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Task force found insufficient evidence for, against recommended screening for AIS
The U.S. Preventive Services Task Force found the current evidence insufficient for making a recommendation for or against the screening of adolescent idiopathic scoliosis in children and adolescents aged 10 to 18 years, according to a recommendation statement published in JAMA
The current evidence was given a grade of “I” or “insufficient” by the U.S. Preventive Services Task Force (USPSTF).
Insufficient evidence on idiopathic scoliosis
"When the Task Force reviewed the latest research, we found that there is not enough evidence to recommend for or against screening for idiopathic scoliosis in children and adolescents,” Alex Kemper, MD, MPH, MS, board-certified pediatrician and chief of the Division of Ambulatory Pediatrics at Nationwide Children’s Hospital, and deputy editor of Pediatrics, told Healio.com/Orthopedics. “New evidence on scoliosis treatments has made it less clear whether this screening will help or harm people in the long run, and more research needs to be done to address this uncertainty. This ‘I’ statement is not a recommendation for or against screening, and physicians should continue to use their judgment when deciding the best approach for each individual patient."
The USPSTF reviewed a recent evidence report of the benefits and harms of screening for and treatment of adolescent idiopathic scoliosis (AIS), which was prepared to update its 2004 recommendations for screening in asymptomatic adolescents. The task force did not find direct evidence on the screening for AIS, health outcomes and harms of screening. They found adequate evidence that bracing may slow curvature progression in adolescents with mild or moderately severe curves; although they found inadequate evidence on a correlation between reduction in spinal curvature in adolescence and long-term health outcomes in adulthood. The evidence on harms of treatment was also found inadequate.
Evidence on benefits, harm of AIS screening
The evidence report was derived from a systematic review, which was also published in JAMA, in which John Dunn, MD, MPH, and his colleagues reviewed abstracts and articles on the accuracy of AIS screening and identified and reviewed 14 studies in 26 articles. There were four studies with evidence of the effect of bracing on curve progression vs. control patients. There were two cohort studies that looked at long-term outcomes and saw that patients with braces said they had a more negative treatment experience and body appearance vs. those who were surgically treated or not treated. Investigators also found a randomized clinical trial that demonstrated the harms of bracing, such as skin problems on the trunk and non-back body pains.
There was little or no evidence from the long-term outcomes for treatment of AIS in adolescents, correlation between curvature at skeletal maturity and adult health outcomes, harms of screening for or treatment of AIS and impact of AIS screening on adult health outcomes, Dunn and colleagues concluded. – by Monica Jaramillo
References:
Dunn J, et al. JAMA. 2018;doi:10.1001/jama.2017.11669.
Grossman DC, et al. JAMA. 2018;doi:10.1001/jama.2017.19342.
Disclosures: Grossman reports Kaiser Permanente Washington Health Research Institute received the contract to perform the systematic evidence review for this topic. Please see the full study for a list of all other authors’ relevant financial disclosures.
The research by Dunn and colleagues was funded under contract HHSA-290-2012-00015-I-357 EPC4, Task Order 6 from the Agency for Healthcare Research and Quality, HHS.
Perspective
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The task force reports there is now “adequate evidence that treatment with bracing may slow curvature progression,” and large curves lead to poor outcomes. So how could they possibly conclude that there is inadequate evidence for scoliosis screening?
Following an exhaustive literature search, task force found the potential harms of early screening and treatments such as bracing or scoliosis-specific exercises are not known. Most of us who treat patients with braces have witnessed psychological challenges to the children and family, which are at times significant. My scoliosis nurse Elaine Butterworth, who is also the mother of a patient with scoliosis, asks what is the real cost to a teenager participating in scoliosis-specific therapy in time, energy and missed opportunities, knowing some are already so busy they are not sleeping adequately? Is there harm in being labeled with a potentially serious disease, along with years of doctor appointments and X-rays?
While I believe that early detection and treatment of scoliosis will maximize the chance of having a smaller curve in adulthood, I will keep an open mind that screening and the burden of treatment may cause harms (or at least missed opportunity costs) that are not fully elucidated at this time.
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