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Letter to the Editor

Incidence of Neuraxial Abnormalities Is Approximately 8% Among Patients With Adolescent Idiopathic Scoliosis

A Meta-analysis

Wang, Hai-Qiang MD, PhD; Zhang, Jun MD; He, Xin MD; Luan, Fu-Jun MD

Clinical Orthopaedics and Related Research®: August 2018 - Volume 476 - Issue 8 - p 1686–1687
doi: 10.1097/CORR.0000000000000341

H-Q Wang, Department of Orthopaedics, Centre for Translational Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China

J. Zhang, Department of Orthopaedics, Baoji Municipal Central Hospital, Baoji, Shaanxi Province, China

X. He, Department of Orthopedics, Tianjin Hospital, No. 406 Jiefang south road , Hexi District, Tianjin, China

F-J Luan, Department of Orthopeadics, Yongchuan Hosptial of Chongqing Medical University, Yongchuan District, Chongqing City, China

Hai-Qiang Wang MD, PhD, Department of Orthopaedics, Centre for Translational Medicine The First Affiliated Hospital of Xi'an Jiaotong University 277 West Yanta Road Xi'an, Shaanxi, China, 710061 Email:

(RE: Faloon M, Sahai N, Pierce TP, Dunn CJ, Sinha K, Hwang KS, Emami A. Incidence of Neuraxial Abnormalities Is Approximately 8% Among Patients With Adolescent Idiopathic Scoliosis: A Meta-analysis. Clin Orthop Relat Res. [Published online ahead of print Feb. 21, 2018]. DOI: 10.1007/s11999.0000000000000196).

The authors certify that neither they, nor any members of their immediate families, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

The letter to the editor is supported by the National Natural Science Foundation of China (81572182).

Received March 18, 2018

Accepted April 17, 2018

To the Editor,

We read the excellent systematic review and meta-analysis by Faloon and colleagues [3] with great interest. The number of studies on adolescent idiopathic scoliosis (AIS) is on the rise [2, 4, 7, 10, 11], but the findings from the meta-analysis shed new light on this common form of scoliosis. In a study that included data from 4746 patients with AIS, Faloon and colleagues found that the pooled proportion of neuraxial abnormalities revealed by MRI was as high as 8% [3]. Despite these interesting findings, there are still two issues we would like to discuss.

First, we believe spinal surgeons are overdependent on diagnostic imaging (and neglect physical examination) when trying to identify the neural etiology of AIS. Clinical imaging facilitates the diagnosis and treatment of human diseases, especially for spinal and knee physicians. Spinal professionals, though, often suggest that patients with low back pain and/or sciatica undergo diagnostic imaging, such as lumbar CT or MRI. But are they carefully evaluating the history and physical manifestation of the pain? Based on diagnostic reports, spinal professionals generally diagnose patients with lumbar disc herniation or lumbar spinal stenosis [8]. Importantly, lumbar disc herniation could be judged by integrating symptoms and physical examination findings, such as the Radicular Pain caused by Disc Herniation (RAPDH) criteria [5]. Additionally, the International Delphi Study supports the clinical diagnosis of lumbar spinal stenosis on seven items of clinical history [9]. As a result, the Denmark National clinical guidelines for low back pain or lumbar radiculopathy suggest diagnostic imaging should not be routinely performed due to uncertain benefits. Nevertheless, careful clinical evaluation will provide sufficient lines of evidence to make a clinical diagnosis. For patients with AIS, a typical right-thoracic curve, female patients, intact motor and sensation function, an intact abdominal wall reflex are all characteristics that are likely to suggest the absence of severe neuraxial pathology. Indeed, idiopathic scoliosis is a diagnosis based on exclusion (Table 1). A neural etiology of spinal deformity should be ruled out in every patient by at least careful physical examination [1], not just by MRI.

Table 1

Table 1

Second, the incidence of neuraxial abnormalities among patients with atypical scoliosis might be higher than typical scoliosis. A male patient, or a left thoracic curve might suggest neuroaxial abnormalities [6]. Despite the meta-analysis finding an insignificant neuroaxial abnormalities difference between typical and non-typical scoliosis, we noted that Faloon and colleagues acknowledged the paucity of strong evidence existing on the issue. We need studies in patients with AIS that have large sample sizes to unravel the important differences between typical and atypical scoliosis.

