Evaluating the extent of clinical uncertainty among treatment options for patients with early-onset scoliosis.
Evaluating the extent of clinical uncertainty among treatment options for patients with early-onset scoliosis.
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DOI：
10.2106/jbjs.k.00805
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发表时间：
2013-05-15
期刊：
影响因子：
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通讯作者：
Vitale, Michael G
中科院分区：
文献类型：
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作者：
Corona, Jacqueline;Miller, Daniel J;Vitale, Michael G
背景：指导早发性脊柱侧凸治疗的文献主要是证据水平较低的研究。临床平衡评估（即，当治疗方式之间没有已知的优势时）允许优先考虑研究工作。本研究的目的是评估儿科脊柱外科医生在治疗早发性脊柱侧凸方面的临床不确定性。方法：14名经验丰富的儿科脊柱外科医生参加了半结构化访谈，以确定影响早发性脊柱侧凸治疗决策的临床变量。315例特发性和神经肌肉性早发性脊柱侧凸患者的一系列病例情景随后被开发，以代表临床实践中遇到的那些。通过一项在线调查，11位外科医生为每种情况选择了8种治疗方案。采用卡方分析和逻辑回归分析评估病例特征与治疗选择之间的关系。然后，参与者回顾调查中确定的治疗不确定性领域，提名感兴趣的其他研究问题，并对他们的兴趣进行排名，以进一步探索已确定的研究问题。结果：集体平衡在调查的许多情况下被确定，跨越一系列的年龄和脊柱侧凸的大小，并在名义群体技术期间确定了额外的问题。临床不确定性最大的领域包括完成生长棒治疗的患者的管理、棒延长间隔的时间以及基于脊柱和肋骨的近端内固定锚定的适应症。在未来的临床试验中，与基于脊柱的锚钉相比，肋骨锚钉的使用被高度评价。结论：对于某些早发性脊柱侧凸患者亚群的最佳治疗方案的决策差异反映了现有证据的差距。结构化的共识方法确定了在脊柱侧凸这一领域更高水平研究的优先事项。更高水平的研究，包括随机试验，应该专注于回答本报告中强调的问题。
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.