Full Text Review
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
Contents
Overview
In 1979,
the Canadian Task Force on the Periodic Health Examination reviewed the
evidence then available and concluded that there was poor evidence to support
the inclusion or exclusion of routine adolescent idiopathic scoliosis screening
in the periodic health examination< 1>
(C Recommendation). A detailed review by one of the Task Force members
was published subsequently.<2> A more recent, updated review of the
evidence by the U.S. Preventive Services Task Force<3> using the same
methodology, arrived at the same conclusion. The Canadian Task Force concurs
with the U.S. Task Force analysis and conclusions.
Burden
of Suffering
A study of over 29,000 children in a community health
district of the province of Quebec demonstrated a prevalence of scoliosis
of 42 per 1,000
in children aged 8-15
years. The Scoliosis Research Society defines scoliosis as a curve of 11°
or
greater. Such curves are reported to have a prevalence of 2-3% in adolescents
at the end of their growth period. Curves which are greater than 40°-50°
have
a reported prevalence of 0.2% and cause disability and significant health
problems later in life. Several investigators have reported the ratio of
affected girls to boys as 1.5:1
and
the prevalence of large and small curves is higher in girls. However, the
prevalence of cases needing treatment in either sex is very low. 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.
There is little firm evidence from epidemiologic
studies that persons with idiopathic scoliosis are at significantly greater
risk of experiencing back pain than the general population. The incidence
of back pain in the general population may be as high as 60-80% and it
is unclear whether the incidence of pain is higher in persons with scoliosis.
Pulmonary disease and other serious health effects attributable to idiopathic
scoliosis occur in individuals with large curves that are easily detected
without screening.
Maneuver
The principal screening test for scoliosis is physical
examination including upright visual inspection of the back and the Adams
forward bending test. The sensitivity and specificity of this examination
in detecting curves greater than 10°
have
been reported as 73.9% and 77.8%, respectively.<4> In an Australian
study, the positive predictive value (PPV) was 78% for curves greater than
5° in a population
with an estimated prevalence for this degree of curvature of 3%.<5>
A Canadian study involving specially trained school nurses reported a PPV
of 18% in
detecting curves greater than 20°.<6>
Based on an extensive prevalence study, Morais et
al<6> estimated the PPV of the forward bending test as 42.8% for scoliotic
curves of 5° or
more, and only 6.4% when curves of 15°
or
more were considered. In typical screening settings where the prevalence
and PPV are relatively low, for every curve >10°
detected,
there are 1-5
false positives; and for every curve >20°
detected
there are 3-24 false positives.<3> There is little evidence about the
incremental value of repeat screening in individuals with previously normal
results. There is insufficient evidence to evaluate the role of other tests,
e.g. inclinometry or Moiré topography, as screening instruments.<7-9>
Effectiveness
of Screening and Treatment
Any proposal to screen for adolescent idiopathic scoliosis
requires that several conditions be met:
-
That the screening test is accurate and reliable detecting
curves that are both clinically significant and unlikely to be detected
otherwise.
-
That earlier detection leads to improved health outcomes.
-
That effective treatment is available for cases detected
through screening.
-
That scoliosis causes important health problems.
-
That small curves detected by screening are likely to
progress to degrees of clinical significance.
-
That the benefits of early detection through screening
outweigh any adverse effects of screening and treatment.
There have been no controlled studies to demonstrate
that adolescents who are screened routinely for scoliosis have better outcomes
than those who are not screened. There are no studies demonstrating a decrease
in spinal fusions by screening or brace treatment. In communities that
have adopted aggressive screening programs, favourable trends in curve
size and surgery rates have been reported but it is unclear whether such
changes are attributable to screening or to other temporal factors.<10-12>
Brace Therapy
There is inadequate evidence to determine whether brace
therapy limits the natural progression of scoliosis in a significant number
of cases. Most evidence concerning its effectiveness comes from uncontrolled
case series reports. Early reports with limited follow-up had suggested
significant degrees of correction. However, long-term studies involving
more than 5 years of follow-up have shown a gradual loss of correction,
with mean overall improvement averaging 2-4% compared with pre-brace curves.<13,14>
One retrospective, case-controlled study showed that braced patients had
a somewhat reduced rate of curve progression as compared to matched controls,
but the difference was not statistically significant.<15>
There have been no controlled studies that provide information on health
outcomes such as back pain, self-esteem or psychosocial impact. Finally,
compliance with the wearing of a brace is frequently poor.<16,17>
An ongoing multicentre trial of brace therapy should provide additional
information on its effectiveness.
