The British decision and subsequent events

To Screen or Not to Screen: "False Positive" Cases-Can They Be Treated as Definitely False? Properly Selecting the Screening Age-Range Groups in Scoliosis Screening Programs

Background/Objectives: This opinion paper provides a brief overview of the history of school scoliosis screening programs following the introduction. Methods: It outlines the international administrative policies of these programs, their impact on the frequency of surgical procedures, and the effects of discontinuing school-based scoliosis screenings. Results: The primary focus is on analyzing the role of "false positive" cases detected during the Adam's bending test, which has contributed to the discontinuation of these programs in certain countries. This focused discussion is based on the impact of growth on the relationship between spinal and rib cage deformities. Furthermore, we propose the selection of the optimal age range for screening, considering the correlation between idiopathic scoliosis prevalence and geographical latitude. Conclusions: Lastly, we emphasize the importance of continuing scoliosis screening programs in schools.

Screening for scoliosis - New recommendations, old dilemmas, no straight solutions

This opinion review considers the prevailing question of whether to screen or not to screen for adolescent idiopathic scoliosis. New and improved standards of people-oriented care and person-centredness, as well as improved principles of preventive screening and guideline development, have been postulated and implemented in health care systems and cultures. Recommendations addressing screening for scoliosis differ substantially, in terms of their content, standards of development and screening principles. Some countries have discontinued issuing recommendations. In the last decade, a number of updated and new recommendations and statements have been released. Systematically developed guidelines and recommendations are confronted by consensus and opinion-based statements. The dilemmas and discrepancies prevail. The arguments concentrate on the issues of the need for early detection through screening in terms of the effectiveness of early treatment, on costs and cost-effectiveness issues, scientific and epidemiologic value of screenings, and the credibility of the sources of evidence. The problem matter is of global scale and applies to millions of people. It regards clinical and methodological dilemmas, but also the matter of vulnerable and fragile time of adolescence and, more generally, children's rights. The decisions need to integrate people's values and preferences - screening tests need to be acceptable to the population, and treatments need to be acceptable for patients. Therefore we present one more crucial, but underrepresented in the discussion, issue of understanding and implementation of the contemporary principles of person-centred care, standards of preventive screening, and guideline development, in the context of screening for scoliosis.

A health economic evaluation of screening and treatment in patients with adolescent idiopathic scoliosis

SUMMARY OF BACKGROUND DATA

Adolescent idiopathic scoliosis can progress and affect the health related quality of life of the patients. Research shows that screening is effective in early detection, which allows for bracing and reduced surgical rates, and may save costs, but is still controversial from a health economic perspective.

STUDY DESIGN

Model based cost minimisation analysis using hospital's costs, administrative data, and market prices to estimate costs in screening, bracing and surgical treatment. Uncertainty was characterised by deterministic and probabilistic sensitivity analyses. Time horizon was 6 years from first screening at 11 years of age.

OBJECTIVE

To compare estimated costs in screening and non-screening scenarios (reduced treatment rates of 90%, 80%, 70% of screening, and non-screening Norway 2012).

METHODS

Data was based on screening and treatment costs in primary health care and in hospital care settings. Participants were 4000, 12-year old children screened in Norway, 115190 children screened in Hong Kong and 112 children treated for scoliosis in Norway in 2012. We assumed equivalent outcome of health related quality of life, and compared only relative costs in screening and non-screening settings. Incremental cost was defined as positive when a non-screening scenario was more expensive relative to screening.

RESULTS

Screening per child was € 8.4 (95% CrI 6.6 to10.6), € 10350 (8690 to 12180) per patient braced, and € 45880 (39040 to 55400) per child operated. Incremental cost per child in non-screening scenario of 90% treatment rate was € 13.3 (1 to 27), increasing from € 1.3 (-8 to 11) to € 27.6 (14 to 44) as surgical rates relative to bracing increased from 40% to 80%. For the 80% treatment rate non-screening scenario, incremental cost was € 5.5 (-6 to 18) when screening all, and € 11.3 (2 to 22) when screening girls only. For the non-screening Norwegian scenario, incremental cost per child was € -0.1(-14 to 16). Bracing and surgery were the main cost drivers and contributed most to uncertainty.

CONCLUSIONS

With the assumptions applied in the present study, screening is cost saving when performed in girls only, and when it leads to reduced treatment rates. Cost of surgery was dominating in non-screening whilst cost of bracing was dominating in screening. The economic gain of screening increases when it leads to higher rates of bracing and reduced surgical rates.

Are current scoliosis school screening recommendations evidence-based and up to date? A best evidence synthesis umbrella review

PURPOSE

Recommendations addressing school screening for adolescents with idiopathic scoliosis are contradictory. Consequently a critical evaluation of the methodological quality of available systematic reviews, including those upon which these recommendations are based, was conducted.

METHODS

Articles meeting the minimal criteria to be considered a systematic review were included for a best evidence synthesis, umbrella review of secondary studies. The primary outcome measure was "any recommendation addressing the continuation, or not, of school screening programs". Multiple general bibliographic databases, guideline registries, as well as websites of institutions were searched. The AMSTAR tool was used to critically appraise the methodology of included reviews. Venn diagrams were created to examine potential overlaps across included papers within different reviews.

