What is the standard approach to charting and treating scoliosis?

Standard Approach to Charting and Treating Scoliosis

The standard approach to charting scoliosis requires upright posteroanterior (PA) and lateral spine radiographs to assess curve severity using the Cobb angle measurement, which is essential for diagnosis, monitoring progression, and guiding treatment decisions. 1

Initial Assessment and Screening

• The Adams forward bend test combined with scoliometer measurement is recommended for initial clinical screening, with the Adams test having a sensitivity of 84.37% and specificity of 93.44% 2
• Physical examination should assess for:
  • Shoulder height asymmetry 2
  • Neurological abnormalities (focal deficits, abnormal reflexes, muscle weakness) 2
  • Skin examination for cutaneous stigmata (hemangiomas, hairy patches, dermal appendages, sinus tracts) that might suggest underlying spinal dysraphism 2

Radiographic Assessment

• Upright PA and lateral spine radiographs are the primary imaging modality for diagnosing and classifying scoliosis 1, 3
• The Cobb angle is measured by:
  • Identifying the most tilted vertebrae at the top and bottom of the curve 4
  • The angle formed by the intersection of lines drawn parallel to the endplates of these vertebrae determines the curve magnitude 4
  • A Cobb angle of 10° or more defines scoliosis 5
• Serial PA spine radiographs are essential for monitoring progression, with frequency determined by skeletal maturity 1
• Limit spine radiographs to once every 12 months for patients at Risser stages 0-3 and every 18 months for patients at Risser stages 4-5 to reduce radiation exposure 1

Documentation Requirements

• Document the following in the patient chart:
  • Curve type (primary or secondary, structural or nonstructural) 5
  • Cobb angle measurement 5
  • Degree of vertebral rotation (measured with the Nash-Moe method) 5
  • Longitudinal extent of spinal involvement (according to the Lenke system) 5
  • Risser sign (skeletal maturity) 6
  • Red flags requiring urgent evaluation:
    • Left thoracic curve (atypical pattern)
    • Short segment curve
    • Absence of apical segment lordosis/kyphosis
    • Rapid curve progression (>1° per month)
    • Functionally disruptive pain
    • Focal neurological findings
    • Male sex 2, 3

Advanced Imaging

• MRI is indicated for:
  • All patients with congenital scoliosis (>20% have neural axis anomalies) 3
  • Patients with atypical curves or neurological findings 3
  • Presurgical planning 3
• CT may be preferred for:
  • Presurgical planning and visualization of bony malformations 1
  • Characterization of osseous septum in type I split cord malformations 1
  • Low-dose protocols should be used when CT is necessary 3

Treatment Algorithm Based on Curve Magnitude

• Curves <20°: Observation with radiographic monitoring 7, 8
• Curves 20-40° in skeletally immature patients: Consider bracing as these curves have a >70% likelihood of progression 1
• Curves >50° in adolescents and young adults: Surgical intervention typically recommended 7, 6
• Curves 40-50° at late skeletal growth (Risser IV-V): Monitor closely as 39.2% experience significant progression, with younger age and Risser stage IV being risk factors 6

Monitoring Progression

• Skeletally immature individuals with Cobb angles >20° have >70% likelihood of curve progression 1
• Skeletally mature patients with thoracic scoliosis >50° may continue to progress at approximately 1° per year 1
• Curve progression is most likely during periods of rapid growth, requiring more frequent monitoring (as short as 4-month intervals) in skeletally immature patients 5
• After skeletal maturity, only curves >30° require continued monitoring for progression 5

Common Pitfalls to Avoid

• Absence of neurological symptoms does not rule out intraspinal abnormalities, particularly in congenital scoliosis 1, 3
• Manual measurement of Cobb angles can have significant inter-observer variability (±3-5°); consider digital measurement tools when available 4, 9
• A child should be referred to a specialist if the curve is >10° in a patient younger than 10 years of age, or >20° in a patient 10 years or older 8
• Patients with congenital scoliosis must be evaluated for associated cardiac and renal abnormalities 8