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

Table 8 Unmet and partially met United States Preventive Services Task Force[26] and United Kingdom National Screening Committee[43] key questions and criteria, tested in recommendation formulation on screening for scoliosis

Criterion	Findings/conclusions
Key Questions, United States Preventive Services Task Force, 2018[26]:
Does screening for improve: (1) Health AIS outcomes, and (2) The degree of abnormal spinal curvature in childhood or adulthood?	No relevant RCTs or CCTs, evaluating the impact of screening on curve severity or adult health outcomes
What is the association between severity of spinal curvature in adolescence and health outcomes in adulthood?	No studies directly addressing this question: none of two included studies reported health outcomes data stratified by curve degree at skeletal maturity
What are the harms of screening for AIS?	No studies met inclusion criteria
What are the harms of treatment of AIS that has a Cobb angle of less than 50° at diagnosis?	Harms of bracing reported in one good-quality study[,81] (relatively benign skin problems and nonback pain; one out of 146 participants hospitalised due to anxiety and depression); no other studies or evidence on other harms
Screening criteria1, United Kingdom National Screening Committee, 2016[43]:
There should be a simple, safe, precise and validated screening test	Not met; Poor PPV of FBT test in distinguishing whether treatment or observation is needed; potential overdetection, waste of resources and unnecessary x-ray exposure
The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed	Partially met; No single established cut-off value; other uncertainties, including additional use of Moiré topography and optimal screening age
There should be an effective treatment or intervention for patients identified through early detection, with evidence of early treatment leading to better outcomes than late treatment	Not met; Two studies were eligible, but were conducted in clinically detected cases, and did not compare treatment after screen detection and after clinical detection; no evidence found on effectiveness of conservative treatments of mild scoliosis and on surgical treatment outcomes in screen-detected vs clinically detected severe cases
There should be agreed evidence based policies covering which individuals should be offered treatment and the appropriate treatment to be offered	Partially met; Specific Cobb angle cut-off for observation or treatment introduction, or a particular treatment approach, difficult to identify
There should be evidence that the complete screening programme (test, diagnostic procedures, treatment/ intervention) is clinically, socially and ethically acceptable to health professionals and the public	Not met; Adherence to bracing prescribed following screen detection difficult to define/recognise; no studies on adherence to other conservative treatments or on uptake following recommendation for surgery

¹There are 20 United Kingdom National Screening Committee screening criteria, addressing the condition, the test, the intervention, the programme, and implementation criteria; the table includes criteria categorised as “unmet” or “partially met” in the Screening for adolescent idiopathic scoliosis: external review against programme appraisal criteria for the United Kingdom National Screening Committee[43]. AIS: Adolescent idiopathic scoliosis; RCT: Randomised controlled trial; CCT: Clinical controlled trial; FBT: Forward bend test.