No recommendation on screening adolescents for idiopathic scoliosis will be forthcoming from the U.S. Preventive Services Task Force (USPSTF), which has concluded there isn’t enough evidence to determine whether the benefits outweigh the harms.
While the Task Force found adequate evidence that treatment with a back brace may slow spinal curvature progression, there was not enough evidence to link this reduction to long-term health outcomes in adulthood, reported David C. Grossman, MD, of the USPSTF, and colleagues.
In addition, there was inadequate evidence on treatment with exercise and surgery, and no direct evidence on either screening for adolescent idiopathic scoliosis or harms of screening for asymptomatic children ages 10 to 18, the authors wrote in the Journal of the American Medical Association.
The recommendation (I statement) was simultaneously published on the USPSTF Web site.
This is a change from the 2004 recommendation statement, which advised against routine screening of asymptomatic adolescents for the spinal curvature (D statement). Previously, the USPSTF stated that there was “moderate” harm of treatment, such as unnecessary wearing of a back brace, and only “fair” evidence that treating scoliosis led to health benefits, such as decreased pain and disability.
However, the USPSTF concluded now that more research is needed on the benefits and harms of the treatment, adding that “new evidence on scoliosis treatments has made it less clear whether this screening will help or harm people in the long run.”
“Our review of the current evidence has pointed to more questions than answers about the benefits and harms of screening children and teenagers with no symptoms of scoliosis,” said Alex R. Kemper, MD, of the USPSTF, in a statement.
New evidence about the benefits of back braces appears to be main factor in triggering the new I statement. Notably, five of seven studies on the effectiveness of treating adolescent idiopathic scoliosis evaluated the effectiveness of three different types of back braces. The authors said that three prospective studies suggested a benefit of treatment with bracing on slowing curvature progression versus observed controls, while two others showed “limited differences” between the two groups.
Only two trials examined the effect of exercise treatment, though both showed significant improvement versus controls. There were no studies about surgical treatment for the condition among adolescents.
An accompanying editorial by John F. Sarwark, MD, and Matthew M. Davis, MD, both of Ann & Robert H. Lurie Children’s Hospital of Chicago, also pointed out the potential health policy implications of this new recommendation, saying that 20 or more states currently mandate or strongly recommend school-based screening for scoliosis.
“Given the new USPSTF recommendations and the I statement, it would be appropriate for states to advise students and parents of the insufficient data about benefits and harms of screening, while also sharing more recent evidence that bracing and exercise therapies may be helpful if scoliosis is clinically diagnosed in screen-positive youth,” the editorialists wrote.
There were also only two trials examining the association between a change in the severity of spinal curvature in adolescence and subsequent changes in adult health outcomes, the authors said. There was no significant difference in quality of life between treated participants and observed controls, nor differences in psychological indicators, such as well-being, self-esteem and social activity, or biological indicators, such as pulmonary or pregnancy outcomes.
But an editorial in JAMA Pediatrics by M. Timothy Hresko, MD, of Boston Children’s Hospital, and colleagues point out that none of these studies “represented the adult health burden of untreated progressive scoliosis, as none documented a natural history of untreated adult disease,” and cited studies that the USPSTF omitted from its report.
Hresko and colleagues further emphasized the importance of early detection on the non-operative treatment of scoliosis, and cited the studies on back braces as an example of this.
“The recent bracing data convincingly support the ability of brace treatment to minimize the risk of progressing to the point of requiring surgical treatment,” the editorialists wrote.
Grossman and colleagues on the USPSTF examined methods to detect scoliosis — defined as a lateral curvature of the spine with a Cobb angle of at least 10° — through screening. The authors said that adequate evidence exists that screening tests can detect adolescent idiopathic scoliosis, but that accuracy improved with the number of screening tests used (the forward bend test, scoliometer measurement and Moiré topography).
In addition, they reported false-positive rates ranging from 0.8% for all three tests to 21.5% for hump assessment. But the USPSTF found no studies examining potential harms of screening or treatment with surgery or exercise. Only one trial examined the harms of bracing and found the intervention group was more likely to experience skin problems and non-back body pain vs controls.
The authors cited several research gaps, including additional prospective, controlled studies on screening, including the potential benefits and harms of screening. They also recommended studies to determine whether an individual’s characteristics contribute to bracing treatment response, as well studies on long-term outcomes of treating this condition in adolescence.
Grossman disclosed his institution had a contract to perform the systematic evidence review for this topic but that he had no involvement in the arrangement of this contract and did not participate in any aspect of the review.
Sarwark and Davis disclosed no conflicts of interest.
Hresko disclosed support from DePuy Spine, NuVasive, Seeger, Don Joy Orthopedics, DePuy, K2M, Medtronics, Boston Orthotics and Prosthetics, as well as being committee chair for the Scoliosis Research Society Awards committee and the POSNA Health Policy Council.
Other editorialists disclose support from K2M, Medtronics, Miracle Feet, Project Perfect, serving as president of Pediatric Orthopedic Society of North America (POSNA), committee chair of the Scoliosis Research Society Health Policy committee, and as executive committee member for the American Academy of Pediatrics.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner