Thoracic Idiopathic Scoliosis: Establishing the Diagnostic Accuracy and Reference Values of Surface Topography

This is a cross-sectional prospective study of diagnostic accuracy. 
 The aim of this study was to establish the diagnostic accuracy and cut-off points of the surface topography parameters. 
Methods: Seventy-seven participants of both genders, aged between 7 and 18 years old, were consecutively included. Each participant was evaluated using two randomly-chosen consecutive procedures, by means of a surface topography scanner and a Scoliometer®. In this study, the angle of trunk rotation (ATR) determined using the Scoliometer® was taken as reference. For statistical purposes, a multiple linear regression analysis was made to establish which surface topography parameters have the highest standardized beta coefficients (β). Based on the β values, two topographic parameters were chosen (apex of the curve and trunk rotation) to compose the Receiver Operating Characteristic (ROC) analysis. 
 The cut-off points for the topographic parameters were established as ATR <5° for subjects without scoliosis and ≥8° for severe scoliosis. The ROC curve analysis for the apex of the curve was significant (p<0.001) with an area under the curve (AUC) ranging between 76% [cut-off point 4.4 mm] for the subjects without scoliosis and 84% [cut-off point 9.4 mm] for the subjects with severe scoliosis. For the trunk rotation parameter, the AUC was also significant, ranging between 68% [cut-off point 1.5°, p=0.023] for subjects without scoliosis, and 73% [cut-off point 4.8°, p=0.018] for the subjects with severe scoliosis. 
  
 Surface topography provides adequate accuracy and can be used to evaluate the presence of the thoracic idiopathic scoliosis.

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title: Anatomical reference marks, evaluation parameters and reproducibility of surface topography for evaluating the adolescent idiopathic scoliosis: a systematic review with meta-analysis.
abstract: Surface topography is a radiation-free examination that provides relevant information for the evaluation of patients with Adolescent Idiopathic Scoliosis (AIS). However, its usage is not standardized, which restricts the applicability of this instrument.



(a) To identify the anatomical reference markers used on surface topography; (b) to identify the parameters used on surface topography; and (c) to pool correlation and reproducibility results.



Systematic searches were conducted following MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. The methodological quality was assessed according to Brink & Louw appraisal tool.



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title: Raster Stereography Versus Radiography in the Long-term Follow-up of Idiopathic Scoliosis
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title: Cancer Mortality among Women Frequently Exposed to Radiographic Examinations for Spinal Disorders
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title: Projecting the lifetime risk of cancer from exposure to diagnostic ionizing radiation for adolescent idiopathic scoliosis.
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title: Back surface measurements by rasterstereography for adolescent idiopathic scoliosis: from reproducibility to data reduction analyses
abstract: PurposeAim of this cross-sectional study was to evaluate the reproducibility of back surface measurements obtained by rasterstereography (RS) in adolescents with idiopathic scoliosis (AIS), and to identify the most informative RS parameters through a multi-step reduction analysis approach.MethodsSixty-six AIS were assessed with a RS scanner. The assessment was repeated in the same day 15 min after the first scan and after 1 week. Intraclass-correlation analyses were conducted to verify the consistency of the measurements. A multi-step reduction technique including correlation, principal component analysis (PCA) and regression was employed to extract a core-set of key RS parameters.ResultsBack surface measures were obtained from 66 AIS aged 10–17 years (median 13), with a mild Scoliosis angle < 25 (median 20). The reliability over the 3 sessions proved high to very high, with all the intraclass correlation coefficients ≥ 0.8 and 32 out of 48 coefficients ≥ 0.9. Only 8 of the 12 parameters provided by the RS device showed significant inter-item correlations and were therefore considered for further analyses. PCA extracted 4 of them, which entered the final regression analysis. High beta coefficients were found for 2 predictors: “Surface rotation-rms” and “Side deviation-rms,” which were found to be significantly associated with the dependent variable “Scoliosis angle.”ConclusionsData showed that RS measurements are reliable in AIS with mild severity of scoliosis. “Surface rotation” and “Side deviation” were the best descriptors of the Scoliosis angle and should be considered as key parameters when surveilling AIS with mild curves by RS surface topography.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

