Screening for scoliosis - New recommendations, old dilemmas, no straight solutions

Table 7 “Drivers of overdiagnosis” and their relation to scoliosis screening

“Drivers of overdiagnosis”, Kale et al[77], 2018		Examples of disputable and unclear scoliosis issues
Category	Factor
Broadening disease definitions	Lowering of diagnostic thresholds	Cut-off point of 10° Cobb, treatment starts from 20°-25° Cobb[26,43]; proposed 6° Cobb cut-off point[79]
	Recognition of risk factors as pre-diseases	Mild scoliosis with no symptoms, disputable risk of progression; inconclusive/unconvincing evidence for treatment effectiveness
Technology	Use of advanced technology for diagnosis	Proposals of advanced imaging technologies[79,80]; and follow-up tests connected to potential overdiagnosis
	Use of more sensitive screening tests
Public health interventions	Widespread screening	Screening programmes mainly school-based[26,56]; millions of adolescents subjected to school screening[56,62-64]
Culture of medical care	Value of diagnosis for its own sake	Testing encouraged by professional organisations[33,35,36,46,59]
Clinician cognitive errors	Overestimation of benefit of therapy in mild or low risk disease	Evidence-to-practice gaps as regards effectiveness of early conservative treatment[25,26,42] and differences in long term health outcomes between treated and untreated people[26,43,81]
System factors	Financial incentives for more testing	-
Evidence limitations	Lack of clarity regarding disease spectrum in studies of diagnostic accuracy	Disputable AIS severity divisions (mild–moderate–severe) vs broad and unspecified curve spectrums (e.g 10°-50° Cobb) and screening test accuracy[26,43]

AIS: Adolescent idiopathic scoliosis.