Scoliosis: The Right Clinical Information, Right Where It's Needed

Scoliosis
The right clinical information, right where it's needed
Last updated: Jun 11, 2018

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Classification 5
Prevention 7
Primary prevention 7
Screening 7
Secondary prevention 8
Diagnosis 9
Case history 9
Step-by-step diagnostic approach 9
Risk factors 12
History & examination factors 13
Diagnostic tests 15
Differential diagnosis 16
Diagnostic criteria 17
Treatment 18
Step-by-step treatment approach 18
Treatment details overview 19
Treatment options 21
Follow up 24
Recommendations 24
Complications 24
Prognosis 26
Guidelines 28
Diagnostic guidelines 28
Treatment guidelines 28
Online resources 29
References 30
Images 36
Disclaimer 42
Summary
◊ Adolescent idiopathic scoliosis (AIS) develops between the ages of 10 and 18 years.
◊ AIS accounts for approximately 90% of idiopathic scoliosis cases.
◊ The diagnosis is one of exclusion and is made after ruling out other causes of spinal deformity such
as neuromuscular, congenital, or syndromic disorders.
◊ The vast majority of patients will never require any form of treatment during the course of their
lifetime.
◊ Patients with a severe curvature are at risk of further curve progression and may develop long-term
problems related to the degree of the deformity caused by this curvature and/or back pain.
◊ It is uncertain whether non-surgical management (i.e., bracing) is efficacious in the treatment of

patients with a severe curvature.
◊ Modern surgical techniques have provided a safe treatment option resulting in excellent deformity
correction and good long-term patient reported outcomes.
Scoliosis Basics
Definition
Adolescent idiopathic scoliosis (AIS) is a structural spinal deformity characterised by decompensation of
the normal vertebral alignment during rapid skeletal growth in otherwise healthy children. The deformity can
BASICS
be described in terms of altered sagittal and coronal balance as well as abnormal vertebral rotation. This
monograph focuses on AIS, as this form of idiopathic scoliosis accounts for the vast majority (approximately
90%) of cases.[1]
Epidemiology
Adolescent idiopathic scoliosis (AIS), which develops between the ages of 10 and 18 years, accounts for
approximately 90% of cases of idiopathic scoliosis. Infantile idiopathic scoliosis develops before the age of 3
years, with a male-to-female ratio of 3:2, and accounts for <1% of idiopathic scoliosis cases, while juvenile
idiopathic scoliosis accounts for the remainder and develops between the ages of 3 and 10 years.[2]
AIS is a diagnosis that falls along a spectrum of spinal deformity disorders. The exact incidence of
asymptomatic spinal deformity is not known, as most patients with minor curvatures have no signs or
symptoms related to the deformity. In the US, the reported prevalence of patients with a curve of >10°
ranges from 0.5 to 3 per 100 children and adolescents, and the estimated prevalence of patients who
will require treatment for spinal deformity ranges from 0.5 to 3 per 1000.[9] [10] In the UK, prevalence of
idiopathic scoliosis ranges from 0.1% in 6- to 8-year-olds, 0.3% in 9- to 11-year-olds, and 1.2% in 12- to 14-
year-olds.[11] The male-to-female ratio is thought to be equal for mild curves. However, curve progression
requiring treatment is much more common in female adolescents, with an estimated ratio of 7-8:1.[12]
Additionally, the number of affected girls increases exponentially with the magnitude of the curvature.[12]
Aetiology
Although many theories have been proposed and extensively tested, the aetiology of adolescent idiopathic
scoliosis (AIS) remains unknown.
There is agreement among investigators that there is a genetic component, as the prevalence of scoliosis
in the daughters of women with AIS is almost 30%.[13] Additionally, twin concordance studies have shown
a prevalence of 73% to 92% in monozygotic twins and 36% to 63% in dizygotic twins.[14] [13] [15] Despite
these observations, specific genetic abnormalities have not been consistently shown.[16] [17] [18] [19] The
true inheritance pattern of AIS is likely to be multifactorial.
Hormonal imbalances, most notably those of decreased melatonin or increased growth hormone levels, have
also been proposed as a contributing factor. However, results from studies are inconsistent.[15] [16] [17] [18]
[19] [20]
Theories involving structural tissue abnormalities within the spine have also been tested. These theories
are based upon the knowledge that conditions involving decreased structural integrity of muscle, bone, or
ligaments (e.g., spinal muscular atrophy, polyostotic fibrous dysplasia of the axial skeleton, and Marfan's
syndrome, respectively) have an increased propensity towards the development of scoliosis.[21] [22]
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 11, 2018.
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Scoliosis Basics
Pathophysiology
The pathophysiological process behind the development of adolescent idiopathic scoliosis (AIS) is also
not known. The observation that curve development and progression correlate with the period of rapid
BASICS
adolescent growth appears to support a biomechanical contribution. However, multiple theories exist that
attempt to explain the process by which the development takes place, and while each makes sense from a
biomechanical standpoint, it has been difficult to directly correlate these theories to the in vivo adolescent
scoliotic spine.
The general concept suggested by the collective literature is that the process begins with a multifactorial
propensity towards the development of scoliosis that is accelerated through the complex biomechanical
environment of the rapidly growing adolescent spine.
Classification
Early versus late[2]
Idiopathic scoliosis can be classified as early onset or late-onset.
Early onset idiopathic scoliosis
• Develops before 10 years of age.

Late-onset idiopathic scoliosis
• Develops after 10 years of age.
Infantile versus juvenile versus adolescent[2]

Idiopathic scoliosis can also be classified as infantile, juvenile, or adolescent.
Infantile idiopathic scoliosis
• Develops before 3 years of age.

• Often occurs with other congenital abnormalities and, in approximately 90% of cases, the curve
resolves without treatment.
• Approximately 90% of cases present with a left thoracic curve.
Juvenile idiopathic scoliosis
• Develops between 3 and 10 years of age.

• Curves are often progressive with the potential for severe truncal decompensation (severe, clinically
apparent deformity in which the trunk is no longer centred over the pelvis, resulting from coronal
imbalance in severe curves) and subsequent cardiac and pulmonary complications.
• Nearly 90% of these patients will require surgical arthrodesis secondary to the magnitude of the
curvature and the degree of curve progression.
Adolescent idiopathic scoliosis
• Develops between 10 and 18 years of age.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jun 11, 2018.
5
Scoliosis Basics
Descriptive system of curve classification
Spinal deformities in scoliosis show a variety of curve patterns. This classification system, first proposed by
Dr Ignacio Ponseti in 1950, has subsequently been modified by the Terminology Committee of the Scoliosis
Research Society.[3] [Scoliosis Research Society]
BASICS
It provides a description of the curvatures based on the location of the apical vertebra and the direction in
which the curve deviates from the midline. For example, the most common curve is a right-sided thoracic
curvature (where the apical vertebra is located between T2 and T11 and the convex side of the curve is to
the right).
• Cervical: curve apex located between C2 and C6

• Cervicothoracic: curve apex located between C7 and T1
• Thoracic: curve apex located between T2 and T11
• Thoracolumbar: curve apex located between T12 and L1
• Lumbar: curve apex located between L2 and L4
• Lumbosacral: curve apex located below L4.
King-Moe system
Previously the most widely used classification for scoliosis, this system was developed by surgeons to
determine which portions of the spine would require instrumentation in order to correct the overall deformity.
It was not designed to be a complete classification system for scoliosis.[4]
There are 4 curve types described within this classification system.
• Type I: lumbar dominant and S-shaped (approximately 10% of curves).

