What are the treatment options for scoliosis?

Treatment Options for Scoliosis

The treatment of scoliosis should be based on curve magnitude, age, skeletal maturity, and associated symptoms, with options ranging from observation for mild curves to bracing for moderate curves and surgery for severe curves or those with significant progression despite conservative treatment.

Diagnosis and Classification

Scoliosis is defined as a lateral curvature of the spine with a Cobb angle of at least 10 degrees in the coronal plane 1. The main types include:

• Idiopathic scoliosis: Accounts for 75-80% of cases, particularly affecting females 2
• Congenital scoliosis: Due to vertebral anomalies
• Neuromuscular scoliosis: Associated with neurological or muscular disorders
• Syndromic scoliosis: Related to conditions like Marfan syndrome, Ehlers-Danlos syndrome 2
• Adult degenerative scoliosis: Develops due to asymmetric degeneration of discs and facet joints 3

Initial Assessment

• Document curve magnitude using Cobb angle from radiographs
• Assess for pain, neurological symptoms, and functional limitations
• Obtain standing full-spine radiographs to evaluate curve severity and pattern 2

Treatment Algorithm Based on Curve Severity

1. Mild Scoliosis (Cobb angle 10-20°)

• Recommended approach: Observation with regular follow-up
• Monitoring frequency: Every 4-6 months during growth periods
• Rationale: Most mild curves do not progress significantly and are usually asymptomatic 1

2. Moderate Scoliosis (Cobb angle 20-50° in skeletally immature patients)

• Recommended approach: Bracing
• Indications for bracing:
  • Documented curve progression ≥5° on serial radiographs
  • Curve magnitude between 20-50°
  • Skeletal immaturity (Risser sign ≤2)
  • Age ≥10 years 2
• Evidence: Low-quality evidence shows that rigid bracing compared with observation significantly increases success rate in 20° to 40° curves at two years' follow-up (RR 1.79,95% CI 1.29 to 2.50) 4
• Bracing protocol: 16-23 hours daily wear until skeletal maturity

3. Severe Scoliosis (Cobb angle >40-50°)

• Recommended approach: Surgical intervention
• Indications for surgery:
  • Curve greater than or equal to 40° in an adolescent younger than 18 years
  • Documented progression despite conservative treatment
  • Significant pain, cosmetic concerns, or respiratory compromise 2
• Surgical goals:
  • Prevent further curve progression
  • Correct existing deformity
  • Improve trunk balance and cosmesis
  • Prevent potential long-term complications
  • Improve pain and self-image 2

Special Considerations for Different Patient Groups

Adolescent Idiopathic Scoliosis

• Most common form requiring intervention
• Bracing is primary non-surgical treatment
• Surgery typically involves posterior spinal fusion with instrumentation

Neuromuscular Scoliosis

• More complex treatment with higher complication rates
• Often requires earlier intervention
• Surgery typically includes fusion to the pelvis to address pelvic obliquity 5

Adult Scoliosis

• Treatment focuses on symptom management rather than curve correction
• Conservative treatment includes physical therapy, pain management, and injections
• Surgical indications include progressive deformity, neurological compromise, or intractable pain 3

Non-Surgical Management Options

Physical Therapy

• Scoliosis-specific exercises may help with pain management and posture
• Limited evidence for preventing curve progression 4

Pain Management

• NSAIDs/COXIBs at maximum tolerated dosage for pain relief
• Short courses of oral prednisolone for severe pain flares
• Avoid long-term use of glucocorticoids 2

Surgical Management

Surgical Approaches

• Posterior approach: Most common, allows for extensive correction
• Anterior approach: Sometimes used for thoracolumbar curves
• Combined approaches: For severe rigid curves

Instrumentation

• Pedicle screw fixation provides superior three-dimensional correction
• Rod configuration should address both coronal and sagittal deformities 2

Expected Outcomes

• Correction rates of 60-86% can be achieved with modern instrumentation
• Improvement in trunk balance, cosmesis, and pain
• Prevention of further curve progression 2

Common Pitfalls and Complications

Treatment Pitfalls

• Delayed referral to specialists
• Inadequate monitoring during growth spurts
• Inconsistent brace wear
• Overlooking non-idiopathic causes of scoliosis 2

Surgical Complications

• Neurological injury
• Implant failure or migration
• Infection
• Pseudarthrosis
• Adjacent segment degeneration
• Reoperation rates of 6-29% 2

Referral Guidelines

A child should be referred to a specialist if:

• The curve is greater than 10 degrees in a patient younger than 10 years of age
• The curve is greater than 20 degrees in a patient 10 years of age or older
• The curve has atypical features
• The curve is associated with back pain or neurological abnormalities 6

Early referral is essential to optimize treatment outcomes and prevent progression to severe deformity requiring more invasive interventions.