What are the treatment options for scoliosis?

Treatment Options for Scoliosis

Treatment for scoliosis is determined by curve magnitude, skeletal maturity, and risk of progression, with observation for curves <25°, bracing for curves 25-45° in growing patients, and surgical fusion for curves >50° or progressive curves despite skeletal maturity. 1, 2

Observation (Curves <25°)

• Clinical monitoring every 6 months using Adam's forward bend test and scoliometer measurement is the standard approach for mild curves. 2
• Radiographic evaluation frequency depends on skeletal maturity: every 12 months for Risser stages 0-3 and every 18 months for Risser stages 4-5. 1
• Physical therapy focusing on core strengthening and postural awareness can help manage symptoms and potentially limit progression, though evidence for quality of life improvement is modest. 3, 4
• Postural awareness training should teach patients to maintain proper alignment during daily activities and avoid leaning on one side, which can exacerbate the curve. 3

Bracing (Curves 25-45° in Growing Patients)

• Bracing is indicated for curves 25-45° in skeletally immature patients, as this represents the critical window where orthotic intervention can prevent progression to surgical thresholds. 2
• Radiographic monitoring every 6 months during active bracing treatment is necessary to assess curve magnitude and progression, using PA technique to minimize breast radiation exposure. 2
• Combined bracing and physical therapy focusing on core strengthening optimizes outcomes. 2
• Studies show modest benefit from bracing to limit progression in mild to moderate scoliosis, though effects on quality of life are limited. 4

Surgical Intervention (Curves >50°)

Surgery is recommended when the Cobb angle exceeds 50° in skeletally mature patients due to the risk of continued progression at approximately 1° per year into adulthood. 1

Surgical Indications:

• Curves >50° in skeletally mature patients 1
• Curves >50° in skeletally immature patients 2
• Documented curve progression despite skeletal maturity 1
• Significant pain not responding to conservative measures 1
• Significant cosmetic concerns affecting quality of life 1

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. 1
• MRI is particularly important for patients with left thoracic curve, short segment curve, absence of apical segment lordosis, rapid curve progression, pain, or neurological findings. 1
• Pulmonology evaluation to assess baseline lung function and screen for sleep hypoventilation with nocturnal oximetry or polysomnography in severe cases. 1
• Cardiology evaluation to assess for cardiomyopathy or arrhythmia risk under anesthesia. 1
• Nutritional optimization must be addressed preoperatively to support healing and minimize complications. 1

Surgical Technique:

• Spinal fusion with instrumentation is the standard surgical approach for adolescent patients. 5
• Both allograft and autograft are medically necessary components of the fusion procedure, optimizing fusion potential while minimizing donor site morbidity. 1
• For children younger than 10 years, growth-friendly surgical techniques should be used to maintain spine and chest wall growth. 5

Post-Operative Management:

• Aggressive airway clearance and respiratory support are critical postoperatively. 1
• If preoperative sleep studies show hypoventilation, noninvasive ventilation should be initiated before surgery and continued postoperatively. 1
• Pain management must be carefully titrated to promote airway clearance while minimizing respiratory suppression. 1

Special Populations

Neurofibromatosis Type 1:

• Annual clinical evaluation with Adam's forward bend test is mandatory, with immediate orthopedic referral if scoliosis is detected. 2
• Dystrophic scoliosis in NF1 progresses more rapidly and presents earlier than non-dystrophic forms. 2
• Approximately 50% of NF1 patients with childhood scoliosis experience curve progression into adulthood with significant back pain. 2

Congenital Scoliosis:

• Patients must be evaluated for cardiac and renal abnormalities. 6

Critical Red Flags Requiring Urgent Evaluation

• Rapid curve progression (>1° per month) indicates aggressive disease requiring escalation of treatment. 2
• Development of new neurological symptoms requires urgent evaluation and MRI. 3
• Atypical features, back pain, or neurological abnormalities warrant specialist referral. 6
• Curves >10° in patients younger than 10 years or >20° in patients 10 years or older require specialist referral. 6

Common Pitfalls to Avoid

• Overlooking potential neural axis abnormalities that should be evaluated with MRI before surgical intervention. 1
• Excessive radiation exposure from too-frequent radiographs—follow recommended monitoring intervals. 3
• Assuming no progression due to absence of symptoms. 3
• Delaying evaluation of new or worsening symptoms. 3