Published online June 2, 2008
PEDIATRICS Vol. 121 No. 6 June 2008, pp. 1297-1298 (doi:10.1542/peds.2008-0773)

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LETTER TO THE EDITOR

Estimating the Effectiveness of Screening for Scoliosis: In Reply

Eveline M. Bunge, MSc
Harry J. de Koning, MD, PhD
Department of Public Health
Erasmus Medical Center
University Medical Center Rotterdam
3000 CA Rotterdam, Netherlands

We thank Richards et al for their comments. We also feel that screening may be justified if screening is effective in preventing surgery in adolescents with scoliosis. However, in our level II-2 evidence study¹ (not IV), we did not find evidence for that, which is in line with an earlier case-control study.²

Richards et al mention that most studies have concluded that brace treatment is effective. However, they did not mention a number of studies that have raised doubt on its effectiveness.^3–5 Dolan and Weinstein⁶ recently published a systematic review of clinical data concerning surgical rates. The pooled surgical rate was 23% after bracing and 22% after observation. They concluded that this provided no evidence to recommend bracing over observation, which means that one of the most important conditions (ie, effective early treatment) before a screening program can be justified has not been met.⁷

Richard et al mention that our report lacked information on patients whose spinal deformities were detected by screening and who were braced successfully. This was actually the first step of our screening evaluation.⁸ We found that screening-detected patients were detected in an earlier stage of the clinical course and that they needed less surgery than the otherwise-detected patients. However, such designs are susceptible to bias.^8,9 Length bias can occur because patients with slow progressive curves have more chance of being detected by screening and less chance of needing surgery than patients with rapidly progressive curves. These patients will be overrepresented in the screening group, thereby overestimating the effect of screening. Overtreatment bias can occur, because by screening more patients will be detected, which can lead to unnecessary treatment of patients who would not need treatment if they had not been screened.

In the Netherlands, there is considerable variation in screening exposure, a prerequisite for a case-control study. If screening for scoliosis would be effective in reducing the need for surgery, then one would expect that patients who needed surgery had been screened less frequently than those in the general population.¹⁰ We could not establish that.¹¹ Half of these surgically treated patients were treated with a brace for 2.5 years before surgery.¹¹ It seems unlikely that these patients represented a group that was "wrongly" treated with a brace, because they were treated by the same orthopedic surgeons who treated the "successfully" braced patients in the preceding study,⁸ although we agree that there is lack of detailed information on compliance.¹¹

Naturally, we recommend orthopedic surgeons to care for individual patients. However, at the same time, apparently, there was momentum to start 2 randomized, controlled trials on the effect of bracing (the Bracing in Adolescent Idiopathic Scoliosis Trial [BrAIST] [see http://clinicaltrials.gov/ct2/show/NCT00448448] and the Effectiveness of Bracing Patients With Adolescent Idiopathic Scoliosis study [see www.trialregister.nl/trialreg/admin/rctsearch.asp?Term=ISRCTN36964733]). For these trials to succeed, it is imperative that orthopedic surgeons explain the current uncertainty about brace effectiveness in a correct and well-balanced way to patients and parents. If these trials establish that bracing is effective, then it would be worthwhile to determine which children could benefit from a screening program.

REFERENCES

1. US Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996
2. Wiegersma PA, Hofman A, Zielhuis GA. The effect of school screening on surgery for adolescent idiopathic scoliosis. Eur J Public Health. 1998;8 (3):237 –240[Abstract/Free Full Text]
3. Dickson RA, Weinstein SL. Bracing (and screening): yes or no? J Bone Joint Surg Br. 1999;81 (2):193 –198[CrossRef][Medline]
4. Focarile FA, Bonaldi A, Giarolo MA, Ferrari U, Zilioli E, Ottaviani C. Effectiveness of nonsurgical treatment for idiopathic scoliosis: overview of available evidence. Spine. 1991;16 (4):395 –401[CrossRef][Web of Science][Medline]
5. Goldberg CJ, Dowling FE, Hall JE, Emans JB. A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls. Spine. 1993;18 (7):902 –908[Web of Science][Medline]
6. Dolan LA, Weinstein SL. Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review. Spine. 2007;32 (19 suppl):S91 –S100[CrossRef][Web of Science][Medline]
7. Wilson J, Junger C. Principles and Practice of Screening for Disease. Geneva, Switzerland: World Health Organization; 1968. WHO public health paper 34
8. Bunge EM, Juttmann RE, de Koning HJ; Steering Committee of the NESCIO Group. Screening for scoliosis: do we have indications for effectiveness? J Med Screen. 2006;13 (1):29 –33[Abstract/Free Full Text]
9. Juttmann RE, Hess J, van Oortmarssen GJ, van der Maas PJ. Patient follow up screening evaluations: examples with regard to congenital hip dislocation and congenital heart disease. J Epidemiol Community Health. 2001;55 (2):126 –131[Abstract/Free Full Text]
10. Weiss NS. Application of the case-control method in the evaluation of screening. Epidemiol Rev. 1994;16 (1):102 –108[Free Full Text]
11. Bunge EM, Juttmann RE, van Biezen FC, et al. Estimating the effectiveness of screening for scoliosis: a case-control study. Pediatrics. 2008;121 (1):9 –14[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Bunge, E. M. Articles by de Koning, H. J. Search for Related Content PubMed Articles by Bunge, E. M. Articles by de Koning, H. J. Related Collections Premature & Newborn Social Bookmarking                         What's this?