What is the basic approach to treating scoliosis, including observation, bracing, physiotherapy, and surgery based on age, growth potential, curve magnitude, location, and progression?

Scoliosis Treatment Algorithm

Treatment of scoliosis is determined by curve magnitude, skeletal maturity (Risser stage), and progression risk, with observation for curves <20°, bracing for curves 20-45° in growing patients, and surgery for curves >50° or progressive curves 40-50° with remaining growth potential. 1

Diagnostic Threshold

• Scoliosis is defined as a Cobb angle >10° measured on standing PA radiographs 2
• Curves <10° are considered normal spinal asymmetry and do not require treatment 2
• All measurements must be performed on weight-bearing radiographs to assess deformity under physiologic loading 2

Treatment Categories Based on Curve Magnitude and Skeletal Maturity

Observation Only (Curves <20°)

• Skeletally immature patients (Risser 0-3) with curves <20° have <30% risk of progression and require only observation 1
• Radiographic surveillance every 12 months for Risser 0-3 patients 1
• Radiographic surveillance every 18 months for Risser 4-5 patients 1
• No active treatment is needed unless progression is documented 1

Bracing (Curves 20-45° in Growing Patients)

• Curves 20-26° may be considered for bracing in skeletally immature patients 2
• Curves 26-45° should undergo bracing and specialist management 2
• Skeletally immature patients with curves >20° have >70% progression risk, making bracing critical 1, 2
• Full-time bracing (23-24 hours per day) for at least 1 year, with gradual weaning of 1-2 hours every 6 months 3
• Bracing can successfully manage even larger curves (45-60°) in motivated patients who refuse surgery, with 71% achieving curve improvement and 52.5% avoiding surgery entirely 3, 4
• Compliance is critical—reported compliance of 94% is associated with successful outcomes 3

Surgery (Curves >50° or Progressive Curves 40-50°)

Absolute Surgical Indications:

• Curves >50° in any patient, regardless of skeletal maturity 5, 1
• Curves >50° progress at approximately 1° per year even after skeletal maturity, leading to cardiopulmonary complications, pain, and reduced quality of life 5, 1
• Posterior spinal fusion with instrumentation and bone grafting is the standard surgical approach 5, 1

Relative Surgical Indications (Curves 40-50°):

• Curves 40-50° with remaining growth potential (Risser 0-2) warrant surgery to prevent further progression 1
• In skeletally mature patients (Risser 4-5) with curves 40-50°, the evidence is more equivocal 6
• A recent 2025 study found that 39.2% of patients with curves 40-50° at Risser IV-V experienced significant progression over 5 years, with 24.7% reaching ≥50° 7
• Risk factors for progression in the 40-50° range include younger age, Risser stage IV (not V), and larger baseline curve magnitude 7
• For skeletally mature patients with curves 40-50° who are asymptomatic and not progressing, observation is reasonable, but close monitoring is essential 6

Pre-Surgical Evaluation Requirements

MRI Indications (Red Flags):

• Obtain MRI complete spine without contrast before surgery if any of the following are present: 1
  • Left thoracic curve pattern 1
  • Short segment curve 1
  • Absence of apical segment lordosis or hyperkyphosis 1
  • Functionally disruptive pain 1
  • Focal neurological findings 1
  • Male sex with idiopathic scoliosis 1
  • Pes cavus deformity 1
• Up to 2-4% of adolescent idiopathic scoliosis patients have neural axis abnormalities that alter surgical planning 1
• For congenital scoliosis, MRI is mandatory before any treatment decision due to 21-43% prevalence of intraspinal anomalies 1

CT Spine for Surgical Planning:

• Obtain CT spine if surgery is being considered, as it reduces screw misplacement from 15.3% to 6.5% 1

Special Populations Requiring Tailored Management

Congenital Scoliosis:

• MRI complete spine is non-negotiable before any treatment decision 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
• Normal neurological exam does not rule out intraspinal anomalies (only 62% accurate) 1

Early Onset Idiopathic Scoliosis (0-9 years):

• Both radiographs and MRI complete spine without contrast are recommended as complementary procedures for initial imaging 1
• Follow the same 6-month maximum interval for radiographic surveillance 1

Cyanotic Congenital Heart Disease:

• Scoliosis is highly prevalent and can impair pulmonary function 1
• Pre-operative assessment by cardiologist and cardiac anesthesiologist is mandatory due to elevated operative risk 1

22q11.2 Deletion Syndrome:

• Routine screening with scoliometer and confirmatory radiographs is recommended 1
• These patients frequently develop clinically significant scoliosis requiring bracing or surgery 1

Common Pitfalls to Avoid

• Never assume no progression due to absence of symptoms—curves can progress silently, particularly in skeletally immature patients 1
• Never skip MRI in congenital scoliosis—21-43% have intraspinal anomalies that alter surgical planning 1
• Do not overlook neural axis abnormalities—up to 2-4% of adolescent idiopathic scoliosis patients have these abnormalities 1
• Do not perform decompression without fusion in pediatric patients—this leads to instability and progression requiring reoperation 5
• Minimize cumulative radiation exposure by adhering to maximum surveillance frequencies and using low-dose imaging protocols when available 1

Timing of Surgical Intervention

• Optimal timing is during early adolescence (Risser 2-3) while the patient still has growth potential but before the curve progresses to severity that increases surgical risks 5
• At Risser stage 2, patients are at ideal age for surgical intervention to maximize correction potential while minimizing risks 5
• Without surgical intervention, curves >50° will likely continue to progress throughout adulthood, potentially leading to cardiopulmonary compromise, decreased pulmonary function, increased pain, and reduced quality of life 5