What are the treatment options for scoliosis?

Treatment Options for Scoliosis

Treatment for scoliosis is determined by curve magnitude, skeletal maturity, and risk of progression, with observation for curves <15°, scoliosis-specific exercises or bracing for curves 15-50°, and surgical fusion for curves >50° in skeletally mature patients. 1

Treatment Algorithm Based on Curve Severity

Mild Curves (10-15 degrees)

• Observation with serial radiographic monitoring is appropriate for curves <15° in skeletally immature patients with no signs of progression 2
• Radiographs should be obtained no more than once every 6 months for skeletally immature patients 3
• For adolescents at Risser stages 0-3, limit spine radiographs to once every 12 months; for Risser stages 4-5, every 18 months 1

Moderate Curves (15-25 degrees)

• Scoliosis-specific exercises are recommended for curves between 15-25° in growing children rather than passive observation alone 2
• Active self-correction treatment strategies should be performed at least three times per week until skeletal maturity or curve progression 4
• In skeletally immature individuals with curves >20°, the likelihood of progression may exceed 70%, warranting active intervention 1

Curves Requiring Bracing (25-50 degrees)

• Brace treatment (such as Boston brace) is indicated for progressive curves in skeletally immature patients to prevent progression to surgical thresholds 5
• Brace treatment has been shown to reduce curve size by approximately 6 degrees during treatment, though curves may return to baseline after maturity 5
• Patients treated primarily with bracing have a 0% rate of requiring surgery, compared to 10% in observation-only groups 5

Severe Curves Requiring Surgery (>50 degrees)

• Surgical intervention with spinal fusion is recommended when the Cobb angle exceeds 50° in skeletally mature patients due to risk of continued progression at approximately 1° per year 1
• Both allograft and autograft are medically necessary components of the fusion procedure to optimize fusion potential while minimizing donor site morbidity 1

Pre-Surgical Evaluation Requirements

Mandatory MRI Assessment

• MRI of the entire spine is mandatory before any surgical intervention to rule out neural axis abnormalities, which occur in more than 20% of patients with severe curves 1, 6
• MRI is particularly critical for patients with red flag features: left thoracic curve, short segment curve, absence of apical segment lordosis, rapid curve progression (>1° per month), functionally disruptive pain, focal neurological findings, or male sex 3, 6

Additional Pre-Operative Evaluations for Severe Scoliosis

• Pulmonology evaluation to assess baseline lung function and screen for sleep hypoventilation with nocturnal oximetry or polysomnography 1
• Cardiology evaluation to assess for cardiomyopathy or arrhythmia risk under anesthesia 1
• Nutritional optimization must be addressed preoperatively to support healing 1

Post-Operative Management

• Aggressive airway clearance and respiratory support are critical postoperatively, with follow-up by a pulmonologist specializing in respiratory care 1
• If preoperative sleep studies show hypoventilation, noninvasive ventilation should be initiated before surgery and continued postoperatively 1
• Pain management must be carefully titrated to promote airway clearance while minimizing respiratory suppression 1

Critical Pitfalls to Avoid

• Do not rely on absence of neurological symptoms to rule out intraspinal abnormalities—2-4% of adolescents with idiopathic scoliosis have intraspinal abnormalities detectable only by MRI 6
• Curves greater than 50° in skeletally mature patients will continue to progress even after skeletal maturity, making early surgical intervention preferable to delayed treatment 1
• Premenarchal status is a significant risk factor for curve progression, requiring more aggressive monitoring and earlier intervention 5

Special Populations

Congenital Scoliosis

• All patients with congenital scoliosis require MRI evaluation, as neural axis anomalies occur in more than 20% of these patients 6
• Patients must be evaluated for cardiac and renal abnormalities 7

Adult Scoliosis

• Treatment is tailored to specific symptomatology, including back pain, leg pain, claudication symptoms, or neurological deficits 8
• Surgical management may consist of decompression, correction, stabilization and fusion procedures, or combinations thereof 8
• Curves of patients with adolescent idiopathic scoliosis with moderate or smaller size at maturity typically do not deteriorate beyond their original curve size at long-term follow-up 5