- Email: [email protected]
SCHOOL SCREENING FOR SCOLIOSIS
863
Letters
to
the Editor
SCHOOL SCREENING FOR SCOLIOSIS
SIR,—Your Aug. 15 editorial and the letter from Professor Warren and his colleagues (Sept. 5, p. 522) show how unsatisfactory is the science of school screening for scoliosis. The editorial states that the screener must be proficient in the "one minute" screening test. Yet such proficiency varies widely, even among experts, as shown by two recent studies in the U.K.l,2 Inonel 15% and in the other2 l-9%of the children were referred for X-ray examination of the spine; but in each study there were only 2-3 per 1000 with lateral spinal curves of 20° or more. Most orthopaedic surgeons will not start brace treatment for an adolescent until a spinal curve reaches 25-30 degrees. Hence the "one minute" screening test is unquestionably too sensitive. In our experience, its use leads to children being referred unnecessarily to hospital. Such referrals can provoke anxiety in children and their parents-who often lose time from work in bringing their child to hospital. There are additional disadvantages-namely, exposure to X-rays and cost to the National Health Service in materials and manpower. Our research has led us to conclude that this screening test is unsatisfactory because it has not been based on objective knowledge of the shape of the normal child’s back. Several workers have devised mechanical systems to measure the severity of a rib hump; 3 they have used children referred to hospital either in the usual way3 or after school screening.4-6 Willner7 used an optical system (Moire photography) again on selected subjects. We have also undertaken studies on selected children but as a pilot study. In 1980, 7370 schoolchildren were screened for scoliosis in Nottinghamshire by school nurses trained in the test. They referred 325 children for an orthopaedic opinion. Examination of referred children in health clinics and at hospital provided the opportunity to develop subjective and objective techniques for recording data from children with posterior chest and lumbar asymmetry. These techniques for clinical back assessment involved using the formulator body contour tracer3 made use of methods we had used and developed when studying growth and natural history of children with idiopathic scoliosis, in collaboration with colleagues in Liverpool and Birmingham.$-1° It became evident that the "one minute" screening test was inadequate in two principal ways: (1) it was subjective, whereas in a proportion of children it needed to be objective, preferably expressed numerically; and (2) it was not known how much posterior trunk asymmetry could be accepted as normal. The need was to examine and measure randomly selected healthy children attending primary and secondary schools. our We have studied 636 healthy children aged 8-15 years clinical back assessment system for primary school children and
using
1. Dickson
RA, Farquharson-Roberts MA, Reid DC, Stamper P, Williams S, Wood JM. The natural history of idiopathic scoliosis: an epidemiological approach. Paper read at combined meeting of the British and Scandinavian Scoliosis Societies (May 21-23, 1981, Jersey).
2. Seal PV. School screening in rural England Paper read at combined meeting of the British and Scandinavian Scoliosis Societies (May 21-23, 1981, Jersey). 3. Thulbourne T, Gillespie R. The rib hump in idiopathic scoliosis: Measurement, analysis and response to treatment. J Bone Joint Surg 1976; 58B: 64-71. 4. Ashworth MA, Ersil AK. The measurement of rib hump inclination: a potential aid in scoliosis screening. Paper read at 15th annual meeting of the Scoliosis Research
Society (Sept. 17-19, 1980, Chicago). WP, Cady RB Angle of trunk rotation (ATR). Paper read at 16th annual meeting of the Scoliosis Research Society (Sept. 16-18, 1981, Montreal). 6 Ponte A. Prognostic evaluation of vertebral rotation in small idiopathic curves. Paper read at 16th annual meeting of the Scoliosis Research Society (Sept. 16-18, 1981, Montreal). 7. Willner S. School screening program. Paper read at combined meeting of the British and Scandinavian Scoliosis Societies (May 21-23, 1981, Jersey). 8 Dangerfield PH, Burwell RG, Vernon CL. Anthropometry and Scoliosis. In: RoafR, ed Spinal deformities. London: Pitman Medical, 1980: 259-80. 5 Bunnell
9. Burwell
RG, Dangerfield PH, Vernon CL. Bone asymmetry and joint laxity in the upper limbs of children with adolescent idiopathic scoliosis. Ann Roy Coll Surg Eng
