What is the treatment for dextroscoliosis (scoliosis with a curvature to the right) in the thoracolumbar (mid-back) region?

Treatment for Thoracolumbar Dextroscoliosis

Treatment depends on curve magnitude and skeletal maturity: observe curves <25°, brace curves 25-45° in skeletally immature patients, and perform surgery for curves >50° or documented progression despite optimal conservative management. 1

Treatment Algorithm by Curve Severity

Curves <25° (Observation)

• Clinical examination every 6 months without intervention is recommended for mild curves. 1
• Radiographic monitoring should be limited to every 12 months for adolescents at Risser stages 0-3 and every 18 months for Risser stages 4-5 to minimize radiation exposure. 2, 3
• Use PA (posteroanterior) technique rather than AP to reduce breast radiation exposure, particularly in pediatric patients. 1

Curves 25-45° (Bracing Window)

• Bracing is indicated for curves in this range in skeletally immature patients, as this represents the critical window where orthotic intervention can prevent progression to surgical thresholds. 1
• Skeletally immature individuals with curves >20° have a >70% likelihood of progression without intervention. 2, 3
• An exercise program should accompany bracing to improve chest mobility, muscle strength, proper breathing, spinal flexibility, and correct posture, making the transition period after brace removal easier. 4
• Assess skeletal maturity using the Risser index on radiographs, as growth potential determines treatment strategy. 1

Curves >50° (Surgical Threshold)

• Surgery is recommended for curves exceeding 50° in skeletally immature patients or curves >50° with documented progression in mature patients. 1, 2
• Thoracic curves >50° in skeletally mature patients may continue to progress at approximately 1° per year even after skeletal maturity, justifying intervention. 2, 3
• Do not perform surgery for moderate scoliosis (25-45°) unless there is documented progression despite optimal bracing. 1

Pre-Surgical Evaluation Requirements

Mandatory MRI Assessment

• MRI of the entire spine is mandatory before any surgical intervention to rule out neural axis abnormalities, which occur in >20% of patients with severe curves. 2
• MRI is particularly critical for atypical presentations including left thoracic curve, short segment curve, absence of apical segment lordosis, rapid curve progression, pain, or neurological findings. 2, 3

Additional Pre-Operative Workup for Severe Cases

• Pulmonology evaluation to assess baseline lung function and screen for sleep hypoventilation with nocturnal oximetry or polysomnography. 2
• Cardiology evaluation to assess for cardiomyopathy or arrhythmia risk under anesthesia. 2
• Nutritional optimization to support healing and minimize complications. 2

Red Flags Requiring Immediate Orthopedic Referral

Urgent referral is mandatory for any of the following: 1

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

Critical Pitfalls to Avoid

• Do not assume no progression due to absence of symptoms—curves >50° can progress silently after skeletal maturity. 1
• Avoid excessive radiation exposure from too-frequent radiographs by adhering to recommended 6-month monitoring intervals during active treatment. 1
• Do not delay evaluation of new or worsening symptoms, which may indicate neural axis abnormalities. 1
• Never overlook neural axis abnormalities before surgery, as absence of neurological symptoms does not rule out intraspinal abnormalities. 3
• Do not fail to assess skeletal maturity, as Risser index and growth potential fundamentally determine treatment strategy. 1

Special Considerations for Adult Thoracolumbar Dextroscoliosis

For skeletally mature patients with thoracolumbar dextroscoliosis, treatment focuses on symptom management rather than curve correction. 5

• Primary degenerative scoliosis in adults often presents with back pain and may be accompanied by spinal stenosis (central or lateral). 5
• Surgical management in adults consists of decompression, correction, stabilization, and fusion procedures tailored to specific symptomatology. 5
• Minimal invasive procedures to address the most relevant clinical problem may be appropriate in older patients, potentially ignoring overall deformity. 5