, indicating the high incidence of suicidal risk in this patient population. Patients with a preoperative mental health diagnosis were at highest risk of screening positive. This initiative also identified a population of at-risk adolescents who access the medical system for targeted needs outside of a mental health origin. There is an opportunity to improve preoperative mental health screening in adolescents undergoing spinal surgery to optimize their postoperative mental health..." (Note: youth with significant AIS may be at risk for suicide ideation. ) -
Jennifer A. Dermott, Liisa Jaakkimainen, Teresa To, Maryse Bouchard, Andrew Howard, David E. Lebel.
Late referral of adolescent idiopathic scoliosis: the impact of socioeconomic status and health care utilization Canadian Journal of Surgery Vol. 67 (6 Suppl 1) November 13, 2024
doi: 10.1503/cjs.011424 CPSS-03. Abstract ID 164. The Hospital for Sick Children, Toronto, Ont.; the University of Toronto, Toronto, Ont.; ICES, Toronto, Ont.; the Sunnybrook Research Institute, Toronto, Ont.; the
SickKids Research Institute, Toronto, Ont, "...Results: In total, 2732 patients with
AIS (2236 [82%] female) were seen in the study period. The average age (± standard deviation) was 14.1 (± 1.7) years (range
10.0–17.9 yr), mean Cobb angle 37.6° (± 14.4°) (range 10°–95°) and mean BMI 20.4 (± 5.2) (range 12.2–54.5). The percentage of
late referrals was 27% (n = 728). Late referral was associated with younger age at presentation (13.8 yr v. 14.2 yr), less mature Risser stage and fewer physician outpatient visits (16.2 v. 18.7). The probability of being referred late increased with lower income (Q1 = 0.32 v. Q5 = 0.23) and higher level of material deprivation
(Q5 = 0.3 4 v. Q1 = 0.22), and decreased when a pediatrician was the primary care provider (0.13 v. 0.35) or with regular annual
health examinations (0.11 v. 0.32). Conclusion:
Both lower SES and health care utilization increased the probability of late AIS referral, particularly when care was not provided by a pediatrician or when annual health examinations were infrequent" - Anthony A, Zeller R, Evans C, Dermott JA.
Adolescent idiopathic scoliosis detection and referral trends: impact treatment options. Spine
Deform. 2021 Jan;9(1):75-84. doi: 10.1007/s43390-020-00182-6. Epub 2020 Aug 11. PMID:
32780304; PMCID: PMC7775861. “Objective: To analyze the patient demographic referred for
scoliosis to the Hospital for Sick Children to determine the proportion of patients suitable for brace
treatment, as per the Scoliosis Research Society guidelines...a greater number of patients present with
large magnitude curves already in range for surgical consideration...As expected, the majority of
curvatures were first detected by a non-medical lay person. . Conclusion:
The majority of AIS patients present too late for effective management with bracing. ” (Sickkids, Toronto, Ontario, Canada) - Paradkar R, Paradkar R, Singh M, Knebel A, Balmaceno-Criss M, Kim J, Nassar JE, Farias MJ, Paulino L, Diebo BG, Daniels AH. The impact of the social determinants of health on adolescent idiopathic scoliosis: a systematic review. Spine Deform. 2025 Jul;13(4):997-1006. doi: 10.1007/s43390-025-01065-4. Epub 2025 Mar 6. Erratum in: Spine Deform. 2026 Mar;14(2):647. doi: 10.1007/s43390-025-01222-9. PMID: 40048140. "Abstract Purpose: Adolescent idiopathic scoliosis (AIS) has been associated with significant physical and psychosocial burdens. Social determinants of health play a well-documented role in treatment and outcomes of various conditions, including AIS. As such, it is crucial to understand the multifaceted socioeconomic factors that may affect its prevalence and severity....Results: Our initial search identified 479 articles, of which 14 met the eligibility criteria. The mean age was 14.1 years, 76.8% were females, 59.6% were White, and 73.6% had private insurance. Black adolescents with AIS presented with more severe forms of the condition that necessitated surgical management. Furthermore, lower socioeconomic status, along with residence in socioeconomically disadvantaged neighborhoods and enrollment in public insurance programs, often contributed to delayed clinical presentation, more severe curves at initial presentation, and delayed treatment. Conclusion: This systematic review revealed disparities in the diagnosis and management of AIS based on race, ethnicity, language, insurance status, and socioeconomic status. These disparities highlight the urgent need for a multifaceted approach to improve equity in AIS care...." (NOte: this study is from the US)