• Type II: thoracic dominant and S-shaped (approximately 33% of curves).
• Type III: thoracic dominant, lumbar, and thoracic curves do not cross the midline (approximately 33%
of curves).
• Type IV: described as long or double thoracic (approximately 10% of curves).
Lenke and associates system

A complex classification system providing guidance on surgical decision making for all scoliosis curve
patterns.[5] [6] [7] [8] It takes into account both coronal and sagittal plane deformity and is composed of
a number (1-6) describing the type of curve, a lumbar curve modifier (A, B, or C), and a thoracic sagittal
modifier (based on degree of kyphosis present).
Scoliosis Prevention
Primary prevention
As the aetiology of adolescent idiopathic scoliosis (AIS) is unknown and the majority of patients are
asymptomatic, healthy, active adolescents, there is no system of primary prevention.
Screening
School screening
Traditionally, school screening programes have been widely instituted in many areas of the world in order to
identify scoliosis at an early stage and thus avoid surgical treatment that may be necessary following later
presentations. These programmes are typically part of a routine annual physical examination undertaken
between 10 and 12 years of age.
However, in order for scoliosis screening to be justified, an effective early treatment must be available.
Given the borderline efficacy of brace treatment, many experts question the cost-effectiveness of scoliosis
PREVENTION
screening.[33] [34] [35] [36] Despite this doubt, screening programmes have helped to increase the
awareness of scoliosis among paediatricians and primary care physicians. Additionally, many experts feel
that screening programmes provide the opportunity for early detection of scoliosis in at-risk populations.[37]
[38] [39]
Adams' forward bend test

Forward bending at the waist (viewed from anterior, posterior, and lateral aspects) provides a good
prospective for identifying thoracic, thoracolumbar, or lumbar paraspinal and thoracic cavity prominences
(which result from abnormal vertebral rotation as well as a combination of abnormal spinal curvature in the
coronal and sagittal planes). Bending forward accentuates paraspinal and rib prominences, suggestive of a
diagnosis of scoliosis.[2] [1]
This is the hallmark examination finding that leads to a suspicion of scoliosis during screening evaluation.
A positive result is observation of an asymmetric paraspinal prominence. The presence of an asymmetric
scapular prominence may suggest an upper thoracic curve.[28]
This test has been shown to have reasonable intra- and interobserver reliability.[2] [1]
Scoliometer measurement
Although not routinely undertaken in the general population, scoliometer measurement allows quantification
of the paraspinal prominences found by Adams' forward bend test.
[Fig-1]
A positive result is one of >5° at any paraspinal prominence (thoracic or lumbar). Although scoliometer
measurements do not exactly represent Cobb angle measurements from plain film radiographs, the 2
values may correlate with one another. In general, scoliometer measurements of 5° and 7° correspond
to a measured Cobb angle of approximately 10° and 20°, respectively.[29] [30] This correlation makes
scoliometer measurements useful as they represent commonly agreed-upon cut-off points used to direct
treatment decisions.
It has been shown that a scoliometer reading of 5° has a sensitivity of 100% and a specificity of 47% for the
detection of adolescent idiopathic scoliosis. Based on this data, a patient with a scoliometer reading of <5°
does not warrant further evaluation with plain film radiographs. However, a scoliometer reading of 7° has a
sensitivity of 83% and a specificity of 86% and thus warrants further evaluation with plain film radiographs
and referral to a spinal deformity specialist.[29] [30]
7
Scoliosis Prevention
Secondary prevention
All patients with a diagnosis of AIS are advised to maintain a regular fitness routine, specifically toward
developing improved core strength and conditioning.
PREVENTION
Scoliosis Diagnosis
Case history
Case history #1
A 12-year-old white girl is referred by her paediatrician for evaluation of truncal asymmetry identified by
screening during a routine physical examination. She and her parents have never noticed an abnormality
in her appearance and she is asymptomatic. She describes herself as very active in school and in her
recreational activities, and has recently noticed a growth spurt. On physical examination, she is thin
and her right shoulder appears to be slightly elevated compared with the left. On forward bending she
is very flexible, easily reaching the floor with her legs straight. A right-sided mid-thoracic prominence
is noted, as well as a smaller left-sided paraspinal prominence at the thoracolumbar junction. These
prominences significantly decrease in size with side bending in the forward flexed position. She has full
and symmetric strength, normal sensation, and symmetric deep tendon reflexes throughout her upper
and lower extremities. She has a normal gag reflex and symmetric abdominal reflexes. Her gait is normal,
including toe and heel walking. The patient is suspected to have adolescent idiopathic scoliosis.
Step-by-step diagnostic approach

