CTF Structured Abstract: Idiopathic Adolescent Scoliosis

Canadian Task Force on Preventive Health Care

Structured Abstract

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Screening for Idiopathic Adolescent Scoliosis

Adapted by Richard B. Goldbloom, OC, MD, FRCPC, Department of Pediatrics, Dalhousie University from the report prepared for the US Preventive Services Task Force by Steven H. Woolf, MD, MPH

These recommendations were finalized by the Task Force in June 1993

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To make recommendations for screening for and treatment of Canadian adolescents for idiopathic scoliosis. This is an update of the 1979 Canadian Task Force guidelines.

Burden of Suffering

The Scoliosis Research Society defines scoliosis as a curve of 11 degrees or greater. Such curves are reported to have a prevalence of 2-3% in adolescents at the end of their growth period, with curves which are greater than 40-50 degrees having a reported prevalence of 0.2%, resulting in disability and significant health problems later in life. Potential adverse effects include cosmetic deformity, back pain, social and psychological problems (e.g. poor self-image, social isolation), limited job opportunities, lower marriage rate and the financial costs of treatment. Pulmonary disease and other serious health effects attributable to idiopathic scoliosis occur in individuals with large curves that are easily detected without screening.

Options

Screening options include physical examination with upright visual inspection of the back and the Adams forward bending test inclinometry, and Moiré topography. Treatment options include brace therapy, lateral electrical surface stimulation, exercise, and therapy.

Outcomes

Sensitivity and specificity of screening tests, rates of surgery, degree of curvatures, adverse effects of treatments (psychosocial effects, discomfort, sleep disturbances, skin irritation, lost productivity, and chronic pain) and costs of screening and treatment.

Evidence

MEDLINE was searched from 1980 to 1992 using the terms scoliosis, screening, Cobb brace, exercise, physical, and surgery. Bibliographies of relevant articles were searched and experts were contacted.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings from January to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

Physical examination and the Adams forward bending test for curvatures of > 10 degrees have a sensitivity of 74% and specificity of 78% and the positive predictive value has a range of 6% to 78%. One study found that for every curvature of > 10 degrees, 1 to 5 false positive cases are detected and for each curve of > 20 degrees detected, 3 to 24 false positive cases are detected. Inclinometry and Moiré topography have insufficient evidence for decision making.

No controlled trials have shown screening or braces have better outcomes or a decrease in rate of spinal fusions than no screening for idiopathic adolescent scoliosis.

Uncontrolled case series reports have shown that brace therapy limits the natural progression of scoliosis. Corrections decrease over time, however. Lateral electrical surface stimulation has better evidence to support its use.

Some studies lacking controls or having methodology problems have suggested that exercise can reduce the need for more extensive treatment.

Surgery is recommended for curvatures of more than 40 to 50 degrees and is done to reduce rib hump, correct spinal rotation, and obtain solid fusion and stability. Surgery reduces, but does not eliminate, spinal curvature. Early detection has not been shown to improve surgical outcomes.

Adverse effects of early detection are labelling and psychosocial effects such as poor self-esteem. Adverse effects of treatment are discomfort, sleep disturbances, skin irritation, high costs, loss of productivity, chronic pain, and further surgery.

Costs were determined from 1 study done in Quebec. Costs were $2.31 to screen each child, $60 per child who goes on to clinical evaluation of positive cases, $194 per case found, and $3505 per reported case brought to treatment.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is poor evidence to include or exclude physical examination of the back (Adams forward bending test) to detect idiopathic scoliosis in the PHE of adolescents [C, II-2, III].

Validation

This report was externally peer reviewed. The Scoliosis Research Society recommends screening for all children 10 to 14 years of age. The American Academy of Orthopedic Surgeons recommended screening for girls at age 11 and 13 and once for boys at 13 to 14 years of age. The American Academy of Pediatrics recommends screening at regular visits (10, 12, 14, and 16 years of age). 2 provinces and 15 U.S. states have legislated screening and 31 states have voluntary programs. The British Orthopaedic Association and the British Scoliosis Society recommend against screening.

Selected References

Source Document

Goldbloom R.B. Screening for idiopathic adolescent scoliosis. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 346-54.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

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A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.