Lateral Electrical
Surface Stimulation (LESS)
Available studies of effectiveness offer little evidence
that LESS results in better clinical outcomes than braces or other forms
of conservative treatment.<18-23>
Exercise
Exercise has been suggested as a means of preventing
the need for more extensive treatment or as an adjunct to the wearing of
a brace.<24> Although published studies are few, exercise alone has
historically demonstrated poor effectiveness in controlling curve progression.<24,25>
A school-based program failed to show any difference in curve progression
after one year between a group treated with exercise and matched controls.<25>
By contrast, a small randomized, controlled trial of scoliotic adolescents
wearing a cast showed that exercise was more effective than traction in
improving curves on lateral bending.<26> An uncontrolled cohort study
showed improved vital capacity in hospitalized scoliosis patients who received
physiotherapy;<27> and a report of an uncontrolled case-series suggested
that some braced patients who performed a thoracic flexion exercise had
reduced vertebral rotation and thoracic curves after exercise.<28> However,
this study lacked controls, follow-up and an assessment of clinical outcomes.
Surgery
Surgery is currently recommended only if a curve progresses
to more than 40-50° or
if the procedure is requested for cosmetic reasons. The goals of internal
fixation are to reduce the rib hump, correct spinal rotation and to obtain
solid fusion and stability. The most well-established procedure is Harrington
instrumentation. Others include Cotrel-Dubousset instrumentation, the Zielke
procedure and Luque sublaminar wiring.
Surgical techniques appear to be effective in reducing,
but not eliminating, the lateral scoliotic curve.<29-33> Axial rotation
is less effectively controlled surgically, and deformities in the sagittal
plane can be exaggerated.<34> Few controlled studies of functional status
following surgery have been reported. There is no evidence that early detection
of severe instances of scoliosis through screening improves surgical outcomes.
Adverse Effects
of Screening and Treatment
Although the initial screening examination has insignificant
adverse effects problems may be associated with follow-up testing of presumed
abnormal findings. Roentgenograms are not obtained routinely on all follow-up
evaluations however, many physicians obtain them to rule out significant
deformity and to provide a baseline for future comparisons. Further evaluation
of the patient may generate anxiety and affect future health insurance
and work eligibility. These are postulated adverse effects and have not
been proven in controlled studies.
Conservative treatment such as braces and LESS may
have adverse medical and psycho-social effects. An association between
brace wear and diminished self-esteem and disturbed peer relationships
has been documented. LESS can produce uncomfortable sensations from the
electrical stimulus, sleep disturbance and skin irritation but reliable
data on these adverse effects are not available. There are few significant
adverse effects associated with exercise therapy.
The potential adverse effects of surgery can be more
substantial. In addition to the general risk of surgery they include financial
cost, lost productivity and external immobilization with casts or braces,
which may be required for months after surgery. Potential long-term effects
occur generally in adults and include chronic pain syndromes and other
complications that may require further surgery.<30,35-37>
Costs
There have been few formal analyses of the cost effectiveness
of screening for scoliosis. A Quebec study estimated a cost of $2.31
per
child for screening and $59.60 per child for the clinical evaluation of
positive cases; the total cost of case finding was $194.27
per case of confirmed scoliosis and $3,505.49 per case of scoliosis brought
to treatment. No studies have fully evaluated the direct and indirect costs
of screening.
Recommendations
of Others
The Scoliosis Research Society has recommended annual
screening of all children aged 10-14
years. The American Academy of Orthopedic Surgeons has recommended screening
girls at ages 11 and
13
years, and boys once at age 13
or 14 years.
The American Academy of Pediatrics has recommended scoliosis screening
at routine health supervision visits at ages 10,
12,
14
and 16. Fifteen
of the U.S. States require scoliosis screening by law, and 31
have
voluntary programs. Only two of the 10
Canadian provinces (Alberta and Prince Edward Island) are officially engaged
in scoliosis screening, in one instance for research projects only. By
contrast, the British Orthopaedic Association and the British Scoliosis
Society issued a statement in 1983
advising against a national policy of screening for scoliosis in the United
Kingdom. Individual authors who have conducted extensive reviews of the
evidence have reached similar conclusions.
Conclusions
and Recommendations
There is insufficient evidence from published clinical
research to indicate that screening for idiopathic scoliosis in adolescents
is either effective or ineffective in improving the outcome (C
Recommendation). It is reasonable for clinicians to include periodic
visual inspection of the back in their examination of adolescents seen
for other reasons. Clinicians and public health personnel should bear in
mind the limited current evidence regarding the effectiveness of scoliosis
screening and treatment and the uncertainties about the natural history
of the condition.
Unanswered
Questions (Research Agenda)
Well-designed clinical trials are needed to evaluate
the effectiveness or ineffectiveness of routine screening for adolescent
idiopathic scoliosis. The cost-effectiveness of scoliosis screening cannot
be determined until its clinical effectiveness has been demonstrated.
Evidence
The literature was identified with a MEDLINE search
for the English language in the years 1980
to 1992,
using the following strategy: MESH term scoliosis and key words screening,
Cobb, brace, exercise or physical and surgery supplemented by references
cited in bibliographies and reviewer comments.
This review was initiated in January 1993
and the recommendations finalized by the Task Force in June 1993.
Full Citation
Link to Structured Abstract of
this review
Link to Summary Table of this
review
Link to Selected References list of this review
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