What is the recommended management for an adult female with scoliosis?

Management of Adult Female Scoliosis

For adult females with scoliosis, management is determined by curve severity: curves <15° require annual monitoring, curves 15-50° need physical therapy with core strengthening plus closer surveillance, and curves >50° warrant surgical evaluation due to progressive deterioration risk of approximately 1° per year. 1

Initial Diagnostic Evaluation

Obtain standing PA and lateral spine radiographs to establish baseline Cobb angle measurement, classify curve type, and assess skeletal maturity. 1 The Adams forward bend test combined with scoliometer measurement provides reliable clinical screening (sensitivity 84-90%, specificity 80-93%). 2

During physical examination, document:

• Shoulder height asymmetry and trunk balance 2
• Neurological status including reflexes, muscle strength, and presence of pes cavus 2
• Skin findings suggesting spinal dysraphism (hemangiomas, hairy patches, dermal sinuses) 2
• Red flags: left thoracic curve, rapid progression (>1°/month), functionally disruptive pain, or focal neurological deficits 2

Treatment Algorithm by Curve Magnitude

Curves <15° (Mild)

• Annual clinical evaluation using Adam's forward bend test 1
• Radiographic monitoring every 12-18 months for stable curves 1
• No active intervention required unless symptomatic 1

Curves 15-50° (Moderate)

• Physical therapy is the primary intervention, focusing specifically on core strengthening and postural awareness 1
• Physiotherapy scoliosis-specific exercises (PSSE) should include: (1) 3-dimensional self-correction, (2) training in activities of daily living, and (3) stabilization of corrected posture 3
• More frequent monitoring than mild curves to detect progression 1
• PSSE can temporarily stabilize progressive curves, improve back asymmetry, reduce secondary muscle imbalance and pain, and improve breathing function in thoracic curves 3

Critical pitfall: Do not substitute unsupervised home exercises for initial instruction by a physical therapist trained in scoliosis-specific techniques. 1

Curves >50° (Severe)

• Refer for surgical evaluation due to documented risk of continued progression at approximately 1° per year even in skeletally mature adults 1, 4
• Thoracic curves >50° demonstrate predictable annual progression of 1° despite skeletal maturity 4
• Surgery becomes medically necessary when curves exceed 50° threshold, show documented progression despite maturity, cause significant refractory pain, or create substantial quality-of-life impairment 4

Special Considerations for Adult Females

Female patients require heightened vigilance due to higher progression risk and osteoporosis susceptibility. 1

Osteoporosis Management

• Screen earlier with DXA scanning compared to general population 1
• Initiate bisphosphonate therapy following standard osteoporosis guidelines 1
• Osteoporosis accelerates curve progression, particularly in post-menopausal women, through asymmetric vertebral fractures and increased asymmetric loading 5

Monitoring Strategy

Avoid routine scheduled repeat radiographs in stable patients already on treatment to minimize radiation exposure. 1 Follow recommended intervals: every 12-18 months for stable curves <15°, more frequently for 15-50° curves showing any progression. 1

Symptom-Specific Management

Pain Management

For symptomatic patients with back or radicular pain:

• Physical therapy remains first-line treatment 1
• Avoid spinal manipulation with high-velocity thrusts in patients with prior spinal fusion or advanced osteoporosis due to fracture risk, spinal cord injury risk, and potential paraplegia 1

Degenerative Changes

Adult scoliosis often involves asymmetric disc and facet joint arthritis, creating a vicious cycle where asymmetric degeneration leads to increased asymmetric loading, further progression, and potential spinal stenosis. 5 This pathomechanism is particularly relevant in primary degenerative ("de novo") scoliosis and progressive idiopathic curves. 5

Pre-Surgical Evaluation (When Indicated)

For curves >50° requiring surgical consultation:

• MRI of entire spine is mandatory before any surgical intervention to rule out neural axis abnormalities, which occur in >20% of severe curves and alter surgical planning 4
• Assess curve flexibility with side bending or traction radiographs 4
• Document any neurological findings requiring intervention 4

Common Pitfalls to Avoid

• Do not overtreat stable curves with unnecessary interventions 1
• Do not delay evaluation of new or worsening symptoms, particularly neurological changes 1
• Do not expose patients to excessive radiation by deviating from recommended monitoring intervals 1
• Do not ignore osteoporosis screening in post-menopausal women, as bone loss accelerates curve progression 1
• Do not use Cobb angle alone to assess post-operative fusion status if surgery has been performed; inter-spinous process distance measurements are superior for detecting pseudarthrosis (sensitivity 91%, specificity 89% vs. 82%/39% for Cobb angle) 4