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The prevalence of scoliosis among adolescents in China: a systematic review and meta-analysis

Journal of Orthopaedic Surgery and Research volume 19, Article number: 585 (2024) Cite this article

Abstract

Background

To systematically evaluate the prevalence of scoliosis in adolescents aged 10–18 years in China, and to provide evidence-based evidence for the early identification, prevention, and management of scoliosis in adolescents.

Methods

We searched 7 databases of CNKI, Wanfang, VIP, PubMed, Web of Science, Embase, and Cochrane Library from January 2000 to June 2024, and included related studies on scoliosis among Chinese adolescents aged 10–18. The quality evaluation criteria of cross-sectional studies recommended by the Agency for Healthcare Research and Quality (AHRQ) were used for literature quality evaluation. Stata 18.0 software was used for statistical analysis.

Results

We finally included 42 studies, involving a total of 1,149,330 subjects from 30 regions. The results showed that the prevalence of scoliosis in Chinese adolescents aged 10–18 years was 1.2% [95%CI (1.1%, 1.4%)]. The results of the subgroup analyses are as follows: ① The prevalence of scoliosis in adolescent women (1.6%) was higher than that in men (1.0%). ② The prevalence of scoliosis in adolescents aged 16–18 (1.3%) was higher than that in adolescents aged 10–15 (1.1%). ③ By region, the prevalence of scoliosis was slightly higher in the North (1.3%) than that in the South (1.2%). ④ According to the time of publication, the prevalence of scoliosis in Chinese adolescents increased from 0.9% during 2000–2015 to 1.6% during 2016–2024. ⑤ According to the degree of the Cobb angle, the curve magnitude was mainly mild (Cobb angle: 10°-19°), and the prevalence rate was 0.7%; the second was moderate (Cobb angle: 20°-39°), with a prevalence of 0.2%.

Conclusion

The prevalence of scoliosis in adolescents aged 10–18 years in China is 1.2%, suggesting that the prevalence may be gradually increasing in recent years. In addition, the degree of scoliosis is mainly mild, and timely intervention and prevention are necessary.

Introduction

Scoliosis is a three-dimensional structural deformity of the spine that is asymmetrically altered, usually accompanied by structural and biomechanical changes around the vertebral body [1]. At present, scoliosis is mainly diagnosed by measuring the Cobb angle by X-ray, with a Cobb angle ≥ 10°as the diagnostic standard [2]. Depending on the cause, scoliosis can be divided into neuromuscular scoliosis, idiopathic scoliosis, congenital scoliosis and scoliosis due to other causes [3]. Idiopathic scoliosis is the most common, especially in adolescents. Epidemiological studies have found that both at home and abroad: in Italy, adolescent idiopathic scoliosis (AIS) incidence is between 0.47% and 5.20% [4]; The prevalence of AIS in Asia and parts of China is about 2% [5, 6].

Mild scoliosis is typically asymptomatic. However, severe scoliosis (Cobb’s angle ≥ 40°) typically manifests with clinical symptoms such as back pain and respiratory disturbances, accompanied by serious social and psychological effects, such as appearance deformity, psychological distress, and even suicidal tendencies [5]. These harms will seriously affect the quality of life of adolescent patients and increase the economic burden on families and society. Domestic and foreign scholars generally believe that adolescents are more suitable as the main objects of scoliosis screening and intervention [1, 7, 8]. Adolescent bones are not yet mature and have strong plasticity. Timely development of scientific intervention programs after diagnosis of scoliosis plays an important role in improving deformities, stabilizing the spine, and relieving pain, and can even improve cardiopulmonary function and psychosocial factors [9]. Timely and effective scoliosis screening is of great significance for maintaining adolescents’ physical and mental health and alleviating social and family burdens. Combined with the current situation in China, the incidence of scoliosis has been on the rise in recent years [6]. Therefore, Chinese health authorities believe that it is essential to promote screening for scoliosis, and suggest that adolescents aged 10–18 should be included as the main screening objects for scoliosis [1]. At present, China has implemented a screening program for adolescent scoliosis in schools. The pertinent departments within the schools collate personal data from the student population, including age, gender, familial history, and other pertinent information. Furthermore, regular scoliosis screenings are conducted, and personal profiles are established for students diagnosed with scoliosis. Firstly, patients exhibiting highly suspicious characteristics are initially screened including a visual inspection method, Adams forward flexion test, scoliosis measuring tape/portable electronic scoliosis screening tool, and Moiré topography. Subsequently, the definitive diagnosis of adolescents exhibiting high suspicion is corroborated through X-ray measurement of the Cobb angle. Ultimately, patients diagnosed with scoliosis, as well as adolescents exhibiting highly suspicious characteristics, require regular follow-up assessments to monitor the progression of their spinal health.

