Debate: School Screening for Scoliosis is Reasonable

Transcription

1 Debate: School Screening for Scoliosis is Reasonable Douglas G. Armstrong, MD Edwards P. Schwentker Professor Division of Pediatric Orthopedics Department of Orthopaedics and Rehabilitation PennState Health Hershey Medical Center

2 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity I do not intend to discuss unapproved use of a commercial device in this presentation

3 Disclosures In a shameless effort to win this debate I have resorted to inclusion of pictures in this presentation, including grandchildren, designed to appeal to your sentimentality.

4 The real problem: Cost of Surgical Care for Adolescent Idiopathic Scoliosis Charges for surgical treatment of AIS: over $1.1 billion in 2012, increased more than 3X over 15 years Vigneswaran HT et al.j Neurosurg Pediatr 2015 Sep;16(3):322-8

5 SRS / AAOS / POSNA /AAP Position Statement on Screening for Early Detection of Scoliosis in Adolescence (December, 2015) AAOS, SRS, POSNA, and AAP believe that screening examinations for spine deformity should be part of the medical home preventive services visit for females at age 10 and 12 years, and males once at age 13 or 14 years AAOS, SRS, POSNA, and AAP believe that effective screening programs must have well trained screening personnel who can utilize forward bending tests and scoliometer measurements to correctly identify and appropriately refer individuals with AIS for further evaluation

6 USPSTF ver.2018 Dunn J, et al. JAMA Jan 2018

7 US Preventative Services Task Force Findings fair quality studies on screening, > 447,000 children, 6 were school settings 7 countries were the sources Screening methods: Forward Bend Test, Moiré topography, Humpometer Wide variation in screeners & their training

8 William Adams The leading English Orthopedic surgeon of his day Toured the US 1876

9 Adams Forward Bend Test

10 Scoliometer App

11 Moiré topography screening for scoliosis Adair I, van Wijk MC, Armstrong GWD. Clin Orthop 1977

12 Thulbourne T., Gillespie R. J Bone Joint Surg Br 1976

13 USPSTF Findings Screening accuracy improved when more than one test was used In a U.S.-based study of FBT with scoliometer: 71% sensitivity, 97% specificity, 3% false-positive, 29% false-negative False positives were lowest in a clinicbased program using all 3 modalities

14 USPSTF I Recommendation based on weak data Heterogenous studies One used a device that is not validated for screening Moiré topography: seldom used in US Only one US-based school screening study, small N compared with others

15 Japan - results of screening program 689,293 students over 33 years, Moiré with secondary screening of positives Screeners were Orthopedic surgeons Fewer children than expected had curves > 40º when seen by surgeon Cost effective Moiré alone; high false positive rate, low predictive value Kuroki H. et al. J Orthop Sci 2018 Jul;23(4):609-13

16 195,100 children screened w Moiré 143 had curves 20º or > High false positive rate (67%) Yamamoto et al Asian Spine J 2015

17 Hong Kong screening program better results with stepwise approach 115,000 children, followed to age 19 yrs Step wise screening program: FBT + Scoliometer + Moiré Positive predictive values: 43.6% for a Cobb angle of 20 or > and 9.4% for needing treatment Referral rate of 2.1% Luk et al Spine 2010

18 Pro: Denmark vs Hong Kong Comparison of patients referred for scoliosis evaluation with those from a non-screened population historical controls 460 children, mean age 14.7 yrs at presentation median Cobb angle was 36º for females & 33º for males Bracing was prescribed for 33%, mean curve 41º Surgery recommended for 16% Conclusion: in a health care system without school screening, patients with AIS referred for evaluation by GPs have larger curve sizes compared to systems with school screening Ohrt Nissen S, et al. Spine Deform 2016 Mar;4(2):120-4

19 Obstacles to Scoliosis School Screening in US Adequately trained personnel, dedicated time and resources to perform the SSS are not consistently available Population to be screened is not generally agreed upon There is no single ideal screening tool Re-screening or secondary screening of initial positives improves accuracy, however is not generally practiced in the US Low cost, low dose radiograms are not widely available Medicolegal & financial aspects

20 Thank you

21 Rebuttal: true facts Meta-analysis of 20 studies, >2.4 million children screened pooled estimate of prevalence of scoliosis: 1.1% for curves greater than 10º, and 0.2% for curves greater than 20º. pooled referral rate to radiography: 6.6% pooled positive predictive values for detecting curves >10 and >20 were 32.3% and 6.5% Conclusion: literature supports screening, Level of Evidence is low to moderate Altaf et al. Spine Deformity 2017

22 Rebuttal Sometimes you win just by participating