To the Editor,
We read the excellent systematic review and meta-analysis by Faloon and colleagues  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% . 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 . 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 . Additionally, the International Delphi Study supports the clinical diagnosis of lumbar spinal stenosis on seven items of clinical history . 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 , not just by MRI.
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 . 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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