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USPSTF goes neutral on adolescent scoliosis screening

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Major research gaps identified

Twenty or more states, including highly populous states such as California, New York, Ohio, and Texas, mandate or strongly recommend school-based screening for scoliosis ... Given the new USPSTF recommendations and the I statement [suggesting insufficient evidence], it would be appropriate for states to advise students and parents of the insufficient data about benefits and harms of screening, while also sharing more recent evidence that bracing and exercise therapies may be helpful if scoliosis is clinically diagnosed in screen-positive youth.

The broad lack of evidence regarding the short-term effect of screening for adolescents and long-term health outcomes in later adolescence and into adulthood is a clear obstacle to moving adolescent idiopathic scoliosis recommendations beyond the I rating. Consequently, the gaps in current understanding serve to highlight immediate opportunities for clinical and health services research. For example, a multisite, multiyear observational study could provide evidence about the association between reduction in spinal curvature in adolescence and long-term health outcomes.

John Sarwark, MD , is head of orthopedic surgery at Ann & Robert H. Lurie Children’s Hospital and a professor of orthopedic surgery at Northwestern University, both in Chicago. Matthew Davis, MD , is head of academic general pediatrics and primary care at Lurie and a pediatrics professor at Northwestern. They made their comments in an editorial published Jan. 9 in JAMA and were not involved with the work ( 2018;319(2):127-129) .



The U.S. Preventive Services Task Force neither recommended for nor recommended against routine screening for adolescent idiopathic scoliosis in new guidelines published Jan. 9 in JAMA.

The determination applies to asymptomatic adolescents 10-18 years old; it does not apply to children and adolescents who present with back pain, breathing difficulties, obvious spine deformities, or abnormal imaging.

A film x-ray show a spinal bend of a teenage patient with Scoliosis. Draw05/Thinkstock
The determination is a switch from the last guidance offered in 2004, when the task force decided that screening harms – false-positives, unnecessary radiation exposure, and the psychosocial effect of being tagged with a potentially nonsignificant problem, among others – outweigh the evidence of benefit.

Studies since then, however, have shifted the calculus a bit so that the group “no longer has moderate certainty that the harms of treatment outweigh the benefits ... As a result, the USPSTF has determined that the current evidence is insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis,” which led the group to issue an “I statement” for “insufficient evidence,” David C. Grossman, MD, MPH, of Kaiser Permanente

Washington Health Research Institute, Seattle, and the other members of the task force wrote.

An I statement means that “if the service is offered, patients should understand the uncertainty about the balance of benefits and harms ... The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation.”

The task force did find that screening using the forward bend test, scoliometer, or both with radiologic confirmation does a good job at detecting scoliosis. It also found a growing body of evidence that bracing can interrupt or slow scoliosis progression; “however, evidence on whether reducing spinal curvature in adolescence has a long-term effect on health in adulthood is inadequate,” and “evidence on the effects of exercise and surgery on health or spinal curvature in childhood or adulthood is insufficient.” Also, the majority of individuals identified through screening will never require treatment, the task force said.

The guidance is based on a review of 448,276 subjects in 14 studies, more than half of which were published after the last guidance.

USPSTF noted that limited new evidence suggests curves “may respond similarly to physiotherapeutic, scoliosis-specific exercise treatment; if confirmed, this may represent a treatment option for mild curves before bracing is recommended.”

Meanwhile, “surgical treatment remains the standard of care for curves that progress to greater than 40-50 degrees; however, there are no controlled studies of surgical [versus] nonsurgical treatment in individuals with lower degrees of curvature,” the task force said in an evidence review that was also published Jan. 9 in JAMA and was led by pediatrician John Dunn, MD, of Kaiser Permanente Washington Health Research Institute, Seattle.

More than half of US states either mandate or recommend school-based screening for scoliosis. The American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics advocate screening for scoliosis in girls at 10 and 12 years and in male adolescents at either 13 or 14 years as part of medical home preventive services. The United Kingdom National Screening Society does not recommend screening for scoliosis given the uncertainty surrounding the effectiveness of screening and treatment.

The work was funded by the Agency for Healthcare Research and Quality. The authors had no relevant disclosures.

SOURCE: US Preventive Services Task Force. JAMA. 2018 Jan 9;319(2):165-72; Dunn J et al. JAMA. 2018;319(2):173-87.

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