Growth Hormone Therapy and Scoliosis in a 12-Year-Old Female
Growth hormone therapy does not need to be stopped solely because scoliosis is present on X-ray, and current evidence does not support that GH hastens scoliosis progression in most patients. 1, 2
Key Recommendation
Continue growth hormone therapy with close monitoring of scoliosis progression every 6 months, as the FDA label specifically warns about "progression of preexisting scoliosis" but does not mandate discontinuation unless progression is documented. 1
Evidence Analysis
Does GH Cause or Worsen Scoliosis?
The evidence is reassuring but requires nuanced interpretation:
Long-term data from 8 years of GH treatment in 103 children with Prader-Willi syndrome showed no difference in prevalence or severity of scoliosis compared to untreated children (77.7% prevalence in treated vs. similar rates in untreated). 2
In a study of 72 PWS patients, 48.8% of GH-treated patients had scoliosis versus 41.9% of untreated patients—no statistical difference (P = 0.56). 3
Importantly, patients who started GH therapy earlier had LESS scoliosis than those who started later (P = 0.021), suggesting early treatment may not be an exacerbating factor. 3
Higher bone mineral density of the lumbar spine was inversely associated with lower Cobb angle (r = -0.270, P = 0.008), suggesting GH's positive effects on bone density may actually be protective. 2
Contradictory Evidence
There is older, lower-quality evidence suggesting concern:
A 1997 study of 250 children on GH found 10 developed scoliosis, with 6 requiring bracing and rapid progression (average 26 degrees/year). 4
However, this study lacked untreated controls and predates our understanding that scoliosis is common in many conditions requiring GH, independent of treatment. 4
Monitoring Protocol
Immediate Assessment Required
Measure the Cobb angle on the current X-ray to establish baseline severity. 1, 5
Obtain spine X-rays every 6 months to monitor for progression (defined as sustained increase ≥5 degrees). 5, 4
Assess Tanner staging and bone age via left wrist radiograph, as pubertal progression increases scoliosis risk independent of GH. 6, 7
When to Consider Stopping GH
Discontinue GH therapy only if: 1
Documented rapid progression of scoliosis occurs (Cobb angle increase ≥5 degrees over 6 months) despite orthotic management. 4
The patient develops slipped capital femoral epiphysis (SCFE), which is an absolute contraindication per FDA labeling. 6, 1
Height velocity drops below 2 cm/year or epiphyseal growth plates show closure, indicating therapy has achieved its goal. 8, 7
The patient reaches genetic target height percentile. 6
Risk Factors for Progression
Be particularly vigilant if:
Double major curves (thoracic and lumbar) are present, as these progressed more frequently in one study. 4
Earlier Risser stage (indicating skeletal immaturity) is present. 4
The patient is entering or in puberty, when scoliosis naturally progresses most rapidly. 9
Asymmetry in paravertebral muscle development is noted on imaging, which may predict progression. 5
Clinical Pitfalls to Avoid
Do not reflexively stop GH just because scoliosis exists—many patients improve or remain stable during treatment. 3
Do not attribute all scoliosis progression to GH—natural progression with age and puberty is common in the underlying conditions requiring GH. 9, 3
Do not delay orthotic management if progression occurs—three patients in one study progressed to fusion despite bracing, emphasizing the need for aggressive orthopedic co-management. 4
Ensure optimal bone mineral density through adequate calcium, vitamin D, and weight-bearing activity, as higher BMD correlates with less severe scoliosis. 2
Multidisciplinary Approach
Establish co-management with pediatric orthopedics for serial monitoring and potential bracing if Cobb angle reaches ≥25 degrees. 4
Continue GH therapy unless clear progression is documented, as the benefits of GH on height, body composition, and bone density likely outweigh theoretical scoliosis risk in most patients. 2, 3