What are the treatment options for moderate scoliosis?

Treatment of Moderate Scoliosis

For moderate scoliosis (curves 25-45°), bracing is the primary treatment in skeletally immature patients to prevent progression, while observation with regular monitoring is appropriate for skeletally mature patients with stable curves. 1, 2

Treatment Algorithm Based on Skeletal Maturity and Curve Magnitude

For Skeletally Immature Patients (Risser 0-3)

Bracing is indicated for curves 25-45° in growing patients, as this represents the window where orthotic intervention can prevent progression to surgical thresholds. 2, 3

• Full-time bracing (23 hours/day initially) is most effective, with gradual weaning of 1-2 hours every 6 months as the curve stabilizes and skeletal maturity approaches. 4
• Multiple brace designs are available (Boston, Chêneau, Sforzesco, Lyon), though no single design has proven superior—selection depends on curve pattern and local expertise. 3
• Compliance is critical: reported compliance of 94% correlates with successful outcomes, including potential curve improvement in 71% of patients. 4
• Combine bracing with physical therapy focusing on core strengthening and postural awareness to optimize outcomes. 1, 5

For Skeletally Mature Patients

• Observation with radiographic monitoring every 12-18 months for stable curves is appropriate. 1
• Thoracic curves >50° may continue progressing at approximately 1° per year even after skeletal maturity, requiring more vigilant monitoring (every 6-12 months). 5
• Physical therapy and pain management (NSAIDs, stretching, heat/massage) address symptoms without altering curve progression. 5

Monitoring Protocol

• Clinical examination every 6 months using Adam's forward bend test and scoliometer measurement. 1, 6
• Radiographic evaluation every 6 months during active treatment to assess curve magnitude and progression, using PA technique (not AP) to reduce breast radiation exposure. 7
• Assess Risser index on radiographs to determine skeletal maturity and progression risk. 7

Red Flags Requiring Urgent Orthopedic Referral

These findings suggest non-idiopathic scoliosis or complications requiring immediate specialist evaluation:

• Rapid curve progression (>1° per month) indicates aggressive disease requiring escalation of treatment. 7, 6
• New neurological symptoms (weakness, numbness, bowel/bladder changes) or focal neurological findings on examination. 6, 5
• Left thoracic curve pattern (atypical for idiopathic scoliosis—suggests intraspinal pathology). 7, 6
• Functionally disruptive pain not responding to conservative measures. 7, 6
• Absence of apical segment lordosis/kyphosis on radiographs (consistent risk factor for neural axis abnormalities). 7

When to Consider MRI

MRI is not routinely indicated for typical idiopathic scoliosis but should be obtained for:

• Any of the red flags listed above, particularly left thoracic curves or rapid progression. 7
• Congenital scoliosis (vertebral anomalies on radiographs), where neural axis abnormalities occur in >20% of cases. 7
• Contrast is unnecessary unless tumor or infection is suspected. 7

Surgical Indications

Surgery is indicated for curves >50° in skeletally immature patients or curves >50° with documented progression in mature patients, as these curves will continue progressing throughout life. 1, 5

• Surgical intervention involves spinal fusion and instrumentation. 2
• Surgery is NOT indicated for moderate scoliosis (25-45°) unless there is documented progression despite optimal bracing or exceptional circumstances. 1

Common Pitfalls to Avoid

• Assuming no progression due to absence of symptoms: curves progress silently, particularly in skeletally immature patients. 1, 5
• Excessive radiation exposure: follow recommended monitoring intervals (every 6 months during active treatment, every 12-18 months for stable curves) rather than obtaining radiographs at every visit. 1
• Delaying evaluation of new symptoms: neurological changes or rapid progression require immediate specialist assessment. 1, 5
• Overtreatment of stable curves: not all moderate curves require bracing—skeletally mature patients with stable curves need only observation. 1
• Underestimating progression risk in high-risk groups: females have 10:1 higher risk for larger curves, and skeletally immature patients require more aggressive monitoring. 1, 5

Special Populations

Neurofibromatosis Type 1

• Annual clinical evaluation with Adam's forward bend test is mandatory, with immediate orthopedic referral if scoliosis is detected. 7
• Dystrophic scoliosis in NF1 progresses more rapidly and presents earlier than non-dystrophic forms. 7
• Approximately 50% of NF1 patients with childhood scoliosis experience curve progression into adulthood with significant back pain. 7