Study design Preliminary analysis of the clinical value of surface topography in a spinal deformity clinic. Objectives The Cobb angle is the gold standard for the monitoring of scoliosis. This study was designed to determine whether surface topography would reflect Cobb angle status with sufficient reliability to permit its safe use as an alternative means of documentation in some circumstances. Summary of background data Surface topography offers the possibility of describing spinal deformity more fully than radiographic measures alone. To be useful, it must ignore changes due to varying posture and reliably detect differences that are clinically significant, while broadening the ability to assess deformity. Methods Surface topography using Quantec () was obtained routinely in all patients attending a spinal deformity unit. Intrasubject variation was reduced by taking the mean for each parameter of four repositioned scans, which gives a smallest detectable change on all measures of approximately 10 U. Fifty-nine patients with two sets of radiographs and topography scans were studied to determine the ability of the different measurements to detect significant change. Results There was a significant correlation between Cobb angle and Quantec spinal angle. A significant change in Cobb angle could be identified by associated change in at least one topographic measure in a significant proportion of cases. Conclusions It is unlikely that topography will supplant radiography for the ascertainment of Cobb angles, because the error margins of both are wide, and the two are not measuring the same aspect of the deformity. The Quantec system is useful in patient monitoring as an alternative to radiography, without diminishing the standard of care.

Surface topography, Cobb angles and cosmetic change in scoliosis

Scoliosis screening has been practiced for nearly 50 years and has provided valuable knowledge about the prevalence and natural history of scoliosis. Early diagnosis allows for nonoperative treatment, like wearing an orthosis that has been shown to be effective by numerous outcome studies. Challenges in scoliosis screening include the low prevalence rate of clinically significant scoliosis, the inverse relationship of sensitivity and specificity in the screening process because of the poor correlation of clinical deformity and radiographic abnormality, and the inflated cost of these programs because of overreferral. Recommendations for improvement include redefinition of what actually constitutes a "significant" scoliosis for screening, diagnostic, and outcome purposes; selective screening of only immature females; the use of objective referral criteria; and re-screening patients rather than referring those who have borderline cases.

Selective screening for scoliosis

This report is the SOSORT Consensus Paper on School Screening for Scoliosis discussed at the 4th International Conference on Conservative Management of Spinal Deformities, presented by SOSORT, on May 2007. The objectives were numerous, 1) the inclusion of the existing information on the issue, 2) the analysis and discussion of the responses by the meeting attendees to the twenty six questions of the questionnaire, 3) the impact of screening on frequency of surgical treatment and of its discontinuation, 4) the reasons why these programs must be continued, 5) the evolving aim of School Screening for Scoliosis and 6) recommendations for improvement of the procedure.

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SOSORT consensus paper: school screening for scoliosis. Where are we today?

Study design A 10-year follow-up evaluation of the effectiveness of school screening for scoliosis performed in a closed island population Objectives To evaluate the diagnostic accuracy of methods used for screening scoliosis and to re-examine the long-term effectiveness of the school scoliosis screening program Summary of background data The diagnostic accuracy of the forward-bending test and the long-term efficacy of the screening programs have not been clearly established Methods In 1987, 2700 pupils aged 8 to 16 years from the island of Samos were screened for scoliosis The Adams forward-bending test, Moire topography, the scoliometer, and the humpometer were used Radiologic evaluation of the spine was available for each pupil and the number of false-negative and false-positive results of the screening methods was calculated Subsequently, sensitivity, specificity, and positive and negative predictive values were estimated for each screening technique Pupils found positive for spinal deformity were then followed up regularly at yearly intervals In 1997, all positive subjects attended a 10-year clinical and radiologic follow-up, and the remaining subjects were re-evaluated by a postal questionnaire and were clinically examined if necessary Results Spinal deformity was found in 153 (566%) pupils Scoliosis (defined as a spinal curvature > or = 10 degrees) was found in 32 pupils, for a prevalence of 118% For scoliosis, the Adams forward-bending test showed a number of false-negative results (in five cases), for a sensitivity of 8437% and specificity of 9344% The sensitivities of Moire topography, the humpometer, and the scoliometer were 100%, 9375%, and 9062%, respectively, and specificity was 8538%, 7811%, and 7976% respectively The negative predictive value of the forward-bending test was inferior to those of the other methods During this scoliosis screening program, if cutoff limits for referral had been used, such as the asymmetry of two Moire fringes, a humpogram deformity of (D + H) = 10 mm, and 8 degrees of scoliometer angle, it would have been possible to reduce radiologic examination by 894% Three (011%) pupils aged between 12 and 14 years with scoliotic deformities greater than 20 degrees underwent satisfactory nonoperative treatment with Boston braces One pupil with a 40 degrees thoracic curvature, underwent satisfactory surgical treatment because of progression 1 year later Of the 121 spinal deformities with an initial Cobb angle less than 10 degrees, 44 (358%), and of the 29 scoliotic deformities with an initial Cobb angle between 10 degrees and 20 degrees, 14 (483%) progressed (a Cobb angle difference of at least 5 degrees in more than one examination) Observation and physiotherapy were the only treatments applied to all except one of the pupils in these groups Conclusions The Adams forward-bending test cannot be considered a safe diagnostic criterion for the early detection of scoliosis (especially when it is used as the only screening tool) because it results in an unacceptable number of false-negative findings For the early detection of scoliosis, a combination of back-shape analysis methods can be safely used with the introduction of cutoff limits for referral being a useful procedure The incidence of significant scoliosis is low, and its natural history seems to be independent of early detection The wide-spread use of school scoliosis screening with the use of the forward-bending test must be questioned

Ten-year follow-up evaluation of a school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis?

A 5-year epidemiological study on the prevalence rate of idiopathic scoliosis in Tokyo: school screening of more than 250,000 children.

Moire topography was added to school scoliosis screening in Singapore in 1982. The results from 1342 topographs, assessed in isolation, were used to study the accuracy of the method in predicting the radiographic location and magnitude of scoliotic curves. Accuracy in identifying the site of the curve was 68% in the thoracic spine, 54% in the thoracolumbar spine, and 15% in the lumbar region. There were 12.7% false-positive results and 4.3% false negatives. Of patients with a deviation of one moire fringe, 76.5% had a curve of 15 degrees or less; of those with a deviation of four moire fringes, 69% had a curve greater than 26 degrees. The prediction of the Cobb angle was less accurate when there was a deviation of two or three fringes. It is suggested that moire topography as a screening device should be reserved for use in the second tier of screening, since the forward-bending test is an effective and cheap method for the first tier of a mass school-screening programme.

P Balasubramaniam

Papers

Moire topography in scoliosis. Its accuracy in detecting the site and size of the curve