SCOLIOSIS SCHOOL SCREENING

SCOLIOSIS SCHOOL SCREENING WE VE GOT YOUR BACK Leigh Ann Lather MD FAAP Associate Professor Orthopaedics and Pediatrics MSK Bootcamp 2018 UVA ORTHOPAEDICS

UVA ORTHOPAEDICS

13y4m BA = 12 13y10m Cobb>20 Progressing Braceable Curve Still Growing Female Tri-radiate open, Risser 0 Tri-radiate closing, Risser 0? Brace Offered

14y4m BA 13.6 15y 11m BA 15 Brace offered again. Did not brace. Lost to f/up for 1.5 yrs. Returned 2⁰pain

MA 13 yo 4 mos F. Delayed bone age 14 y 5 mos 15 y 5 mos

LM 13 y 4 mo F Celiac dz Growth delay Osteoporosis mult fx L spine DXA < -3.2 13 y 11 mo 10 th 75 th Percentile height 14y 11 mo 15 y 5 mo

There is a treatment that can effectively change the natural history of the condition The New England Journal of Medicine original article Effects of Bracing in Adolescents with Idiopathic Scoliosis Stuart L. Weinstein, M.D., Lori A. Dolan, Ph.D., James G. Wright, M.D., M.P.H., and Matthew B. Dobbs, M.D. September 19, 2013 Data and recommendations added to UpToDate website on January 8, 2014

January 2013 Study Terminated by NIH Only ~2% studies terminate early due to accumulated data re: efficacy or toxicity Adjusted Odds ratio 2.03 in favor bracing 50% risk reduction of progression to surgical size curve if brace worn Strong positive association between: Hours of brace wear and Rate of success 12.9 hours, rate of success = 90-93%

OUTCOMES 1 st 6 mos: Mean hours of wear time = 12.1 hours, +/- 6.6 hours

OTHER OUTCOMES PedsQL scores did not differ between groups at baseline at follow up Adverse events did not differ between groups including percentage reporting back pain # needed to treat (to prevent 1 surgery) = 3

What is the goal? Adolescent Idiopathic Scoliosis

Screening- just do it. AAOS, SRS, POSNA, AAP ALL recommend scoliosis screening Twice Age 10-12 4 th -6 th grade Combine with 6 th grade required immunizations Every WCC Once Age 13-14 7 th -8 th grade Part of Sports Physical

My definition: screening test A good screening test identifies a condition that causes significant morbidity or mortality in an otherwise healthy population at risk. The test is valid, cost-effective, well-tolerated, and there is an intervention that can effectively change the natural history of the condition.

A valid, cost-effective, well-tolerated screening test exists. Adam s forward bend + scoliometer 10k patients Scoliometer = 7⁰ trunk rotation Valid and Reliable predictor Curve >10 Cobb angle *suggest 5⁰ for overwt, BMI >85 th %ile*

Adam s forward bend, with scoliometer! < $35

There s an app for that $1.99 Validation of a Scoliometer Smartphone App to Assess Scoliosis Franko, Orrin I. MD*; Bray, Christopher MD ; Newton, Peter O. MD *Department of, University of California, San Diego, J.Pediatric Orthopaedics, 2012

Scoliosis screening effectiveness: should we bother to screen at all? International task force of 8 experts nominated by the SRS Necessary because data is limited, conflicting, and of variable quality. CONCLUSIONS There is sufficient data to support: Technical, program, treatment, and clinical efficacy of scoliosis screening Insufficient data exists to make a statement re: cost-effectiveness *Construct used by WHO and others For analyzing screening test effectiveness. Scoliosis screening App $1 1 Spine fusion surgery costs > $170,000 >1 billion dollar industry

Incidence severe AIS = 1:1000 We are currently mandated to screen for many diseases that are less common Some would argue that these severe cases are rare and will present themselves anyway

Risk of curve progression To find your patients when they are young and their curves are small and painless You have LOOK.

Problem with screening in schools Even many public schools lack a nurse. In the hands of well-meaning personnel who are improperly trained or educated, scoliosis screening can lead to: Misdiagnosis, over-diagnosis Undue anxiety for child and parents Unnecessary: medical costs for extra doctor visits Imaging/exposure from imaging Referrals to specialist

Look from a different angle

Scoliosis School Screening Think of all the school screenings we do every day in our offices every day

Just do it Should there be scoliosis school screening? YES!! Does it have to happen IN A SCHOOL? NO.

The time has come There is sufficient data to support: Technical, program, treatment, and clinical efficacy of scoliosis screening

Scoliosis School Screening

Scoliosis School Screenings

Scoliosis School Screening PA scoliosis C2 - pelvis

Scoliosis School Screening

Scoliosis School Screening

Incidence of AIS in 10-16 yo = 3/100

Cost effectiveness Scoliosis screening app cost = $1 1 minute of your time at routine WCC/sports PE if you re gonna pick a booger, you better know what to do with it $ and anxiety saved when screening test performed by a trained, informed physician

Scoliosis School Screening AAOS,SRS,POSNA,AAP B. Stephens Richards, Michael G. Vitale; Screening for Idiopathic Scoliosis in Adolescents An Information Statement*. The Journal of Bone & Joint Surgery. 2008