Spinal Deformities Assessment in ASD Subjects: A CROSS Sectional Study

Background: The term “spinal deformity” includes conditions such as post-traumatic deformities, iper-kyphosis, iper-lordosis and idiopathic adolescence scoliosis. Early identification and effective treatment of mild scoliosis could slow or stop curvature progression before skeletal maturity, thereby improving long-term outcomes in adulthood (US task force JAMA 2018). In a systematic review (PROSPERO registration number CRD 42018100894), we found that spinal deformities appear to be understudied within autism research and that no studies on spinal deformities assessment in ASD subjects exist. Since severe spinal deformities may be associated with adverse long-term health outcomes (e.g. pulmonary disorders, disability, back pain, psychological effects, and reduced quality of life), the value of spinal deformities screening becomes increasingly relevant.

Objectives: Our study aims to assess the applicability of a spinal deformities screening protocol in ASD subjects.

Methods: The screening protocol included two tests: the “Adam Test”, measured with the Bunnell method for assessing the trunk asymmetry on the frontal plane, and the “Sagittal Index” as suggested by Zaina that gives a measure of spinal deformities on a sagittal plane. The Literature indicates that subjects who present “Adam Test” or “Sagittal Index” values above cut-off limits are in need of second level clinical assessment. We also considered the three ASD severity grades and the four intellectual disability (ID) categories (mild, moderate, severe and profound) as suggested by DSM-V.

Results: Sixty-one subjects (mean age 14.03 – SD 4.26; 55 males) were included in the study. Seven out of 61 subjects (11,5%) presented grade 1, 26 (42,6%) grade 2, and 28 (45,9%) grade 3 ASD severity. Three subjects (4,9%) exhibited mild ID, 22 (36,1%) moderate ID, 34 (55,7%) severe ID, and 2 (3,3%) profound ID. Despite the relatively high autism severity of our sample, we found the screening test applicable to 92% of our population. Five subjects were non-testable because of their behavioral difficulties; all of them had high ASD severity grades and moderate to severe ID. Using this protocol screening, we found 11 ASD subjects (18%) presenting abnormal values: three subjects (4,9%) with Adam’s test values over cut-off (>5°), and eight subjects (13,1%) with “Sagittal Index” values over the cut-off (>9,5 cm). Using a chi-square test, we found that subjects over the cut-off limits had higher ASD severity (p=0.039), and ID severity (p=0.002).

Conclusions: The screening protocol for spinal deformity is generally applicable in ASD, also in subjects with high ASD severity and severe ID. About 20% of ASD subjects present spinal deformities, a value in line to what described in the general population (15%-20% over cut off) therefore deserving special attention for eventual adverse long-term health outcomes.