This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you requested follows this cover page. Screening for Idiopathic Scoliosis in Adolescents. An Information Statement B. Stephens Richards and Michael G. Vitale J Bone Joint Surg Am. 2008;90:195-198. doi:10.2106/JBJS.G.01276 This information is current as of July 20, 2010 Reprints and Permissions Click here to order reprints or request permission to use material from this article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org 195 C OPYRIGHT Ó 2008 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED the Orthopaedic forum Screening for Idiopathic Scoliosis in Adolescents An Information Statement* By B. Stephens Richards, MD, and Michael G. Vitale, MD Executive Summary information statement. The societies ital radiography, is signiﬁcantly smaller Many states mandate school screening acknowledge the important role of a than in the past. to identify children at risk for scoliosis, systematic review of the literature as Opponents to scoliosis screening though recent studies have cast some well as the role of consensus expert have focused on concerns about a low controversy on the effectiveness of opinion in the common situation predictive value of screening and the routine scoliosis screening. Previous where the available evidence does not cost-effectiveness of referral. There have studies have both supported and dis- yet exist to speak deﬁnitely for, or also been concerns about the possibil- couraged routine screening. against, an evaluation or intervention. ity of unnecessary treatment, including Prevention of severe scoliosis is a Costs involved with scoliosis brace use, and the effect of exposure to major commitment of physicians car- screening are relatively low on a soci- radiation when radiographs are ing for children with spinal deformi- etal level and may justify the possibility obtained. ties. For this reason, the American of preventing surgery in adolescents With regard to early treatment in Academy of Orthopaedic Surgeons with scoliosis. Adolescents without sig- those adolescents detected with mod- (AAOS), the Scoliosis Research Soci- niﬁcant spinal deformity who are re- erate scoliosis, the available data neither ety (SRS), the Pediatric Orthopaedic ferred to a specialist for evaluation deﬁnitively support nor refute the efﬁ- Society of North America (POSNA), often do not require radiographs. For cacy of bracing. To most effectively an- and the American Academy of Pediat- those who do need radiographic evalu- swer this, a well-organized level I study rics (AAP) convened a task force to ation, it is important to know that the is needed. Such a study, a ﬁve-year mul- examine issues related to scoliosis radiation exposure using current-day ticenter randomized controlled trial of screening and to put forth the present radiographic techniques, including dig- bracing sponsored by the National In- Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other beneﬁts or a commitment or agreement to provide such beneﬁts from a commercial entity. Commercial entities (Biomet Spine, Medtronic, and Stryker Spine) paid or directed in any one year, or agreed to pay or direct, beneﬁts in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonproﬁt organization with which one or more of the authors, or a member of his or her immediate family, is afﬁliated or associated. *This statement has been reviewed by the Boards of Directors of the American Academy of Orthopaedic Surgeons (September 2007), Scoliosis Research Society (August 2007), Pediatric Orthopaedic Society of North America (August 2007), and the American Academy of Pediatrics (September 2007). All four boards have endorsed this statement. The American Academy of Orthopaedic Surgeons notes that the statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented in this Opinion Statement and reach their own conclusions. J Bone Joint Surg Am. 2008;90:195-8 d doi:10.2106/JBJS.G.01276 196 T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G d S C R E E N I N G F O R I D I O PAT H I C S C O L I O S I S V O LU M E 90 -A N U M B E R 1 J A N UA R Y 2 008 d d IN ADOLESCENTS stitutes of Health/National Institute of subset of children with adolescent idi- nosed as qualifying for surgery, with- Arthritis and Musculoskeletal and Skin opathic scoliosis may exhibit rapid out the screening program and without Diseases (NIH/NIAMS), is currently progression. Every year, thousands of modifying the indications for treat- under way. operations are performed for the pri- ment before and after the implemen- In 1996, the United States Pre- mary diagnosis of adolescent idiopathic tation of the screening program. Their ventive Services Task Force (USPSTF) scoliosis in patients between the ages of conclusion