Eclinicalmedicine: Sabrina Donzelli, Fabio Zaina, Stefano Negrini

EClinicalMedicine 18 (2020) 100244
Contents lists available at ScienceDirect
EClinicalMedicine
journal homepage: https://www.journals.elsevier.com/eclinicalmedicine
Commentary
Predicting scoliosis progression: a challenge for researchers and clinicians

Sabrina Donzellia,*, Fabio Zainaa, Stefano Negrinib,c
a
ISICO Italian Scientific Spine Institute, Milan, Italy
b
Department of Biomedical, Surgical and Dental Sciences, University of Milan “La Statale”, Milan, Italy
c
IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
A R T I C L E I N F O “for each patient, it is mandatory to choose the correct step of treat-

ment, where the most efficacious is also the most demanding” [4].
Article History: Expert clinicians should always choose the option they think is the
Received 12 December 2019
most likely to reach the goals agreed with the patient but also the
Accepted 12 December 2019
Available online 6 January 2020 less invasive in the attempt to balance between undertreatment (that
leads to little or no efficacy) and overtreatment (too much burden on
the patient, without further benefit). Moreover, goals of treatment
may vary according to patients' perspectives, with aesthetics being
Idiopathic Scoliosis (IS) is a three-dimensional deformity of the one of the most important goals for patients, sometimes underesti-
spine with a prevalence ranging between 1 and 4 % [1,2]. IS treatment mated by researchers [5]. That means that we cannot define over-
during growth is secondary prevention with the primary aim to and undertreatment only according to the Cobb angle. Surgery
reduce the trunk deformity and avoid progression over 30° Cobb; the remains the last treatment option; it exposes to higher risks, and it is
secondary aim is to avoid surgery whose threshold is above 45 50° the most invasive treatment [9].
[3]. It has been shown that ending growth below 30° allows prevent- The introduction of a composite model, including genetic factors,
ing progression, disability and pain in adulthood [4]. is the novelty of this study, but some clinical questions remain open.
IS has a multifactorial aetiology [4] showing a wide range of dif- The type and quality of treatment applied, the compliance to treat-
ferent forms: anatomical (single or multiple curves and different ment and the dosage of brace-wear have not been included in the
localization), aesthetical (milder curves with visible changes and model, although they are recognised as determinants of final results
severe hiding perfectly), and prognostical (from highly to non-pro- [10]. The chosen threshold of 40° is questionable, though justified by
gressive). the authors. Surgery is indicated for curves exceeding 50° [2]. The 30°
One of the major challenges faced by clinicians is related to IS degrees threshold is the most important for patients' future [2]. From
prognosis and to making decisions on which would be the best treat- a clinical point of view, the 40° threshold is too low for surgery indi-
ment for every single patient [4,5]. In this context, experts use some cation and too high for the best achievable result from patients' per-
known clinical risk factors, the most important being residual spective.
growth: the more it is, the more the risk [6]. Other factors include the A prognostic model should help clinicians in their choices after
deformity in sagittal and transversal planes (rotation and flat back), risks estimation, but according to the Evidence Base Practice princi-
familiarity and joint laxity [4]. Genetics investigations have recently ples, in clinical decision-making patients' attitudes towards the treat-
highlighted the heterogeneity of IS and the major role of non-genetic ment option should always be considered [4]. The currently
factors [7]. developed composite prediction model for progression over 40°
Considering the involvement of a multifactorial pathomechanism, showed that the major predictor is Cobb degrees at start. In the logis-
in this article of EClinicalMedicine Zhang and colleagues developed a tic regression equation, only weight reaches significance level, while
clinically applicable composite model using quantitative factors the other factors seem to work more as confounders than covariates:
including circulating markers to predict the probability of progres- delayed menarche, lower body weight, Risser sign and genetic factors
sion to 40° [8]. The test of the accuracy of the model showed 80% of play a marginal role, as shown in the comparison of the predictive
specificity and 92% of sensitivity, thus meaning that the model is power. The relatively small sample of subjects used to develop the
good in discriminating patients at high risk for progression to 40°. model exposes to some risk of overfitting. The authors managed this
According to the model, there is a 20% risk of overtreating patients limitation by reducing the alpha level to 0.01 and validated the model
with less aggressive IS. Is this enough? It depends on the treatment in a real sample, thus increasing the external validity of their results.
used to avoid progression. The SOSORT Guidelines recommend that The fact that Cobb at start is the major predictor, confirms the
key-role played by screening and conservative care: exercises and
bracing to prevent progression should be started at early stages of
DOI of original article: http://dx.doi.org/10.1016/j.eclinm.2019.12.006.
the deformity when it is early diagnosed. Composite models, includ-
* Corresponding author.
E-mail address: [email protected] (S. Donzelli). ing genetic factors, showed to offer promising improvement to the
https://doi.org/10.1016/j.eclinm.2019.100244
2589-5370/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)
2 S. Donzelli et al. / EClinicalMedicine 18 (2020) 100244
prediction of IS progression, but need to be validated in larger sam- [4] Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, et al.
ples and with more complex validation techniques. SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scolio-
sis during growth. Scoliosis Spinal Disord. 2018;13:3.
[5] Negrini S, Grivas TB, Kotwicki T, Maruyama T, Rigo M, Weiss HR, et al. Why do we
Declaration of Competing Interest
treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for
our patients. SOSORT 2005 Consensus paper. Scoliosis 2006;1:4.
SD nothing to disclose. FZ nothing to disclose. SN owns ISICO [6] Duval-Beaupere G, Dubousset J, Queneau P, Grossiord A. [A unique theory on the
course of scoliosis]. Presse Med. 1970;78(25):1141–6 passim.
stocks.
[7] Roye BD, Wright ML, Williams BA, Matsumoto H, Corona J, Hyman JE, et al. Does
ScoliScore provide more information than traditional clinical estimates of curve
References progression? Spine 2012;37(25):2099–103.
[8] Zhang J, Cheuk KJ, Xu L, Wang Y, Feng Z, Sit T, Cheng KI, Nepotchatykh E, Lam T,
[1] Nachemson AL, Lonstein JE, Weinstein SL. Report of the prevalence and natural history Liu Z, Hung ALH, Zhu Z, Moreau A, Cheng JCY, Qiu Y, Lee WYW. A validated com-
committee of the Scoliosis Research Society. Denver: Scoliosis Research Society; 1982. posite model to predict risk of curve progression in adolescent 2 Idiopathic scolio-
[2] Weinstein SL. The natural history of adolescent idiopathic scoliosis. J Pediatr sis. EClinicalMedicine 2020;18:100236.
Orthop 2019;39(6 Suppl 1):S44–6. [9] Bastrom TP, Yaszay B, Shah SA, Miyanji F, Lonner BS, Kelly MP, et al. Major com-
[3] Negrini S, Hresko TM, O’Brien JP, Price N, SOSORT Boards, SRS Non-Operative plications at two years after surgery impact SRS scores for adolescent idiopathic
Committee. Recommendations for research studies on treatment of idiopathic scoliosis patients. Spine Deform 2019;7(1):93–9.
scoliosis: Consensus 2014 between SOSORT and SRS non-operative management [10] Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Design of the bracing in adolescent
committee. Scoliosis 2015;10:8. idiopathic scoliosis trial (BrAIST). Spine. 2013;38(21):1832–41.

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EClinicalMedicine 18 (2020) 100244

Contents lists available at ScienceDirect

Predicting scoliosis progression: a challenge for researchers and clinicians

A R T I C L E I N F O “for each patient, it is mandatory to choose the correct step of treat-

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