The diagnosis of adolescent idiopathic scoliosis (AIS) is one of exclusion and is made after ruling out other
causes of spinal deformity, such as neuromuscular, congenital, or syndromic disorders.
When evaluating a patient who is suspected to have scoliosis, the focus of investigation should centre on
3 main topics: exclusion of other causes of spinal deformity; estimation of remaining growth potential; and
determination of the degree of truncal decompensation (severe, clinically apparent deformity in which the
trunk is no longer centred over the pelvis, resulting from coronal imbalance in severe curves) and asymmetry
caused by the curvature.[27]
History
DIAGNOSIS
The majority of patients identified as having a spinal deformity are asymptomatic at initial presentation.
Patients are usually identified through screening methods used by paediatricians and primary care
physicians during routine annual physical examinations. These include assessment with Adams' forward
bend test, and scoliometer measurement of identified paraspinal prominences.
Patients and their families should be asked about recent growth spurts and growth patterns, and whether
they have noticed evidence of postural asymmetry during activities, while looking in the mirror, during
daily hygiene, or while dressing.
It is also important to ask about the alarm symptoms of back pain and alterations in sensation or motor
control. The presence of these symptoms is not typical of AIS and may represent a serious underlying
intraspinal pathology.
A thorough past medical history, including a developmental history, should be taken to rule out other
causes of spinal deformity, and any family history of scoliosis, other spinal deformities, or major
musculoskeletal conditions should be elicited.
9
Scoliosis Diagnosis
Physical examination
The physical examination focuses on assessment of the patient's standing, walking, and bending, as well
as a thorough neurological examination and assessment of the patient's pubertal status.
Examination on standing
• Undertaken from anterior, posterior, and lateral aspects with complete (yet appropriate) exposure.
• The skin should be examined for lesions that may indicate other causes of scoliosis, such as hair
patches, sinuses, and dimples in neural tube defects, and café au lait spots and axillary spotting in
neurofibromatosis.
• Evaluation of shoulder height, waist asymmetry, asymmetry of the thoracic cavity, ribs, and breasts,
and evidence of truncal decompensation (severe, clinically apparent deformity in which the trunk is
no longer centered over the pelvis, resulting from coronal imbalance in severe curves) should be
undertaken, as well as palpation for asymmetric paraspinal prominences.
• Leg-length discrepancy, which can lead to the development of a compensatory spinal curvature to
balance the trunk over the lower extremities, should also be ruled out. Assessment on sitting allows
the pelvis and spine to balance without the influence of any leg-length discrepancy, thus correcting
the observed spinal deformity. This would not occur in the presence of scoliosis.
Assessment of gait
• Assessment of toe and heel walking can be used to elicit subtle motor weakness in distal lower
extremity muscle groups.
Examination on movement
• Adams' forward bend test (forward bending at the waist, viewed from anterior, posterior, and lateral
aspects) provides a good prospective for identifying thoracic, thoracolumbar, or lumbar paraspinal
and thoracic cavity prominences (which result from abnormal vertebral rotation as well as from
a combination of abnormal spinal curvature in the coronal and sagittal planes). Bending forward
accentuates paraspinal and rib prominences, which is suggestive of scoliosis.[2] [1] This is the
DIAGNOSIS
hallmark examination finding that leads to a suspicion of scoliosis during screening evaluation.
A positive result is observation of an asymmetric paraspinal prominence. The presence of an
asymmetric scapular prominence may suggest an upper thoracic curve.[28]
• A scoliometer is used to quantify right- and left-sided asymmetries (paraspinal prominences)
identified on Adams' forward bend test. A positive result is one of >5° at any paraspinal
prominence (thoracic or lumbar).
[Fig-1]
• In patients with a flexible spinal deformity, side bending towards the observed paraspinal
prominence in the forward flexed position results in decreased magnitude of the observed
prominence.
Neurological examination
• Involves examination of all 4 extremities.

• Includes graded strength testing; assessment of dermatomal sensation, and vibratory and position
sense (proprioception); and evaluation of deep tendon reflexes, clonus, and the Babinski reflex.
• The gag reflex and supine straight leg raise should also be tested. The presence of a positive
supine straight leg raise is evidence of nerve root impingement and is suspicious of an anatomic
Scoliosis Diagnosis
lesion, which may be contributing to the observed spinal deformity. An abnormal gag reflex may
represent an abnormality involving the hindbrain, such as in Arnold-Chiari malformation.
• Abdominal reflexes are assessed to rule out intramedullary lesions of upper motor neurons.
The umbilicus should deviate towards the abdominal quadrant being stimulated during the
examination. Asymmetry or absence of this reflex is suggestive of underlying neuropathology such
as syringomyelia.
Assessment of pubertal status
• Pubertal status (menarche in girls, development of axillary and facial hair in boys) should also
be assessed in order to estimate the time of onset of the peak adolescent growth spurt, as these
features occur 6 to 12 months after this period.
Investigations
Plain film radiographs
• It is not routinely recommended to obtain x-rays before consulting a spine specialist, as these will
routinely be obtained upon the patient's presentation to the specialist.
• Patients with scoliometer values of 5° or greater (correlates with Cobb angle measurements of at
least 10°) warrant further investigation with x-rays.[29] [30] These should include standing PA and
lateral views of the entire spine from the cervicothoracic junction to the hips, including the pelvis, on
a single film.
[Fig-2]
[Fig-3]
• Allow evaluation of the iliac apophysis (Risser sign) [23] [24] [25] [31] and triradiate cartilage[26] in
order to calculate bone age and estimate remaining growth potential. The iliac apophysis develops
from lateral to medial on a coronal view, with the most immature patients having no evidence of an
apophysis and the most mature having a fully developed and fused apophysis that extends to the
sacroiliac joint. The risk for curve progression in patients with a Risser sign of 1 or less can be as
DIAGNOSIS
high as 70%. In a patient with a Risser sign of 3, the risk of progression is approximately 10%.[24]
[25]
• On both PA and lateral projections, each cervical/thoracic/lumbar vertebra should be counted, as
well as each rib and pedicle bilaterally, in order to identify failures of segmentation or formation that
may be the cause of the deformity.
• On PA x-rays, Cobb angle measurements should be made for all major and minor curvatures. Cobb
angles are measured by determining the most tilted vertebrae at the cranial and caudal end of each
curve.[32] These vertebrae are referred to as the end vertebrae (EV). A line is drawn along the
upper vertebral end plate of the EV at the top of the curve and along the lower vertebral end plate
of the EV at the bottom of the curve. A perpendicular line is then created from each of these lines
and the angle formed by the intersection of these perpendicular lines represents the Cobb angle for
that particular curvature.
• A Cobb angle >10° establishes a diagnosis of scoliosis. The major curve is that with the largest
Cobb angle and is always structural. All other curves noted on the PA x-ray are known as minor
curves. Minor curves may be structural or compensatory.
• PA x-rays also allow evaluation of the degree of truncal decompensation (severe, clinically apparent
deformity in which the trunk is no longer centred over the pelvis, resulting from coronal imbalance
in severe curves) and overall coronal balance. The extent of coronal decompensation is measured
11
Scoliosis Diagnosis
by comparing the distance between the C7 plumb line (C7PL) and the central sacral vertical line
(CSVL).
• On lateral x-rays, the sagittal balance should be determined by measuring the distance from the C7
plumb line to the posterior superior corner of the S1 vertebral body (the C7PL should pass through
the posterior superior corner of S1 on a standing lateral projection). It is also possible to measure
the degree of thoracic kyphosis and lumbar lordosis from the standing lateral x-ray.
MRI
• An MRI scan of the entire spine and brainstem is recommended in cases where intraspinal
pathology (e.g., syringomyelia, Arnold-Chiari malformation, intramedullary tumour/mass) cannot
be confidently ruled out as the inciting cause of the spinal deformity through the clinical history,
examination, or plain x-ray, as well as in patients with an atypical presentation or abnormality on
neurological examination.
Referral to specialist
Referral to an orthopaedic surgeon specialising in paediatric spinal deformity is recommended for patients
with paraspinal or rib prominences on the Adams' forward bend test and scoliometer measurements of
>5°.[29] [30]
Risk factors
Strong
positive FHx
• The prevalence of scoliosis in the daughters of women with adolescent idiopathic scoliosis (AIS) is
almost 30%.[13] Additionally, twin concordance studies have shown a prevalence of 73% to 92% in
monozygotic twins and 36% to 63% in dizygotic twins.[14] [13] [15]
• Despite these observations, specific genetic abnormalities have not been consistently shown.[16] [17]
DIAGNOSIS
[18] [19] The true inheritance pattern of AIS is likely to be multifactorial.
peak adolescent growth spurt

