At what degree of scoliosis curvature should a patient be referred to an orthopedic (bone) specialist?

Scoliosis Referral to Orthopedic Specialist

Refer patients to an orthopedic specialist when the Cobb angle exceeds 20 degrees in skeletally immature patients (age 10 or older), or when the curve exceeds 10 degrees in children younger than 10 years. 1

Referral Thresholds by Age and Curve Severity

Children Under 10 Years

• Refer immediately for any curve >10 degrees due to high risk of progression with remaining growth 1
• Early-onset scoliosis requires both radiographic and MRI evaluation to exclude congenital anomalies and neural axis abnormalities 2

Adolescents Age 10 and Older

• Curves >20 degrees warrant specialist referral for consideration of bracing or closer monitoring 1, 3
• Skeletally immature patients with curves >20 degrees have progression likelihood exceeding 70% 4, 2
• Curves 20-26 degrees: Referral is reasonable for bracing consideration 3
• Curves 26-45 degrees: Bracing is recommended and specialist management is essential 3
• Curves >40-50 degrees: Surgical intervention should be considered, particularly with remaining growth potential 2, 5

Additional Red Flags Requiring Immediate Referral

Regardless of curve magnitude, refer immediately if any of these features are present:

• Left thoracic curve pattern (atypical for idiopathic scoliosis, suggests possible neural abnormality) 2
• Back pain or neurological abnormalities (not typical of adolescent idiopathic scoliosis) 1
• Rapid curve progression (>1 degree per month) 4
• Short segment curve (4-6 vertebral levels only) 4
• Absence of apical segment lordosis (hyperkyphosis at curve apex) 4
• Male sex with significant curve (idiopathic scoliosis is 10:1 female predominant for large curves) 4

Monitoring Schedule for Curves Below Referral Threshold

For curves <20 degrees in adolescents that don't yet warrant specialist referral:

• Risser stages 0-3: Repeat radiographs every 12 months 4, 2
• Risser stages 4-5: Repeat radiographs every 18 months 4, 2
• Monitor clinically at each well-child visit for curve progression 6

Common Pitfalls to Avoid

• Don't assume small curves won't progress: Curves can progress silently, particularly in skeletally immature patients with significant remaining growth 2
• Don't delay referral for atypical presentations: Left thoracic curves, painful scoliosis, or neurological findings require immediate specialist evaluation and likely MRI 4, 2
• Don't overlook congenital scoliosis: These patients need evaluation for cardiac and renal abnormalities in addition to orthopedic management 1
• Don't wait until curves are massive: Optimal outcomes occur with earlier intervention—curves >50 degrees continue progressing at approximately 1 degree per year even after skeletal maturity 4, 5

Special Population: Duchenne Muscular Dystrophy

For patients with DMD who develop scoliosis:

• Refer when curves reach 30 degrees for surgical planning 4
• Surgery is typically scheduled when Cobb angle is between 30-50 degrees 4
• Timing is critical—intervene while lung function is satisfactory and before severe cardiomyopathy develops 4
• Preoperative pulmonology and cardiology evaluation should occur at least 2 months before surgery 4