Spinal Screening Policy (updated August 2018)

In September 2015, the Scoliosis Research Society (SRS) published a joint position statement paper with the American Academy of Orthopedic Surgeons (AAOS), the Pediatric Orthopedic Society of North America (POSNA), and the American Academy of Pediatrics (AAP) and have the following recommendation: “AAOS, SRS, POSNA, and AAP believe that screening examinations for spine deformity should be part of the medical home preventative services visit for females at age 10 and 12 years, and males once at age 13 or 14 years.”

Grade-based screening is considered an acceptable alternative to age-based screening in a school setting.  The grades, however, must align with the professionally recommended ages so that most children are screened at the appropriate age, or as close to it as reasonably possible. View the vision, hearing, and spinal screening requirements flyer. [PDF 584KB]

In compliance with the Health and Safety Code, Chapter 37, all children shall undergo screening for abnormal spinal curvature per the following schedule:

• Girls will be screened two times, once at age 10 (or fall semester of grade 5) and again at age 12 (or fall semester of grade 7).
• Boys will be screened one time at age 13 or 14 (or the fall semester of grade 8).

Schools must identify outliers (i.e., children promoted to higher grades or held back) and ensure their screenings align with appropriate ages rather than grades.

The current professional recommendation encourages screening performed in a medical home. Texas Health and Safety Code, Chapter 37, requires school administrations to ensure compliance with the screening requirement. Soliciting documentation from parents that spinal screening has been performed by a professional may reduce the number of students who need to be screened and prevent unnecessary additional screening.

School administrators may solicit documentation that spinal screening has been, or will be, performed in a medical home or that it is being declined based on religious tenets. Documentation includes an affidavit from a licensed professional or the parent, guardian, or managing conservator as described below:

1. Documentation from a licensed professional that the individual is actively under medical care for one or more spinal problems [25 TAC §37.143(c)]; or
2. A signed form from the parent, guardian, or managing conservator that screening for abnormal spinal curvature was, or will be, performed during a professional examination [25 TAC §37.144(d)]; or
3. A signed form from the parent, legal guardian, or managing conservator in place of the screening record(s) stating the screening conflicts with the tenets and practices of a church or religious denomination of which the affiant is an adherent or member [25 TAC §37.144(e)]. 

If the parent, guardian, or managing conservator is unable to provide documentation, the school administrator must ensure spinal screening is performed according to the procedures outlined below, per the Spinal Screening Guidelines Manual.

School Administrator Responsibilities

The chief administrator responsible for the school’s/district’s spinal screening program must coordinate screening activities with teachers, parents, nurses, and screeners. If screeners are not school staff, they must coordinate with school staff to ensure all components of the spinal screening program are carried out. Coordination of screening activities includes the following:

• Verify screeners are state-certified.
• Conduct an in-service educational program for school system resource personnel, administrators, school nurses, physical educators, and parents.
• Discuss the legal requirements for spinal screening, the scope of the health issues, and the rationale for and technique of screening.
• Discuss which students are exempt and the methodology for screening, including how follow-up of positive cases and referrals will be carried out.
• The chief administrator of each school is responsible for ensuring that each student admitted to the school complies with applicable spinal screening requirements or submits an affidavit of exemption.
• Complete follow-up and referral activities.
• Submit an annual aggregate report online.

Refer to the Spinal Screening Guidelines Manual for more information related to the procedure and technique for performing spinal screening.

Who May Screen

A spinal screener must be certified to conduct spinal screenings. The Department of State Health Services (DSHS) offers spinal screening certification courses and issues certificates to those who successfully complete the course. Spinal screening certificates also may be issued by an instructor who has been trained and authorized by DSHS to issue certificates. To be eligible to take a spinal screening certification course, one must be a high school graduate. 

Professionals licensed under state law, including physicians, chiropractors, physical therapists, and registered nurses, who have completed a course of study in physical assessment may conduct spinal screenings without being certified by the department.

Spinal screening instructors must complete a department instructor training course. They must first meet the following qualifications:

1. Have experience conducting training for groups of adults; and
2. Be physicians, chiropractors, physical therapists, or registered nurses, and must have the applicable Texas license, current and in good standing under Texas law.

Screening for Scoliosis

For scoliosis, each student is observed from the front, side, and back: (a) while standing straight, and (b) while gradually bending forward, with the arms hanging down and palms touching, as if diving into a pool. The screener looks for head misalignment to one side of the cleft in the buttocks; one shoulder or hip higher than the other; prominence of the rib cage or the small of the back; unequal distance between arms and body; and a curve in the spine. An experienced person should be able to screen 25-30 students per hour. Screening should be performed with the subject's shoes taken off. 

Spinal Screening Procedure - Forward Bend Technique 

Position I - Student stands facing the screener. He/she should stand straight, feet slightly apart with weight evenly distributed, knees straight, arms at the side, and eyes straight ahead.

Observe the following:

• Shoulder - Is one shoulder higher than the other one?
• Waist - Is the waistline the same on both sides or is there a larger space between the arm and flank on one side?
• Hips - Are the hips level and equal? Is one side higher or does it stand out more than the other?

Position II - While still facing the screener, the student bends slowly forward until his back is parallel to the floor. The feet are slightly apart, the knees straight, and the palms of the hands are together and hanging down as if diving into a pool. The head is down and relaxed.

Observe the following:

• Chest Cage Hump - Are both sides of the back of the rib cage equal or does the rib cage have a hump on one side?
• Lumbar Inequality - Are both muscle masses in the small of the back equal or does one stand out more than the other?

Position III - Student stands as in Position I, with his/her side toward the screener.

Observe the following:

• Round Back - Is there an exaggerated roundness in the upper back?
• Sway Back - Is there an exaggerated arch in the lower back?

Position IV - With his/her side toward the screener, the student bends forward as in Position II.

Observe the following:

• Rib Hump - Is there an accentuated roundness over the rib cage or the area between the lower rib cage and the small of the back? 

Position V - Student has back toward the screener, and stands straight as in Position I. Long hair should be pinned up or evenly separated and brought forward in front of each shoulder. The examiner views the entire back. 

Observe the following:

• Head - Does the head line up over the crease in the buttocks or is it displaced to one side? 
• Shoulders - Is one shoulder higher than the other? 
• Shoulder Blade (Scapula) - Is the wing on one shoulder blade higher or does it stand out more than the other one? 
• Spine - Is the spine straight or does it curve sideways? 
• Waist - Is the waistline the same on both sides or is there a larger space between the arm and flank on one side? 

Position VI - With the back still toward the screener, the student bends forward as in Position II. 

• Is there a bulge on one side of the rib cage?
• Is there a bulge on one side of the lower back?

Training and Materials

For information regarding spinal screener training in your area, call the school health specialist at the nearest Regional Education Service Center or email the Spinal Screening Program at vhssprogram@dshs.texas.gov.

To order training workshop materials, you must be a certified trainer and use the DSHS Spinal Screening Materials Request Form [DOC 22KB]. Please allow at least two weeks for materials to be delivered.