1981, 63: 209-10. RG, Vernon CL, Dangerfield PH. Skeletal measurement. In: Owen R, Goodfellow J, Bullough P, eds. Scientific foundation of orthopaedics and traumatology. London William Heinemann Medical Books, 1980: 317-29. 11. Burwell RG, James NJ, Webb JK. The rib hump score: a guide to referral and prognosis? Proceedings of the British Association of Clinical Anatomists (Jan. 16, 1981, London). Ann Roy Coil Surg Eng (in press). 10. Burwell
for the entire sample.12 The severity of a rib hump is expressed as the rib hump score. It is calculated by a new method which accommodates the symmetrical back and size variation of normal children. Rib humps were considered to be objectively detectable only if the scores were outside two standard deviations ofthe error of the method. The lumbar hump scores for these children have been calculated. We make three recommendations for school screening:12
(1) A rib hump in children examined in schools is usually a normal finding; (2) the presence of a rib hump should not be used for referring a child to hospital, but as an alerting sign to look for clinical evidence of structural scoliosis; and
(3) the presence of clinically detectable structural scoliosis with the rib hump may together provide a guide for referring a child for an orthopaedic opinion. score
In view of the complexity of clinical back assessment in a child we support the view ofR. Gray (in the September, 1981, edition of the Midland edition of CENTRE) that every 10-year-old in Britain should have a Moiré photograph. We support the plea of Warren and his colleagues for a coordinated epidemiological and clinical approach with basic data collection. We suggest that investigators in different regions of the U.K. plan and work together. In this way it should be possible to create an efficient and practical system of school screening in a reasonable time. The system will need to be such that it can be accommodated by existing resources in various regions of the country. The basic data collected in a few detailed studies will define natural history and may aid prognosis of juvenile and adolescent idiopathic scoliosis. There is a need to screen for infantile idiopathic cannot
scoliosis. Department of Human Morphology, Queen’s Medical Centre, University of Nottingham, Nottingham NG7 2UH Scoliosis
R. GEOFFREY BURWELL
Unit,
Harlow Wood Mansfield
Orthopaedic Hospital,
JOHN K. WEBB
Child Health
Services, Nottinghamshire AHA (T)
ELEANOR J. MORE
WHO SHOULD TREAT CANCER?
SIR,-A Lancet editorial, with its cloak of authoritative anonymity, would normally be expected to have the last word, particularly after a lengthy correspondence had provided the controversy which often precedes such editorials. However, your editorial of Sept. 26 (p. 674) draws conclusions which we feel are quite unjustified. A good part of our papers in your April 18 issuel,2 addressed the question of training for cancer specialists, yet the final section of your editorial suggests what sounds like a heavy reliance on surgeons, physicians and gynaecologists quite untrained in the use of these highly dangerous drugs, when all the evidence suggests that this recommendation is not only counterproductive but also fraught with hazard. It is also naive to suggest that one can sidestep the need for greater numbers of properly trained clinical oncologists, whilst at the same time avoiding "the indiscriminate and unmonitored use of these drugs". Since we rely heavily on large trials to establish new approaches, it is also unrealistic to suppose that specialised units can define the most effective drug regimens, with general physicians and surgeons in district general hospitals applying these treatments once they have become established. Cancer chemotherapy does not evolve in this straightforward way, and anyone closely associated with the development of new approaches over the past decade would surely agree that this proposal betrays a surprising lack of insight. Several recommendations in the concluding paragraph struck us as shortsighted and dangerous, though we do at least agree that cancer medicine needs to be well taught at undergraduate level. The statement that most surgeons and gynaecologists have already 12. Burwell RG, James NJ, Johnson F, Webb JK The rib hump score. A guide to referral and prognosis? Proceedings of the British Orthopaedic Association (Sept. 30 to Oct.
2, 1981, London). JBone Joint Surg (in press). 1. Tobias JS, Harper PG, Tattersall MHN. Who should treat cancer’ Lancet 1981, i: 884-86. 2. Peckham MJ Clinical oncology The future of radiotherapy and medical oncology. Lancet 1981; i: 886-87.
