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Evaluating the Extent of Clinical Uncertainty Among Treatment Options for Patients with Early-Onset Scoliosis
Jacqueline Corona, MD1; Daniel J. Miller, MD2; Jenny Downs, PhD, MSc3; Behrooz A. Akbarnia, MD4; Randal R. Betz, MD5; Laurel C. Blakemore, MD6; Robert M. Campbell, MD7; John M. Flynn, MD7; Charles E. Johnston, MD8; Richard E. McCarthy, MD9; David P. Roye, MD10; David L. Skaggs, MD11; John T. Smith, MD12; Brian D. Snyder, MD, PhD13; Paul D. Sponseller, MD, MBA14; Peter F. Sturm, MD15; George H. Thompson, MD16; Muharrem Yazici, MD17; Michael G. Vitale, MD, MPH10
1 Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, 701 North First Street, Room D220, Springfield, IL 62702
2 Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, Ph 11, New York, NY 10032
3 Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, P.O. Box 855, West Perth, Western Australia 6009, Australia
4 San Diego Center for Spinal Disorders, 4130 La Jolla Village Drive, Suite 300, La Jolla, CA 92037
5 Department of Orthopaedic Surgery, Shriners Hospital for Children, 3551 North Broad Street, Philadelphia, PA 19140
6 Department of Orthopaedic Surgery and Sports Medicine, Children’s National Medical Center, 111 Michigan Avenue N.W., Washington, DC 20010
7 Division of Orthopaedics, Children’s Hospital of Philadelphia, 324 South 34th Street, Philadelphia, PA 19104
8 Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219
9 Arkansas Children’s Hospital, 1 Children’s Way, Suite 584, Little Rock, AR 72202
10 Morgan Stanley Children’s Hospital of New York, Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032. E-mail address for M.G. Vitale: mgv1@columbia.edu
11 Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #69, Los Angeles, CA 90027
12 Department of Orthopaedics and Pediatrics, The University of Utah School of Medicine, Primary Children’s Medical Center, 100 Mario Capecchi Drive, Salt Lake City, UT 84113
13 Department of Orthopaedic Surgery, Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115
14 Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Suite 5253, Baltimore, MD 21287
15 Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229
16 Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106
17 Department of Orthopaedics and Traumatology, Hacettepe University, 06100 Sihhiye, Ankara, Turkey
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  • Disclosure statement for author(s): PDF

Investigation performed at Columbia University Medical Center, New York, NY

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 May 15;95(10):e67 1-10. doi: 10.2106/JBJS.K.00805
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Literature guiding the management of early-onset scoliosis consists primarily of studies with a low level of evidence. Evaluation of clinical equipoise (i.e., when there is no known superiority among treatment modalities) allows for prioritization of research efforts. The objective of this study was to evaluate areas of clinical uncertainty among pediatric spine surgeons regarding the treatment of early-onset scoliosis.


Fourteen experienced pediatric spine surgeons participated in semistructured interviews to identify clinical variables that influence decision making in the treatment of early-onset scoliosis. A series of case scenarios of 315 patients with idiopathic and neuromuscular early-onset scoliosis was then developed to be representative of those encountered in clinical practice. Using an online survey, eleven surgeons selected their choice of eight treatment options for each case scenario. Associations between case characteristics and treatment choices were assessed with chi-square and logistic regression analysis. Participants then reviewed the areas of treatment uncertainty identified in the survey, nominated additional research questions of interest, and ranked their interest to further explore the identified research questions.


Collective equipoise was identified in numerous scenarios in the survey spanning a range of ages and magnitudes of scoliosis, and additional questions were identified during the nominal group technique. Areas that had the greatest clinical uncertainty included the management of patients who have finished treatment with a growing-rod, timing of rod-lengthening intervals, and indications for spine-based and rib-based proximal instrumentation anchors. The use of rib anchors compared with spine-based anchors was ranked highly for consideration in future clinical trials.


Variability in decision making with regard to the optimum treatment of certain subsets of patients with early-onset scoliosis reflects gaps in the available evidence. Structured consensus methods identified priorities for higher levels of research in this area of scoliosis. Higher-level studies, including randomized trials, should focus on answering the questions highlighted in this report.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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