Since 2014, a series of screening for scoliosis has been carried out in the Chinese mainland, but the lack of a unified screening scheme among the studies has led to great heterogeneity, which poses a great challenge for the government to carry out nationwide screening and formulate prevention and control strategies for scoliosis [10]. At present, we find that China has begun to pay attention to the epidemiological information on scoliosis in Chinese adolescents. In 2015, Zhang et al. [6]. reported on the prevalence of scoliosis among primary and secondary school students in the Chinese mainland. However, their studies were limited to primary and secondary school students in Chinese mainland, and the included studies were all published before 2014. Their findings may not reflect the latest picture of the prevalence of scoliosis. Furthermore, the study by Shao et al. [11]. made up for these shortcomings by including the latest research on scoliosis in Chinese adolescents. However, the number and quality of the included studies were small and may affect the representativeness of the results, and the features of scoliosis have not been explored in depth. In addition, in the past few years, several large-scale sample studies have been published at home and abroad, which can be used for systematic review and meta-analysis. Therefore, we plan to take Chinese adolescents aged 10–18 years as research objects to evaluate the prevalence of adolescent scoliosis in China and provide more corresponding evidence-based evidence for early identification, management, prevention, and treatment of adolescent scoliosis patients in China.

Methods

Literature search strategy

This study was conducted following the PRISMA statement [12] and the specific program has been registered with PROSPERO with the number CRD42024554961. We used PICOS algorithm principles to guide the initial literature search:

P (population): Chinese adolescents aged 10–18;

I (intervention): no intervention;

C (comparison): no comparison;

O (outcome): The prevalence of scoliosis;

S (study): cross-sectional study/retrospective study.

The search databases were CNKI, Wanfang, VIP, PubMed, Web of Science, Embase, and Cochrane Library from January 2000 to June 2024. The method of “subject word + the free word” was used to search, and the Chinese search terms were “scoliosis, scoliosis”, “prevalence, epidemiology, screening”; The English search terms were “scoliosis”, “prevalence, epidemiology, screening”, “China, Chinese”. Taking PubMed as an example, the search formula is as follows: ((scoliosis[All Fields]) AND (((prevalence[All Fields]) OR (epidemiology[All Fields])) OR (screening[All Fields]))) AND ((China[All Fields]) OR (Chinese[All Fields]))(For the literature search formula, see Supplementary File 1).

Literature inclusion and exclusion criteria

Inclusion criteria

① The subjects involved Chinese adolescents aged 10–18 years; ② The study provided data on the prevalence of scoliosis, or data that can be used to calculate the prevalence; ③ Screening methods and diagnostic criteria for scoliosis were clearly defined in the study, and Cobb’s angle ≥ 10° was used as the final diagnostic criterion; ④ Considering the author’s language ability, the language of literature retrieval is limited to Chinese or English; ⑤ Cross-sectional study or retrospective study.

Exclusion criteria

① Republished literature; ② Literature published in the form of reviews, short commentaries, or conference abstracts; ③ The full text or incomplete data cannot be obtained; ④ Literature with unreasonable research scheme design and poor reliability of results; Literature that has not been published publicly or in other languages.

Literature screening and data extraction

First, the retrieved literature was imported into EndNoteX9.1 software to eliminate duplicate literature. Secondly, read the title, abstract, and keywords of the literature for preliminary screening. Finally, the remaining literature was read in full text for final inclusion and exclusion. In this process, two reviewers (SL.M. and W.L.) independently cross-checked the included literature. If there is any dispute, it will be resolved through discussion between the two parties or by introducing a third evaluator (XL.F.) to review.