title: School screening for scoliosis: can surface topography replace examination with scoliometer?
abstract: BackgroundClinical examination with the use of scoliometer is a basic method for scoliosis detection in school screening programs. Surface topography (ST) enables three-dimensional back assessment, however it has not been adopted for the purpose of scoliosis screening yet. The purpose of this study was to assess the usefulness of ST for scoliosis screening.Methods996 girls aged 9 to 13 years were examined, with both scoliometer and surface topography. The Surface Trunk Rotation (STR) was introduced and defined as a parameter allowing comparison with scoliometer Angle of Trunk Rotation taken as reference.ResultsIntra-observer error for STR parameter was 1.9°, inter-observer error was 0.8°. Sensitivity and specificity of ST were not satisfactory, the screening cut-off value of the surface topography parameter could not be established.ConclusionsThe study did not reveal advantage of ST as a scoliosis screening method in comparison to clinical examination with the use of the scoliometer.

title: Methodology of evaluation of morphology of the spine and the trunk in idiopathic scoliosis and other spinal deformities - 6th SOSORT consensus paper
abstract: BackgroundComprehensive evaluation of the morphology of the spine and of the whole body is essential in order to correctly manage patients suffering from progressive idiopathic scoliosis. Although methodology of clinical and radiological examination is well described in manuals of orthopaedics, there is deficit of data which clinical and radiological parameters are considered in everyday practise. Recently, an increasing tendency to extend scoliosis examination beyond the measure of the Cobb angle can be observed, reflecting a more patient-oriented approach. Such evaluation often involves surface parameters, aesthetics, function and quality of life.Aim of the studyTo investigate current recommendations of experts on methodology of evaluation of the patient with spinal deformity, essentially idiopathic scoliosis.MethodsStructured Delphi procedure for collecting and processing knowledge from a group of experts with a series of questionnaires and controlled opinion feedback was performed. Experience and opinions of the professionals - physicians and physiotherapists managing scoliosis patients - were studied. According to Delphi method a Meeting Questionnaire (MQ) has been developed, resulting from a preliminary Pre-Meeting Questionnaire (PMQ) which had been previously discussed and approved on line. The MQ was circulated among the SOSORT experts during Consensus Session on "Measurements" which took place at the Annual Meeting of the Society, totally 23 panellists being engaged. Clinical, radiological and surface topography parameters were checked for agreement.Results90% agreement or more was reached in 35 items and superior than 75% agreement was reached in further 25 items. An evaluation form was proposed to be used by clinicians and researchers.ConclusionThe consensus was reached on evaluation of the morphology of the patient with idiopathic scoliosis, comprising clinical, radiological and, to less extend, surface topography assessment. Considering the variety of parameters indicated by the panellists, the Cobb angle, yet the gold standard, can be seen neither as the unique nor the only decisive parameter in the management of patients with idiopathic scoliosis.

title: Validity and reliability testing of the Scoliometer.
abstract: This study was designed to evaluate the Scoliometer, an instrument that measures axial trunk rotation in individuals with scoliosis. The objectives included determining 1) the Scoliometer's screening capability and validity and 2) the intrarater and interrater reliability of Scoliometer measurements. Scoliometer measurements made by two raters on 65 persons with idiopathic scoliosis were correlated with radiographic assessment of vertebral (pedicle) rotation and lateral curvature (Cobb method). Correlation ranged from .32 to .46 with pedicle rotation and from .46 to .54 with the Cobb angle. Frequency analysis revealed relatively good specificity, sensitivity, and predictive capability of the Scoliometer. Intrarater and interrater reliability coefficients were high (r = .86-.97). These results indicate good measurement reproducibility. The less-than-optimal between-method correlation coefficients suggest that the validity of Scoliometer measurements is not sufficient to use this method alone for determining patient diagnosis and management. Based on the positive-frequency analysis, however, the use of this tool as a screening device would be appropriate.

