Orthopedic, pediatric and scoliosis societies call for early scoliosis detection

Recent high-quality evidence confirming the effectiveness of early screening and appropriate treatment for scoliosis has led to a revised position statement from several orthopedic and pediatric organizations.

Perspective from R. Shay Bess, MD; Stuart L Weinstein, MD

After a review of results from the NIH-funded study, “Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST),” the American Academy of Orthopaedic Surgeons (AAOS), the American Academy of Pediatrics (AAP), the Pediatric Orthopaedic Society of North America (POSNA) and the Scoliosis Research Society (SRS) recently issued a joint statement supporting the need for early scoliosis detection. The joint statement is entitled “Screening for the Early Detection of Idiopathic Scoliosis in Adolescents.”

Early bracing is key

M. Timothy Hresko, MD, of AAOS and a co-author of the joint statement, told Spine Surgery Today the renewed enthusiasm for early detection of scoliosis has been based on strong clinical evidence that nonoperative treatment with a brace, and perhaps by scoliosis-specific exercises, can reduce the number of patients who go on to require spine surgery.

“Early detection of scoliosis is mandatory in order to offer patients nonoperative methods to prevent progression of the condition. Nonoperative management is preferred by patients when there is a reasonable chance of success. Over two thirds of the patients in the patient preference arm of the BrAIST preferred bracing over observation. We can offer nonoperative treatment for idiopathic scoliosis only when detected in the mild to moderate stage, which is why early recognition and diagnosis is important,” Hresko told Spine Surgery Today.

Richard M. Schwend

The evidence to support the value of bracing for moderate idiopathic scoliosis is overwhelming, Hresko said. Studies by Katz, Weinstein, Negrini and others all show bracing treatment is successful when the brace is worn for the required amount of time, he noted.

“The joint statement on the value of early detection of scoliosis will encourage primary care providers to examine teenagers for scoliosis during annual visits,” Hresko said.

Early detection needed

The revised statement highlights the BrAIST research and strongly recommends the following:

•Screening examinations for spine deformity be part of medical home preventive care visits for girls at age 10 and age 12; for boys, once they are 13 or 14 years old;

• Screening programs have well-trained personnel who can appropriately administer forward bending tests, they use a scoliometer to correctly measure and identify abnormal spine curvature, and the programs refer patients for additional tests and imaging, as needed;

&bull ;Any imaging tests adhere to the principles of ALARA (As Low as Reasonably Achievable) standards to minimize radiation exposure in young patients; and

• Bracing is an effective nonoperative intervention to reduce the risk of progression to surgical treatment.

• In 2013, the BrAIST study was released and documented significant success in preventing spinal curve progression and surgery in children who were screened, diagnosed and treated with a custom brace, according to a press release from the AAOS.

Cooperation applauded

Richard M. Schwend, MD, immediate past chair of the Section on Orthopaedics of the AAP, said the high-quality evidence of the BrAIST study shows bracing for scoliosis is effective in halting the progression of scoliosis in children.

“However to be effective, children need to have their scoliosis detected early enough for the treatment to be helpful. Early detection at a stage when the child has no symptoms requires visual inspection of the spine. The joint statement emphasizes early detection at key periods of early adolescence, ideally performed in the medical home by an experienced health care provider,” he told Spine Surgery Today.

Schwend applauded cooperation between the AAP and the AAOS, POSNA and SRS to prepare the statement. The process was a complex one that involved the AAP Section on Orthopaedics, Council on School Health and the Committee on Medical Liability and Risk Management, he said.

“The AAP looked very critically at new literature to make sure the statement is evidence-based, provides clear advice to pediatricians and is in the best interest of children,” Schwend said. – by Robert Linnehan

Reference:
American Academy of Orthopaedic Surgeons. New research reinforces call for early detection, appropriate treatment for scoliosis patients. Available at: http://newsroom.aaos.org/media-resources/news/new-research-reinforces-call-for-early-detection-appropriate-treatment-for-scoliosis-patients.htm. Accessed Jan. 29, 2016.

