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School Scoliosis Screening: The Controversy Continues



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ChiroACCESS Editorial Staff

  

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June 17, 2010

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Two studies from the May and June 2010 issues of Spine evaluated past and contemporary methods of school scoliosis screening Two studies from the May and June 2010 issues of Spine evaluated past and contemporary methods of school scoliosis screening.  The first study was a meta-analysis of previous research.  The forward bending test has been the most commonly used component of scoliosis screening.  The conclusion from the meta-analysis was that the forward bending test alone was inadequate to screen children for scoliosis.  They noted that, in their opinion, “We need large, retrospective cohort studies with sufficient follow-up to properly assess the clinical effectiveness of school scoliosis screening”.

The second study was a large (157,444 students) retrospective cohort conducted by the same authors.  In this work they measured both the traditional forward bending test but added what they refer to as an angle of trunk rotation assessment (ATR).  The rotation of the trunk with the ATR was measured using Moire photography.  Moire is an old technology used by many chiropractors in the 1970s and 80s.  Combining the two tests, this “Hong Kong” scoliosis screening protocol provided a sensitive method for the identification of scoliosis.  “Respectively 88.1% and 80.0% of adolescents who had a Cobb angle (equal or greater than 20 degrees) and required treatment for scoliosis were detected by the school scoliosis screening program.”  This new protocol is significantly better in predicting and referring students for x-ray assessment than previous systems published in the literature.

Clinical Effectiveness of School Screening for Adolescent Idiopathic Scoliosis: A Large Population-Based Retrospective Cohort Study.  [LINK]

Spine (Phila Pa 1976). 2010 May 5. [Epub ahead of print]

Luk KD, Lee CF, Cheung KM, Cheng JC, Ng BK, Lam TP, Mak KH, Yip PS, Fong DY.
From the Departments of *Orthopaedics and Traumatology and daggerNursing Studies, The University of Hong Kong, Pokfulam, Hong Kong SAR, China; double daggerDepartment of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China; section signDepartment of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong SAR, China; paragraph signDepartment of Health, Hong Kong SAR, China; and parallelDepartment of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China.

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 >/=15 degrees , >/=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 >/=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.

A meta-analysis of the clinical effectiveness of school scoliosis screening.  [LINK]

Spine (Phila Pa 1976). 2010 May 1;35(10):1061-71.

Fong DY, Lee CF, Cheung KM, Cheng JC, Ng BK, Lam TP, Mak KH, Yip PS, Luk KD.
Department of Nursing Studies, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.

STUDY DESIGN: A meta-analysis that systematically reviewed the evaluation studies of a scoliosis screening program reported in the literature.

OBJECTIVE: To evaluate the best current evidence on the clinical effectiveness of school screening for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA: The use of school scoliosis screening is controversial, and its clinical effectiveness has been diversely reported.

METHODS: Data sources included 3 databases, namely, PubMed, Google scholar, CINAHL database, and the references from identified reviews and studies. Studies were included if: (1) they adopted a retrospective cohort design; (2) were screened using either the forward bending test (FBT), angle of trunk rotation, or Moiré topography; (3) reported results of screening tests and radiographic assessments; (4) screened adolescents only; (5) reported the incidence of curves with a minimum Cobb angle of 10 degrees or greater; and (6) reported the number of referrals for radiography. Reviews, comments, case studies, and editorials were excluded.

RESULTS: Thirty-six studies, including 34 from the 775 initially identified studies and 2 from the references, met the selection criteria. The pooled referral rate for radiography was 5.0%, and the pooled positive predictive values for detecting curves > or =10 degrees , curves > or =20 degrees , and treatment were 28.0%, 5.6%, and 2.6%, respectively. There was substantial heterogeneity across studies. Meta-regression showed that programs using the FBT alone reported a higher referral rate (odds ratio [OR] = 2.91) and lower positive predictive values for curves > or =10 degrees (OR = 0.49) and curves > or =20 degrees (OR = 0.34) than programs using other tests. Only one small study followed students until skeletal maturity and reported the sensitivity of screening; however, the specificity was not reported. No severe publication bias was noted.

CONCLUSION: The use of the FBT alone in school scoliosis screening is insufficient. We need large, retrospective cohort studies with sufficient follow-up to properly assess the clinical effectiveness of school scoliosis screening.
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