was that screening decreased concluded that there was insufﬁcient 10 and 18. This spinal disorder can have the demand for surgery because scolio- evidence to make a recommendation a signiﬁcant impact on the physical and sis would be detected at a younger age for, or against, screening. However, in psychosocial health of affected with smaller curves, thus having a better 2004, the USPSTF changed their posi- individuals. prognosis. tion and recommended against the Prevention of severe scoliosis is a Conversely, other investigators routine screening of asymptomatic ad- major commitment of orthopaedic sur- provided different conclusions. Yawn olescents for idiopathic scoliosis. The geons caring for spinal deformities. et al.3 reported on a population-based AAOS, SRS, POSNA, and AAP have Beginning in 1984, the AAOS and the school screening program in Rochester, concerns that this change in position by SRS formally endorsed the concept of Minnesota. In this retrospective cohort the USPSTF came in the absence of any school screening for the early detection study, 4.1% of the 2242 children signiﬁcant change in the available liter- of scoliosis in children whose defor- screened positively and were referred ature, in the absence of any change in mities may have gone unnoticed. This for evaluation. The positive predictive position statements by the AAOS, SRS, endorsement was based on the as- value was low (0.05) and they con- POSNA, and AAP, and in the absence of sumption that early detection in those cluded that roughly 450 children would any signiﬁcant input from specialists children at risk for worsening would need to be screened for every child who who commonly care for children with lead to the institution of nonoperative subsequently received treatment as a scoliosis. treatment that could have a positive result of screening. A limitation of this As the primary care providers for impact on the long-term natural history study is that the community in Roches- adolescents with idiopathic scoliosis, the of this disorder. Without treatment, ter is not representative of the general AAOS, SRS, POSNA, and AAP do not many curves could be expected to population, with more than 90% of support any recommendation against worsen over the long-term, with some of the population being white, having scoliosis screening, given the available them eventually needing surgical inter- higher-than-average income, and hav- literature. vention. In addition, those children with ing excellent access to specialized care. more signiﬁcant scoliosis, who may have A year later, the same no other symptoms, could be detected investigators4 examined issues related to Information Statement: by clinical screening at a time when charges, including the primary care Screening for Idiopathic Scoliosis surgical treatment for their deformity visit, orthopaedic surgeon visit, and ra- in Adolescents could be performed most effectively. diographs. The total costs were esti- mated to be $34.40 per child screened, Purpose Screening for Scoliosis—The Evidence $4,198.67 per case identiﬁed, and The purpose of the current information For and Against $15,115.20 per child treated. These esti- statement is to provide material to pa- Routine clinical screening for scoliosis mates were signiﬁcantly higher than tients, physicians, and decision makers continues to be controversial with less those previously reported. regarding issues related to screening for than half of the states in the United Twenty years ago, Morais et al.5 scoliosis. Screening is deﬁned as a clin- States currently legislating school concluded that the prevalence of the ical, rather than radiographic, screening. Previous studies have both disease was too low to beneﬁt from a examination. supported1,2 and discouraged routine screening program. The authors com- screening3-5. There have been no recent mented on their concern of radiation Introduction scientiﬁc publications on screening for exposure that the children may have Adolescent idiopathic scoliosis is a scoliosis. undergone following clinical screen- spine deformity characterized by lateral In 1993, Montgomery and Will- ing. Of note, radiation exposure is and rotational curvature of the spine. ner2 supported the routine use of school signiﬁcantly reduced with current It usually becomes evident in the screening. They reported that the in- techniques of shielding, the use of spe- early adolescent years and, although troduction of school screening pro- cial ﬁlms, and the institution of digital signiﬁcant progress has been made in grams decreased the relative risk of radiography. the genetic study of this disorder, its progression into a surgical range by a Each of the above studies has sig- cause presently remains unknown, thus factor of