0
Scientific Articles   |    
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
View Disclosures and Other Information
  • 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
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

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.

Methods: 

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.

Results: 

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.

Conclusions: 

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.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    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.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    04/02/2014
    W. Virginia - Charleston Area Medical Center
    12/31/2013
    S. Carolina - Department of Orthopaedic Surgery Medical Univerity of South Carlonina
    12/04/2013
    New York - Icahn School of Medicine at Mount Sinai
    02/28/2014
    District of Columbia (DC) - Children's National Medical Center