What are the treatment options for a patient (Pt) with scoliosis?

Treatment Options for Scoliosis

Treatment for scoliosis is determined by curve magnitude, skeletal maturity, and etiology, with observation for curves <25°, bracing for curves 25-45° in growing patients, and surgery reserved for curves >50° or documented progression despite conservative management. 1, 2

Initial Diagnostic Evaluation

Spinal radiography is the primary imaging modality for diagnosing and classifying scoliosis, evaluating severity, and monitoring progression. 3

• Use PA (posteroanterior) technique instead of AP to reduce breast radiation exposure in pediatric patients. 3, 1
• Obtain both PA and lateral radiographs initially, then lateral views only as dictated by changes in sagittal balance. 3
• Assess the Risser index on radiographs to determine skeletal maturity and predict progression risk. 3, 1
• Limit radiographic follow-up to every 6 months during active treatment to minimize radiation exposure. 3, 1

When to Obtain MRI

MRI of the complete spine is indicated for specific high-risk scenarios, not routine idiopathic scoliosis. 3

• Congenital scoliosis: MRI is mandatory preoperatively, as neural axis abnormalities occur in >20% of cases (including syringohydromyelia, Chiari malformation, cord tethering). 3, 2
• Risk factors in idiopathic scoliosis: left thoracic curve, short segment curve (4-6 levels), absence of apical segment lordosis, rapid progression (>1° per month), functionally disruptive pain, focal neurologic findings, male sex. 3, 2
• Before any surgical intervention to rule out neural axis abnormalities that may alter surgical planning. 2

Treatment Algorithm by Curve Magnitude

Observation (Curves <25°)

Monitor with clinical examination every 6 months using Adam's forward bend test and scoliometer measurement. 1

• Radiographic monitoring intervals: every 12 months for Risser stages 0-3, every 18 months for Risser stages 4-5. 2
• Physical therapy focusing on core strengthening and postural awareness can help manage symptoms and potentially limit progression. 4

Bracing (Curves 25-45° in Growing Patients)

Bracing is indicated for curves 25-45° in skeletally immature patients, as this represents the window where orthotic intervention can prevent progression to surgical thresholds. 1

• Combine bracing with physical therapy focusing on core strengthening and postural awareness to optimize outcomes. 1, 4
• Continue radiographic monitoring every 6 months during active bracing treatment. 1
• Assess compliance and brace fit regularly, as effectiveness depends on wear time and proper fitting.

Surgery (Curves >50°)

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 at approximately 1° per year. 1, 2

Additional surgical indications include:

• Documented curve progression despite skeletal maturity. 2
• Significant pain not responding to conservative measures. 2
• Significant cosmetic concerns affecting quality of life. 2

Surgery is NOT indicated for moderate scoliosis (25-45°) unless there is documented progression despite optimal bracing. 1

Special Considerations by Etiology

Congenital Scoliosis

Congenital scoliosis results from vertebral formation or segmentation failures and accounts for up to 10% of surgical patients. 3

• MRI is mandatory before surgery due to the 21-43% incidence of intraspinal anomalies (diastematomyelia most common). 3
• Evaluate for cardiac and renal abnormalities, as these are commonly associated with congenital vertebral anomalies. 5
• Unilateral bar with contralateral hemivertebra may progress >10° per year, requiring aggressive monitoring. 3

Adolescent Idiopathic Scoliosis (AIS)

AIS is the most common type, occurring in 1-2% of children and constituting 75-80% of all scoliosis cases, with a 10:1 female predominance for curves >40°. 4

• Thoracic curves >50° in skeletally mature patients may continue progressing at approximately 1° per year into adulthood. 4, 2
• MRI is NOT routinely indicated unless risk factors are present (see above). 3
• Regular monitoring is essential even after skeletal maturity for curves approaching or exceeding 50°. 4

Adult Scoliosis

Adult scoliosis includes primary degenerative ("de novo"), progressive idiopathic, and secondary curves from metabolic bone disease or adjacent segment degeneration. 6

• Patients present predominantly with back pain, then leg pain and claudication, rarely with neurological deficits. 6
• Treatment is tailored to specific symptomatology: decompression for stenosis, stabilization for instability, correction for progressive deformity. 6
• Consider minimal invasive procedures in elderly patients to address the most relevant clinical problem rather than overall deformity. 6

Critical Red Flags Requiring Urgent Evaluation

Immediate orthopedic referral is warranted for:

• Rapid curve progression (>1° per month), indicating aggressive disease requiring treatment escalation. 1, 4
• Development of new neurological symptoms (weakness, numbness, bowel/bladder dysfunction). 4
• Functionally disruptive pain not responding to conservative measures. 3, 4
• Focal neurological findings on examination. 3, 4
• Curves >10° in patients <10 years of age (early-onset scoliosis). 5
• Curves >20° in patients ≥10 years of age. 5
• Atypical features or curves associated with back pain. 5

Common Pitfalls to Avoid

• Excessive radiation exposure from too-frequent radiographs: follow recommended monitoring intervals. 4
• Assuming no progression due to absence of symptoms: curves >50° can progress silently after skeletal maturity. 4
• Delaying evaluation of new or worsening symptoms: may indicate neural axis abnormalities. 4
• Overlooking neural axis abnormalities before surgery: MRI is essential in high-risk cases. 2
• Failing to assess skeletal maturity: Risser index and growth potential determine treatment strategy. 3, 1