title: A Study of the Diagnostic Accuracy and Reliability of the Scoliometer and Adam's Forward Bend Test
abstract: Study of the diagnostic accuracy and interexaminer reliability of scoliosis diagnostic tests.  To estimate the sensitivity, specificity, and predictive value of the Scoliometer (National Scoliosis Foundation, Watertown, MA) and Adam's forward bend test in diagnosing scoliosis, and to determine the interexaminer reliability of the Scoliometer and Adam's forward bend test.  Exposure to diagnostic radiation in patients with adolescent idiopathic scoliosis may result in a small but significant increase in cancer rates. The full‐spine radiographic examination remains the standard procedure for the assessment of scoliosis. There is a need for a valid and reliable noninvasive test to assess scoliosis.  Two examiners independently assessed 105 patients presenting to a scoliosis clinic for trunk asymmetry with Adam's forward bend test and axial trunk rotation with the Scoliometer. The Cobb method served as the gold standard.  The interexaminer agreement for the Scoliometer is excellent in the thoracic spine and substantial in the lumbar spine. The interexaminer measurement error shows poor precision for thoracic and lumbar Scoliometer measurements. The interexaminer agreement for Adam's forward bend test is substantial in the thoracic spine and poor in the lumbar spine. Adam's forward bend test is more sensitive than the Scoliometer in detecting thoracic curves measuring 20° or more by the Cobb method. Receiver operating characteristic curve analysis suggests that the use of the Scoliometer marginally improves the ability of diagnosing a scoliosis in the thoracic spine.  The Scoliometer and Adam's forward bend tests have adequate interexaminer reliability for the assessment of thoracic curves. The Scoliometer has better interexaminer agreement in the lumbar spine. However, the Scoliometer has a high level of interexaminer measurement error that limits its use as an outcome instrument. Because Adam's forward bend test is more sensitive than the Scoliometer, the authors believe that it remains the best noninvasive clinical test to evaluate scoliosis.

title: Cut‐off Point of the Scoliometer in School Scoliosis Screening
abstract: A large‐scale study on school screening for scoliosis was conducted to assess the referral rate, prevalence rate, and positive predictive value using different angles of trunk rotation as criteria for referral.  To determine an ideal angle of trunk rotation cut‐off point to be used for referral in school screening for scoliosis.  When using the Scoliometer (Orthopedic Systems, Inc., Hayward, CA) in school scoliosis screening, 5° and 7° angles of trunk rotation have been recommended as criteria for referral. Low positive predictive values and over‐referral at these levels have been reported.  The Adams forward bend test and Scoliometer measurement were combined for school scoliosis screening in 33,596 girls from the fifth, sixth and seventh grades. Nurses were the primary screeners. Girls with trunk rotation angles of 5° or more were referred for radiography.  The referral rate was 5.2%. By selecting 6°, 7°, 8°, 9° or 10° angles of trunk rotation as criteria for referral, the referral rate became 2.4%, 1.4%, 0.7%, 0.5%, or 0.3%, respectively. The prevalence rate for scoliosis equal to or larger than 10°, 20°, 30°, or 40° of the Cobb angle was 1.47%, 0.21%, 0.04% and 0.02%, respectively, by using a 5° angle of trunk rotation as the criterion for radiography. The positive predictive value was 28.3% for scoliosis of 10° or more, 4% for scoliosis of 20° or more, 0.8% for scoliosis of 30° or more, and 0.4% for scoliosis of 40° or more with a 5° angle of trunk rotation as the criterion for referral. By selecting angles of trunk rotation larger than 5° as criteria for referral for radiography, the positive predictive value increased, but positive cases with larger Cobb angles also decreased markedly.  The optimal cut‐off point for referral when using the Scoliometer in school screening of scoliosis is still difficult to determine.

title: 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth
abstract: BackgroundThe International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines’ version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS).MethodsPhysicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016.ResultsThe contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation “I” and level of evidence “II”. Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8.ConclusionThe 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

title: Confiabilidade interavaliadores e intra-avaliador do escoliômetro
abstract: The scoliometer was developed to analyze the axial rotation of the trunk in patients with idiopathic scoliosis. However, there is controversy regarding the reliability of the measures obtained with this device.  To test the intra-rater and inter-rater reliability of the scoliometer in patients with scoliosis.  24 volunteers of both sex with idiopathic scoliosis diagnostic (18±4 years-old) and curvatures with mean and standard deviation of 24.8±12.7o Cobb. The measurement procedure was accomplished in one day by two trained examiners. The palpation and determination of each spinal level was accomplished by just one examiner. Each examiner obtained one measure with the device for each vertebra from the thoracic and lumbar levels in each evaluation. For statistical analysis the measurements were divided by spinal levels into upper thorax, medium thorax, lower thorax and lumbar segments. The Intraclass Correlation Coefficient type 1,1 (ICC1,1) was used to determine the intra-rater reliability while the ICC3,1 was used to determine the inter-rater reliability.  The observed intra-rater reliability values for the medium and lower thorax and lumbar segments of the subjects ranged from very good to excellent. The inter-rater reliability of the measures of axial trunk rotations was considered good to the upper thorax and excellent for the medium and lower thorax and lumbar spine.  The scoliometer is a device that has intra-rater reliability estimates ranging from very good to excellent. The inter-rater reliability for the upper and low thorax and for the lumbar spine is relatively lower than the intra-rater values for the same spinal segments, even when the errors from palpation and positioning of the instrument were eliminated.

