In the current issue of JAMA is the latest recommendation statement by the US Preventive Services Task Force (USPSTF),1 and accompanying evidence report,2 on the value of screening asymptomatic adolescents for adolescent idiopathic scoliosis. Since the topic was last reviewed in 2004, important new evidence has emerged that potentially supports scoliosis screening. In this update, the USPSTF changed its grade of the evidence from a “D” (discourage the use of screening programs) to an “I” (uncertainty about the balance of benefits and harms of the service).1 The recommendation highlights the high sensitivity, specificity, and predictive value and the low false-positive rate of screening programs when the Adams forward bend test is paired with scoliometer measurements and Moiré topography. It is important to recognize that a properly implemented screening program will identify potential patients who can benefit from brace treatment, possibly avoiding surgery. In addition, spinal deformity may be the presenting sign of a variety of conditions, including heritable collagen disease, neurological conditions, or skeletal dysplasia unrecognized until adolescence. Even if surgery cannot be averted, early diagnosis of progressive curves allows for surgical intervention at the most opportune time. The most important development since the last task force evaluation was the publication of prospectively controlled studies on the efficacy of brace treatment, which found a benefit in brace treatment over observation when comparing curve progression rates.3-5 The National Institutes of Health (NIH)–funded Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)4 evaluated brace treatment and observation in adolescents with idiopathic scoliosis between 20 and 40 degrees. It showed that brace treatment provided for a 56% reduction in the relative risk of scoliosis curve progression past 50 degrees, which was the defined measure of bracing failure, and also found a high correlation between bracing success and the number of hours of brace wear. There was limited evidence of treatment harms. Skin problems on the trunk (under the brace) and nonback body pains were more frequently reported in braced participants than in observed controls, but anxiety and depression rates were low and similar between groups. The study’s interim analysis showed that braced patients had significantly better rates of treatment success than nonbraced patients; therefore, the NIH Data Safety and Monitoring Board concluded the study prior to full enrollment. The BrAIST study4 highlights several challenges of generating level 1 evidence on screening and brace treatment programs. Insufficient enrollment in the randomized arm of the study led to the inclusion of the patient preference arm of the BrAIST study in which the patients/parents showed a greater than 2 to 1 patient enrollment preference for brace treatment over observation. The ethics of future observational studies, given the strength of evidence in favor of brace treatment, is in question. Similarly, prospectively evaluating the adult impact of untreated idiopathic scoliosis with a 30-year or longer observational study would present an enormous challenge. Undetected scoliosis deformity that advances to a surgical level carries its own significant consequences, which were not addressed by the Task Force recommendation.1 Whereas brace treatment in adolescence is relatively low cost with little risk of adverse events, surgical treatment is extremely costly. In uncomplicated surgical cases, the family burden and loss of school time are measurable, but more concerning are the risks of surgical complications, including paralysis and deep infection, in the more severe deformities.6 Furthermore, the need for long-term revision surgery is as high as 22%.7,8 Curves that progress past adolescence and require adult reconstruction are associated with dramatically increased risks of operative complications and even higher reoperation rates.9-12 The USPSTF does not consider costs for any of the preventive services in its recommendations, as a matter of scope. By not giving adequate consideration to the risks and costs of surgical treatment in adolescence and adulthood compared with those of brace treatment, the analysis underestimated the value of early diagnosis that can be achieved through screening programs. The USPSTF recommendation1 referenced a number of studies evaluating the association of adults’ patient-reported health outcomes with the severity of their adolescent spinal curves. However, these studies were limited either by shortterm follow-up (to adolescence) or by patients having in fact received bracing or surgical treatment. None of the study groups referenced in the USPSTF report represented the adult health burden of untreated progressive scoliosis, as none documented a natural history of untreated adult disease. The results were thereby biased against demonstrating the effect of pediatric bracing programs on adult health-related qualityof-life (QOL) measures. Several adult spinal deformity study groups have published extensively on the effect of untreated progressive deformity on adult health-related QOL measures and their effects on health economics.13-18 Their studies indirectly underscore the long-term treatment effects of a pediatric bracing program on adult QOL. These studies, however, did not appear in the USPSTF report. The USPSTF should be applauded for the change in recommendation from a “D” to an “I”. But a potential unintended consequence of the USPSTF recommendation is how clinicians will use it in their everyday practice. The evidence report addresses 6 key questions specific to a diagnosis of Related articles at jama.com Opinion