eight. They obtained an eight niﬁcant ﬂaws with regard to methodo- the label ‘‘idiopathic’’ scoliosis. Curve times greater risk of deterioration of the logical rigor. To date, no level I progression is unpredictable, though a curve to 45°, which would be diag- evidence studies have been performed 197 T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G d S C R E E N I N G F O R I D I O PAT H I C S C O L I O S I S V O LU M E 90 -A N U M B E R 1 J A N UA R Y 2 008 d d IN ADOLESCENTS on screening for scoliosis, and such a Treatment for Those Detected from school environment, provides the op- study is unlikely to be performed at the Scoliosis Screening portunity to diagnose the condition and current time. Therefore, deﬁnitive con- In general, treatment must attempt to make referral for appropriate medical clusions regarding the effectiveness of alleviate current problems and symp- care. Brace treatment in children with scoliosis screening cannot be made from toms and to ultimately alter long-term signiﬁcant scoliosis may avoid the need the available evidence in the literature. natural history. Brace treatment for for surgical intervention. Those with This concern was echoed by the 1996 scoliosis is the most effective primary deformities in need of surgery may be USPSTF report which concluded that nonoperative method used over the past identiﬁed by screening at a time when there was insufﬁcient evidence to make 40 years. In recent years, reﬁnements operative intervention can be per- a recommendation for, or against, have been made in identifying which formed most effectively. Many of these screening6. However, in 2004, the patients with idiopathic scoliosis may patients may otherwise go undetected, USPSTF changed their recommenda- beneﬁt most with this treatment9. particularly in patient populations un- tion7. Citing a low predictive value of With the information available in derserved by medicine. screening, a relatively small percentage the literature today, it is difﬁcult to Females achieve adolescence of children whose curves progress, and speak with absolute certainty about the about two years before males and are the possibility of unnecessary treatment effectiveness of bracing. There are no afﬂicted with a magnitude of scoliosis, including brace use, they issued a rec- level I evidence bracing studies currently requiring treatment three to four times ommendation against the routine in the literature. Though nearly all brace more frequently than males. As a result, screening of asymptomatic adolescents studies are level III or level IV evidence if scoliosis screening is undertaken, the for idiopathic scoliosis. Of note, the studies, many of them represent im- AAOS, SRS, POSNA, and AAP agree Task Force’s change in their recom- portant and well-organized research that females should be screened twice, at mendation was largely based on a and most conclude that brace treatment age 10 and 12 (grades 5 and 7), and boys change in methodological approach of is effective in diminishing curve pro- once, at age 13 or 14 (grades 8 or 9). the USPSTF, rather than any real change gression10-29. The most common pa- The AAOS, SRS, POSNA, and in available information. rameter used to assess the effectiveness AAP believe that school screening per- A recent article (May 2007) ex- of brace treatment is the amount of sonnel should be educated in the de- amined professional opinion concern- curve progression that occurs, usually tection of spinal deformity. Screening ing the effectiveness of bracing relative with success deﬁned by curve progres- should always include the forward to observation in adolescent idiopathic sion of £5 degrees at maturity. The bending test, the most speciﬁc test scoliosis8. The authors polled a group of other parameter used to assess the suc- for true scoliosis, though no single clinicians with signiﬁcant experience cess of brace treatment is the prevention test is completely reliable for screen- with scoliosis treatment. While there of surgery. A recent evidence-based re- ing. Therefore, considerable judgment was signiﬁcant variability in opinion view of the literature reported a 20% to on the part of the screener is neces- among the expert panel, on average, the 24% risk of needing surgery despite best sary to achieve an appropriate referral expert panel felt that bracing would efforts at bracing30. The risk of surgery rate and to avoid unnecessary referrals. decrease the risk of progression in pre- without any brace treatment in the same To meet the objectives of scoliosis menarchal patients by 20% to 30%, patient population is currently un- screening programs, the AAOS, SRS, depending on the exact clinical scenario. known. This fact alone emphasizes the POSNA, and AAP recognize the