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1. Diab M. Physical examination in adolescent idiopathic scoliosis. Neurosurg Clin N Am. 2007;18:229–236.
2. Doody MM, Lonstein JE, Stovall M, Hacker DG, Luckyanov N, Land CE. Breast cancer mortality after diagnostic radiography: Findings from the U.S. scoliosis cohort study. Spine. 2000;25:2052–2063.
3. Faloon M, Sahai N, Pierce TP, Dunn CJ, Sinha K, Hwang KS, Emami A. Incidence of neuraxial abnormalities is approximately 8% among patients with adolescent idiopathic scoliosis: A meta-analysis. Clin Orthop Relat Res. [Published online ahead of print . , 2018]. DOI: .
4. Force USPST, Grossman DC, Curry SJ, Owens DK, Barry MJ, Davidson KW, Doubeni CA, Epling JW Jr., Kemper AR, Krist AH, Kurth AE, Landefeld CS, Mangione CM, Phipps MG, Silverstein M, Simon MA, Tseng CW. Screening for adolescent idiopathic scoliosis: US preventive services task force recommendation statement. JAMA. 2018;319:165–172.
5. Genevay S, Courvoisier DS, Konstantinou K, Kovacs FM, Marty M, Rainville J, Norberg M, Kaux JF, Cha TD, Katz JN, Atlas SJ. Clinical classification criteria for radicular pain caused by lumbar disc herniation: the radicular pain caused by disc herniation (RAPIDH) criteria. Spine J. 2017;17:1464–1471.
6. Jada A, Mackel CE, Hwang SW, Samdani AF, Stephen JH, Bennett JT, Baaj AA. Evaluation and management of adolescent idiopathic scoliosis: A review. Neurosurg Focus. 2017;43:E2.
7. Levy AR, Goldberg MS, Mayo NE, Hanley JA, Poitras B. Reducing the lifetime risk of cancer from spinal radiographs among people with adolescent idiopathic scoliosis. Spine. 1996;21:1540–1547; discussion 1548.
8. Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, Andersen MO, Fournier G, Hojgaard B, Jensen MB, Jensen LD, Karbo T, Kirkeskov L, Melbye M, Morsel-Carlsen L, Nordsteen J, Palsson TS, Rasti Z, Silbye PF, Steiness MZ, Tarp S, Vaagholt M. National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27:60–75.
9. Tomkins-Lane C, Melloh M, Lurie J, Smuck M, Battie MC, Freeman B, Samartzis D, Hu R, Barz T, Stuber K, Schneider M, Haig A, Schizas C, Cheung JP, Mannion AF, Staub L, Comer C, Macedo L, Ahn SH, Takahashi K, Sandella D. ISSLS prize winner: Consensus on the clinical diagnosis of lumbar spinal stenosis: Results of an international Delphi study. Spine (Phila Pa 1976). 2016;41:1239–1246.
10. Wu N, Ming X, Xiao J, Wu Z, Chen X, Shinawi M, Shen Y, Yu G, Liu J, Xie H, Gucev ZS, Liu S, Yang N, Al-Kateb H, Chen J, Zhang J, Hauser N, Zhang T, Tasic V, Liu P, Su X, Pan X, Liu C, Wang L, Shen J, Shen J, Chen Y, Zhang T, Zhang J, Choy KW, Wang J, Wang Q, Li S, Zhou W, Guo J, Wang Y, Zhang C, Zhao H, An Y, Zhao Y, Wang J, Liu Z, Zuo Y, Tian Y, Weng X, Sutton VR, Wang H, Ming Y, Kulkarni S, Zhong TP, Giampietro PF, Dunwoodie SL, Cheung SW, Zhang X, Jin L, Lupski JR, Qiu G, Zhang F. TBX6 null variants and a common hypomorphic allele in congenital scoliosis. N Engl J Med. 2015;372:341–350.
11. Zheng YP, Lee TT, Lai KK, Yip BH, Zhou GQ, Jiang WW, Cheung JC, Wong MS, Ng BK, Cheng JC, Lam TP. A reliability and validity study for Scolioscan: A radiation-free scoliosis assessment system using 3D ultrasound imaging. Scoliosis Spinal Disord. 2016;11:13.
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