- Thornley P, Garner S, Rogers KJ, Yorgova P, Gabos PG, Shah SA. Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis. J Pediatr Orthop. 2024 Feb 1;44(2):e163-e167. doi: 10.1097/BPO.0000000000002551. Epub 2023 Oct 23. PMID: 37867376."...Conclusion: Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care." (Note: US study)
- Hartley L, Jones C, Lui D, Bernard J, Bishop T, Herzog J, Chan D, Stokes O, Gardner A. An Examination of the Number of Adolescent Scoliotic Curves That Are Braceable at First Presentation to a Scoliosis Service. Healthcare (Basel). 2023 Feb 3;11(3):445. doi: 10.3390/healthcare11030445. PMID: 36767020; PMCID: PMC9914198. “... In conclusion, the data presented here demonstrate that only a small number of adolescents presenting with AIS to tertiary scoliosis centres in the UK would have met the criteria to be suitable for management with a brace. Whilst scoliosis surgery will remain, it is the authors’ view that, were the delays to review by a specialist reduced or eliminated, and the acceptable parameters within the criteria for bracing altered to be more inclusive, a greater number of adolescents would potentially benefit from a spinal brace, which could reduce the need for surgical intervention.” (comment: following Canada's lead in the 1980's Britain stopped school screening & experiences similar patient-care issues. )
- Pontes MDS, Soeira TP, Sampaio ML, Pratali RR, Pompeu Y, Herrero CFPDS. The impacts of waiting for surgical correction of Adolescent Idiopathic Scoliosis and its repercussions for publicly funded health systems: systematic review. Eur Spine J. 2023 Feb;32(2):617-624. doi: 10.1007/s00586-022-07487-2. Epub 2022 Dec 15. PMID: 36520211.
"Conclusion:
Observational studies show that, in individuals who are on
waiting lists for AIS surgery, there is a worsening of the spinal deformity (substantial evidence), an increasing cost of treatment (moderate evidence) and it may negatively impact patients' quality of life..." - Pereira Duarte, M., Joncas, J., Labelle, H. et al. COVID-19 significantly impacted initial consultation for idiopathic scoliosis. Spine Deform 12, 1675–1682 (2024). https://doi.org/10.1007/s43390-024-00902 2 “We aim to document the progression of IS curves during COVID-19 pandemic reflected by the late presentation of patients at the initial visit with higher Cobb angles and to evaluate its influence on health-related quality of life scores....Patients presented at the scoliosis clinic for the 1st time after the 1st COVID-19 wave with significantly larger Cobb angles, and likely contributed to an increased proportion of PSF, as the potential window for bracing or VBT was missed due to a delayed consultation.”
- Heemskerk JL, de Groot C, Willigenburg NW, Altena MC, Kempen DHR. Screening for adolescent idiopathic scoliosis is more accurate when performed by healthcare professionals compared to untrained parents: a diagnostic accuracy study. Eur Spine J. 2022 Sep;31(9):2339-2347. doi: 10.1007/s00586-022-07115-z. Epub 2022 Apr 7. PMID: 35389103.
- de Groot C, Heemskerk JL, Willigenburg
NW, Altena MC, Kempen DHR. Educating Parents Improves Their Ability to Recognize
Adolescent Idiopathic Scoliosis: A Diagnostic Accuracy Study. Children (Basel). 2022 Apr
15;9(4):563. doi: 10.3390/children9040563. PMID: 35455607; PMCID: PMC9025014. “The negative
consequences of the discontinuation of professional screening are becoming evident, and a situation
with no screening regulation seems suboptimal.
