What are the treatment options for a patient with levoscoliosis?

Treatment of Levoscoliosis

Treatment for levoscoliosis follows a severity-based algorithm: observation for curves <25°, bracing for curves 25-45° in growing patients, and surgery for curves >50°. 1, 2

Treatment Algorithm by Curve Severity

Curves <25° - Observation Only

• Monitor with clinical examination every 6 months using the Adam's forward bend test and scoliometer measurement to detect progression 1, 2
• Obtain upright PA and lateral spine radiographs initially to confirm diagnosis and measure Cobb angle, using PA technique to reduce breast radiation exposure 2
• Limit follow-up radiographs to once every 12 months for patients at Risser stages 0-3, and every 18 months for Risser stages 4-5, unless objective clinical changes occur 2
• Assess the Risser index on radiographs to determine skeletal maturity and predict progression risk, as this determines whether observation alone is sufficient 1, 2
• No bracing is indicated unless progression is documented 2

Curves 25-45° - Bracing in Growing Patients

• Bracing is indicated for curves 25-45° in skeletally immature patients, as this represents the window where orthotic intervention can prevent progression to surgical thresholds 1, 2, 3
• Combine bracing with physical therapy focusing on core strengthening and postural awareness to optimize outcomes 2, 3
• Obtain radiographic evaluation every 6 months during active treatment to assess curve magnitude and progression 1, 3
• Surgery is NOT indicated for moderate scoliosis (25-45°) unless there is documented progression despite optimal bracing 1, 3

Curves >50° - Surgical Intervention

• Surgery is indicated for curves >50° in skeletally immature patients or curves >50° with documented progression in mature patients, as these curves will continue progressing throughout life 1, 2, 3
• The high likelihood of continued progression throughout life justifies surgical correction and fusion 2

Critical Red Flags Requiring Immediate Orthopedic Referral

Refer immediately to orthopedics if any of the following develop:

• Rapid curve progression (>1° per month), indicating aggressive disease requiring treatment escalation 1, 2, 3
• New neurological symptoms including weakness, numbness, or bowel/bladder dysfunction 1, 2
• Functionally disruptive pain not responding to conservative measures 1, 2
• Focal neurological findings on examination 1, 2

When to Obtain MRI

• MRI is not routinely indicated for typical adolescent idiopathic scoliosis with mild curves and no risk factors 2
• Obtain MRI if red flags are present, including left thoracic curve (levoscoliosis itself is a red flag), short segment curve, absence of apical segment lordosis, rapid progression, functionally disruptive pain, focal neurologic findings, or male sex 2
• MRI of the complete spine is mandatory preoperatively for congenital scoliosis, as neural axis abnormalities occur in >20% of cases 1
• Up to 2-4% of adolescents with scoliosis have intraspinal abnormalities detectable only by MRI 2

Risk Stratification

• In skeletally immature individuals with curves >20°, progression risk may exceed 70%, justifying closer monitoring and potential intervention 2
• For mild curves (<25°), the risk of progression is substantially lower, supporting observation rather than active intervention 2
• Do not assume no progression based solely on absence of symptoms, as curves >50° can progress silently after skeletal maturity and curves can progress silently in skeletally immature patients 1, 2

Special Considerations for Congenital Scoliosis

• Evaluate for cardiac and renal abnormalities in congenital scoliosis 1, 4
• MRI is mandatory preoperatively for congenital scoliosis due to high prevalence of neural axis abnormalities 1

Common Pitfalls to Avoid

• Avoid excessive radiation exposure from too-frequent radiographs by following recommended monitoring intervals of 12 months for immature patients 1, 2
• Avoid failing to assess skeletal maturity, as Risser index and growth potential determine treatment strategy 1, 2
• Avoid delaying evaluation of new or worsening symptoms, which may indicate neural axis abnormalities 1
• Avoid overlooking neural axis abnormalities before surgery, as MRI is essential in high-risk cases 1