Idiopathic Scoliosis: Screening--Children and adolescents aged 10 to 18 years


General

Grade: I

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in children and adolescents aged 10 to 18 years.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

Patient Population Under Consideration

This recommendation applies to asymptomatic children and adolescents aged 10 to 18 years. This recommendation does not apply to children and adolescents presenting for evaluation of back pain, breathing difficulties, abnormal radiography findings or other imaging studies, or obvious deformities in spinal curvature.

Screening Tests

Most screening tests for adolescent idiopathic scoliosis are noninvasive. Screening is usually done by visual inspection of the spine to look for asymmetry of the shoulders, shoulder blades, and hips. In the United States, the forward bend test is commonly used to screen for idiopathic scoliosis. First, a clinician visually inspects the spine of a patient while the patient is standing upright. Next, the patient stands with feet together and bends forward at the waist with arms hanging and palms touching. The clinician repeats the visual inspection of the spine.1, 4 A scoliometer, which measures the angle of trunk rotation, may be used during the forward bend test. An angle of trunk rotation of 5° to 7° is often the threshold for referral for radiography.1 Other screening tests include a humpometer, the plumb line test, and Moiré topography (creating a 3-dimensional image of the surface of a patient’s back) (Table).

If idiopathic scoliosis is suspected, radiography is used to confirm the diagnosis and to quantify the degree of curvature (ie, the Cobb angle) and the Risser sign (the stage of ossification of the iliac apophysis).1 US organizations that advocate screening recommend the forward bend test combined with scoliometer measurement.

Treatment

The goal of treatment is to decrease or stop progression of spinal curvature during the period of adolescent growth prior to skeletal maturity. Treatment of adolescent idiopathic scoliosis is determined by the degree of spinal curvature and the potential for further growth and generally includes observation, bracing, surgery, and exercise.1

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Most children and adolescents with scoliosis do not have symptoms. Generally, smaller spinal curvatures remain stable, while larger curvatures tend to progress in severity.

Pulmonary dysfunction can be clinically significant in patients with spinal curvatures greater than 100°; however, curvatures of that severity are rare. Back pain is more common, but its effect on functioning or disability is unclear.1 Current evidence suggests that the presence of back pain does not necessarily correlate with the degree of spinal curvature in adulthood. Adults with adolescent idiopathic scoliosis may have poor self-reported health, appearance, and social interactions. Mortality is similar to that among unaffected adults.1

Potential Harms

Evidence on the harms of screening for adolescent idiopathic scoliosis is limited. False-positive results are an important potential harm, with rates ranging from 0.8% to 21.5%.1, 5, 6 However, the direct harms of screening are unclear. Potential harms of false-positive results include unnecessary follow-up visits, increased cancer risk attributable to radiation exposure, overtreatment, or psychosocial effects associated with the diagnosis of clinically nonsignificant scoliosis.1

Current Practice

Various organizations have recommended routine screening for scoliosis in children and adolescents since the 1980s.1, 4 More than half of US states either mandate or recommend school-based screening for scoliosis.1, 4, 7 Children and adolescents are usually screened with the forward bend test, with or without scoliometer measurement.1, 4

In general, patients with a Cobb angle of less than 20° are observed without treatment; however, exercise may be recommended at this time. Patients with a Cobb angle greater than 30° or a Cobb angle of 20° to 30° that progresses 5° or more over 3 to 6 months are treated with bracing. Patients with a Cobb angle of 40° to 50° may be treated with bracing or surgery, while those with a Cobb angle greater than 50° typically require surgery.1


Rationale

Importance

Adolescent idiopathic scoliosis is a lateral curvature of the spine of unknown cause with a Cobb angle (a measure of the curvature of the spine) of at least 10° that occurs in children and adolescents aged 10 to 18 years. It is the most common form of scoliosis and usually worsens during adolescence before skeletal maturity. In the United States, the estimated prevalence of adolescent idiopathic scoliosis with a Cobb angle of at least 10° among children and adolescents aged 10 to 16 years is 1% to 3%.1, 2 Most patients with a spinal curvature of greater than 40° at skeletal maturity will likely experience curvature progression in adulthood. Severe spinal curvature may be associated with adverse long-term health outcomes (eg, pulmonary disorders, disability, back pain, psychological effects, cosmetic issues, and reduced quality of life).1, 3 Therefore, early identification and effective treatment of mild scoliosis could slow or stop curvature progression before skeletal maturity, thereby improving long-term outcomes in adulthood.

