What is the overview of idiopathic scoliosis treatment for children and adults?

Overview of Idiopathic Scoliosis in Children and Adults

Definition and Epidemiology

Idiopathic scoliosis is a lateral spinal curvature exceeding 10 degrees with vertebral rotation, occurring in otherwise healthy individuals without identifiable cause, affecting 1-2% of children and representing 75-80% of all scoliosis cases. 1

• Adolescent idiopathic scoliosis (AIS) is the most common form, occurring in skeletally immature patients older than 10 years 2
• Female predominance is striking, with a 10:1 female-to-male ratio for curves exceeding 40 degrees 1
• The condition is classified by age of onset: infantile (<3 years), juvenile (3-10 years), and adolescent (>10 years) 2

Screening and Detection

Screen females twice at ages 10 and 12 years, and males once at age 13-14 years using the Adam's forward bend test with scoliometer measurement. 3, 2

• Clinical examination should occur every 6 months during active monitoring using Adam's forward bend test 3
• Refer to orthopedics if curves exceed 10 degrees in patients under 10 years, or exceed 20 degrees in patients 10 years or older 4
• Immediate referral is warranted for atypical features, back pain, or neurological abnormalities 4

Radiographic Evaluation and Monitoring

Obtain radiographs using posteroanterior (PA) technique to minimize breast radiation exposure, with frequency determined by skeletal maturity status. 3, 5

• For adolescents at Risser stages 0-3: radiographs every 12 months 5
• For Risser stages 4-5: radiographs every 18 months 5
• During active treatment (bracing): radiographs every 6 months to assess curve magnitude and progression 3
• Always assess Risser index on radiographs to determine skeletal maturity and progression risk 3

Treatment Algorithm for Children

Observation (Curves <25 degrees)

• Monitor with clinical examination every 6 months 3
• Follow radiographic monitoring schedule based on Risser stage 5
• Skeletally immature patients with curves >20 degrees have >70% likelihood of progression 5

Bracing (Curves 25-45 degrees)

Bracing combined with physical therapy focusing on core strengthening and postural awareness is indicated for curves 25-45 degrees in growing patients to prevent progression to surgical thresholds. 3

• This represents the critical window where orthotic intervention can prevent surgical necessity 3
• Physical therapy should include postural awareness training to maintain proper alignment during daily activities and avoid leaning on one side 1
• Core strengthening prevents progression and deterioration of lung function, particularly important as scoliosis can aggravate restrictive lung disease 1
• Monitor every 6 months with clinical examination and radiographs during active bracing 3

Surgery (Curves >50 degrees)

Surgical intervention is indicated for curves exceeding 50 degrees in skeletally immature patients, as these curves will continue progressing throughout life at approximately 1 degree per year. 3, 5

• Additional surgical indications include documented progression despite optimal bracing, rapid curve progression (>1 degree per month), and significant pain unresponsive to conservative measures 3, 5
• Pedicle screw instrumentation with spinal fusion provides excellent curve correction and stabilization 6
• MRI evaluation before surgery is recommended to rule out neural axis abnormalities, particularly for left thoracic curves, short segment curves, rapid progression, pain, or neurological findings 5
• Both allograft and autograft are medically necessary components optimizing fusion potential while minimizing donor site morbidity 5

Management of Adults with Idiopathic Scoliosis

Adults with adolescent idiopathic scoliosis require regular radiographic monitoring as skeletally mature patients with thoracic curves greater than 50 degrees may continue progressing at approximately 1 degree per year. 1

Adult Scoliosis Classification

Adult scoliosis encompasses four major types 7:

• Type 1: Primary degenerative scoliosis from asymmetric disc/facet arthritis
• Type 2: Adolescent idiopathic scoliosis progressing into adulthood with secondary degeneration
• Type 3a: Secondary curves from previous surgical treatment or adjacent segment degeneration
• Type 3b: Curves from metabolic bone disease (osteoporosis) with asymmetric arthritis

Conservative Management for Adults

Physical therapy focusing on core strengthening and postural awareness combined with pain management strategies forms the foundation of adult conservative treatment. 1

• Pain management includes regular stretching exercises, NSAIDs, and physical modalities such as heat or massage 1
• Regular radiographic monitoring tracks potential curve progression 1
• MRI evaluation should be considered if new neurological symptoms develop or curves show unexpected progression 1

Surgical Indications for Adults

Surgery is indicated for curves greater than 50 degrees with documented progression despite skeletal maturity, significant pain not responding to conservative measures, or significant cosmetic concerns affecting quality of life. 1, 5

• Surgical procedures may include decompression, correction, stabilization, fusion, or combinations thereof 7
• Treatment must be tailored to specific symptomatology, considering age, general medical condition, fusion length, adjacent segment condition, and osteoporosis 7

Critical Red Flags Requiring Urgent Evaluation

Development of new neurological symptoms, rapid curve progression, functionally disruptive pain, or focal neurological findings on examination require immediate evaluation. 1

• Rapid curve progression exceeding 1 degree per month indicates aggressive disease requiring treatment escalation 3
• Atypical curve patterns (left thoracic, short segment) warrant MRI before any surgical intervention 5
• Never assume no progression due to absence of symptoms 1
• Never delay evaluation of new or worsening symptoms 1

Special Considerations for Neurofibromatosis Type 1

All individuals with NF1 require annual clinical evaluation with Adam's forward bend test and immediate orthopedic referral if scoliosis is detected. 3

• Dystrophic scoliosis in NF1 progresses more rapidly and presents earlier than non-dystrophic forms 3
• Approximately 50% of NF1 patients with childhood scoliosis experience curve progression into adulthood with significant back pain 8, 3
• Significant scoliosis-associated pathology includes dural ectasia, vertebral degenerative changes, and spinal compression 8

Common Pitfalls to Avoid

• Excessive radiation exposure from too-frequent radiographs—follow recommended monitoring intervals based on Risser stage 1, 5
• Overlooking potential neural axis abnormalities that should be evaluated with MRI before surgical intervention 5
• Assuming curves under 25 degrees in skeletally immature patients are benign without appropriate monitoring 5
• Failing to recognize that curves exceeding 50 degrees will progress even after skeletal maturity 1, 5