February 2000 Bulletin

Scoliosis school screening needed

Proven brace treatment effective if curves detected early

By Robert B. Winter, MD

Recently, an article was published in the Journal of the American Medical Association, reporting on the statistical results of school screening for scoliosis in Olmsted County, Minn. (Rochester).4 It once again raised the question of whether such screening was worthwhile in view of the fact that of 2,242 children screened, only 92 were referred for medical evaluation, and only nine needed treatment.

The written conclusion of the study states, "Therefore, individual communities and state legislators will need to decide what is appropriate and feasible for their schools based on the best available data".

The authors themselves do not agree on how to interpret the data. Barbara Yawn, MD, an epidemiologist and lead author, thinks school screening should be abandoned, while William Shaughnessy, MD, a pediatric orthopaedic surgeon at the Mayo Clinic in Rochester, believes the program is very worthwhile.1

As in all medical research, there are the factual results (data) developed, and there are the conclusions drawn from that data. It is the drawing of conclusions that can be treacherous. There are several ways that the data in this study can be interpreted.

From a purely epidemiologic point of view, one can make the argument that if only nine of the 2,242 children needed treatment, the "yield rate" is too low to justify the cost, especially since the condition is non-fatal. This particular argument is severely flawed since it introduces the cost element and there is no control to the study, i.e., what are the costs of nonscreening?

Dr. Shaughnessy points out that since the school screening in Olmsted County costs about $20,000 per year to screen 16,000 students, and since it costs about $60,000 for a single scoliosis operation, school screening is probably very cost effective to society as a whole, even if not to the local school board budget.

A second, and quite valid argument, is that even if not cost effective, isn’t the health of our children worth the expenditure of money? Since it is now well known that brace treatment of early curves does prevent many surgeries,2 isn’t it worth the money to spare these children unnecessary surgery? In Great Britain, where school screening is not done, the children with scoliosis are not coming in until their curves are quite large, most of them needing both anterior and posterior spine fusions.3

Dr. Yawn, in a separate interview, stated "it can be caught by physical exams".1 This argument would be valid if all children had an annual physical examination and at that examination the spine was carefully evaluated for scoliosis. The truth is that many children do not have such an annual physical and even if they do, the spine is not even looked at. This is born out by the statistics in the study; only three of the nine patients needing treatment had been detected by physician examinations. It should also be noted that 26 percent of the parents did not take their child in for medical examination, even when notified of a positive finding on school screening. This poor rate of parental compliance was in a highly educated, health-conscious community. What might it be in an inner-city urban setting?

In conclusion, Dr. Yawn and colleagues have once again raised the issue of the value of school screening for scoliosis, but at the same time have provided no solid evidence that it should be discontinued. Since it is now well proven that brace treatment can be effective, but only if the curves are detected early, we should not abandon the only effective means for such early detection.

References

  1. Majeski, T: Debate rages over school screening. The Orange County Register, Oct. 27, 1999.
  2. Nachemson, A; Peterson, L; and members of the Brace Study Group of the Scoliosis Research Society: Effectiveness of Treatment with a Brace in Girls who have Adolescent Idiopathic Scoliosis. J Bone Joint Surg 77A: 815-822, 1995.
  3. Nordeen, H: Personal communication, 1999.
  4. Yawn, BP; Yawn, RA; Hodge, D; Kurland, M; Shaughnessy, WJ; Ilstrup, D; Jacobsen, SJ: A Population-based Study of School Scoliosis Screening. JAMA 282: 1427-1432, 1999 (Oct. 20).

Robert B. Winter, MD, is a clinical professor of orthopaedic surgery, University of Minnesota, and a research consultant to the Twin Cities Spine Center. He is a founding member of the Scoliosis Research Society and 1973 President.


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