Do I need treatment for my scoliosis and what criteria determine observation, bracing, or surgery?

Does Your Scoliosis Need Treatment?

Treatment for scoliosis depends on curve magnitude, skeletal maturity, and progression risk: curves under 20 degrees require observation only, curves 20-45 degrees in skeletally immature patients warrant bracing, and curves exceeding 45-50 degrees require surgical intervention. 1

Observation Only (No Active Treatment)

If your curve is less than 20 degrees, you only need monitoring—no bracing or surgery. 1

• Skeletally immature patients with curves under 20 degrees have less than 30% risk of progression 1
• For adolescents at Risser stages 0-3 (still growing), obtain spine radiographs once every 12 months 1
• For Risser stages 4-5 (nearly mature), radiographs every 18 months are sufficient 1
• In adults with curves under 50 degrees who are skeletally mature, regular monitoring is appropriate with less frequent imaging 2

Bracing (Conservative Treatment)

Bracing is indicated for skeletally immature patients with curves between 20-45 degrees to prevent progression. 1, 3

• Progressive scoliosis between 25-45 degrees before skeletal maturity can be treated with a brace 3
• Bracing is only effective while the skeleton is still growing and cannot reverse existing curves 3
• Once skeletal maturity is reached, bracing is no longer effective 1

Surgical Intervention Thresholds

Surgery is recommended when curves exceed 45-50 degrees, as these curves will continue to progress even after skeletal maturity. 1

• Curves exceeding 50 degrees in skeletally mature patients require surgical intervention due to continued progression risk of approximately 1 degree per year 1
• Curves exceeding 40-50 degrees with remaining growth potential warrant surgery to prevent further progression 1
• Documented curve progression despite skeletal maturity is an indication for surgery 1
• Thoracic curves greater than 50 degrees may progress at 1 degree per year after skeletal maturity 1, 2

Critical Risk Factors for Progression

Certain factors dramatically increase your risk of curve progression and may warrant more aggressive treatment:

• Skeletally immature individuals with curves greater than 20 degrees have progression likelihood exceeding 70% 1
• Congenital scoliosis with unilateral bar and contralateral hemivertebra has extremely high progression risk exceeding 10 degrees per year 1
• Female patients have higher progression risk, with a 10:1 female-to-male ratio for larger curves 2

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if you develop any of these warning signs:

• New neurological symptoms (weakness, numbness, bowel/bladder changes) 1, 2
• Rapid curve progression exceeding 1 degree per month 1, 4
• Functionally disruptive pain not responding to conservative measures 1, 4
• Left thoracic curve pattern (atypical and concerning) 1, 4
• Focal neurological findings on examination 1, 4

Pre-Surgical Evaluation Requirements

Before any surgery, you must have an MRI to rule out neural axis abnormalities:

• MRI evaluation is required to rule out neural axis abnormalities, particularly with left thoracic curve pattern or short segment curves 1
• Up to 2-4% of adolescent idiopathic scoliosis patients have neural axis abnormalities that must be evaluated before surgery 1
• For congenital scoliosis, MRI is mandatory before any treatment decision due to 21-43% prevalence of intraspinal anomalies 1
• CT spine may be obtained for surgical planning if surgery is being considered 1

Special Considerations for Specific Populations

Cyanotic heart disease patients: Scoliosis occurs in a high percentage of patients with cyanotic congenital heart disease and may be severe enough to compromise pulmonary function and require surgical intervention, but preoperative evaluation by a cardiologist and cardiac anesthesiologist is essential due to increased surgical risk 5

22q11.2 deletion syndrome patients: Scoliosis is common and significant, sometimes requiring bracing or spinal surgery, with routine screening recommended using scoliometer and x-rays when clinically indicated 5

Common Pitfalls to Avoid

• Never assume no progression due to absence of symptoms—curves can progress silently, particularly in skeletally immature patients 1, 2
• Never skip MRI in congenital scoliosis—21-43% have intraspinal anomalies that alter surgical planning, and normal neurological exam accuracy is only 62% 1
• Never delay evaluation of new or worsening symptoms—these may indicate curve progression or neurological compromise requiring urgent intervention 2
• Avoid excessive radiation exposure—follow recommended monitoring intervals rather than obtaining too-frequent radiographs 2

Conservative Management for Adults

For adults with curves under 50 degrees who are skeletally mature, conservative management focuses on symptom control:

• Physical therapy focusing on core strengthening and postural awareness can help manage symptoms 2
• Pain management strategies include regular stretching exercises, non-steroidal anti-inflammatory medications, and physical modalities such as heat or massage 2
• Regular radiographic monitoring is essential to track potential curve progression 2