• Scoliosis curve development and progression have been shown to correlate closely with the period of
peak skeletal growth during adolescence.
• Objective clinical data, such as bone age and pubertal status, are used to estimate the patient's
remaining growth potential. Classically, information regarding bone age is obtained through evaluation
of the developing iliac apophysis, known as the Risser sign.[23] The iliac apophysis develops from
lateral to medial on a coronal view, with the most immature patients having no evidence of an
apophysis and the most mature having a fully developed and fused apophysis that extends to the
sacroiliac joint. The risk for curve progression in patients with a Risser sign of 1 or less can be as high
as 70%. In a patient with a Risser sign of 3, the risk of progression is approximately 10%.[24] [25]
• Another method is evaluation of the acetabular tri-radiate cartilage on PA pelvis x-rays to predict the
patient's proximity to peak skeletal growth, as closure of this cartilage has been shown to coincide with
the end of the peak adolescent growth spurt.[26]
• The onset of menses in girls, as well as the development of axillary and facial hair in boys, occurs 6
to 12 months after the peak adolescent growth rate. Although growth beyond the onset of menses or
development of facial hair slows significantly, it can continue for up to 2 years thereafter.
Scoliosis Diagnosis
History & examination factors

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include a positive family history, and onset of the peak adolescent growth spurt.
age >10 years (common)

• In order to be diagnosed with adolescent idiopathic scoliosis (AIS), the patient must be at least 10
years of age.
6 to 12 months post puberty (common)

• Menarche in girls or development of axillary and facial hair in boys should be assessed in order to
estimate the time of onset of the peak adolescent growth spurt, as these features occur 6 to 12 months
after this period.
postural asymmetry (common)

• Asymmetry of posture may be noted during activities, while looking in the mirror, during daily hygiene,
or while dressing.
absent or minimal pain (common)

• Back pain is usually minimal or absent at presentation. Significant pain at presentation should warrant
a careful evaluation for other causes of the spinal deformity.
absence of neurological symptoms with normal neurological exam

(common)
• Patients with AIS should not have abnormal neurological symptoms at presentation and the
neurological examination is normal. Even subtle abnormalities, such as sensation changes or motor
weakness, warrant advanced neurological imaging with MRI.
DIAGNOSIS
paraspinal prominences on forward bending (common)
• Asymmetric thoracic, thoracolumbar, or lumbar paraspinal prominences result from abnormal vertebral
rotation as well as a combination of abnormal spinal curvature in the coronal and sagittal planes.
• The presence of such a prominence is the hallmark examination finding that leads to a suspicion of
scoliosis during screening evaluation with Adams' forward bend test.
• A positive result on Adams' forward bend test is observation of an asymmetric paraspinal prominence.
The presence of an asymmetric scapular prominence may suggest an upper thoracic curve.[28]
• This key sign may be recognised by the patient before or after the diagnosis is made.
scoliometer measurement of >5° at paraspinal prominence (common)

• This measurement allows quantification of the paraspinal prominences (which result from abnormal
vertebral rotation as well as a combination of abnormal spinal curvature in the coronal and sagittal
planes) found by Adams' forward bend test.
• A positive result is one of >5° at any paraspinal prominence (thoracic or lumbar).
[Fig-1]
• Although scoliometer measurements do not exactly represent Cobb angle measurements from plain
film radiographs, the 2 values may correlate with one another. In general, scoliometer measurements
13
Scoliosis Diagnosis
of 5° and 7° correspond to a measured Cobb angle of approximately 10° and 20°, respectively.[29]
[30]
• This correlation makes scoliometer measurements useful, as they represent commonly agreed-upon
cut-off points used to direct treatment decisions.
symmetric abdominal reflexes (common)

• Abdominal reflexes are assessed to rule out intramedullary lesions of upper motor neurons.
• Patients with AIS should have normal abdominal reflexes. The umbilicus should deviate towards the
abdominal quadrant being stimulated during the examination. Asymmetry or absence of this reflex is
suggestive of underlying neuropathology.
Other diagnostic factors

shoulder asymmetry (common)
• Results from abnormal spinal curvature in the coronal plane.
• In the majority of cases it is present on the convex side of the major structural curve, most commonly
with elevation of the right shoulder in a right main thoracic structural curve.
• This may be recognised by the patient before or after the diagnosis is made.
waist-line asymmetry (common)

• May signify truncal decompensation (severe, clinically apparent deformity in which the trunk is no
longer centred over the pelvis, resulting from coronal imbalance in severe curves) from a spinal
deformity. May also be present in patients with leg-length discrepancy.
thoracic wall or breast asymmetry (common)

• This is a result of abnormal vertebral rotation that alters rib orientation, resulting in a change in shape
between the 2 hemithoraces.
DIAGNOSIS
normal gag reflex (uncommon)

• Patients with AIS have a normal gag reflex. An abnormal gag reflex may be an abnormality involving
the hindbrain, such as in Arnold-Chiari malformation.
truncal decompensation (uncommon)

