Adolescents should be screened routinely for scoliosis in the medical home, according to an updated position statement endorsed by four child health associations including the Academy.
Screening for the Early Detection of Idiopathic Scoliosis in Adolescents (http://bit.ly/1KfKn27) also is endorsed by the Scoliosis Research Society, Pediatric Orthopaedic Society of North America and American Academy of Orthopaedic Surgeons.
The position statement, updated from 2007, is based on recent research emphasizing the benefits of scoliosis screening. They include earlier identification of severe deformities requiring surgery and the potential to manage some cases without surgery.
This 13-year-old girl didn't have the benefit of early detection of scoliosis. Her condition progressed to a severe deformity and she required surgery. Image courtesy of Richard M. Schwend, M.D., FAAP
A 2013 trial on bracing for adolescent idiopathic scoliosis found “significant success” in preventing spinal curve progression and surgery in children who were screened, diagnosed and treated with a custom brace. In another study the same year, an international task force of the Scoliosis Research Society reached consensus on five domains that supported the value of screening: technical efficacy; and clinical, program and treatment effectiveness. There was insufficient evidence, however, to make a statement on cost-effectiveness.
The earlier endorsement from the Academy and others also supported routine screening, but the topic has remained controversial.
In 2004, the U.S. Preventive Services Task Force (USPSTF) opposed routine screening of adolescents, grading it a “D,” meaning “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” The task force cited a low predictive value from asymptomatic screening, a relatively small percentage of children who progress and the possibility of unnecessary treatments.
But that review was issued when the treatment was not proven to be so effective and when radiation doses from X-rays were much higher, said Richard M. Schwend, M.D., FAAP, one of the current statement’s lead authors and past chair of the AAP Section on Orthopaedics Executive Committee.
Idiopathic scoliosis is the most common form of scoliosis, which usually becomes evident in early adolescence. It also can be the first sign of heritable collagen diseases, neurologic conditions or skeletal dysplasia.
For all of these reasons, a recommendation against screening doesn’t make sense to Dr. Schwend.
“In reality, if the pediatrician already has the child in the office, what are they supposed to do, not look at the child’s back? … That’s just part of what we do as practitioners. … So to have a recommendation that says, ‘Don’t look at a child’s back or don’t screen for scoliosis,’ it’s really tough to put that into actual practice,” Dr. Schwend said.
The USPSTF is re-evaluating the new evidence for screening for idiopathic scoliosis in adolescents, a move he finds encouraging.
The statement also recommends use of a scoliometer (inclinometer). An economical approach is to use a scoliometer app, Dr. Schwend said. Options are available for Apple devices at http://apple.co/21wyqfX and Android devices at http://bit.ly/1pldh7k.
Recommendations
- Screening exams for spine deformity should be part of medical home preventive services for girls at ages 10 and 12 years and boys at age 13 or 14.
- Effective screening programs must have well-trained personnel who can administer forward-bending tests and scoliometer measurements to correctly identify and appropriately refer individuals with adolescent idiopathic scoliosis.
- To decrease radiation exposure from spinal imaging, the principles of ALARA (as low as reasonably achievable) should be applied.
- Nonoperative interventions like bracing and scoliosis-specific exercises can decrease the likelihood of curve progression to the point of requiring surgery.