More AIS patients are presenting with large curvatures at the orthopedic clinic, resulting in more patients requiring surgical correction . This situation is not only more invasive for the patient, but it also increases hospital expenses” - Cho NI, Hwang CJ, Kim HY, Baik JM, Joo YS, Lee CS,
Lee MY, Yoon SJ, Lee DH.Referral patterns and patient characteristics at the first visit to a
scoliosis center: a 2-year experience in South Korea without a school scoliosis-screening program.
J Neurosurg Pediatr. 2018 Apr;21(4):414-420. doi: 10.3171/2017.10.PEDS17348. Epub 2018 Feb 2.
PMID: 29393816. “...CONCLUSIONS Under the current health care system in South Korea, a
substantial number of patients with presumed adolescent idiopathic scoliosis are
referred either late or inappropriately to a tertiary medical center...” - Ohrt-Nissen S, Hallager DW, Henriksen JL, Gehrchen M,
Dahl B. Curve Magnitude in Patients Referred for Evaluation of Adolescent Idiopathic Scoliosis:
Five Years' Experience From a System Without School Screening. Spine Deform. 2016
Mar;4(2):120-124. doi: 10.1016/j.jspd.2015.10.001. Epub 2016 Feb 2. PMID: 27927543.
“Conclusion:The present study confirms that
in a health care system without school screening, patients with AIS referred for evaluation by GPs have larger curve sizes compared to systems with school screening .” (note, that translates to more costly and invasive surgeries) - Adobor RD, Riise RB, Sørensen R, Kibsgård TJ, Steen H,
Brox JI. Scoliosis detection, patient characteristics, referral patterns and treatment in the absence
of a screening program in Norway. Scoliosis. 2012 Oct 25;7(1):18. doi: 10.1186/1748-7161-7-18.
PMID: 23098059; PMCID: PMC3527139. “...School scoliosis screening programs were abolished in
Norway in 1994 for lack of evidence that the programs improved outcome and for the costs involved.
The consequences of this decision are discussed. ..Conclusion: In the absence of scoliosis screening,
lay persons most often detect scoliosis. Many patients presented with a mean Cobb angle
approaching the upper limit for brace treatment indications.
The frequency of brace treatment has been reduced and surgery is increased during the recent period without screening compared with the period in the past when screening was still conducted. ” - Beauséjour, Marie MASc*†; Roy-Beaudry, Marjolaine MSc*; Goulet, Lise MD, PhD†‡;
Labelle, Hubert MD*§. Patient Characteristics at the Initial Visit to a Scoliosis Clinic: A Cross
sectional Study in a Community Without School Screening. Spine 32(12):p 1349-1354, May 20,
2007. | DOI: 10.1097/BRS.0b013e318059b5f7 “...Of the 489 suspected cases of AIS, 206 (42%) had no significant deformity (Cobb angle <10°) and could be considered as inappropriate referrals. In subjects with confirmed AIS, 91 patients
(32%) were classified as late referrals with regards to brace treatment indications...These findings suggest that current referral mechanisms for AIS are leading to a suboptimal case-mix in orthopedics in terms of appropriateness of referral." Note: this was published in Canada in 2007. And no screening programs resulted. - Toombs C, Lonner
B, Fazal A, Boachie-Adjei O, Bastrom T, Pellise F, Ramadan M, Koptan W, ElMiligui Y, Zhu F, Qiu Y,
Shufflebarger H. The Adolescent Idiopathic Scoliosis International Disease Severity Study: Do
Operative Curve Magnitude and Complications Vary by Country? Spine Deform. 2019
Nov;7(6):883-889. doi: 10.1016/j.jspd.2019.04.004. PMID: 31731998. ”Conclusions Larger curve
magnitudes in the least-access countries correlated with more levels fused, longer OT, and greater
EBL...we suggest that increased curve magnitude leads to longer OTs and more complications.
A lack of access to orthopedic care may be the largest contributor to the postponement of treatment. ” (note: this appears to describe the crisis situation in Canada, a first-world country) - Regan C, Transtrum MB, Jilakara B, Milbrandt TA, Larson AN. How Long Can You Delay? Curve Progression While Awaiting Vertebral Body Tethering Surgery. J Clin Med. 2024 Apr 11;13(8):2209. doi: 10.3390/jcm13082209. PMID: 38673483; PMCID: PMC11050359.
