What are the treatment options for mild scoliosis?

Treatment of Mild Scoliosis

For mild scoliosis (curves <25°), observation with clinical examination every 6 months is the recommended approach, with radiographic monitoring limited to every 12 months in skeletally immature patients to minimize radiation exposure. 1, 2

Initial Assessment and Monitoring

Clinical evaluation should occur every 6 months using the Adam's forward bend test and scoliometer measurement to detect progression. 1, 2 The key is determining skeletal maturity and progression risk, which dictates treatment intensity.

Radiographic Protocol

• Obtain upright PA (posteroanterior) and lateral spine radiographs initially to confirm diagnosis and measure Cobb angle. 3, 2
• Use PA technique rather than AP to reduce breast radiation exposure, particularly in female adolescents. 2
• Limit follow-up radiographs to once every 12 months for patients at Risser stages 0-3, and every 18 months for Risser stages 4-5, unless objective clinical changes occur. 3
• Assess the Risser index on each radiograph to determine skeletal maturity and predict progression risk. 1, 2

Risk Stratification

The likelihood of progression depends critically on skeletal maturity. In skeletally immature individuals with curves >20°, progression risk may exceed 70%. 3 However, for mild curves (<25°), the risk is substantially lower, justifying observation rather than active intervention.

Treatment Algorithm by Curve Severity

Curves <25° (Mild Scoliosis)

• Observation with clinical monitoring every 6 months is appropriate. 1, 2
• No bracing is indicated unless progression is documented. 1, 2
• Consider scoliosis-specific exercises focusing on core strengthening and postural awareness, though evidence for preventing progression is limited. 4, 5

Curves 25-45° (Moderate Scoliosis)

• Bracing is indicated in growing patients, as this represents the window where orthotic intervention can prevent progression to surgical thresholds. 1, 2
• Combine bracing with physical therapy focusing on core strengthening and postural awareness. 1

Curves >50°

• Surgery is indicated, as these curves will continue progressing throughout life at approximately 1° per year even after skeletal maturity. 1, 4, 2

Physical Therapy Considerations

While observation is the primary approach for mild scoliosis, physical therapy focusing on core strengthening and postural awareness can help manage symptoms and may provide modest benefit. 4, 6 However, there is no high-quality evidence that exercises prevent curve progression or improve quality of life in mild cases. 6

Postural awareness training should teach patients to maintain proper alignment during daily activities and avoid leaning on one side, which can exacerbate the curve. 4

Critical Red Flags Requiring Immediate Escalation

Refer immediately to orthopedics if any of the following develop:

• Rapid curve progression (>1° per month), indicating aggressive disease. 1, 2
• Development of new neurological symptoms (weakness, numbness, bowel/bladder dysfunction). 2
• Functionally disruptive pain not responding to conservative measures. 1, 2
• Focal neurological findings on examination. 1, 2

When to Consider MRI

MRI is NOT routinely indicated for typical adolescent idiopathic scoliosis with mild curves and no risk factors. 3, 2 However, MRI should be obtained if red flags are present, including left thoracic curve, short segment curve (4-6 levels), absence of apical segment lordosis, rapid progression, functionally disruptive pain, focal neurologic findings, or male sex. 3

Up to 2-4% of adolescents with scoliosis have intraspinal abnormalities (Chiari I malformation, syrinx, cord tethering) detectable only by MRI. 3 However, the clinical relevance of most asymptomatic intraspinal findings remains unclear, and their detection rarely changes management in mild curves. 3

Common Pitfalls to Avoid

• Avoid excessive radiation exposure from too-frequent radiographs; follow the 12-month interval for immature patients. 3, 2
• Do not assume no progression based solely on absence of symptoms; curves can progress silently in skeletally immature patients. 2
• Do not delay evaluation if new symptoms develop or clinical examination shows progression. 2
• Avoid failing to assess skeletal maturity (Risser index), as growth potential determines whether observation alone is sufficient. 2

Special Population: Neurofibromatosis Type 1

For patients with NF1, annual clinical evaluation with Adam's forward bend test is mandatory, with immediate orthopedic referral if scoliosis is detected, as dystrophic scoliosis in NF1 progresses more rapidly. 1