What is the approach to assessment and management of adolescent idiopathic scoliosis (AIS)?

From the Guidelines

The assessment and management of idiopathic scoliosis requires a systematic approach based on curve severity and skeletal maturity, with initial evaluation including a detailed physical examination, measurement of curve magnitude using the Cobb angle, and assessment of skeletal maturity using the Risser sign or Sanders classification 1. The approach to idiopathic scoliosis involves several key steps, including:

• Initial evaluation with a detailed physical examination using the Adam's forward bend test to identify trunk asymmetry
• Measurement of curve magnitude using the Cobb angle on standing posteroanterior radiographs
• Assessment of skeletal maturity using the Risser sign or Sanders classification
• For mild curves (Cobb angle <25°), observation with follow-up radiographs every 4-6 months during growth is recommended 1
• For moderate curves (25-45°) in skeletally immature patients, bracing is the mainstay of treatment, typically with a thoracolumbosacral orthosis (TLSO) worn 16-23 hours daily until skeletal maturity 1
• Physical therapy focusing on core strengthening and postural awareness can complement bracing but is not a substitute
• Surgical intervention is typically recommended for curves exceeding 45-50° or for progressive curves despite bracing, with posterior spinal fusion using pedicle screws and rods being the most common procedure 1 The natural history of idiopathic scoliosis involves potential curve progression during growth spurts, with the risk being highest in girls with larger curves who are skeletally immature, making timely intervention essential to prevent cardiopulmonary complications and cosmetic concerns in adulthood. Some key points to consider in the management of idiopathic scoliosis include:
• The use of PA instead of anteroposterior technique to reduce breast dose in radiography 1
• The employment of lower-dose radiography techniques, such as computed and digital radiography, to minimize radiation exposure 1
• The importance of early detection through school screening programs to prevent progression and improve outcomes 1

From the Research

Approach to Assessment

• The approach to assessment and management of idiopathic scoliosis involves evaluating the magnitude and pattern of the deformity, as well as its potential for progression 2.
• The treatment options include observation, bracing, and/or surgery, with the choice of treatment depending on the severity of the curve and the patient's skeletal maturity 2.

Indications for Bracing

• Bracing is recommended for growing children with a curve of 25°-40° or a curve less than 25° with documented progression 2.
• Curves of 20°-25° in patients with pronounced skeletal immaturity should also be treated with bracing 2.
• The purpose of bracing is to prevent the progression of the curve and improve the patient's quality of life 3.

Efficacy of Bracing

• Studies have shown that bracing can be effective in preventing the progression of scoliosis, especially in patients with a Cobb angle of 25-35° 3.
• Bracing has been shown to be more effective than observation in preventing curve progression, and may not have a negative impact on patients' quality of life 3.
• However, the quality of evidence is limited due to the low methodological quality of most studies, and further research is needed to establish clearer guidelines for bracing 3.

Alternative Treatments

• Other forms of conservative treatment, such as chiropractic or osteopathic manipulation, acupuncture, exercise, or diet and nutrition, have not been proven to be effective in controlling spinal deformity progression 2.
• However, some studies have shown that comprehensive spinal correction rehabilitation (CSCR) can be effective in improving spinal deformity and lung function in patients with early-onset idiopathic scoliosis 4.
• The use of a scoliosis activity suit has also been shown to be effective in preventing curve progression in patients with mild adolescent idiopathic scoliosis 5.

Standards of Management

• The SOSORT Consensus 2008 provides guidelines on the standards of management of idiopathic scoliosis with corrective braces, including recommendations for experience/competence, behaviors, prescription, construction, brace check, and follow-up 6.
• These guidelines aim to increase efficacy and compliance to treatment, and should be followed in clinical practice and research studies 6.