Who should a child with scoliosis be referred to for treatment?

Referral for Children with Scoliosis

Children with scoliosis should be referred to a pediatric orthopedic surgeon for evaluation and management. 1

Indications for Referral to Pediatric Orthopedic Surgeon

• Infants, children, and adolescents with significant spinal deformity (scoliosis or kyphosis) require specialized care from a pediatric orthopedic surgeon 1
• 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 2
  • The curve is greater than 20 degrees in a patient 10 years of age or older 2
  • The curve has atypical features or is associated with back pain or neurological abnormalities 2

Qualifications of a Pediatric Orthopedic Surgeon

• A pediatric orthopedic surgeon has completed a residency in orthopedics and an additional Accreditation Council for Graduate Medical Education–approved 1-year fellowship in pediatric orthopedics 1
• This specialized training ensures expertise in managing pediatric spinal conditions including scoliosis 1

Types of Scoliosis and Management Considerations

• Different types of scoliosis may require different approaches:
  • Idiopathic scoliosis (most common type, 75-80% of all cases) 3
  • Congenital scoliosis (requires evaluation for associated cardiac and renal abnormalities) 2
  • Neuromuscular scoliosis 2
  • Syndrome-related scoliosis 4

Red Flags Requiring Urgent Evaluation

• Left thoracic curve (atypical pattern) 4
• Short segment curve (4-6 levels) 1
• Absence of apical segment lordosis/kyphosis 1
• Rapid curve progression (more than 1° per month) 1, 4
• Functionally disruptive pain 1, 4
• Focal neurological findings 1, 4
• Male sex (less common presentation) 1, 4

Imaging Considerations Before Referral

• Radiographs of the complete spine are usually appropriate for initial imaging of adolescents (10-18 years) with idiopathic scoliosis and no risk factors 1
• For children with congenital scoliosis or early-onset idiopathic scoliosis (0-9 years), both radiographs and MRI of the complete spine without IV contrast are recommended 1
• MRI evaluation should be considered if new neurological symptoms develop or if the curve shows unexpected progression 3

Treatment Approaches by Pediatric Orthopedic Surgeons

• Observation is appropriate for curves <20° in patients with high growth potential (Risser 0-2) and curves <40° in patients with minimal growth potential (Risser 3-5) 5
• Bracing is appropriate for patients with curves of 20-40° with high growth potential 5
• Surgical intervention is typically considered for:
  • Curves greater than 40-50° 6, 5
  • Documented curve progression despite skeletal maturity 3
  • Significant pain not responding to conservative measures 3

Importance of Early Referral

• Early diagnosis and referral to a pediatric spine service can improve outcomes 5
• Regular monitoring is essential, especially during growth spurts when curve progression risk is highest 3, 4
• Delayed referral may lead to more complex treatment requirements and potentially poorer outcomes 7