What are the treatment options for scoliosis?

Treatment Options for Scoliosis

The management of scoliosis should follow a stepwise approach based on curve magnitude, with surgical intervention recommended when the Cobb angle exceeds 50 degrees in skeletally mature patients due to the risk of continued progression at approximately 1° per year. 1

Classification and Assessment

• Scoliosis is defined as a lateral curvature of the spine with a Cobb angle of at least 10 degrees 2
• Initial assessment should include the Adams forward bend test combined with scoliometer measurement, which provides the most reliable clinical assessment (sensitivity 84.37%, specificity 93.44%) 3
• Radiography is essential for definitive diagnosis, classification, and treatment planning, as clinical examination alone cannot determine exact curve magnitude 3
• Scoliosis can be classified as:
  • Idiopathic (most common, 75-80% of cases)
  • Congenital
  • Neuromuscular
  • Syndrome-related
  • Secondary to other conditions 4

Treatment Algorithm Based on Curve Severity

Mild Curves (10-25 degrees)

• Regular monitoring with radiographs is recommended, but no more frequently than every 12 months for adolescents at Risser stages 0-3 and every 18 months for Risser stages 4-5 1
• Physiotherapy Scoliosis-Specific Exercises (PSSE) are recommended for curves between 15-25 degrees, particularly in skeletally immature patients 5, 6
• PSSE approaches include:
  • 3-dimensional self-correction
  • Training in activities of daily living
  • Stabilization of the corrected posture 5
• Core strengthening and postural awareness training can help manage symptoms and potentially reduce curve progression 7

Moderate Curves (25-40 degrees)

• Bracing is the primary non-surgical intervention for moderate curves in skeletally immature patients 2
• Physical therapy focusing on core strengthening should be continued during bracing 7
• Pain management strategies may include regular stretching exercises, non-steroidal anti-inflammatory medications, and physical modalities such as heat or massage 7

Severe Curves (>40 degrees)

• Surgical intervention is typically recommended when:
  • The Cobb angle exceeds 50 degrees in skeletally mature patients 1
  • There is documented curve progression despite skeletal maturity 1
  • Significant pain is not responding to conservative measures 1
  • Significant cosmetic concerns are affecting quality of life 1
• Surgical procedures typically involve correction, stabilization, and fusion 8
• Both allograft and autograft materials are considered medically necessary components of the fusion procedure 1

Special Considerations

• Adult scoliosis often presents with different symptoms than adolescent scoliosis, with back pain and spinal stenosis being more common complaints than cosmetic concerns 8
• MRI evaluation should be considered before surgery to rule out neural axis abnormalities, particularly in patients with atypical curve patterns 1
• Red flags requiring urgent evaluation include:
  • Left thoracic curve (atypical pattern)
  • Short segment curve
  • Absence of apical segment lordosis
  • Rapid curve progression (>1° per month)
  • Functionally disruptive pain
  • Focal neurological findings 3

Monitoring and Follow-up

• All individuals with scoliosis should have annual clinical evaluation of the back with Adam's forward bend test 9
• Skeletally mature patients with thoracic scoliosis greater than 50° may continue to progress at approximately 1° per year, requiring more vigilant monitoring 7
• Development of new neurological symptoms, rapid curve progression, or functionally disruptive pain requires urgent evaluation 7

Common Pitfalls

• Assuming no progression due to the absence of symptoms 7
• Delaying evaluation of new or worsening symptoms 7
• Excessive radiation exposure from too-frequent radiographs 7
• Overlooking potential neural axis abnormalities that should be evaluated with MRI before surgical intervention 1