中文翻译：

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早期发现脊柱侧弯——USPSTF“I”对我们意味着什么

在当前一期的 JAMA 中，美国预防服务工作组 (USPSTF) 1 和随附的证据报告 2 关于筛查无症状青少年的青少年特发性脊柱侧凸的价值的最新建议声明。自 2004 年对该主题进行最后审查以来，出现了可能支持脊柱侧弯筛查的重要新证据。在这次更新中，USPSTF 将其证据等级从“D”（不鼓励使用筛查项目）改为“I”（不确定服务的利弊平衡）1。该建议强调了高当 Adams 前弯测试与侧弯测量和莫尔地形相结合时，筛查程序的灵敏度、特异性和预测值以及低假阳性率。重要的是要认识到正确实施的筛查计划将识别可以从支具治疗中受益的潜在患者，可能避免手术。此外，脊柱畸形可能是多种疾病的先兆，包括遗传性胶原病、神经系统疾病或直到青春期才被发现的骨骼发育不良。即使无法避免手术，对渐进性曲线的早期诊断也允许在最合适的时间进行手术干预。自上次工作组评估以来最重要的进展是关于支具治疗效果的前瞻性对照研究的发表，该研究发现在比较曲线进展率时支具治疗优于观察。3-5 美国国立卫生研究院 (NIH) 资助的青少年特发性脊柱侧弯试验中的支具 (BrAIST)4 评估了对患有 20 到 40 度的特发性脊柱侧弯的青少年的支具治疗和观察。结果表明，支具治疗可将脊柱侧弯进展超过 50 度的相对风险降低 56%，这是支具失败的定义衡量标准，并且还发现支具成功与支具佩戴小时数之间存在高度相关性。治疗危害的证据有限。与观察到的对照组相比，使用支具的参与者更常报告躯干（支具下方）的皮肤问题和非背部疼痛，但两组之间的焦虑和抑郁率较低且相似。该研究的中期分析表明，使用支具的患者的治疗成功率明显高于未使用支具的患者；因此，NIH 数据安全和监测委员会在完全注册之前结束了这项研究。BrAIST 研究 4 强调了在筛查和支具治疗计划中生成 1 级证据的几个挑战。该研究随机组的招募人数不足导致纳入了 BrAIST 研究的患者偏好组，在该组中，患者/父母表现出超过 2 比 1 的患者登记偏好对支具治疗而不是观察。考虑到支持支具治疗的证据强度，未来观察性研究的伦理是有问题的。相似地，通过 30 年或更长时间的观察性研究前瞻性评估未经治疗的特发性脊柱侧凸对成人的影响将是一个巨大的挑战。未发现的脊柱侧弯畸形发展到手术水平会带来其自身的重大后果，工作组的建议并未解决这些问题。1 虽然青春期支具治疗费用相对较低，不良事件风险很小，但手术治疗费用极高。在不复杂的手术病例中，家庭负担和上学时间的损失是可以衡量的，但更令人担忧的是手术并发症的风险，包括在更严重的畸形中出现的瘫痪和深部感染。 6 此外，需要长期进行翻修手术高达 22%.7，8 超过青春期并需要成人重建的曲线与手术并发症的风险显着增加和更高的再手术率相关。9-12 USPSTF 在其建议中没有考虑任何预防服务的成本，作为范围问题。与支具治疗相比，由于没有充分考虑青春期和成年期手术治疗的风险和成本，该分析低估了通过筛查计划可以实现的早期诊断的价值。USPSTF 建议 1 引用了许多评估成人患者报告的健康结果与其青少年脊柱弯曲严重程度之间的关联的研究。然而，这些研究要么受到短期随访（青春期）的限制，要么受到实际上接受过支具或手术治疗的患者的限制。USPSTF 报告中提到的所有研究组都没有代表未经治疗的进行性脊柱侧弯的成人健康负担，因为没有一个研究组记录了未经治疗的成人疾病的自然史。因此，结果不利于证明儿科支具计划对成人健康相关生活质量 (QOL) 措施的影响。几个成人脊柱畸形研究小组已经广泛发表了未经治疗的渐进性畸形对成人健康相关 QOL 措施的影响及其对健康经济学的影响。 13-18 他们的研究间接强调了儿科支具计划对成人的长期治疗效果。生活质量。然而，这些研究，没有出现在 USPSTF 报告中。USPSTF 的建议从“D”变为“I”，值得称赞。但 USPSTF 建议的潜在意外后果是临床医生将如何在日常实践中使用它。证据报告解决了特定于 jama.com 上相关文章诊断的 6 个关键问题 意见