What are the treatment options for scoliosis?

Treatment of Scoliosis

Treatment for scoliosis is determined by curve magnitude, skeletal maturity, and progression risk: observation for curves <20°, bracing for curves 20-45° in skeletally immature patients, and surgical intervention for curves >45-50°. 1, 2

Treatment Algorithm Based on Curve Severity

Observation Only (Curves <20°)

• Skeletally immature patients (Risser 0-3) with curves under 20° have less than 30% risk of progression and require only monitoring with spine radiographs once every 12 months. 1
• For patients at Risser stages 4-5, radiographs every 18 months are sufficient. 1
• This conservative approach minimizes radiation exposure while ensuring timely detection of progression. 1

Bracing (Curves 20-45°)

• Bracing is recommended when curves exceed 20-25° in skeletally immature patients to prevent progression. 1
• Full-time bracing (23-24 hours per day) with gradual weaning can achieve curve improvements even in severe cases, with 71% of patients showing improvement in curves initially measuring 45-58°. 3
• High compliance (>90%) is essential for bracing success, achieved through proper fitting and patient education. 3
• Treatment duration typically spans 4+ years with weaning of 1-2 hours every 6 months. 3

Surgical Intervention (Curves >45-50°)

• Curves exceeding 50° in skeletally mature patients require surgical intervention due to continued progression risk of approximately 1° per year even after skeletal maturity. 1, 2
• In skeletally immature individuals with curves >20°, progression likelihood exceeds 70%, making surgery necessary for curves 40-50° with remaining growth potential. 1, 2
• Posterior spinal fusion with instrumentation is the standard surgical approach, with bone grafting (allograft and/or autograft) necessary to achieve solid arthrodesis. 1, 4

Critical Pre-Surgical Evaluation

Mandatory MRI Screening

• Before proceeding with surgery, obtain MRI evaluation to rule out neural axis abnormalities, particularly in high-risk presentations. 1, 2
• MRI is mandatory for:
  • Left thoracic curve pattern 1
  • Short segment curves 1
  • Congenital scoliosis (21-43% have intraspinal anomalies) 1
  • Early onset idiopathic scoliosis (0-9 years) 1
• Normal neurological examination does not predict normal MRI, with physical exam accuracy only 62% for detecting intraspinal anomalies. 1

Additional Pre-Operative Assessments

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

Special Populations

Congenital Scoliosis

• MRI of the complete spine is mandatory before any treatment decision due to 21-43% prevalence of intraspinal anomalies including tethered cord, filar lipoma, syringohydromyelia, and diastematomyelia. 1
• CT spine for surgical planning if surgery is considered, as it reduces screw misplacement from 15.3% to 6.5%. 1
• Serial PA radiographs every 6 months maximum to monitor progression. 1
• Unilateral bar with contralateral hemivertebra has high progression risk (>10° per year). 1

Early Onset Idiopathic Scoliosis (0-9 years)

• Both radiographs and MRI of complete spine are recommended as complementary procedures for initial imaging. 1
• Follow 6-month maximum interval for radiographic surveillance. 1

Neuromuscular Scoliosis

• Scoliosis aggravates restrictive lung disease due to imbalance between altered respiratory mechanics and respiratory muscle strength. 5
• Maintaining assisted ambulation as long as possible (walkers instead of wheelchairs) may prevent scoliosis progression. 5

Common Pitfalls to Avoid

• Never assume no progression due to absence of symptoms—curves can progress silently, particularly in skeletally immature patients. 1
• Never overlook neural axis abnormalities—up to 2-4% of adolescent idiopathic scoliosis patients have neural axis abnormalities that should be evaluated before surgery. 1
• Never skip MRI in congenital scoliosis, as 21-43% have intraspinal anomalies that alter surgical planning. 1
• Never perform decompression without fusion in young patients, as this leads to instability and progression requiring reoperation. 4

Post-Operative Management

• Aggressive airway clearance and respiratory support are critical postoperatively. 2
• If preoperative sleep studies show hypoventilation, initiate noninvasive ventilation before surgery and plan to extubate to noninvasive ventilation postoperatively. 2
• Pain management must be carefully titrated to promote airway clearance while minimizing respiratory suppression. 2