RESULTS

Six reviews undertaken between 2002 and 2011, scored as moderate to low quality, were included. The 2012 US Preventive Services Task Force recommendation against screening was found to be based on an outdated (2004) low-quality review, whilst two higher quality and more recent (2009 and 2010) reviews support the continuation of school screening programs.

CONCLUSIONS

As the existing recommendations supporting screening are based on moderate quality evidence whilst the recommendations against screening are based on low-quality evidence, the latter recommendations appear to be both unconvincing and methodologically invalid.

Clinical effectiveness of school screening for adolescent idiopathic scoliosis: a large population-based retrospective cohort study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the clinical effectiveness of school scoliosis screening using a large and long-term-followed cohort of students in Hong Kong.

SUMMARY OF BACKGROUND DATA

School screening for adolescent idiopathic scoliosis has been criticized as resulting in over-referrals for radiography and having low predictive values. Indeed, all but one previous retrospective cohort studies had no follow-up assessments of students until their skeletal maturity, leaving any late-developed curves undetected. The one study that completed this follow-up was well conducted but had low precisions due to its small sample size.

METHODS

A total of 157,444 students were eligible for a biennial scoliosis screening, and their screening results and medical records up to 19 years of age were available. Students first had forward bending test and angle of trunk rotation (ATR) performed. Those with ATR between 5 degrees and 14 degrees or signs of adolescent idiopathic scoliosis were assessed by moiré topography regularly. Students with an ATR >or=15 degrees , >or=2 moiré lines, or significant clinical signs were referred for radiography and had their Cobb angle measured.

RESULTS

Of the 115,190 screened students in the cohort, 3228 (2.8%, 95% confidence interval [CI] = 2.7%-2.9%) were referred for radiography. At the final follow-up, the positive predictive values were 43.6% (41.8%-45.3%) for a Cobb angle >or=20 degrees and 9.4% (8.4%-10.5%) for needing treatment, while the sensitivities were 88.1% (86.4%-89.6%) and 80.0% (75.6%-83.9%), respectively.

CONCLUSION

This is the largest study that has demonstrated that school scoliosis screening in Hong Kong is predictive and sensitive with a low referral rate. Screening should thus be continued in order to facilitate early administration of conservative treatments.

Relatively lower body mass index is associated with an excess of severe truncal asymmetry in healthy adolescents: Do white adipose tissue, leptin, hypothalamus and sympathetic nervous system influence truncal growth asymmetry?

BACKGROUND

In healthy adolescents normal back shape asymmetry, here termed truncal asymmetry (TA), is evaluated by higher and lower subsets of BMI. The study was initiated after research on girls with adolescent idiopathic scoliosis (AIS) showed that higher and lower BMI subsets discriminated patterns of skeletal maturation and asymmetry unexplained by existing theories of pathogenesis leading to a new interpretation which has therapeutic implications (double neuro-osseous theory).

METHODS

5953 adolescents age 11-17 years (boys 2939, girls 3014) were examined in a school screening program in two standard positions, standing forward bending (FB) and sitting FB. The sitting FB position is thought to reveal intrinsic TA free from back humps induced by any leg-length inequality. TA was measured in both positions using a Pruijs scoliometer as angle of trunk inclinations (ATIs) across the back at each of three spinal regions, thoracic, thoracolumbar and lumbar. Abnormality of ATIs was defined as being outside 2 standard deviations for each age group, gender, position and spinal region, and termed severe TA.

RESULTS

In the sitting FB position after correcting for age,relatively lower BMIs are statistically associated with a greater number of severe TAs than with relatively higher BMIs in both girls (thoracolumbar region) and boys (thoracolumbar and lumbar regions).The relative frequency of severe TAs is significantly higher in girls than boys for each of the right thoracic (56.76%) and thoracolumbar (58.82%) regions (p = 0.006, 0.006, respectively). After correcting for age, smaller BMIs are associated with more severe TAs in boys and girls.

DISCUSSION

BMI is a surrogate measure for body fat and circulating leptin levels. The finding that girls with relatively lower BMI have significantly later menarche, and a significant excess of TAs, suggests a relation to energy homeostasis through the hypothalamus. The hypothesis we suggest for the pathogenesis of severe TA in girls and boys has the same mechanism as that proposed recently for AIS girls, namely: severe TAs are initiated by a genetically-determined selectively increased hypothalamic sensitivity (up-regulation, i.e. increased sensitivity) to leptin with asymmetry as an adverse response to stress (hormesis), mediated bilaterally mainly to the growing trunk via the sympathetic nervous system (leptin-hypothalamic-sympathetic nervous system (LHS) concept). The putative autonomic dysfunction is thought to be increased by any lower circulating leptin levels associated with relatively lower BMIs. Sympathetic nervous system activation with asymmetry leads to asymmetries in ribs and/or vertebrae producing severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk. A test of this hypothesis testing skin sympathetic responses, as in the Rett syndrome, is suggested.

