Is a 2D (two-dimensional) echocardiogram (echo) necessary for patients undergoing scoliosis correction surgery?

2D Echocardiography for Scoliosis Surgery: Not Routinely Indicated

For patients with severe scoliosis (≥90°) undergoing corrective surgery who have no cardiac history, symptoms, or associated syndromes, routine preoperative 2D echocardiography does not contribute to perioperative risk assessment or anesthetic management and should not be routinely ordered. 1

Evidence-Based Approach to Cardiac Screening

Patients WITHOUT Cardiac Risk Factors

• In patients with large curve scoliosis (≥90°) and no cardiac history or symptoms, screening echocardiograms identified abnormalities in only 24% of cases, but none resulted in changes to perioperative management. 1

• The most recent high-quality study (2024) demonstrated that among 50 patients with curves ≥90° and no cardiac history, 76% had completely normal echocardiograms. 1

• Of the 24% with findings (mild aortic dilation, mild valvular regurgitation, small ASD, trace effusion), zero patients had their surgical plan modified based on echocardiogram results. 1

• Only 1 of 50 patients required postoperative cardiology follow-up, and postoperative vasopressor use (16% of patients) was unrelated to echocardiographic findings. 1

Patients WITH Cardiac Risk Factors or Comorbidities

Echocardiography IS indicated when:

• Known or suspected congenital heart disease exists - these patients require thorough preoperative cardiac evaluation and may need cardiac intervention before scoliosis surgery. 2, 3

• Connective tissue disorders are present (Marfan syndrome, Ehlers-Danlos) - these conditions are associated with aortic root abnormalities and valvular disease. 1

• Comorbid conditions exist - patients with comorbidities show a 50% prevalence of valvular anomalies versus 17.2% in those without comorbidity (p=0.004). 4

• Low body weight or short stature for age - these physical findings correlate with higher rates of cardiac abnormalities in scoliosis patients. 3

• Cardiac symptoms are present - any history of chest pain, palpitations, syncope, or exercise intolerance warrants evaluation. 1

Clinical Algorithm

Step 1: Screen for cardiac risk factors

• History of congenital heart disease 2, 3
• Known connective tissue disorder 1
• Family history of cardiac disease or sudden death 4
• Cardiac symptoms (chest pain, palpitations, syncope, dyspnea) 1
• Abnormal physical examination (murmur, abnormal heart sounds) 5
• Low weight/height for age 3
• Comorbid systemic conditions 4

Step 2: If ANY risk factors present → Order 2D echocardiogram

• Focus on aortic root dimensions, valvular function, and chamber sizes 5
• Coordinate with cardiology for interpretation and perioperative planning 2

Step 3: If NO risk factors present → Echocardiogram NOT indicated

• Proceed with standard preoperative evaluation 1
• Reserve resources for higher-yield testing 1

Important Caveats

The EKG Question

• Electrocardiograms provide even less useful information than echocardiograms - in one study, 85% were normal, 13% showed normal variants, and the 2% with left ventricular hypertrophy findings had normal echocardiograms. 6

• EKG does not provide significant information compared to echocardiogram in asymptomatic AIS patients. 6

Specific Findings in Scoliosis Populations

• When cardiac abnormalities are found in idiopathic scoliosis patients, mitral valve prolapse is most common (11.68%), followed by atrial septal defects (1.13%). 3

• Aortic root/valve abnormalities occur in 3.3% of scoliosis patients versus 0.6% in healthy adolescents, suggesting a possible association worth investigating when risk factors exist. 6

• The overall incidence of cardiac abnormalities in surgical scoliosis patients ranges from 24-28%, but most are clinically insignificant. 1, 3

Resource Utilization Considerations

• Routine screening creates unnecessary social, time, and financial burdens on families without improving outcomes. 1

• Evidence-based guidelines for perioperative testing ensure appropriate risk assessment and proper utilization of healthcare resources. 1

When Findings DO Matter

• In the rare cases where significant abnormalities are detected (severe CHD, large ASDs), cardiac intervention may be required before scoliosis surgery, potentially delaying the procedure. 2, 6

• Patients with reduced cardiorespiratory function from prior cardiac surgery require intensive perioperative monitoring regardless of echocardiogram findings. 2