• In more severe curves, coronal imbalance can develop, resulting in a severe, clinically apparent
deformity in which the trunk is no longer centred over the pelvis.
Scoliosis Diagnosis
Diagnostic tests
1st test to order
Test Result
clinical exam an asymmetric thoracic,
thoracolumbar, or lumbar
• It is not routinely recommended to obtain x-rays before consulting a
spine specialist, as these will routinely be obtained upon the patient's paraspinal prominence
may be observed when
presentation to the specialist.
patient bends forward
Other tests to consider
Test Result
standing PA x-rays of cervical, thoracic, and lumbar spine, and positive finding: coronal
pelvis plane spinal curvature
>10°
• Should include visualisation of the entire spine (i.e., from the
cervicothoracic junction to the hips), as well as the pelvis, on a single
film.
[Fig-2]
• Each vertebra should be counted as well as each rib and pedicle,
bilaterally, in order to identify failures of segmentation or formation
that may be the cause of the deformity.
• Allow evaluation of the iliac apophysis (Risser sign)[23] [24] [25] [31]
and acetabular tri-radiate cartilage[26] in order to calculate bone age
and estimate remaining growth potential. There is no evidence of an
apophysis in the most immature patients, while in mature patients it is
fully developed. Closure of the triradiate cartilage coincides with the
end of the peak adolescent growth spurt.[26]
• Allow determination of the extent of coronal decompensation by
comparing the distance between the C7 plumb line (C7PL) and the
DIAGNOSIS
central sacral vertical line (CSVL).
• The Cobb angle should be measured for all major and minor curves.
An angle >10° establishes a diagnosis of scoliosis.
standing lateral x-rays of cervical, thoracic, and lumbar spine, positive finding: hypo-
and pelvis or hyperk yphosis of the
thoracic spine
• Should include visualisation of the entire spine (i.e., from the
cervicothoracic junction to the hips), as well as the pelvis, on a single
film.
[Fig-3]
• The sagittal balance should be determined by measuring the distance
from the C7PL to the posterior superior corner of the S1 vertebral
body (the C7PL should pass through the posterior superior corner of
S1 on a standing lateral projection).
• It is also possible to measure the degree of thoracic kyphosis and
lumbar lordosis from the standing lateral radiograph.
• Positive findings are subtler on lateral than on PA films.
15
Scoliosis Diagnosis
Test Result
MRI of cervical, thoracic, lumbar, and sacral spine, and normal
brainstem
• Should be undertaken with and without gadolinium contrast.
• Recommended in patients with an atypical presentation or
abnormality on neurological examination to rule out intraspinal
pathology (e.g., syringomyelia, Arnold-Chiari malformation,
intramedullary tumour/mass) as the inciting cause of the spinal
deformity.
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Congenital scoliosis • Presents with a clinically • PA and lateral x-
evident spinal deformity at a rays: vertebral or rib
much younger age.[2] [1] abnormalities.
Neuromuscular scoliosis • Spinal deformity presenting • EMG and nerve conduction

in patient with an underlying testing: evidence of upper
neurological or muscular motor neuron lesions.
disorder that is usually • MRI of brain: to evaluate
evident by abnormal the aetiology of the
developmental history or abnormalities found on
examination findings. physical examination.
• Neurological examination
shows motor weakness,
spasticity, or difficulties
initiating or controlling motor
activity, indicative of upper
motor neuron lesions.
• Gait assessment reveals
DIAGNOSIS
abnormalities related
to muscle weakness or
difficulty with initiation and
control of motor activity.
Syringomyelia • May present in a very similar • MRI: in patients where

manner to adolescent there is concern, it is
idiopathic scoliosis (AIS). recommended to obtain an
• Earlier onset, with atypical MRI of the entire spine to
curve patterns and evaluate for an abnormality
significant curve magnitude that may be causing the
at presentation. Subtle deformity.
neurological abnormalities of • If the abnormality is large
asymmetric or hyperreflexive enough to be the cause of
deep tendon reflexes, the patient's presentation/
clonus, a positive Babinski, deformity, it should be
and abnormal or asymmetric identifiable on MRI.
abdominal reflexes.
Scoliosis Diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Spina bifida • In cases where the condition • Plain films and advanced
is severe enough to cause imaging modalities (e.g.,
spinal deformity, neurological MRI): to reveal incomplete
abnormalities such as union of the posterior
sensory and motor deficits elements of vertebral levels
corresponding to the level demonstrating various
of the deformity usually co- degrees of failure of neural
exist. tube closure.
Arnold-Chiari • Clinical features range from • MRI of the entire spine: to

malformation (tethered headaches to identifiable evaluate for an abnormality
spinal cord) neurological abnormalities that may be causing
such as an abnormal gag the deformity, such as a
reflex and sensory and motor tethered spinal cord or an
deficits corresponding to the abnormal position of the
level of the abnormality. hindbrain in relation to the
foramen magnum (tonsillar
herniation).
Leg-length discrepancy • Results in the development • Orthoroentgenogram: to

of a compensatory spinal quantify the degree of leg-
curvature to balance length discrepancy.
the trunk over the lower • After determination of
extremities. leg-length discrepancy,
• Examined in both standing repeat standing x-rays with
and sitting positions. the patient standing on a
Assessment on sitting block to account for the
allows the pelvis and discrepancy demonstrates
spine to balance without correction of the postural
the influence of the leg- abnormality.
length discrepancy, thus
correcting the observed
spinal deformity. This would
DIAGNOSIS
not occur in the presence of
scoliosis.
Diagnostic criteria
Rule-in criteria
• Scoliometer measurement of >5°
[Fig-1]
• Cobb angle measurement, of a major structural curve, of >10° (cut-off based on natural history
studies and evaluation of curve progression rates)[14] [1]
[Fig-2]
[Fig-3]
• Absence of other possible cause for the spinal deformity.
17
Scoliosis Treatment
Step-by-step treatment 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.[2] [12]
[1] [40] [41] [42] [43] [44] [45]
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 at 4- to 12-month
intervals (depending on the estimated rate of growth and remaining growth potential at the time of
evaluation) should be undertaken.[2] [12] [1] [40] [41] [42] [43] [44] [45]
Standing coronal Cobb angle measurement of 21° to 45°

Brace treatment has traditionally been used in patients with a curve of >21°.[2] [1] Many brace options
are available, and the specific type of orthotic used varies between surgeons and from country to
country.[46] 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 Scoliosis Research Society consensus supports the use of an 18-hour-per-day bracing
schedule. [Scoliosis Research Society] Other organisations have also attempted to develop 'Consensus
of Care' statements and guidelines in an effort to standardise scoliosis brace treatment protocols.[3] [47]
The goal of brace therapy is to prevent curve progression until skeletal maturity, at which time the risk of
TREATMENT
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.[48] A 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.[49]
Scoliosis Treatment
[Fig-4]
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.[50]
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.[50]
Most deformities can be addressed with a posterior approach that has traditionally been the optimal
technique for surgical arthrodesis of the scoliotic spine.[51] [52] [53] [54]Some surgeons use an anterior
approach with the belief that the deformity can be corrected with a lower number of fused levels.[55]
[56] [57] [58] [59] [60] [61] [62] [63] 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.[64] [65] [66]
[Fig-2]
[Fig-3]
[Fig-5]
[Fig-6]
Treatment details overview

Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )
Ongoing ( summary )
screening scoliometer measurement
<5° or coronal Cobb angle
measurement of ≤10°
1st regular exercise
with worsening postural plus observational monitoring

asymmetry or symptom
development
TREATMENT
standing coronal Cobb angle

measurement of 11° to 20°
1st observational monitoring
19
Scoliosis Treatment
Ongoing ( summary )
plus regular exercise

