What are the treatment options for managing pain in patients with scoliosis?

Pain Management in Patients with Scoliosis

The most effective approach to managing pain in patients with scoliosis involves a combination of non-pharmacological interventions (particularly physical therapy and exercise) and pharmacological treatments (primarily NSAIDs), with more invasive options reserved for refractory cases. 1, 2

Non-Pharmacological Approaches

Exercise and Physical Therapy

• Regular individualized exercise programs that include supervision, stretching, and strengthening are recommended as first-line treatment for chronic pain in scoliosis 2, 3
• Both individual and group physical therapy should be considered, with evidence showing supervised programs provide better outcomes than unsupervised home exercises 4
• Physiotherapy Scoliosis-Specific Exercises (PSSE) can temporarily stabilize progressive curves and may reduce pain related to muscle imbalance 3
• The main principles of effective physical therapy include 3-dimensional self-correction, training in activities of daily living, and stabilization of the corrected posture 3

Heat Application

• Application of heat using heating pads or heated blankets can provide short-term relief for acute pain associated with scoliosis 2
• There is good evidence of moderate benefits with superficial heat application for acute low back pain 4

Bracing

• Brace treatment has demonstrated effectiveness for patients with scoliosis and chronic non-specific low back pain when exercise treatment alone is not effective 5
• A clinical test can help predict which patients will benefit most from brace treatment 5

Pharmacological Management

NSAIDs

• NSAIDs are recommended as first-line drug treatment for patients with scoliosis-related pain 1, 2
• There is convincing evidence (level Ib) that NSAIDs improve spinal pain, peripheral joint pain, and function in the short term (up to 6 weeks) 4
• For patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor should be considered 1

Analgesics

• Acetaminophen and opioids may be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2
• The combination of acetaminophen plus opioids increases the probability of symptom relief compared to placebo (high-certainty evidence) 4

Corticosteroid Injections

• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be considered 1
• However, systemic corticosteroids for axial disease are not supported by evidence 1

Interventional and Surgical Options for Refractory Pain

Spinal Manipulation

• Spinal manipulation administered by appropriately trained providers shows small to moderate short-term benefits for acute pain 2
• When combined with home exercises and counseling, spinal manipulation produces greater improvement in leg and back pain at 12 weeks compared to home exercises alone 4

Surgical Interventions

• For patients with refractory pain or disability and radiographic evidence of structural damage, total hip arthroplasty should be considered, independent of age 1
• Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients 1
• Lumbar fusion is recommended for carefully selected patients with disabling low-back pain due to one- or two-level degenerative disease without stenosis or spondylolisthesis 1

Important Considerations and Pitfalls

• Avoid prolonged bed rest as it can lead to deconditioning and potentially worsen symptoms; remaining active is more effective for managing back pain with radicular symptoms 2
• Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation 1
• There is no evidence for the efficacy of Disease-Modifying Antirheumatic Drugs (DMARDs), including sulfasalazine and methotrexate, for the treatment of axial disease in ankylosing spondylitis, which shares some pain management approaches with scoliosis 1
• NSAIDs should be used with caution in older patients and those with cardiovascular, renal, or gastrointestinal risk factors 2
• Scoliosis with a primary diagnosis (non-idiopathic) must be recognized to identify causes that may require specific intervention 6

By following this evidence-based approach to pain management in scoliosis, clinicians can help patients achieve better pain control and improved quality of life.