need to Thus, it appears that many of those who importance that a level I evidence study limit the number of referrals of those most commonly treat scoliosis perceive could have in clarifying the effectiveness individuals suspected of having a potential positive effect of bracing. of brace treatment in preventing the scoliosis. Representing the primary care need for surgery. Such a study, a ﬁve- The AAOS, SRS, POSNA, and providers for adolescents with idio- year multicenter randomized controlled AAP maintain their commitment to pathic scoliosis, the AAOS, SRS, trial of bracing sponsored by the NIH/ avoid the inappropriate use of spine POSNA, and AAP do not support any NIAMS, is currently under way. radiographs. Not all children referred formal recommendations against scoli- as a result of screening require radio- osis screening, given the available liter- Scoliosis Screening in 2007 graphs. If radiographs are needed, ature. All four societies recognize the Although the AAOS, SRS, POSNA, and physicians should take necessary pre- beneﬁts that can be provided by effec- AAP recognize that support for scoliosis cautions to limit the patient’s exposure tive clinical screening programs, in- screening has limitations, the potential to radiation. cluding (1) the potential prevention of beneﬁts that patients with idiopathic Educational materials that pro- deformity progression by brace treat- scoliosis receive from early treatment of vide more speciﬁc guidelines for con- ment and (2) the earlier recognition of their deformities can be substantial. ducting school screening programs for severe deformities requiring operative Scoliosis screening, whether in the scoliosis are available to physicians and correction. physician’s ofﬁce, nurses’ clinics, or school authorities. 198 T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G d S C R E E N I N G F O R I D I O PAT H I C S C O L I O S I S V O LU M E 90 -A N U M B E R 1 J A N UA R Y 2 008 d d IN ADOLESCENTS 9. Richards BS, Bernstein RM, D’Amato CR, 20. Katz DE, Durrani AA. Factors that inﬂuence B. Stephens Richards, MD Thompson GH. Standardization of criteria for outcome in bracing large curves in patients with Texas Scottish Rite Hospital for Children, 2222 adolescent idiopathic scoliosis brace studies: SRS adolescent idiopathic scoliosis. Spine. Welborn Drive, Dallas, TX 75219. E-mail Committee on Bracing and Nonoperative 2001;26:2354-61. address: firstname.lastname@example.org Management. Spine. 2005;30:2068-77. 21. Lonstein JE, Winter RB. The Milwaukee brace for 10. Allington NJ, Bowen JR. Adolescent idiopathic the treatment of adolescent idiopathic scoliosis. A Michael G. Vitale, MD scoliosis: treatment with the Wilmington brace. A review of one thousand and twenty patients. J Bone comparison of full-time and part-time use. 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J. 2003;12:141-8. based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995; 2. Montgomery F, Willner S. Screening for idiopathic 13. D’Amato CR, Griggs S, McCoy B. Nighttime 77:815-22. scoliosis. Comparison of 90 cases shows less bracing with the Providence brace in adolescent surgery by early diagnosis. Acta Orthop Scand. girls with idiopathic scoliosis. Spine. 2001;26: 24. Olafsson Y, Saraste H, Soderlund V, Hoffsten M. 1993;64:456-8. 2006-12. Boston brace in the treatment of idiopathic scoliosis. J Pediatr Orthop. 1995;15:524-7. 3. Yawn BP, Yawn RA, Hodge D, Kurland M, 14. Danielsson AJ, Nachemson AL. Radiologic Shaughnessy WJ, Ilstrup D, Jacobsen SJ. A ﬁndings and curve progression 22 years after 25. Price CT, Scott DS, Reed FR Jr, Sproul JT, population-based study of school scoliosis screening. treatment for adolescent idiopathic scoliosis: Riddick MF. Nighttime bracing for adolescent JAMA. 1999;282:1427-32. comparison of brace and surgical treatment with idiopathic scoliosis with the Charleston Bending matching control group of straight individuals. Spine. Brace: long-term follow-up. J Pediatr Orthop. 4. Yawn BP, Yawn RA. The estimated cost of school 2001;26:516-25. 1997;17:703-7. scoliosis screening. Spine. 2000;25:2387-91. 15. Emans JB, Kaelin A, Bancel P, Hall JE, Miller ME. 26. Rowe DE, Bernstein SM, Riddick MF, Adler F, 5. Morais T, Bernier M, Turcotte F. Age- and sex- The Boston bracing system for idiopathic scoliosis. Emans JB, Gardner-Bonneau D. A meta-analysis of the speciﬁc prevalence of scoliosis and the value of Follow-up results in 295 patients. Spine. 1986; efﬁcacy of non-operative treatments for idiopathic school screening programs. Am J Public Health. 11:792-801. scoliosis. J Bone Joint Surg Am. 1997;79:664-74. 1985;75:1377-80. 16. Fernandez-Feliberti R, Flynn J, Ramirez N, 27. Trivedi JM, Thomson JD. 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