In the data extraction stage, two researchers (SL.M. and W.L.) will undertake the data extraction independently. Subsequently, both parties will engage in a process of data summary, exchange, and review. In the event of any discrepancy, a third party (XL.F.) will be consulted for an impartial assessment. The content of extracted data mainly includes: (1) Basic information of the included literature: first author, publication year, survey region, etc.; (2) Data on the prevalence of scoliosis were calculated; (3) Key information of literature quality evaluation.

Literature quality evaluation

We adopt the cross-sectional study quality evaluation criteria recommended by the Agency for Healthcare Research and Quality (AHRQ) score for literature quality evaluation [13]. The evaluation criteria consist of 11 items, with a rating scale of 1 point for “yes” and 0 points for “no/unclear”. A total score of 8–11 indicates high quality, 4–7 indicates moderate quality, and 0–3 indicates low quality (See Table 1 for details).

Table 1 AHRQ cross-sectional study quality evaluation standard table
Full size table

Statistics

We used Stata18.0 software to statistically analyze the prevalence data of scoliosis in adolescents aged 10–18 years in China and analyzed the heterogeneity of the included studies through Q test and I2 value. If I2 > 50%, and p < 0.1, it indicates that there is high heterogeneity among studies, and the random effects model is used for analysis; otherwise, the fixed effects model will be used for statistical analysis [14]. If the heterogeneity among the included studies is large, further analysis of the sources of heterogeneity is needed, and subgroup analysis can be used to try to find out the obvious sources of heterogeneity. The subgroups included: sex, age, region, publication time, and Cobb angle. Statistical significance p-values were set at 0.05 for all statistical analyses.

In this study, we did not check the publication bias. The reasons are as follows: publication bias is a phenomenon in which studies with significant results are easier to publish than those with insignificant results, which may lead to systematic differences between published and unpublished studies [15]. However, in the observational study of prevalence, there are no significant or insignificant results, and it is not recommended to use mature methods to test this deviation in the systematic evaluation of prevalence research. Therefore, we did not check the publication bias.

Result

Literature screening process and results

After a preliminary search, we obtained a total of 3972 related articles, and after a layer-by-layer screening, we finally included 42 studies, with a total of 1,149,330 subjects(For the process and results of literature screening, see Fig. 1).

Fig. 1
figure 1

Literature retrieval process diagram

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Basic characteristics and quality evaluation results of included literature

A total of 42 articles involving 1,149,330 subjects from 30 regions were included in this study. The general situation and quality evaluation results of the included literature are detailed in Table 2 (For the detailed results of the literature evaluation, see Supplementary File 2).

Table 2 General information and quality evaluation results of the included literature
Full size table

Meta-analysis results

Meta-analysis of the prevalence of scoliosis in adolescents in China

We conducted a meta-analysis of the prevalence of scoliosis in Chinese adolescents. The results of the meta-analysis showed that I2 = 99.4% (p < 0.001), indicating high heterogeneity among the studies, so the random effects model was used for analysis. The results of the meta-analysis showed that the prevalence of scoliosis in adolescents aged 10–18 in China was 1.2% [95%CI (1.1%, 1.4%)], as shown in Fig. 2; Table 3.

Fig. 2
figure 2

Meta-analysis Forest figure of the prevalence of scoliosis in adolescents in China

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Subgroup analysis of the prevalence of scoliosis in adolescents in China

Meta-analysis of the prevalence of scoliosis among adolescents in China suggests high heterogeneity among studies. Therefore, we adopted the subgroup analysis method to identify the source of heterogeneity. The subgroups in this study included: sex (Men; Women), age (10–15; 16–18), region (South/North; With Qinling Mountains and Huaihe River as the boundary, the north of Qinling Mountains and Huaihe River is the north, and the south is the south), Publication year (2000–2015; 2016–2024), Cobb angle (10°-19°; 20°-39°). The results of the subgroup analysis are shown in Table 3.

