Approach

Treatment decisions for adolescent idiopathic scoliosis (AIS) are based on the initial deformity at presentation and rate of curve progression, as well as an overall assessment of the patient's growth potential.

The main goal of treatment is to prevent progression of the spinal deformity until the patient reaches skeletal maturity. Once the patient has reached skeletal maturity, the risk of curve progression decreases significantly. Treatment options for AIS include observational monitoring, bracing, or surgical spinal arthrodesis (fusion). The selection of treatment is based on the severity of the curve and the amount of growth remaining until skeletal maturity.

Screening scoliometer measurement <5° or standing coronal Cobb angle measurement ≤10°

These measurements allow a diagnosis of postural deformity to be made. No treatment or observational monitoring is necessary unless the patient or family identify worsening postural asymmetry or the patient develops symptoms to suggest the presence of another underlying cause for the spinal deformity.[1][2][13][50][51][52][53][54][55]

The patient should be advised to maintain a regular fitness routine, specifically towards developing improved core strength and conditioning.

Standing coronal Cobb angle measurement of 11° to 20°

Observational monitoring with follow-up standing PA and lateral scoliosis x-rays should be undertaken at 4- to 12-month intervals (depending on the estimated rate of growth and remaining growth potential at the time of evaluation).[1][2][13][50][51][52][53][54][55]

The patient should be advised to maintain a regular fitness routine, specifically towards developing improved core strength and conditioning.

Standing coronal Cobb angle measurement of 21° to 45°

Brace treatment has traditionally been used in patients with a curve of >21°.[1][2] Many brace options are available, and the specific type of orthotic used varies between surgeons and from country to country.[56] Braces commonly used in the US are the Boston and Rosenberger braces and the Charleston bending brace.

Several brace-wearing schedules have also been proposed, ranging from 23 hours per day to nighttime-only bracing. While some studies have supported a dose-dependent relationship between brace wearing and curve progression, it is still unclear which brace-wearing schedule provides the most reliable outcome. The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) consensus supports the use of an 18-hour-per-day bracing schedule.[32] Other organisations have also attempted to develop 'Consensus of Care' statements and guidelines in an effort to standardise scoliosis brace treatment protocols.[32][57][58]

The goal of brace therapy is to prevent curve progression until skeletal maturity, at which time the risk of further curve progression significantly reduces. Data from the BrAIST (Bracing in Adolescent Idiopathic Scoliosis Trial) trial have shown a significantly lower risk of curve progression in patients with AIS who wore a brace compared with those who did not.[45] One Cochrane review concluded that all of the included studies consistently showed that bracing in AIS prevented curve progression, including 7 separate studies that included a total of 662 participants.[59]

The patient should be advised to maintain a regular fitness routine, specifically towards developing improved core strength and conditioning.[Figure caption and citation for the preceding image starts]: Typical thoracic-lumbar-sacral orthosis (TLSO) scoliosis braceWeinstein SL, et al. Adolescent idiopathic scoliosis. Lancet. 2008;371:1527-1537. Used with permission [Citation ends].com.bmj.content.model.Caption@6e165708

Standing coronal Cobb angle measurement of >45°

Due to risk of further curve progression and associated morbidity as an adult, the treatment recommended for this group of patients is to proceed with surgical spinal arthrodesis. Spinal arthrodesis with instrumentation serves several treatment objectives, including achievement of maximal deformity correction, improvement in appearance with trunk balancing, cessation of continued curve progression, and reduction of both short- and long-term complications related to the spinal deformity.[60]

The choice of surgical approach and instrumentation technique is dictated by the characteristics of the deformity (e.g., location of the curve apex), degree of spinal flexibility, and surgeon preference.[60] Most deformities can be addressed with a posterior approach that has traditionally been the optimal technique for surgical arthrodesis of the scoliotic spine.[61][62][63][64]Some surgeons use an anterior approach with the belief that the deformity can be corrected with a lower number of fused levels.[65][66][67][68][69][70][71][72][73] However, this approach has a higher incidence of implant failure and pseudarthrosis compared with the posterior approach, and has been associated with a risk of pulmonary complications secondary to the need for 'single lung' anaesthesia during the procedure.[74][75][76]

The patient should be advised to maintain a regular fitness routine, specifically towards developing improved core strength and conditioning.[Figure caption and citation for the preceding image starts]: Posteroanterior scoliosis radiograph of a 13-year-old girl with a 49° right thoracic curvature with apex at the T9-T10 disc spaceFrom the collection of Stuart Weinstein, MD, University of Iowa; used with permission [Citation ends].com.bmj.content.model.Caption@7a7ae6ab[Figure caption and citation for the preceding image starts]: Lateral scoliosis radiograph of a 13-year-old girl with a 49° right thoracic curvatureFrom the collection of Stuart Weinstein, MD, University of Iowa; used with permission [Citation ends].com.bmj.content.model.Caption@33f903a[Figure caption and citation for the preceding image starts]: Thirteen-year-old girl post-posterior spinal instrumentation and fusion for progressive scoliosisFrom the collection of Stuart Weinstein, MD, University of Iowa; used with permission [Citation ends].com.bmj.content.model.Caption@752010c5[Figure caption and citation for the preceding image starts]: Thirteen-year-old girl post-posterior spinal instrumentation and fusion for progressive scoliosisFrom the collection of Stuart Weinstein, MD, University of Iowa; used with permission [Citation ends].com.bmj.content.model.Caption@1d5c2902

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