title: An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting.
abstract: We examined the ability of the Adams forward bend test and the scoliometer to detect truncal rotation or asymmetry in a school screening setting. Of 954 sixth graders examined with each test independently, 123 and 13 [using an angle of trunk rotation (ATR) of > 5 and 7 degrees, respectively] were found to be abnormal on scoliometer examination but appeared normal on the Adams test. Selecting children for scoliometer examination on the basis of the Adams test is not supported by our data and may not be consistent with generally accepted principles of public health screening.

title: Radiation dose of digital radiography (DR) versus micro-dose x-ray (EOS) on patients with adolescent idiopathic scoliosis: 2016 SOSORT- IRSSD “John Sevastic Award” Winner in Imaging Research
abstract: BackgroundPatients with adolescent idiopathic scoliosis (AIS) frequently receive x-ray imaging at diagnosis and subsequent follow monitoring. The ionizing radiation exposure has accumulated through their development stage and the effect of radiation to this young vulnerable group of patients is uncertain. To achieve the ALARA (as low as reasonably achievable) concept of radiation dose in medical imaging, a slot-scanning x-ray technique by the EOS system has been adopted and the radiation dose using micro-dose protocol was compared with the standard digital radiography on patients with AIS.MethodsNinety-nine participants with AIS underwent micro-dose EOS and 33 underwent standard digital radiography (DR) for imaging of the whole spine. Entrance-skin dose was measured using thermoluminescent dosimeters (TLD) at three regions (i.e. dorsal sites at the level of sternal notch, nipple line, symphysis pubis). Effective dose and organ dose were calculated by simulation using PCXMC 2.0. Data from two x-ray systems were compared using independent-samples t-test and significance level at 0.05. All TLD measurements were conducted on PA projection only. Image quality was also assessed by two raters using Cobb angle measurement and a set of imaging parameters for optimization purposes.ResultsEntrance-skin dose from micro-dose EOS system was 5.9–27.0 times lower at various regions compared with standard DR. The calculated effective dose was 2.6 ± 0.5 (μSv) and 67.5 ± 23.3 (μSv) from micro-dose and standard DR, respectively. The reduction in the micro-dose was approximately 26 times. Organ doses at thyroid, lung and gonad regions were significantly lower in micro-dose (p < 0.001). Data were further compared within the different gender groups. Females received significantly higher (p < 0.001) organ dose at ovaries compared to the testes in males. Patients with AIS received approximately 16–34 times lesser organ dose from micro-dose x-ray as compared with the standard DR. There was no significant difference in overall rating of imaging quality between EOS and DR. Micro-dose protocol provided enough quality to perform consistent measurement on Cobb angle.ConclusionsEntrance-skin dose, effective dose and organ dose were significantly reduced in micro-dose x-ray. The effective dose of a single micro-dose x-ray (2.6 μSv) was less than a day of background radiation. As AIS patients require periodic x-ray follow up for surveillance of curve progression, clinical use of micro-dose x-ray system is beneficial for these young patients to reduce the intake of ionizing radiation.

title: SOSORT 2012 consensus paper: reducing x-ray exposure in pediatric patients with scoliosis
abstract: This 2012 Consensus paper reviews the literature on side effects of x-ray exposure in the pediatric population as it relates to scoliosis evaluation and treatment. Alternative methods of spinal assessment and imaging are reviewed, and strategies for reducing the number of radiographs are developed. Using the Delphi technique, SOSORT members developed consensus statements that describe how often radiographs should be taken in each of the pediatric and adolescent sub-populations.