Table 3 Summary table of the meta-analysis results of the prevalence of scoliosis in Chinese adolescents
Full size table

Sensitivity analysis of the prevalence of scoliosis in adolescents in China

We performed a sensitivity analysis of the total prevalence of scoliosis by eliminating the included literature one by one. The results showed that the prevalence of scoliosis among Chinese adolescents aged 10–18 years did not change in directional variability for each outcome, suggesting that the results of the study are relatively robust (See Fig. 3).

Fig. 3
figure 3

Sensitivity analysis figure of the prevalence of scoliosis in adolescents in China

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Discussion

This study showed that the prevalence of scoliosis in Chinese adolescents aged 10–18 years was 1.2%, which is closer to the findings of Miao et al. [58] and Shao et al. [11]. It is recommended that parents and educators pay attention to the spinal health in adolescents, employing corrective measures for poor postures, conducting regular health assessments, and directing particular attention to the presence of trunk asymmetry during health assessments. In addition, the prevalence of scoliosis in Chinese adolescents also has the following characteristics: First, the prevalence of scoliosis in adolescent women (1.6%) was higher than that in men (1.0%). Secondly, the prevalence of scoliosis in adolescents aged 16–18 (1.3%) was higher than that in adolescents aged 10–15 (1.1%). Third, by region, the prevalence of scoliosis was slightly higher in the North (1.3%) than in the South (1.2%). Fourth, the prevalence of scoliosis in Chinese adolescents increased from 0.9% during 2000–2015 to 1.6% during 2016–2024. Fifth, according to the degree of the Cobb angle, the degree of scoliosis illness was mainly mild (Cobb angle: 10°-19°), and the prevalence rate was 0.7%; the second was moderate (Cobb angle: 20°-39°), with a prevalence of 0.2%.

The results of the subgroup analysis showed an association between sex, age, and the prevalence of scoliosis in Chinese adolescents. We found that the prevalence of scoliosis in adolescent women (1.6%) was higher than that in men (1.0%), which is consistent with studies in many countries and regions at home and abroad [6, 10, 59, 60]. Women are more likely to suffer from scoliosis in adolescence than men, and the reasons may be related to female muscle strength, hormone level, activity level, and adolescent development [10]. These factors, alone or together, may contribute to the higher prevalence of scoliosis in women. In this study, we divided 10-18-year-olds into two age groups for subgroup analysis, and the results showed that the prevalence of 16-18-year-olds (1.3%) was higher than that of 10-15-year-olds (1.1%). Our study is consistent with the results of Shao et al. [11], and the specific reason may be related to the developmental characteristics of adolescents. Teenagers are in the stage of skeletal muscle growth and development (strong bone plasticity and variability), if the body is in an incorrect posture for a long time, it easily leads to scoliosis [1, 7]. In addition, adolescents in the 16–18 age group are usually in high school and face significant academic pressures, which may contribute to a sedentary and physically inactive lifestyle, factors that may increase the risk of scoliosis in this age group [11].

In terms of time-space distribution, we found that the prevalence of scoliosis among Chinese adolescents increased compared with the previous period (from 0.9% in 2000–2015 to 1.6% in 2016–2024), which is consistent with the study of Xu. et al. [10]. This may be related to the improvement of medical technology, which leads to the improvement of the accuracy of spinal screening [61], such as the increase of X-ray film resolution and sensitivity. At present, we predict that the prevalence of scoliosis in adolescents aged 10–18 years in China may be gradually increasing, which needs to be paid attention to by public health departments. In addition, we speculate that the possible factors leading to the increase in the prevalence of scoliosis are as follows: ① With the progress of medical diagnosis technology, especially MRI, CT, and other imaging technology, more congenital scoliosis cases may be diagnosed early. ②Population aging: A decline in birth rates in a country or region may reduce the proportion of young people, resulting in a higher proportion of congenital scoliosis in young people in the general population;③Environmental and genetic factors: Exposure to certain toxins or genetic mutations may increase the risk of congenital scoliosis; ④Increased social awareness of congenital scoliosis may have led to more cases being reported and recorded, which may also have made the prevalence appear to have increased. However, given that our findings are based on objective data, we still cannot ignore the possible rise in congenital scoliosis.

