USPSTF: Data Insufficient for Scoliosis Screening

Diana Phillips

January 11, 2018

In a revised recommendation statement on routine screening of adolescents for asymptomatic scoliosis, the US Preventive Services Task Force (USPSTF) no longer discourages screening but states there is insufficient evidence to determine the balance of benefits and harms.

The USPSTF published the updated recommendation in the January 9 issue of JAMA.

The updated recommendation statement reflects the findings of an evidence report prepared by John Dunn, MD, from Kaiser Permanente Research Affiliates Evidence-based Practice Center in Seattle, Washington, and colleagues, which appears in the same issue and includes new evidence suggesting the benefit of scoliosis screening.

Called an "I statement," this conclusion supplants the USPSTF's 2004 final recommendation against screening in this population, made on the basis of D-grade evidence.

Grade D evidence indicates moderate or high certainty that the service or treatment has no net benefit or that the harms outweigh the benefits. In contrast, an "I" statement indicates that the available evidence is lacking, of poor quality, or conflicting, and as such is insufficient to assess the balance of benefits and harms of the service or treatment.

In particular, the evidence suggests that screening programs using the Adams forward bend test paired with scoliometer measurements and Moire topography have the highest sensitivity (93.8%; 95% confidence interval [CI], 93.3% - 94.3%) and specificity (99.2%; 95% CI, 99.2% - 99.2%). This combination also produces the highest positive predictive value (81.0%; 95% CI, 80.3% - 81.7%) and, on the basis of one study, the lowest false-positive rate (0.8%), the recommendation authors report. Single screening tests are associated with the highest false-positive rates.

In contrast to the 2004 evidence review, which identified moderate harms associated with treating screen-detected adolescent idiopathic scoliosis at that time, including unnecessary bracing and referral to specialty care, the new systematic data review found adequate evidence that treatment with bracing may decrease scoliosis progression in adolescents with mild or moderate curvature severity and only limited available evidence on the harms of screening and treatment.

"Although the USPSTF previously found that treatment has moderate harms, a change in the analytic framework, outcomes, and applicability of older evidence resulted in the USPSTF assessing the evidence on harms of treatment as inadequate," the authors state.

Similar to the 2004 review, the updated review found no direct evidence linking screening with health outcomes and inadequate evidence on treatment with exercise and surgery. "Therefore, the USPSTF concludes that the current evidence is insufficient and that the balance of benefits and harms of screening for adolescent idiopathic scoliosis cannot be determined," the revised statement authors write.

In an evaluation of the evidence "fit" with the biological understanding of scoliosis, the authors note that mild/moderate idiopathic scoliosis, defined as Cobb angle of less than 40° to 50°, is often asymptomatic in adolescence and does not progress substantially. Further, "[t]he likelihood of progression in adulthood is small for persons with a spinal curvature of less than 30° at skeletal maturity," they write. "However, there is no validated way to easily identify which cases of asymptomatic scoliosis will worsen during adolescence and lead to poor long-term outcomes."

According to the USPSTF, the recommendations recognize "that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation."

Despite the insufficient evidence, multiple professional and advocacy organizations, including the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics, recommend screening for scoliosis in girls at 10 and 12 years of age and one time in boys at age 13 or 14 years as part of routine preventive health services, "if screening is performed by well-trained screening personnel."

"It is important to recognize that a properly implemented screening program will identify potential patients who can benefit from brace treatment, possibly avoiding surgery," M. Timothy Hresko, MD, from Boston Children's Hospital, Massachusetts, and colleagues write in an editorial published in JAMA Pediatrics. "In addition, spinal deformity may be the presenting sign of a variety of conditions, including heritable collagen disease, neurological conditions, or skeletal dysplasia unrecognized until adolescence. Even if surgery cannot be averted, early diagnosis of progressive curves allows for surgical intervention at the most opportune time."

Although the USPSTF "should be applauded" for upgrading the evidence from a D grade to an I statement, the essentially neutral rating should not be misperceived as a lack of support for screening or treatment, the editorial writers explain, noting the challenges of generating level 1 evidence on screening and bracing.

Citing one large bracing study in which insufficient enrollment in the randomized group as a result of patient/parent preference for bracing led to the inclusion of a patient preference group, the editorial authors question the ethics of future observational studies given the evidence of treatment preference.

The editorialists also argue the analysis did not give due consideration to the risks and costs of surgical treatment relative to bracing and, as such, "underestimated the value of early diagnosis that can be achieved through screening programs," they write. "The critical concept is that early detection of scoliosis and nonoperative treatment are inseparable. If presurgical curves are not clinically detected, patients cannot benefit from the potential surgical risk reduction of a brace treatment program."

In a second editorial, also published in in the January 9 issue of JAMA, John F. Sarwark, MD, from the Division of Orthopaedic Surgery and Sports Medicine and Matthew M. Davis, MD, from the Stanley Manne Children's Research Institute, both at Ann & Robert H. Lurie Children's Hospital of Chicago in Illinois, point to the need for and importance of further research regarding the benefits of therapy for adolescent idiopathic scoliosis.

The USPSTF statement, they write, points to "gaps in current understanding" that highlight opportunities for future research into the link between reducing spinal curvature in adolescents and long-term health outcomes, long-term outcomes of patients who screen positive for scoliosis in adolescence, prospective assessments of the psychological ramifications of screening, and clinical outcomes of screening programs in various clinical and community (school) settings.

Referring to the positions of multiple professional societies and advocacy groups in favor of routine screening and the associated recommendation that screening programs be facilitated by well-trained personnel who can use the most effective screening tests and tools, Dr Sarwark and Dr Davis propose standardized training for screening personnel and targeted training for primary care clinicians and school nurses who perform screenings. Such activities, they note, "could serve as an opportunity to understand the potential for rigorous training programs to improve the accuracy of screening efforts."

The USPSTF members receive travel reimbursement and an honorarium for participating in USPSTF meetings. One editorialist reports financial relationships with DePuy Spine, NuVasive, Seeger, Don Joy Orthopedics, and K2M. One editorialist reports relationships with K2M, Medtronics, Miracle Feet, Project Perfect, the Pediatric Orthopedic Society of North America, the Scoliosis Research Society Health Policy committee, and the American Academy of Pediatrics. One editorialist reports relationships with the Scoliosis Research Society Awards Committee, the Pediatric Orthopedic Society of North America Health Policy Council; Medtronics, NuVasive, and Boston Orthotics and Prosthetics.

JAMA. Published online January 9, 2018. Article full text, Evidence report full text, Editorial full text

JAMA Pediatr. Published online January 9, 2018. Editorial full text

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