1st bracing

measurement of >45°
1st surgical spinal arthrodesis

TREATMENT
Scoliosis Treatment
Treatment options
Ongoing
screening scoliometer measurement
<5° or coronal Cobb angle
measurement of ≤10°
screening scoliometer 1st regular exercise

measurement <5° or coronal
Cobb angle measurement of » The patient should be advised to maintain
≤10° a regular fitness routine, specifically towards
developing improved core strength and
conditioning.
with worsening postural plus observational monitoring
asymmetry or symptom
development » If 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,
observational monitoring with follow-up standing
PA and lateral scoliosis x-rays at 4- to 12-month
intervals (depending on the estimated rate of
growth and remaining growth potential at the
time of evaluation) should be undertaken.
1st observational monitoring
» Follow-up standing PA and lateral scoliosis

x-rays at 4- to 12-month intervals (depending
on the estimated rate of growth and remaining
growth potential at the time of evaluation) should
be undertaken.
» The patient should be advised to maintain

a regular fitness routine, specifically towards
conditioning.
1st bracing
» Many brace options are available, and the

specific type of orthotic used varies from
surgeon to surgeon and country to country.
Braces commonly used in the US are the Boston
and Rosenberger braces and the Charleston
TREATMENT
bending brace.
[Fig-4]
» Several brace-wearing schedules exist,

ranging from 23 hours per day to nighttime-
21
Scoliosis Treatment
Ongoing
only bracing. The Scoliosis Research Society
consensus supports the use of an 18-
hour-per-day bracing schedule. [Scoliosis
Research Society] Other organisations have
also attempted to develop 'Consensus of
Care' statements and guidelines in an effort
to standardise scoliosis brace treatment
protocols.[3] [47]
» The goal of brace treatment 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.[48] A 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.[49]

conditioning.
measurement of >45°
1st surgical spinal arthrodesis
» Spinal arthrodesis with instrumentation aims to

achieve maximal deformity correction, improve
appearance with trunk balancing, stop continued
curve progression, and reduce short- and
long-term complications related to the spinal
deformity.[50]
[Fig-2]
[Fig-3]
[Fig-5]
[Fig-6]
» The choice of surgical approach and

TREATMENT
instrumentation technique is dictated by the

characteristics of the deformity (e.g., location of
the curve apex), degree of spinal flexibility, and
surgeon preference.[50] Most deformities are
treated with a posterior approach, although some
surgeons use an anterior approach with the
Scoliosis Treatment
Ongoing
belief that the deformity can be corrected with a
lower number of fused levels.[55] [56] [57] [58]
[59] [60] [61] [62] [63] However, this approach
has a higher incidence of implant failure and
pseudarthrosis, and has been associated with
a risk of pulmonary complications secondary to
the need for 'single lung' anaesthesia during the
procedure.[64] [65] [66]

conditioning.
TREATMENT
23
Scoliosis Follow up
Recommendations
Monitoring
FOLLOW UP
Once the diagnosis of AIS has been made, patients are typically monitored at 4- to-6-monthly intervals
until skeletal maturity is reached. This monitoring involves repeat clinical evaluation (including history of
recent growth, development of symptoms, and assessment of changes in symmetry) and standing PA and
lateral x-rays to assess for curve progression and radiographic evidence of advancing skeletal maturity/
remaining skeletal growth).
After skeletal maturity, the patient is monitored in 1-, 2-, or 3-year increments depending on the curve
severity and patient symptoms. Based on long-term follow-up data, it is likely not necessary to continue
radiographic follow-up in patients with curves <30° after skeletal maturity.[40]
If curve progression requires surgical arthrodesis, the patient is typically monitored more frequently in the
initial postoperative period in order to check for the development of postoperative complications, including
infection, neurological deficit or injury, pseudarthrosis, proximal or distal junctional kyphosis, and the
crankshaft phenomenon.
Once clinical and radiographic evidence of arthrodesis has been established, the patient is monitored
annually.
Patient instructions
A diagnosis of AIS does not generally result in a restriction of physical activity. Patients who are
treated with observational monitoring or brace therapy can perform all activities without restriction or
increased risk of injury, although patients treated with bracing should not wear their brace during such
activities. Patients who undergo surgical treatment may require activity restrictions based on the extent of
arthrodesis required to achieve the treatment goals of the procedure.
All patients with a diagnosis of AIS are advised to maintain a regular fitness routine, specifically toward
developing improved core strength and conditioning. The Scoliosis Research Society provides useful
patient information. [Scoliosis Research Society]
Complications
Complications Timeframe Likelihood

cardiopulmonary complications variable low
In patients with adolescent idiopathic scoliosis (AIS), this complication is exceedingly rare. These patients
do not generally develop cardiopulmonary difficulties that can be linked to the degree of curvature,
although those with thoracic curvatures of >50° have been shown to demonstrate abnormalities on
pulmonary function testing (PFTs) consistent with a pattern of restrictive lung disease. These abnormalities
are rarely clinically significant.[45] [69] [70] [71] [72] [73] [74]
Some experts believe that only juvenile (or early onset) scoliosis has the potential for development of
severe thoracic deformity leading to cardiopulmonary complications.[75] [40]
postoperative infection variable low
Scoliosis Follow up

The development of a postoperative wound infection following scoliosis surgery is relatively rare.
FOLLOW UP
While the estimated incidence of infection after all spinal deformity surgery combined is approximately 2%,
infection after surgery for AIS is believed to be much less than 1%.[2]
Routine radiographs are obtained at each follow-up visit to evaluate for pseudarthrosis and other
postoperative complications that may develop.
postoperative neurological deficit or injury variable low
With the use of modern surgical techniques and instrumentation, as well as the implementation of
intraoperative neurological monitoring, the incidence of neurological injury during scoliosis surgery is very
low.
The estimated rate of neurological injury for all patients undergoing spinal deformity correction, for a
variety of causes including for AIS, is 1-2 per 1000.
Postoperative neurological deficit may be caused by traction injuries from correction of the deformity, direct
injury during vertebral instrumentation, or hypoperfusion injury due to hypotensive anaesthetic techniques
used to decrease the amount of intraoperative blood loss.
postarthrodesis pseudarthrosis variable low
The rate of pseudarthrosis, or failure of fusion, following surgical spinal arthrodesis varies, depending on
the surgical approach, the type of instrumentation used, and other patient factors such as the presence of
medical comorbidities, errors in bone metabolism, or the use of glucocorticoids.
Additionally, the reported incidence of this complication varies widely when comparing results of similar
surgical techniques from different surgical centres and surgeons. It is also important to point out that not
all patients with a pseudarthrosis will develop symptoms. For instance, in a 5-year follow-up study on the
treatment of main thoracic scoliosis with anterior thoracoscopic instrumentation, investigators identified
radiographic evidence of fusion at 151 of 155 (97%) instrumented motion segments. Each of these 4
pseudarthroses occurred at a single level in 4 of the 25 patients who were included in the study. Therefore,
the incidence of this particular complication in this patient group was 4 in 25, or 16%. Hardware failure
with rod breakage was identified in 3 of these 4 patients. These 3 patients all had revision surgery with
posterior instrumentation and fusion. The fourth patient remained asymptomatic and was managed by
observation without activity modification.[76]
In a published review of 114 patients who underwent posterior spinal fusion with pedicle screw-only
instrumentation for adolescent idiopathic scoliosis, investigators reported the identification of only one
patient with a single-level pseudarthrosis.[77] While these data do follow a trend within the literature that
this complication is more common with anterior fusion procedures, it is difficult to objectively compare the
data given the number of uncontrolled variables between the two patient groups.
Fusion rates following surgery for AIS are much higher than those after adult spinal surgery.
25
Scoliosis Follow up