Letters
to
the Editor
SCHOOL SCREENING FOR SCOLIOSIS
SIR,—Your Aug. 15 editorial and the letter from Professor Warren and his colleagues (Sept. 5, p. 522) show how unsatisfactory is the science of school screening for scoliosis. The editorial states that the screener must be proficient in the "one minute" screening test. Yet such proficiency varies widely, even among experts, as shown by two recent studies in the U.K.l,2 Inonel 15% and in the other2 l-9%of the children were referred for X-ray examination of the spine; but in each study there were only 2-3 per 1000 with lateral spinal curves of 20° or more. Most orthopaedic surgeons will not start brace treatment for an adolescent until a spinal curve reaches 25-30 degrees. Hence the "one minute" screening test is unquestionably too sensitive. In our experience, its use leads to children being referred unnecessarily to hospital. Such referrals can provoke anxiety in children and their parents-who often lose time from work in bringing their child to hospital. There are additional disadvantages-namely, exposure to X-rays and cost to the National Health Service in materials and manpower. Our research has led us to conclude that this screening test is unsatisfactory because it has not been based on objective knowledge of the shape of the normal child’s back. Several workers have devised mechanical systems to measure the severity of a rib hump; 3 they have used children referred to hospital either in the usual way3 or after school screening.4-6 Willner7 used an optical system (Moire photography) again on selected subjects. We have also undertaken studies on selected children but as a pilot study. In 1980, 7370 schoolchildren were screened for scoliosis in Nottinghamshire by school nurses trained in the test. They referred 325 children for an orthopaedic opinion. Examination of referred children in health clinics and at hospital provided the opportunity to develop subjective and objective techniques for recording data from children with posterior chest and lumbar asymmetry. These techniques for clinical back assessment involved using the formulator body contour tracer3 made use of methods we had used and developed when studying growth and natural history of children with idiopathic scoliosis, in collaboration with colleagues in Liverpool and Birmingham.$-1° It became evident that the "one minute" screening test was inadequate in two principal ways: (1) it was subjective, whereas in a proportion of children it needed to be objective, preferably expressed numerically; and (2) it was not known how much posterior trunk asymmetry could be accepted as normal. The need was to examine and measure randomly selected healthy children attending primary and secondary schools. our We have studied 636 healthy children aged 8-15 years clinical back assessment system for primary school children and
using
1. Dickson
RA, Farquharson-Roberts MA, Reid DC, Stamper P, Williams S, Wood JM. The natural history of idiopathic scoliosis: an epidemiological approach. Paper read at combined meeting of the British and Scandinavian Scoliosis Societies (May 21-23, 1981, Jersey).
2. Seal PV. School screening in rural England Paper read at combined meeting of the British and Scandinavian Scoliosis Societies (May 21-23, 1981, Jersey). 3. Thulbourne T, Gillespie R. The rib hump in idiopathic scoliosis: Measurement, analysis and response to treatment. J Bone Joint Surg 1976; 58B: 64-71. 4. Ashworth MA, Ersil AK. The measurement of rib hump inclination: a potential aid in scoliosis screening. Paper read at 15th annual meeting of the Scoliosis Research
Society (Sept. 17-19, 1980, Chicago). WP, Cady RB Angle of trunk rotation (ATR). Paper read at 16th annual meeting of the Scoliosis Research Society (Sept. 16-18, 1981, Montreal). 6 Ponte A. Prognostic evaluation of vertebral rotation in small idiopathic curves. Paper read at 16th annual meeting of the Scoliosis Research Society (Sept. 16-18, 1981, Montreal). 7. Willner S. School screening program. Paper read at combined meeting of the British and Scandinavian Scoliosis Societies (May 21-23, 1981, Jersey). 8 Dangerfield PH, Burwell RG, Vernon CL. Anthropometry and Scoliosis. In: RoafR, ed Spinal deformities. London: Pitman Medical, 1980: 259-80. 5 Bunnell
9. Burwell
RG, Dangerfield PH, Vernon CL. Bone asymmetry and joint laxity in the upper limbs of children with adolescent idiopathic scoliosis. Ann Roy Coll Surg Eng
