What kind of patient is suitable for scoliosis treatment?

Patient Selection for Scoliosis Treatment

Treatment decisions for scoliosis depend primarily on three factors: curve magnitude (Cobb angle), skeletal maturity (Risser stage), and curve type (congenital, idiopathic, or neuromuscular). 1, 2

Observation Only (No Active Treatment)

Skeletally immature patients with curves under 20 degrees have less than 30% risk of progression and require only observation. 2

• Monitor adolescents at Risser stages 0-3 with spine radiographs once every 12 months 2
• For Risser stages 4-5, radiographs every 18 months are sufficient 2
• These patients typically remain asymptomatic and do not require intervention 3

Bracing Candidates

Bracing is indicated for skeletally immature patients with curves between 20-40 degrees who have significant remaining growth potential. 2, 4

• Skeletally immature individuals with curves >20 degrees have progression likelihood exceeding 70%, making them prime candidates for bracing 2
• Treatment should be initiated when curves exceed 20-25 degrees in skeletally immature patients 2
• Bracing shows modest benefit in limiting progression but has not demonstrated improvement in quality of life outcomes 3

Surgical Candidates

Surgery is typically recommended when the Cobb angle exceeds 50 degrees in skeletally mature patients due to continued progression risk of approximately 1 degree per year. 1, 2

Primary Surgical Indications:

• Curves exceeding 40-50 degrees with remaining growth potential warrant surgery to prevent further progression 2
• Documented curve progression despite skeletal maturity 1, 2
• Significant pain not responding to conservative measures 1
• Significant cosmetic concerns affecting quality of life 1

Critical Pre-Surgical Evaluation Requirements:

MRI of the entire spine is mandatory before any surgical intervention to rule out neural axis abnormalities, particularly in severe and young cases. 1

Obtain MRI evaluation if any of these risk factors are present 1, 2:

• Left thoracic curve pattern
• Short segment curve
• Absence of apical segment lordosis
• Rapid curve progression
• Pain or neurological findings
• Neural axis abnormalities occur in more than 20% of patients with severe curves 1

For severe scoliosis cases, additional pre-operative evaluation includes 1:

• Pulmonology evaluation to assess baseline lung function and screen for sleep hypoventilation
• Cardiology evaluation to assess for cardiomyopathy or arrhythmia risk
• Nutritional optimization to support healing

Special Populations Requiring Different Approaches

Congenital Scoliosis:

Both radiographs of the complete spine and MRI complete spine without IV contrast are usually appropriate for initial imaging, as these procedures are complementary. 5

• These patients must be evaluated for cardiac and renal abnormalities 4

Early Onset Idiopathic Scoliosis (0-9 years):

Both radiographs and MRI complete spine without IV contrast are usually appropriate for initial imaging. 5

• Any child with a curve greater than 10 degrees who is younger than 10 years should be referred to a specialist 4

Adolescent Idiopathic Scoliosis (10-18 years):

Radiographs of the complete spine are usually appropriate for initial imaging when there are no risk factors. 5

• Referral to a specialist is indicated if the curve is greater than 20 degrees in patients 10 years or older 4

Adult Scoliosis:

Skeletally mature patients with thoracic scoliosis greater than 50 degrees may continue to progress at approximately 1 degree per year, requiring vigilant monitoring. 6

• Surgical treatment should be considered for curves greater than 50 degrees due to continued progression risk 6
• Physical therapy focusing on core strengthening and postural awareness can help manage symptoms 6

Common Pitfalls to Avoid

• Assuming no progression due to absence of symptoms - curves can progress silently, particularly in skeletally immature patients 2
• Overlooking neural axis abnormalities - up to 2-4% of adolescent idiopathic scoliosis patients have neural axis abnormalities that should be evaluated before surgery 2
• Excessive radiation exposure from too-frequent radiographs should be avoided by following recommended monitoring intervals 6
• Delaying evaluation of new or worsening symptoms requires urgent assessment 6