Get documents about "Screening for Idiopathic Scoliosis in Adolescents
Document Sample
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: steve.richards@tsrh.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. J Bone Joint Surg Am. 1994;76:1207-21.
Children’s Hospital of New York–Presbyterian, Joint Surg Am. 1996;78:1056-62.
3959 Broadway, 8 North, New York, NY 10032 22. Montgomery F, Willner S. Prognosis of brace-
11. Carr WA, Moe JH, Winter RB, Lonstein JE. treated scoliosis. Comparison of the Boston and
Treatment of idiopathic scoliosis in the Milwaukee Milwaukee methods in 244 girls. Acta Orthop Scand.
brace. J Bone Joint Surg Am. 1980;62:599-612. 1989;60:383-5.
References 12. Coillard C, Leroux MA, Zabjek KF, Rivard CH. 23. Nachemson AL, Peterson LE. Effectiveness of
1. Ashworth MA, Hancock JA, Ashworth L, Tessier KA. SpineCor–a non-rigid brace for the treatment of treatment with a brace in girls who have adolescent
Scoliosis screening. An approach to cost/benefit idiopathic scoliosis: post-treatment results. Eur Spine idiopathic scoliosis. A prospective, controlled study
analysis. Spine. 1988;13:1187-8. 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. Results of Charleston
6. U.S. Preventive Services Task Force (USPSTF).
Trautmann M, Alegria M. Effectiveness of TLSO bracing in skeletally immature patients with idiopathic
Recommendation statement: screening for idiopathic
bracing in the conservative treatment of idiopathic scoliosis. J Pediatr Orthop. 2001;21:277-80.
scoliosis in adolescents. 1996. http://
scoliosis. J Pediatr Orthop. 1995;15:176-81.
www.ncbi.nlm.nih.gov/books/ 28. Wiley JW, Thomson JD, Mitchell TM, Smith BG,
bv.fcgi?rid=hstat3.section.10931#14788. Accessed 17. Gepstein R, Leitner Y, Zohar E, Angel I, Shabat S, Banta JV. Effectiveness of the boston brace in
31 Oct 2007 Pekarsky I, Friesem T, Folman Y, Katz A, Fredman B. treatment of large curves in adolescent idiopathic
Effectiveness of the Charleston bending brace in the scoliosis. Spine. 2000;25:2326-32.
7. U.S. Preventive Services Task Force (USPSTF).
treatment of single-curve idiopathic scoliosis. J
Recommendation statement: screening for idiopathic o
29. Yrj¨ nen T, Ylikoski M, Schlenzka D, Kinnunen R,
Pediatr Orthop. 2002;22:84-7.
scoliosis in adolescents. 2004 Jun. http:// Poussa M. Effectiveness of the Providence nighttime
www.ahrq.gov/clinic/3rduspstf/scoliosis/ 18. Green NE. Part-time bracing of adolescent bracing in adolescent idiopathic scoliosis: a
scoliors.htm#ref1. Accessed 31 Oct 2007 idiopathic scoliosis. J Bone Joint Surg Am. 1986; comparative study of 36 female patients. Eur Spine J.
68:738-42. 2006;15:1139-43.
8. Dolan LA, Donnelly MJ, Spratt KF, Weinstein SL.
Professional opinion concerning the effectiveness of 19. Katz DE, Richards BS, Browne RH, Herring JA. A 30. Dolan LA, Weinstein SL. Surgical rates after
bracing relative to observation in adolescent comparison between the Boston brace and the observation and bracing for adolescent idiopathic
idiopathic scoliosis. J Pediatr Orthop. 2007;27: Charleston bending brace in adolescent idiopathic scoliosis: an evidence-based review. Spine.
270-6. scoliosis. Spine. 1997;22:1302-12. 2007;32(19 Suppl):S91-S100.
Related docs