Muscle imbalance in volleyball players initiates scoliosis in immature spines: a screening analysis

Study Design

Retrospective comparative study using radiographs and clinical findings.

Purpose

To test the hypothesis that asymmetric loading of immature spines in young athletes initiates scoliosis.

Overview of Literature

Scoliosis in athletes has been reported in the literature, but its causative factors have not been investigated.

Methods

We compared the incidence, type and magnitude of scoliotic curves in volleyball players with those in the non-player population. One hundred sixteen adolescent volleyball players were grouped for selective screening. Data regarding their playing duration, handedness, age, height, and menarchal status (in girls) were recorded, along with clinical examination and radiological investigation when necessary. We analyzed data from 46,428 non-player school children, and their data were compared to athletes to determine differences.

Results

Volleyball players had a statistically significant increase in the incidence of scoliotic spinal curves. Playing hand dominance was related to the curve direction. Cobb angle had no significant correlation with the duration of playing.

Conclusions

There is a five-fold increase in the incidence of mild scoliosis in volleyball players. A high percentage (41%) of asymmetry was present on the Adams forward bending test, as compared to controls. The curves were either thoracic or thoracolumbar.

SOSORT consensus paper: school screening for scoliosis. Where are we today?

This report is the SOSORT Consensus Paper on School Screening for Scoliosis discussed at the 4th International Conference on Conservative Management of Spinal Deformities, presented by SOSORT, on May 2007. The objectives were numerous, 1) the inclusion of the existing information on the issue, 2) the analysis and discussion of the responses by the meeting attendees to the twenty six questions of the questionnaire, 3) the impact of screening on frequency of surgical treatment and of its discontinuation, 4) the reasons why these programs must be continued, 5) the evolving aim of School Screening for Scoliosis and 6) recommendations for improvement of the procedure.

The direct cost of "Thriasio" school screening program

Background

There is great diversity in the policies for scoliosis screening worldwide. The initial enthusiasm was succeeded by skepticism and the worth of screening programs has been challenged. The criticisms of school screening programs cite mainly the negative psychological impact on children and their families and the increased financial cost of visits and follow-up radiographs. The purpose of this report is to evaluate the direct cost of performing the school screening in a district hospital.

Methods

A cost analysis was performed for the estimation of the direct cost of the "Thriasio" school-screening program between January 2000 and May 2006. The analysis involved all the 6470 pupils aged 6–18 years old who were screened at schools for spinal deformities during this period. The factors which were taken into consideration in order to calculate the direct cost of the screening program were a) the number of the examiners b) the working hours, c) the examiners' salary, d) the cost of transportation and finally e) the cost of examination per child.

Results

During the examined period 20 examiners were involved in the program and worked for 1949 working hours. The hourly salary for the trainee doctors was 6.80 euro, for the Health Visitors 6.70 euro and for the Physiotherapists 5.50 euro in current prices. The cost of transportation was 32 euro per year. The direct cost for the examination of each child for the above studied period was calculated to be 2.04 euro.

Conclusion

The cost of our school-screening program is low. The present study provides a strong evidence for the continuation of the program when looking from a financial point of view.

Selective screening for scoliosis

Scoliosis screening has been practiced for nearly 50 years and has provided valuable knowledge about the prevalence and natural history of scoliosis. Early diagnosis allows for nonoperative treatment, like wearing an orthosis that has been shown to be effective by numerous outcome studies. Challenges in scoliosis screening include the low prevalence rate of clinically significant scoliosis, the inverse relationship of sensitivity and specificity in the screening process because of the poor correlation of clinical deformity and radiographic abnormality, and the inflated cost of these programs because of overreferral. Recommendations for improvement include redefinition of what actually constitutes a "significant" scoliosis for screening, diagnostic, and outcome purposes; selective screening of only immature females; the use of objective referral criteria; and re-screening patients rather than referring those who have borderline cases.

The benefits of school screening for scoliosis in the central part of The Netherlands

The Netherlands has well-organized school health services, and children are assessed on a regular basis for scoliosis among other disturbances and pathologies. The purpose of this study was to assess the benefits of an annual screening programme for scoliosis in the Netherlands. Three cohorts of 10,000 children sampled at 10, 12 and 14 years of age, respectively, were followed for 3 years. Children with a positive bending sign were referred to a second screening stage, in which external asymmetry was quantified. Children diagnosed via the programme (group 1) were compared with those children who had been referred for treatment independently of the screening (group 2). The total number of children in these groups combined was then compared with the number that would have been expected on the basis of accepted prevalence figures for idiopathic scoliosis given in current literature. Over 30,000 children were screened. Although the programme established a total of 57 cases of definite scoliosis (0.18%), the 34 cases (0.11%) already known, mainly detected by previous school health checks, were more severe regarding the risk of progression and treatment. The annual screening programme did not detect a single case that needed surgery. These figures provide the basis on which to decide for or against adopting an annual screening programme for scoliosis; the decision is a socio-political one. Based on this study, we expect all scoliotic patients needing treatment should be detected in time if periodic health checks will be maintained biennially. On medical grounds, it is our view, that screening for scoliosis should not be performed in the Netherlands annually.