Detection

The USPSTF found adequate evidence that currently available screening tests can accurately detect adolescent idiopathic scoliosis. The accuracy of screening was highest (93.8% sensitivity and 99.2% specificity) when 3 separate screening tests were used (eg, the forward bend test, scoliometer measurement, and Moiré topography); sensitivity was lower when screening programs used just 1 or 2 screening tests (eg, 71.1% for the forward bend test and scoliometer measurement and 84.4% for the forward bend test alone).

Benefits of Early Detection and Intervention or Treatment

The USPSTF found no direct evidence regarding the effect of screening for adolescent idiopathic scoliosis on patient-centered health outcomes. The USPSTF found inadequate evidence on the treatment of idiopathic scoliosis (Cobb angle <50° at diagnosis) in adolescents with exercise (2 small studies) or surgery (no studies) or its effects on health outcomes or the degree of spinal curvature in childhood or adulthood. The USPSTF found adequate evidence (5 studies) that treatment with bracing may decrease curvature progression in adolescents with mild or moderate curvature severity (an intermediate outcome). However, it found inadequate evidence on the association between reduction in spinal curvature in adolescence and long-term health outcomes in adulthood.

Harms of Early Detection and Intervention or Treatment

The USPSTF found no studies on the direct harms of screening, such as psychological harms or harms associated with confirmatory radiography. The USPSTF found inadequate evidence to determine the harms of treatment.

USPSTF Assessment

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.


Others

Other Considerations Research Needs and Gaps The USPSTF identified several research gaps. Prospective, controlled screening studies that allow for comparison of screened and nonscreened populations and different screening settings, personnel, and procedures are needed. Good-quality studies with prospective identification of cohorts at the time of diagnosis (eg, from geographical areas with and without routine screening for adolescent idiopathic scoliosis) or treatment (eg, treated vs observed cohorts) for the purpose of long-term follow-up are important. High-quality studies on the potential harms of screening and treatment are also needed. Additional studies to help determine whether individual characteristics (eg, body mass index) may influence response to bracing treatment would be helpful. Studies on long-term outcomes are needed and should stratify results by degree of spinal curvature at diagnosis and at skeletal maturity. Better information on long-term outcomes such as pulmonary disorders, disability, back pain, psychological effects, cosmetic issues, and quality of life would be helpful. Good-quality studies on treatment with exercise, bracing, and surgery among screen-detected patients are needed. Studies conducted in primary care settings are also needed.   Recommendations of Others Several national specialty groups have published statements in support of screening. 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 once in male adolescents at 13 or 14 years as part of medical home preventive services, if screening is performed by well-trained screening personnel.26 The UK National Screening Society does not recommend screening for scoliosis, given the uncertainty surrounding the effectiveness of screening and treatment.27 However, the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment recommends screening for idiopathic scoliosis through school-based programs, and that screening should be performed by clinicians who specialize in spinal deformities.28   Update of Previous USPSTF Recommendation This recommendation updates the 2004 USPSTF recommendation, in which the USPSTF recommended against routine screening for idiopathic scoliosis in asymptomatic adolescents (D recommendation).8 In 2004, the USPSTF found fair evidence that treatment of adolescent idiopathic scoliosis leads to health benefits (ie, decreased pain and disability) in a small proportion of persons. The USPSTF bounded the harms of treatment as moderate (eg, unnecessary brace wear or unnecessary referral to specialty care). Therefore, at that time, the USPSTF concluded that the harms of screening exceeded the potential benefits.8 To update its recommendation, the USPSTF commissioned a systematic review of the evidence. Because of new research, the USPSTF determined that it no longer has moderate certainty that the harms of treatment outweigh the benefits. The USPSTF found no direct evidence of a benefit of screening for adolescent idiopathic scoliosis on health outcomes. A growing body of evidence suggests that brace treatment 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. Evidence on the effects of exercise and surgery on health or spinal curvature in childhood or adulthood is insufficient. 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. 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, leading the USPSTF to issue an I statement.  


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