postarthrodesis proximal or distal junctional k yphosis variable low
FOLLOW UP
This complication is believed to be secondary to increased stress and mechanical load on vertebral
segments adjacent to the area of fusion.
In severe cases, the kyphosis can lead to neurological deficits secondary to cord impingement at the level
of the deformity.
It can be prevented or minimised by the careful selection of levels to incorporate into the fusion during the
procedure.
crankshaft phenomenon following posterior spinal variable low

fusion
This phenomenon involves the progressive development of spinal deformity secondary to continued
anterior vertebral growth following posterior spinal fusion and instrumentation in the immature spine.[26]
It can be prevented by performing an anterior spinal fusion (intervertebral) in conjunction with the posterior
spinal fusion and instrumentation in at-risk patients, such as younger patients with a significant amount of
remaining growth potential at the time of surgical arthrodesis.
Prognosis
Sequelae of adolescent idiopathic scoliosis

This varies greatly in adolescent idiopathic scoliosis (AIS) depending on the degree of spinal deformity
present and the treatment selected. Most studies on the topic focus on the 4 main sequelae of AIS (curve
progression, back pain, cardiopulmonary complications, and psychosocial effects) and their effect on the
overall health and functioning of the patient.
Curve progression
• Curve progression requiring treatment is much more common in female adolescents, with an
estimated ratio of 7-8:1.[12] Additionally, the number of affected girls increases exponentially with the
magnitude of the curvature.[12]
• Determination of the risk of further curve progression is the essence of scoliosis treatment.
• The highest risk is during the rapid period of adolescent growth, although theoretically the risk
continues after skeletal maturity. In general, the risk of curve progression depends on the maturity of
the patient (determined by estimation of the remaining skeletal growth and pubertal status), the size of
the curve, and the position of the curve apex. Curves with a high measured Cobb angle have a high
risk of progression with continued growth.[24]
• Major structural curves with an apex above the level of T12 have a higher likelihood of progression
than those with an apex below T12.[25]
• It has been shown that, if patients reach skeletal maturity without curve progression beyond 30°,
quality of life and functionality is similar to those without scoliosis.
Scoliosis Follow up
• Based on natural history studies, patients with a scoliotic curvature of >45° and evidence of remaining
skeletal growth have a high risk of further curve progression and associated morbidity in adulthood,
such as significant back pain, truncal decompensation (severe, clinically apparent deformity in which
the trunk is no longer centred over the pelvis, resulting from coronal imbalance in severe curves),
FOLLOW UP
and sagittal imbalance.[2] [12] [1] [40] [41] [42] [43] [44] [45] These patients are therefore treated with
surgical spinal arthrodesis.
• It is estimated that patients with curves of >50° will have continued curve progression of approximately
1° per year after skeletal maturity.[43] [44] [45]
Back pain
• There is debate in the literature regarding the prevalence of back pain in patients with scoliosis.
Although most experts believe that patients with scoliosis experience back pain with a similar
incidence to the general population of age-matched adults, some researchers have shown that
patients with scoliosis experience a higher frequency and intensity of back pain.[40] [43] [45] [67] [68]
• The majority of patients with scoliosis work and perform daily activities without limitation and do not
report significant disability related to back pain compared with their peers.[40] [69]
Cardiopulmonary complications
• Unlike patients with juvenile (or early-onset) scoliosis, those with AIS do not generally develop
clinically significant cardiopulmonary difficulties that can be linked to the degree of curvature.
• AIS patients with thoracic curvatures of >50° have been shown to demonstrate abnormalities on
pulmonary function testing (PFTs) consistent with a restrictive pattern of lung disease, but these are
rarely clinically significant.[45] [69] [70] [71] [72] [73] [74]
Psychosocial effects
• There is debate in the literature regarding the effect of scoliosis on the overall self-image and
perceived health of patients with AIS.
• Untreated patients with scoliosis who develop a significant deformity do report that they are much less
satisfied with their body image and appearance in clothing than age-matched peers.
• Approximately 30% of untreated patients feel that their curvature and resulting deformity has limited
them in some way with respect to self-consciousness and reduced physical ability.[40] [67] [69]
Surgical complications of AIS are much less common than those experienced with surgical treatment of
adults with spinal deformity. The incidence of each complication is variable depending on many patient
factors (magnitude and rigidity of the curve, presence of comorbidities), as well as factors associated with
the selected surgical technique (anterior approach, posterior approach, combined anterior and posterior
approach, type of hardware selected, bone grafting technique). Perhaps the most important measure to
consider is whether a particular complication will result in the need for further surgical intervention. This is
of utmost importance in the minds of patients and their families. In general, reported re-operation rates in
the literature vary from as low as 3% to 4%, to as high as 14%. The most commonly reported reasons for re-
operation include request for thoracoplasty (surgical re-shaping of the prominent hemithorax for improved
cosmetic result), extension of fusion to include cranial or caudal segments (due to the development of
symptomatic junctional deformity or coronal/sagital decompensation), hardware failure (rod breakage), and
symptomatic pseudarthrosis. The individual incidence of each complication varies widely throughout the
literature.
27
Scoliosis Guidelines
Diagnostic guidelines
North America
Screening for the early detection for idiopathic scoliosis in adolescents SRS/
POSNA/AAOS /AAP position statement
Published by: Scoliosis Research Society Last published: 2015
Treatment guidelines
Europe
The MAGEC system for spinal lengthening in children with scoliosis

