At what degree of thoracic scoliosis (scoliosis of the thoracic spine) should a pediatric patient be referred for further evaluation and potential treatment?

Referral Thresholds for Pediatric Thoracic Scoliosis

Pediatric patients with thoracic scoliosis should be referred for specialist evaluation when the Cobb angle reaches 20 degrees or greater, as these curves have a high likelihood of progression (>70%) in skeletally immature individuals. 1

Evaluation and Measurement

Scoliosis is defined as a lateral curvature of the spine exceeding 10 degrees on a standing posteroanterior (PA) radiograph. The severity is measured using the Cobb angle, which determines the appropriate management pathway:

• 10-19 degrees: Mild scoliosis - monitor with regular radiographs
• 20-40 degrees: Moderate scoliosis - referral to specialist for potential bracing
• >40-50 degrees: Severe scoliosis - referral for surgical evaluation 1, 2

Clinical Screening Tools

• Scoliometer readings can help determine when radiographs are necessary:
  • Thoracic or right convex curves: Refer if Angle of Trunk Rotation (ATR) > 7 degrees
  • Thoracolumbar/lumbar or left convex curves: Refer if ATR > 6 degrees 3

Referral Algorithm Based on Curve Magnitude

1. Cobb angle 20-25 degrees in skeletally immature patients

   • Immediate referral to orthopedic specialist
   • High risk of progression (>70%) 1
   • Bracing typically recommended

2. Cobb angle >40 degrees in adolescents under 18

   • Urgent referral for surgical evaluation 2
   • American College of Radiology recommends surgical consideration

3. Cobb angle >50 degrees in any pediatric patient

   • Immediate surgical referral 2
   • High risk of continued progression (approximately 1° per year) even after skeletal maturity 1, 2

Risk Factors for Progression Requiring Earlier Referral

Even with smaller curves, earlier referral is warranted with:

• Rapid curve progression (>1° per month)
• Skeletally immature patient (Risser 0-2)
• Female gender (10:1 female-to-male ratio for curves >40°)
• Family history of progressive scoliosis
• Left thoracic curve (higher association with neural axis abnormalities)
• Absence of apical segment lordosis/kyphosis 1

Monitoring Recommendations

For curves below referral thresholds:

• Risser stages 0-3: Radiographs every 12 months
• Risser stages 4-5: Radiographs every 18 months
• More frequent monitoring with clinical changes 1

Special Considerations

• Atypical curve patterns: Left thoracic curves, short segment curves (4-6 levels), or curves with rapid progression warrant MRI evaluation to rule out neural axis abnormalities, which occur in 2-4% of adolescent idiopathic scoliosis patients 1, 2

• Bracing: Can be effective even for curves 45-60° in patients refusing surgery, with proper expertise and compliance 4

• Surgical indications: Curves >50° have documented risk of continued progression even after growth completion, making surgical intervention a reasonable option 2

Common Pitfalls to Avoid

1. Delayed referral: Waiting until curves exceed 30° can result in missed opportunities for conservative treatment

2. Inadequate monitoring: Failure to obtain regular radiographs in growing children with smaller curves

3. Overlooking neural axis abnormalities: Atypical curve patterns require MRI evaluation

4. Ignoring skeletal maturity: The same curve magnitude has different implications based on skeletal maturity status

Remember that early detection and referral are critical, as they may allow for curve stabilization and prevention of thoracic deformity and secondary complications 5.