- No Child Elects to Wait Timely Access to Pediatric Spinal Surgery, The
Conference Board of Canada, Sept 25, 2023 “...
adolescent idiopathic scoliosis (AIS) surgery is the most common reason for elective (planned) pediatric orthopedic surgery ...4 in 10 pediatric spinal surgeries are done after the recommended clinical time frame ...we estimate that 2,778 children with AIS in Canada are facing delayed surgery...the estimated cost of delaying pediatric scoliosis surgery to the healthcare system is $44.6 million. In addition, we estimate $1.4 million in lost productivity to the Canadian economy due to added caregiver responsibility...The shortage of nurses and anesthesiologists is a significant factor contributing to the cancellation and delay of surgeries. According to the Canadian Anesthesiologists’ Society,Canada has far fewer anesthesiologists for every 100,000 people than other countries , including the United States and Australia...” - Heffernan MJ, Younis M, Song B, Fontenot B, Dewitz R, Brooks JT, Leonardi C, Barnett SA. Disparities in Pediatric Scoliosis: The Impact of Race and Insurance Type on Access to Nonoperative Treatment for Adolescent Idiopathic Scoliosis. J Pediatr Orthop. 2022 Sep 1;42(8):427-431. doi: 10.1097/BPO.0000000000002213. Epub 2022 Jul 19. PMID: 35856501."...Conclusion: This study demonstrated disparity in access to nonoperative treatment for pediatric scoliosis. Black patients with public insurance were the most at-risk to present with curve magnitudes exceeding brace indications. Future work focused on understanding the reasons for this significant disparity may help to promote more equitable access to effective nonoperative treatment for adolescent idiopathic scoliosis." (Note: this is a US study)
- Chung WH, Lee YJ, Chiu CK, Hasan MS, Chan CYW, Kwan MK. Severe Lenke 1 and 2 adolescent idiopathic scoliosis had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost compared to non-severe scoliosis. Eur Spine J. 2022 Apr;31(4):1051-1059. doi: 10.1007/s00586-022 07118-w. Epub 2022 Jan 23. PMID: 35066683.
- Kenner P, McGrath S, Woodland P. What Factors Influence Delayed Referral to Spinal Surgeon in Adolescent Idiopathic Scoliosis? Spine (Phila Pa 1976). 2019 Nov 15;44(22):1578-1584. doi: 10.1097/BRS.0000000000003146. PMID: 31689253. “In a condition in which early detection and intervention may halt progression of disease, AIS is detected relatively late and there are specific delays to diagnosis and referral to specialist clinics.”
- Ramo B, Tran DP, Reddy A, Brown K, Niswander C, Erickson M, Garg S. Delay to Surgery Greater Than 6 Months Leads to Substantial Deformity Progression and Increased Intervention in Immature Adolescent Idiopathic Scoliosis (AIS) Patients: A Retrospective Cohort Study. Spine Deform. 2019 May;7(3):428-435. doi: 10.1016/j.jspd.2018.09.012. PMID: 31053313.
- Tarrant, R., D. Moore, and P. Kiely. “Impact of Longer Surgical Wait-List Times on Length of Hospitalisation, Return to Function and Cost of Surgical Treatment in Patients with Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion.” Global Spine Journal 6, no. 1-suppl (2016): s-0036 1583053–s-0036 1583053. Accessed August 27, 2023. https://doi.org/10.1055/s-0036-1583053
- Yang JH, Bhandarkar AW, Rathanvelu B, Hwang JH, Hong JY, Modi HN, Suh SW. Does delaying surgery in immature adolescent idiopathic scoliosis patients with progressive curve, lead to addition of fusion levels? Eur Spine J. 2014 Dec;23(12):2672-9. doi: 10.1007/s00586-014-3421-9. Epub 2014 Jun 20. PMID: 24947183. ”...Conclusions Delay of surgery in immature AIS patients whose Cobb’s angle exceed 40° initially and showing subsequent progression of the curve, of more than 10° can lead to alterations in the curve pattern and the need for increase in fusion levels.”