1981, 63: 209-10. RG, Vernon CL, Dangerfield PH. Skeletal measurement. In: Owen R, Goodfellow J, Bullough P, eds. Scientific foundation of orthopaedics and traumatology. London William Heinemann Medical Books, 1980: 317-29. 11. Burwell RG, James NJ, Webb JK. The rib hump score: a guide to referral and prognosis? Proceedings of the British Association of Clinical Anatomists (Jan. 16, 1981, London). Ann Roy Coil Surg Eng (in press). 10. Burwell
for the entire sample.12 The severity of a rib hump is expressed as the rib hump score. It is calculated by a new method which accommodates the symmetrical back and size variation of normal children. Rib humps were considered to be objectively detectable only if the scores were outside two standard deviations ofthe error of the method. The lumbar hump scores for these children have been calculated. We make three recommendations for school screening:12
(1) A rib hump in children examined in schools is usually a normal finding; (2) the presence of a rib hump should not be used for referring a child to hospital, but as an alerting sign to look for clinical evidence of structural scoliosis; and
(3) the presence of clinically detectable structural scoliosis with the rib hump may together provide a guide for referring a child for an orthopaedic opinion. score
In view of the complexity of clinical back assessment in a child we support the view ofR. Gray (in the September, 1981, edition of the Midland edition of CENTRE) that every 10-year-old in Britain should have a Moiré photograph. We support the plea of Warren and his colleagues for a coordinated epidemiological and clinical approach with basic data collection. We suggest that investigators in different regions of the U.K. plan and work together. In this way it should be possible to create an efficient and practical system of school screening in a reasonable time. The system will need to be such that it can be accommodated by existing resources in various regions of the country. The basic data collected in a few detailed studies will define natural history and may aid prognosis of juvenile and adolescent idiopathic scoliosis. There is a need to screen for infantile idiopathic cannot
scoliosis. Department of Human Morphology, Queen’s Medical Centre, University of Nottingham, Nottingham NG7 2UH Scoliosis
R. GEOFFREY BURWELL
Unit,
Harlow Wood Mansfield
Orthopaedic Hospital,
JOHN K. WEBB
Child Health
Services, Nottinghamshire AHA (T)
ELEANOR J. MORE
WHO SHOULD TREAT CANCER?
SIR,-A Lancet editorial, with its cloak of authoritative anonymity, would normally be expected to have the last word, particularly after a lengthy correspondence had provided the controversy which often precedes such editorials. However, your editorial of Sept. 26 (p. 674) draws conclusions which we feel are quite unjustified. A good part of our papers in your April 18 issuel,2 addressed the question of training for cancer specialists, yet the final section of your editorial suggests what sounds like a heavy reliance on surgeons, physicians and gynaecologists quite untrained in the use of these highly dangerous drugs, when all the evidence suggests that this recommendation is not only counterproductive but also fraught with hazard. It is also naive to suggest that one can sidestep the need for greater numbers of properly trained clinical oncologists, whilst at the same time avoiding "the indiscriminate and unmonitored use of these drugs". Since we rely heavily on large trials to establish new approaches, it is also unrealistic to suppose that specialised units can define the most effective drug regimens, with general physicians and surgeons in district general hospitals applying these treatments once they have become established. Cancer chemotherapy does not evolve in this straightforward way, and anyone closely associated with the development of new approaches over the past decade would surely agree that this proposal betrays a surprising lack of insight. Several recommendations in the concluding paragraph struck us as shortsighted and dangerous, though we do at least agree that cancer medicine needs to be well taught at undergraduate level. The statement that most surgeons and gynaecologists have already 12. Burwell RG, James NJ, Johnson F, Webb JK The rib hump score. A guide to referral and prognosis? Proceedings of the British Orthopaedic Association (Sept. 30 to Oct.
2, 1981, London). JBone Joint Surg (in press). 1. Tobias JS, Harper PG, Tattersall MHN. Who should treat cancer’ Lancet 1981, i: 884-86. 2. Peckham MJ Clinical oncology The future of radiotherapy and medical oncology. Lancet 1981; i: 886-87.