What are the treatment options for idiopathic scoliosis?

Treatment Options for Idiopathic Scoliosis

Treatment for idiopathic scoliosis follows a curve magnitude-based algorithm: observation for curves <25°, bracing for curves 25-45° in skeletally immature patients, and surgery for curves >50° or documented progression despite bracing. 1

Treatment Algorithm by Curve Severity

Curves <25 Degrees

• Observation with clinical examination every 6 months is recommended, with radiographic monitoring limited to every 6 months during active surveillance to minimize radiation exposure 1
• The American College of Radiology specifically recommends limiting spine radiographs to once every 12 months for adolescents at Risser stages 0-3 and every 18 months for Risser stages 4-5 2
• PA (posteroanterior) radiographic technique should be used instead of AP to reduce breast radiation exposure in pediatric patients 1

Curves 25-45 Degrees

• Bracing is the first-line treatment for skeletally immature patients, as this represents the critical window where orthotic intervention can prevent progression to surgical thresholds 1, 3
• Bracing should be initiated promptly in patients with remaining growth potential, as the likelihood of progression may exceed 70% in skeletally immature individuals with curves >20° 2
• Close follow-up is essential to track curve progression and determine if conservative management is failing 3

Curves >50 Degrees

• Surgery is recommended for curves exceeding 50° in skeletally immature patients or curves >50° with documented progression in mature patients 1
• Thoracic curves >50° in skeletally mature patients may continue to progress at approximately 1° per year even after skeletal maturity, justifying surgical intervention 2
• Pedicle screw instrumentation with spinal fusion provides excellent curve correction and stabilization for spinal deformities 3

Special Surgical Considerations

Pre-operative Evaluation

• 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 2
• MRI is particularly important for patients with atypical curve patterns (left thoracic curve, short segment curve, absence of apical segment lordosis) 2
• Pulmonology evaluation is recommended to assess baseline lung function and screen for sleep hypoventilation in patients with severe scoliosis 2
• Cardiology evaluation is necessary to assess for cardiomyopathy or arrhythmia risk under anesthesia 2

Surgical Techniques

• Both allograft and autograft are medically necessary components of the fusion procedure, optimizing fusion potential while minimizing donor site morbidity 2
• Curve flexibility should be assessed using radiographic techniques such as side bending, push prone, fulcrum bending, and traction radiographs to influence surgical planning 2

Critical Red Flags Requiring Immediate Orthopedic Referral

The following warrant urgent evaluation and potential treatment escalation 1:

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

Common Pitfalls to Avoid

• Do not assume no progression due to absence of symptoms, as curves >50° can progress silently after skeletal maturity 1
• Avoid excessive radiation exposure from too-frequent radiographs by adhering to recommended monitoring intervals 1
• Do not delay evaluation of new or worsening symptoms, which may indicate neural axis abnormalities 1
• Always assess skeletal maturity using the Risser index, as growth potential determines treatment strategy 1
• Do not overlook that younger age and Risser stage IV are significant risk factors for curve progression in patients with curves between 40-50° 4

Moderate Curves (40-50 Degrees) at Late Skeletal Maturity

This represents a nuanced clinical scenario requiring individualized assessment:

• In patients at Risser stage IV or V with curves 40-50°, approximately 39% will experience significant progression over 5+ years 4
• Younger age and Risser stage IV are significant risk factors for progression, with an annual progression rate of approximately 0.35° 4
• Surgery should not be performed for moderate scoliosis (25-45°) unless there is documented progression despite optimal bracing 1
• However, 24.7% of patients with curves 40-50° at late skeletal growth will eventually reach ≥50°, particularly those with larger baseline curves and Risser stage IV 4