Does school scoliosis screening make the grade?

Scoliosis Screening

The national recommendations for school screening programs for scoliosis in the United States have undergone a shift in perspective over the past two decades. In 2004, the United States Preventive Services Task Force recommended against screening programs but changed its recommendation to be inconclusive in 2018. Early diagnosis of scoliosis can allow for close monitoring of the deformity and early initiation of bracing treatment when appropriate, with the goal of preventing costly and invasive surgical intervention. Several different diagnostic tools are available, including Adam's forward bending test alone, Adam's forward bending test with scoliometry, the humpometer, and Moiré topography, each with varying degrees of sensitivity and specificity. Controversy prevails over the cost efficacy of screening programs and possible unnecessary exposure of adolescents to radiation for confirmatory radiographs after a positive screening test. However, the recent definitive evidence of bracing treatment efficacy in slowing the progression of scoliotic curves and preventing the need for surgery indicates that school screening programs may still have a role in allowing early diagnosis.

The Potential Role of Preoperative Pain, Catastrophizing, and Differential Gene Expression on Pain Outcomes after Pediatric Spinal Fusion

BACKGROUND

Adolescent idiopathic scoliosis is one of the most common spinal deformities in children and adolescents requiring extensive surgical intervention. Due to the nature of surgery, spinal fusion increases their risk of experiencing persistent postsurgical pain. Up to 20% of adolescents report pain for months or years after corrective spinal fusion surgery.

AIMS

To examine the influence of preoperative psychosocial factors and mRNA expression profiles on persistent postoperative pain in adolescents undergoing corrective spinal fusion surgery.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Two freestanding academic children's hospitals.

METHODS

Utilizing a longitudinal approach, adolescents were evaluated at baseline (preoperatively) and postoperatively at ±1 month and ±4-6 months. Self-report of pain scores, the Pain Catastrophizing Scale-Child, and whole blood for RNA sequencing analysis were obtained at each time point.

RESULTS

Of the adolescents enrolled in the study, 36% experienced persistent pain at final postoperative follow-up. The most significant predictors of persistent pain included preoperative pain severity and helplessness. Gene expression analysis identified HLA-DRB3 as having increased expression in children who experienced persistent pain postoperatively, as opposed to those whose pain resolved. A prospective validation study with a larger sample size is needed to confirm these findings.

CONCLUSIONS

While adolescent idiopathic scoliosis is not often classified as a painful condition, providers must be cognizant of pre-existing pain and anxiety that may precipitate a negative recovery trajectory. Policy and practice change are essential for early identification and subsequent intervention.

Adolescent Idiopathic Scoliosis Care in an Underserved Inner-City Population: Screening, Bracing, and Patient- and Parent-Reported Outcomes

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVES

This preliminary investigation sought to identify the quality of care adolescent idiopathic scoliosis (AIS) patients from our large, underserved community had received before presenting at this institution's clinic.

SUMMARY OF BACKGROUND DATA

AIS affects 1% to 4% of children between ages 10 and 16. Barriers to health care for patients in underserved populations have not been well studied.

METHODS

Patients who visited a single surgeon's clinic for primary AIS between June 2016 and January 2017 were enrolled. Patients had 36-inch full-spine radiographs and completed a survey of demographics, prior AIS care received (screening, bracing, etc), socioeconomic parameters, and patient-reported outcomes (PROs; Scoliosis Research Society [SRS]-30 Questionnaire and Body Image Disturbance Questionnaire [BIDQ]). Parametric and nonparametric analyses were used and percentages and mean/median values were reported.

RESULTS

47 patients (age: 15 ± 3 years; 82.7% female) were included. Overall, 25.5% of patients reported a family history of scoliosis, and 42.6% had no prior knowledge of scoliosis. Per Scoliosis Research Society (SRS) recommendations, 15 patients required observation (main Cobb angle: <25°), 22 patients were eligible for bracing (25°-45°), and 10 patients were surgical candidates (>45°). In addition, 21.3% of all patients were never screened for scoliosis; of these, 50% had a main scoliosis curve >25°. Seventy percent of surgical candidates never wore a brace, and 59.3% of screened patients who were eligible for bracing were not braced at initial presentation. Patients who were left unbraced when eligible exhibited worse BIDQ scores (1.7 vs. 1.4, p < .05).

CONCLUSIONS

One of five children in our population was never screened for scoliosis, and nearly three of five children did not receive optimal care as recommended by SRS. AIS patients in our inner-city populations are potentially at risk of continuing to experience a significant disadvantage in health care access.

LEVEL OF EVIDENCE

Level IV case series.

2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

BACKGROUND

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).

METHODS

Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.

RESULTS

The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.

CONCLUSION

The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

Does School Screening Affect Scoliosis Curve Magnitude at Presentation to a Pediatric Orthopedic Clinic?

BACKGROUND

With new data supporting the efficacy of bracing, the role of school screening for early detection of moderate scoliosis curves has been revisited. Because of a high rate of false-positive screening and cost concerns, a comprehensive county-wide school screening program was discontinued in 2004. We aim to determine the impact of a comprehensive school screening program on curve magnitude at presentation and initial scoliosis treatment for all local county patients presenting to a pediatric orthopedic clinic from all referral sources.

METHODS

Between 1994 and 2014, a total of 761 county patients presented to a pediatric orthopedic clinic for new scoliosis evaluation. Curve magnitude and recommended treatment were recorded. Treatment indications for bracing, surgery, and observation were consistent over the study period.

RESULTS

From January 1994 to July 2004 (school screening period), 514 children were seen by a pediatric orthopedic specialist for scoliosis evaluation compared to 247 patients from August 2004 to December 2014 (no school screening). There was a 48% decrease in the number of county children who were evaluated for idiopathic scoliosis by pediatric orthopedics once school screening was discontinued. Mean maximal Cobb angle at presentation increased from 20° (range, 4°-65°) to 23° (range, 7°-57°). At presentation, 5 of 514 (0.97%) patients in the screened group required surgery and 68 of 514 (13.2%) required bracing, compared to 3 of 247 (1.2%) patients in the nonscreened group requiring surgery and 47 of 247 (19%) requiring bracing (p>.05, p=.04, respectively).

CONCLUSION

After school screening was discontinued, mean curve magnitude and rates of bracing at presentation statistically increased in county patients evaluated for new scoliosis, although the clinical significance is unclear. After school screening was discontinued, there were fewer patient referrals, braces prescribed, and unnecessary evaluations (patients discharged at first visit). This study provides data to evaluate the role of school screening for children with regular access to health care.

LEVEL OF EVIDENCE

Level 3.

Public Health Interventions for School Nursing Practice

School nurses (SNs) use public health nursing knowledge and skills to provide nursing services to school populations. The Public Health Intervention Wheel is a practice framework that can be used to explain and guide public health nursing interventions. SNs who were also members of the National Association of School Nurses completed an electronic survey on their use of public health interventions as defined by the wheel. Although 67% of the participants were not familiar with the Public Health Intervention Wheel, respondents reported conducting activities that were consistent with the Wheel interventions. Screening, referral and follow-up, case management, and health teaching were the most frequently performed interventions. Intervention use varied by educational level, age of nurse, years of practice, and student population. The Public Health Intervention Wheel is a relevant and useful framework that provides a language to explain population-based school nursing practice.