SECTION III: REGULAR AND SPECIAL FEATURES: Orthopaedic • Radiology • Pathology Conference: Letters to the Editor
To the Editor:
Bunnell recently “reviewed briefly the collective experience and newer knowledge about scoliosis having direct implications for screening”, and made recommendations for increasing screening effectiveness.1 He concluded that spinal screening creates the opportunity to institute early nonsurgical treatment of spinal deformities and thereby reduces the need for spinal fusions; he also concluded that selective screening of high-risk students can greatly enhance the effectiveness of spinal screening programs. However, we think the conclusion that, “screening reduces the need for spinal fusions”, cannot be fully supported by the literature. First, it is not clear how Bunnell performed the literature search, so it cannot be repeated, nor do we know the criteria to fulfill some quality conditions. Second, he stated that screening for scoliosis has proven effective in many ways. However, many of the studies cited by Bunnell were studies without the direct purpose of evaluating the effect of screening on the number of surgeries. To our knowledge, there have been no randomized controlled trials for screening of scoliosis, and there has been only one case control study that evaluated the effect of screening for scoliosis on reducing the need for surgery. In this ecologic case control study, 182 cases (ie, patients with adolescent idiopathic scoliosis [AIS] who were treated surgically) and 1,089,992 controls were included. The odds ratio for the risk of surgery for AIS in nonscreening areas was 1.00 (95% CI, 0.74 - 1.35), which gives no indication that screening for scoliosis is effective.4 Unfortunately, this article cannot be located with a PubMed search, because papers published in the European Journal of Public Health before March 2001 are not cited in PubMed. Finally, but probably most importantly, Bunnell stated that bracing for patients with idiopathic scoliosis is effective. A more effective early treatment is a prerequisite screening program. None of the several available papers in which authors expressed their doubts regarding the effectiveness of bracing3 or papers in which authors recommended a randomized controlled trial on bracing2 were cited. Furthermore, to date no randomized controlled trials have been done to evaluate the effectiveness of bracing patients.
We think, based on the literature, that there is reasonable doubt regarding the effectiveness of screening and bracing, and that additional research on both of these areas is needed before definitive conclusions may be reached.
Eveline M. Bunge, MSc
Harry J. de Koning, MD, PhD
Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
1. Bunnell WP. Selective screening for scoliosis. Clin Orthop Relat Res
2. Dickson RA, Weinstein SL. Bracing (and screening)-yes or no? J Bone Joint Surg Br. 1999;81:193-198
3. Goldberg CJ, Moore DP, Fogarty EE, Dowling FE. Adolescent idiopathic scoliosis: the effect of brace treatment on the incidence of surgery. Spine
4. Wiegersma PA, Hofman A, Zielhuis GA. The effect of school screening on surgery for adolescent idiopathic scoliosis. Eur J Public Health