PEDIATRICS Vol. 121 No. 6 June 2008, pp. 1296-1297 (doi:10.1542/peds.2008-0234)
LETTER TO THE EDITOR |
Estimating the Effectiveness of Screening for Scoliosis
B. Stephens Richards, MDPresident-Elect
Pediatric Orthopaedic Society of North America
Rosemont, IL 60018-4226
James H. Beaty, MD
President
American Academy of Orthopaedic Surgeons
Rosemont, IL 60018-4262
George H. Thompson, MD
President
Scoliosis Research Society
Milwaukee, WI 53202-3823
R. Baxter Willis, MD
President
Pediatric Orthopaedic Society of North America
Rosemont, IL 60018-4226
To the Editor.—
On behalf of the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, and the Pediatric Orthopaedic Society of North America, we are writing to express our concern regarding the recent article entitled "Estimating the Effectiveness of Screening for Scoliosis: A Case-Control Study" by Bunge et al.1 In this level IV evidence case-control diagnostic study, the authors concluded that there was no evidence that screening for scoliosis reduced the need for surgery and that abolishing screening seemed justified. We believe the information found in the article provided no support for making these statements and that the conclusions are erroneous.
Prevention of severe scoliosis is a major commitment of physicians who care for children with spinal deformities. With this in mind, the goal of scoliosis screening is twofold. First, we need to identify those patients with curves that are at risk for progression to the point at which surgical intervention becomes necessary. Doing so allows the physician to introduce nonoperative brace treatment that may prevent the need for surgery. Although nearly all brace studies are level III or IV evidence studies, many of them represent important and well-organized research, and most conclude that brace treatment is effective in diminishing curve progression.2–21 The effectiveness of bracing will be further clarified after completion of a level I study that is currently being sponsored by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. The second goal of scoliosis screening is to identify those patients with severe curves that are in need of operative correction before the magnitude of the deformity compromises an optimal surgical outcome.
In their article, Bunge et al selected 108 patients from 10 different institutions in the Netherlands who were treated surgically for idiopathic scoliosis and compared their exposure to scoliosis screening with a similarly matched control group without scoliosis. They reported exposure to screening in 80.5% of the surgery group and 74% of the control group. The majority of the article then focused on the surgically treated patients, comparing those who had been screened with those who had not been screened. As would be expected, the authors found that the screening-detected patients who ultimately needed surgery had significantly smaller curves at the time of diagnosis (34°) compared with otherwise-detected surgical patients (46°) (P < .01). Screening-detected patients were also 2.5 years younger at detection and at the time of formal diagnosis of scoliosis.
What was noticeably absent in this report was any information on patients whose spinal deformities were detected by screening and who then were treated successfully by bracing alone. Perhaps they represented a large number of successful outcomes; we do not have that information to know. In addition, for those surgically treated patients in this study who were screened, braced, and still progressed to operative intervention, no information was reported on the brace treatment that was rendered, such as curve magnitude or maturity at brace initiation, type of brace, hours prescribed per day, duration of bracing, or compliance. To simply compare whether a surgically treated patient had been screened and then forgo any information on the nonoperative treatment that could be initiated once the scoliosis was detected provides no basis for determining a lack of evidence for the value of screening. It also does not provide any justification for making the statement that "abolishing screening seems justified."
In 2007, the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics convened a task force to examine issues related to scoliosis screening and put forth an information statement. The resulting statement was endorsed by all 4 societies and was recently published in the American Journal of Bone and Joint Surgery.22 As summarized in that statement, all 4 societies (as the primary care providers for adolescents with idiopathic scoliosis) recognized the benefits that can be provided by effective clinical screening programs, including (1) the potential prevention of deformity progression by brace treatment and (2) the earlier recognition of severe deformities requiring operative correction. As such, none of these 4 societies support any recommendation against scoliosis screening, given the available literature.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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