For more information:

M. Timothy Hresko, MD, can be reached at Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115; email: timothy.hresko@childrens.harvard.edu.
Richard M. Schwend, MD, can be reached at Children’s Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108; email: rmschwend@cmh.edu.

Disclosures: Hresko and Schwend report no relevant financial disclosures.

Perspective

R. Shay Bess, MD

Early detection of scoliosis historically included primary care provider and school screening of children and adolescents via clinical examination using Adams Forward Bend Test to assess for rib asymmetry as a clinical indicator for referral to a specialist for further evaluation for potential scoliosis. Work by Lonstein and colleagues and Torell and colleagues indicated the scoliosis screening program was inexpensive, reduced the number of scoliosis surgeries performed each year and indicated the early diagnosis of scoliosis provided by the screening program was responsible for a reduction of the magnitude of the scoliotic curvature when patients required scoliosis surgery. However, the practice of routine scoliosis screening came into question by researchers in the United States and United Kingdom who indicated that routine scoliosis screening led to unnecessary referrals to specialists, and that the natural history of idiopathic scoliosis was unknown. The joint statement from the American Academy of Orthopaedic Surgeons (AAOS), the American Academy of Pediatrics (AAP), the Pediatric Orthopaedic Society of North America (POSNA) and the Scoliosis Research Society (SRS) supporting, Screening for the Early Detection of Idiopathic Scoliosis in Adolescent, supports the original contention that early detection of scoliosis is an important initiative. This statement is partly due to findings from the BrAIST study by Weinstein and colleagues, who indicated that, if initiated early, bracing for adolescent idiopathic scoliosis is effective in the prevention of scoliosis from progressing to the threshold for surgery. The study (which included a prospective, randomized arm and an observational arm) found that for skeletally immature patients, aged 10 years to 15 years, and a Cobb angle for the largest scoliosis of 20° to 40°, the rate of treatment success was 72% after bracing compared with 48% for the observation group. As a consequence, due of the superior efficacy of bracing compared to observation, the BrAIST study (which was an NIH-funded study) was terminated early due to concerns regarding inhumane study conditions by potentially withholding brace treatment in the observational arm of the randomized study. These findings and the joint statement by AAOS, AAP, POSNA and SRS have encouraged physicians and state programs to come full circle and support what Lonstein and other pioneers of scoliosis treatment originally advocated: early detection of scoliosis is critical to help prevent scoliosis progression and potentially avert the need for surgery.

References:
Jakubowski TL, et al. NASN Sch Nurse. 2014; doi:10.1177/1942602X14542131.
Lonstein JE, et al. J Bone Joint Surg Am. 1982;64:481-488.
Torell G, et al. J Bone Joint Surg Am. 1981;63:337-341.

R. Shay Bess, MD

Chief, Adult Spinal Deformity Service and Director. Spine Research

NYU Langone Medical Center

New York

Disclosures: Disclosure: Bess reports no relevant financial disclosures.

Perspective

Stuart L Weinstein, MD

The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) study give patients affected by adolescent idiopathic scoliosis and who are at high risk of curve progression, level 1 evidence that appropriate bracing can prevent the curve from reaching a degree where surgery would be needed. This high-level evidence makes it imperative that primary care health care providers need to incorporate a scoliosis screening exam into their routine patient evaluations so that affected children can be promptly referred for treatment.

References:
Weinstein SL, et al. N Engl J Med. 2013; doi:10.1056/NEJMoa1307337.

Stuart L Weinstein, MD

Ignacio V. Ponseti Chair and Professor of Orthopaedic Surgery, Professor of Pediatrics

Department of Orthopaedic Surgery, University Hospital

Iowa City, Iowa

Disclosures: Disclosure: Weinstein reports he is the principal investigator of the BrAIST study.