Screening for Idiopathic Scoliosis in Adolescents by kse10139

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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

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                                      C OPYRIGHT Ó 2008    BY   T HE J OURNAL   OF   B ONE   AND J OINT   S URGERY, I NCORPORATED




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                    Orthopaedic
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       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
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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
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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.
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