What is the recommended evaluation and management plan for an adult female patient with scoliosis?

Management of Scoliosis in Adult Female Patients

Adult female patients with scoliosis require a structured evaluation beginning with standing PA and lateral spine radiographs to measure the Cobb angle, followed by risk stratification based on curve magnitude, skeletal maturity, and symptoms to determine whether observation, conservative management, or surgical intervention is indicated. 1, 2

Initial Diagnostic Evaluation

Essential Imaging

• Obtain upright (standing) PA and lateral spine radiographs as the primary diagnostic modality—supine films underestimate curve magnitude and should not be used for initial assessment 3
• Measure the Cobb angle using standardized technique, recognizing that this measurement has moderate inter-observer reliability (ICC 0.74) but remains the clinical standard for surgical decision-making 1, 3
• Document skeletal maturity status, curve location (thoracic vs. thoracolumbar vs. lumbar), and any evidence of degenerative changes 4

When to Obtain MRI

MRI of the complete spine without contrast is mandatory before any surgical intervention and should be obtained earlier if any of these red flags are present 1, 2:

• Left thoracic curve pattern
• Short segment curve
• Rapid curve progression (>1° per month)
• Functionally disruptive pain
• Any neurological findings on examination
• Absence of expected apical lordosis

The American College of Radiology emphasizes that neural axis abnormalities occur in more than 20% of patients with severe curves, and failure to obtain pre-operative MRI can miss pathology that would alter surgical planning 1, 2

Classification and Risk Stratification

Adult scoliosis falls into distinct categories that guide management 4:

Type 1: Primary degenerative (de novo) scoliosis

• Develops from asymmetric disc and facet joint arthritis
• Predominantly presents with back pain ± spinal stenosis symptoms
• Most common in post-menopausal women due to osteoporosis accelerating progression 4

Type 2: Progressive adolescent idiopathic scoliosis

• Pre-existing curves from adolescence that continue to progress in adulthood
• Thoracic curves >50° progress at approximately 1° per year even after skeletal maturity 1, 2

Type 3: Secondary curves

• From leg length discrepancy, hip pathology, metabolic bone disease, or prior surgery 4

Treatment Algorithm Based on Curve Magnitude

Curves <50° in Skeletally Mature Patients

Observation with periodic monitoring:

• Serial radiographs every 12-18 months depending on progression risk 2, 3
• Address pain with conservative measures (physical therapy, NSAIDs, epidural injections) 4
• Consider bracing only if documented progression occurs despite skeletal maturity 2

Critical pitfall: Do not assume absence of symptoms means no progression—curves can progress silently, particularly in the setting of osteoporosis 2

Curves 50° or Greater in Skeletally Mature Patients

Surgical intervention is typically recommended when curves exceed 50° due to the risk of continued progression at ~1° per year 1, 2. Additional surgical indications include:

• Documented curve progression despite skeletal maturity 1, 2
• Significant pain not responding to conservative measures (≥6 months) 1
• Progressive neurological compromise from spinal stenosis 4
• Significant cosmetic concerns affecting quality of life 1

Pre-Surgical Workup Requirements

Mandatory imaging:

• MRI complete spine without contrast to rule out neural axis abnormalities (syringomyelia, Chiari malformation, tethered cord) 1, 2
• Contrast is NOT routinely needed unless infection or tumor is suspected 2
• Consider CT spine for surgical planning if complex anatomy or prior surgery 2

Curve flexibility assessment using side-bending, push-prone, fulcrum bending, or traction radiographs influences surgical planning and predicts achievable correction 1, 5

Additional evaluations for severe curves or comorbidities:

• Pulmonology assessment with baseline pulmonary function tests and nocturnal oximetry if restrictive lung disease suspected 1
• Cardiology evaluation if cardiac comorbidities present 1
• Nutritional optimization (albumin, vitamin D, bone density) 1

Surgical Approach

Posterior spinal fusion with instrumentation is the standard surgical approach for curves exceeding surgical thresholds 2. Key technical considerations:

• Bone grafting (allograft and/or autograft) is medically necessary to achieve solid arthrodesis, with cadaveric allograft and demineralized bone matrix considered appropriate regardless of implant shape 1, 2
• Fusion length must address the entire structural curve and extend to stable vertebrae 4
• In degenerative scoliosis, decompression of stenotic segments must be combined with fusion to prevent instability 4

Post-operative monitoring:

• Use inter-spinous process distance measurements rather than Cobb angle to assess fusion status, as inter-spinous measurements have superior diagnostic performance (sensitivity 91%, specificity 89%) compared to Cobb angle (sensitivity 82%, specificity 39%) for detecting pseudarthrosis 1

Special Considerations for Adult Women

Osteoporosis significantly accelerates curve progression in post-menopausal women and complicates surgical fixation 4. Address bone health proactively:

• Obtain bone density testing (DEXA scan) in all post-menopausal women with scoliosis
• Optimize vitamin D and calcium supplementation
• Consider bisphosphonates or other osteoporosis medications before elective surgery 4

Degenerative changes are common in adult scoliosis and may be the primary pain generator rather than the curve itself—targeted diagnostic blocks (facet blocks, epidural injections) can help identify pain sources and guide treatment 4

Common Pitfalls to Avoid

• Never assume a normal neurological exam rules out intraspinal abnormalities—physical exam accuracy is only 62% for detecting neural axis pathology 2
• Do not use supine radiographs for curve measurement, as they underestimate severity 3
• Do not skip MRI in surgical candidates—up to 20% have neural axis abnormalities that alter surgical planning 1, 2
• Recognize that scoliosis in adults is often multifactorial—asymmetric degeneration, osteoporosis, and prior trauma all contribute to progression 4
• Address chronic pain and muscle imbalance pre-operatively—long-standing pain patterns are difficult to reverse surgically 4