In addition, we found that the prevalence of scoliosis among adolescents in the northern region (1.3%) was slightly higher than that in the Southern region (1.2%). The studies of Zhang et al. [6] and Grivas et al. [62] also showed that the prevalence of scoliosis would slightly increase with the increase of dimensions, and the specific reasons may be related to the local lifestyle. The time-space differences in the prevalence of scoliosis in Chinese adolescents need to be further studied in the future.

We also found that the degree of scoliosis illness was mainly mild (Cobb angle: 10°-19°), which accounted for 77.0%. Moderate scoliosis (Cobb angle: 20°-39°) constituted the remaining 19.5%. This conclusion is also supported by the retrospective study conducted in the Netherlands [63]. Timely and appropriate interventions are important when scoliosis is diagnosed. The early detection of scoliosis cases and the implementation of early intervention strategies, such as regular screening for scoliosis, increasing the amount of time spent on extracurricular activities in schools, the use of lifting desks and chairs for adjusting and standardizing sitting postures, and lectures on the prevention and treatment of adolescent scoliosis, can effectively halt the progression of the disease and improve the prognosis of the disease. Screening and intervention for adolescent scoliosis are of great significance and can reflect the level of adolescent health care in a country.

This study is currently the most geographically diverse and the highest quality of included studies in the epidemiological study of scoliosis in Chinese adolescents aged 10–18 years. Based on the latest scoliosis screening study, we reported the latest data for scoliosis in Chinese adolescents aged 10–18 years. This has an important guiding role in reducing the design cost and carrying out unified screening work in the whole country and typical areas and provides a theoretical basis for health policymakers. However, this study also has certain limitations: First, due to the characteristics of individual studies, different screening methods, and regional differences, there may be potential heterogeneity in the summary analysis based on previous screening work. Secondly, there is less relevant data for some subgroups, which may affect the representativeness of the conclusions to a certain extent. Finally, the studies we included were all cross-sectional or retrospective studies, which may have some limitations in terms of evidence level, screening methods, and consistency of field implementation.

Conclusion

A total of 42 articles involving 1,149,330 subjects from 30 regions were included in this study. The results of the meta-analysis showed that the overall prevalence of scoliosis among Chinese adolescents aged 10–18 years was 1.2%, suggesting that the prevalence may be gradually increasing in recent years. This phenomenon should attract the attention of public health authorities. In addition, the degree of scoliosis in Chinese adolescents is mainly mild, and timely intervention and prevention are necessary.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

We thank all our colleagues at the Fujian University of Traditional Chinese Medicine.

Funding

The study was funded by the Fujian Natural Science Foundation project (2023J0112). The funders had no role in the study design, data collection, and analysis, interpretation of data, and writing the manuscript.

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Author notes

  1. Xinlei Fu and Shilong Meng contributed equally to this work and are the co-first authors.

Authors and Affiliations

  1. The First School of Clinical Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, 350122, China

    Xinlei Fu & Xiating Huang

  2. The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China

    Shilong Meng, Wei Li & Baisheng Ye

  3. Xiamen Hospital of Traditional Chinese Medicine Affiliated to Beijing University of Chinese Medicine, Xiamen, 361006, China

    Siwen Chen

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  1. Xinlei Fu
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  2. Shilong Meng
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  4. Wei Li
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  5. Baisheng Ye
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Contributions

XL.F and SL.M are responsible for writing the manuscript; SL.M and W.L are responsible for the conceptual design and feasibility analysis of the study. W.L, XT.H and BS.Y are responsible for data collection, data extraction and analysis, and quality evaluation; SW.C underwent revision and overall quality control. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Siwen Chen.

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This study is an epidemiological investigation and therefore does not require ethical approval.

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The authors declare no competing interests.

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Fu, X., Meng, S., Huang, X. et al. The prevalence of scoliosis among adolescents in China: a systematic review and meta-analysis. J Orthop Surg Res 19, 585 (2024). https://doi.org/10.1186/s13018-024-05077-0

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  • DOI: https://doi.org/10.1186/s13018-024-05077-0

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X