GUIDELINES
Published by: National Institute for Health and Care Excellence Last published: 2014
Scoliosis Online resources
Online resources
1. Scoliosis Research Society (external link)
ONLINE RESOURCES
29
Scoliosis References
Key articles
• Parent S, Newton PO, Wenger DR. Adolescent idiopathic scoliosis: etiology, anatomy, natural history,
REFERENCES
and bracing. Instr Course Lect. 2005;54:529-536. Abstract
• Newton PO, Wenger DR. Idiopathic scoliosis. In Morrissy RT, Weinstein SL, eds. Lovell and Winter's
pediatric orthopaedics. 6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2006:693-762.
• Negrini S, Grivas TB, Kotwicki T, et al; International Society on Scoliosis Orthopaedic and
Rehabilitation Treatment (SOSORT). Guidelines on "Standards of management of idiopathic scoliosis
with corrective braces in everyday clinics and in clinical research": SOSORT Consensus 2008.
Scoliosis. 2009;4:2. Full text Abstract
• Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine
extent of spinal arthrodesis. J Bone Joint Surg Am. 2001;83-A:1169-1181. Abstract
• Harrop JS, Birknes J, Shaffrey CI. Noninvasive measurement and screening techniques for spinal
deformities. Neurosurgery. 2008;63(3 suppl):46-53. Abstract
• Cobb JR. The problem of the primary curve. J Bone Joint Surg Am. 1960;42-A:1413-425. Abstract
• Yawn B, Yawn RA. Efficacy of school scoliosis screening. Orthopedics. 2001;24:317. Abstract
• Weinstein SL, Dolan LA, Spratt KF, et al. Health and function of patients with untreated idiopathic
scoliosis: a 50-year natural history study. JAMA. 2003;289:559-567. Full text Abstract
• Weinstein SL. Idiopathic scoliosis. Natural history. Spine. 1986;11:780-783. Abstract
• Dolan LA, Wright JG, Weinstein SL. Effects of bracing in adolescents with idiopathic scoliosis. N Engl
J Med. 2014;370:681. Full text Abstract
• Dickson JH, Mirkovic S, Noble PC, et al. Results of operative treatment of idiopathic scoliosis in adults.
J Bone Joint Surg Am. 1995;77:513-523. Abstract
• Suk SI, Lee CK, Kim WJ, et al. Segmental pedicle screw fixation in the treatment of thoracic idiopathic
scoliosis. Spine. 1995;20:1399-1405. Abstract
• Betz RR, Harms J, Clements DH 3rd, et al. Comparison of anterior and posterior instrumentation for
correction of adolescent thoracic idiopathic scoliosis. Spine. 1999;24:225-239. Abstract
• Ascani E, Bartolozzi P, Logroscino CA, et al. Natural history of untreated idiopathic scoliosis after
skeletal maturity. Spine. 1986;11:784-789. Abstract
• Edgar MA, Mehta MH. Long-term follow-up of fused and unfused idiopathic scoliosis. J Bone Joint
Surg Br. 1988;70:712-716. Full text Abstract
References
1. Parent S, Newton PO, Wenger DR. Adolescent idiopathic scoliosis: etiology, anatomy, natural history,
and bracing. Instr Course Lect. 2005;54:529-536. Abstract
REFERENCES
2. Newton PO, Wenger DR. Idiopathic scoliosis. In Morrissy RT, Weinstein SL, eds. Lovell and Winter's
pediatric orthopaedics. 6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2006:693-762.
3. Negrini S, Grivas TB, Kotwicki T, et al; International Society on Scoliosis Orthopaedic and
Rehabilitation Treatment (SOSORT). Guidelines on "Standards of management of idiopathic scoliosis
with corrective braces in everyday clinics and in clinical research": SOSORT Consensus 2008.
Scoliosis. 2009;4:2. Full text Abstract
4. King HA, Moe JH, Bradford DS, et al. The selection of fusion levels in thoracic idiopathic scoliosis. J
Bone Joint Surg Am. 1983;65:1302-1313. Abstract
5. Lenke LG, Betz RR, Bridwell KH, et al. Intraobserver and interobserver reliability of the classification of
thoracic adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1998;80:1097-1106. Abstract
6. Lenke LG, Betz RR, Clements D, et al. Curve prevalence of a new classification of operative
adolescent idiopathic scoliosis: does classification correlate with treatment? Spine. 2002;27:604-611.
Abstract
7. Lenke LG, Betz RR, Haher TR, et al. Multisurgeon assessment of surgical decision-making in
adolescent idiopathic scoliosis: curve classification, operative approach, and fusion levels. Spine.
2001;26:2347-2353. Abstract
8. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine
extent of spinal arthrodesis. J Bone Joint Surg Am. 2001;83-A:1169-1181. Abstract
9. Kane WJ. Scoliosis prevalence: a call for a statement of terms. Clin Orthop Relat Res. 1977:43-46.
Abstract
10. Montgomery F, Willner S. The natural history of idiopathic scoliosis. Incidence of treatment in 15
cohorts of children born between 1963 and 1977. Spine. 1997;22:772-774. Abstract
11. Stirling AJ, Howel D, Millner PA, et al. Late-onset idiopathic scoliosis in children six to fourteen years
old. A cross-sectional prevalence study. J Bone Joint Surg Am. 1996;78:1330-1336. Abstract
12. Bunnell WP. The natural history of idiopathic scoliosis before skeletal maturity. Spine.
1986;11:773-776. Abstract
13. Hadley Miller N. Spine update: genetics of familial idiopathic scoliosis. Spine. 2000;25:2416-2418.
Abstract
14. Kesling KL, Reinker KA. Scoliosis in twins. A meta-analysis of the literature and report of six cases.
Spine. 1997;22:2009-2014. Abstract
15. Lowe TG, Edgar M, Margulies JY, et al. Etiology of idiopathic scoliosis: current trends in research. J
Bone Joint Surg Am. 2000;82-A:1157-1168. Abstract
31
16. Chan V, Fong GC, Luk KD, et al. A genetic locus for adolescent idiopathic scoliosis linked to
chromosome 19p13.3. Am J Hum Genet. 2002;71:401-406. Full text Abstract
REFERENCES
17. Justice CM, Miller NH, Marosy B, et al. Familial idiopathic scoliosis: evidence of an X-linked
susceptibility locus. Spine. 2003;28:589-594. Abstract
18. Salehi LB, Mangino M, De Serio S, et al. Assignment of a locus for autosomal dominant idiopathic
scoliosis (IS) to human chromosome 17p11. Hum Genet. 2002;111:401-404. Abstract
19. Wise CA, Barnes R, Gillum J, et al. Localization of susceptibility to familial idiopathic scoliosis. Spine.
2000;25:2372-2380. Abstract
20. Morcuende JA, Minhas R, Dolan L, et al. Allelic variants of human melatonin 1A receptor in patients
with familial adolescent idiopathic scoliosis. Spine. 2003;28:2025-2028. Abstract
21. Leet AI, Magur E, Lee JS, et al. Fibrous dysplasia in the spine: prevalence of lesions and association
with scoliosis. J Bone Joint Surg Am. 2004;86-A:531-537. Abstract
22. Mancini F, Corsi A, De Maio F, et al. Scoliosis and spine involvement in fibrous dysplasia of bone. Eur
Spine J. 2009;18:196-202. Abstract
23. Risser JC. The Iliac apophysis; an invaluable sign in the management of scoliosis. Clin Orthop.
1958;11:111-119. Abstract
24. Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during
growth. J Bone Joint Surg Am. 1984;66:1061-1071. Abstract
25. Peterson LE, Nachemson AL. Prediction of progression of the curve in girls who have adolescent
idiopathic scoliosis of moderate severity. Logistic regression analysis based on data from The Brace
Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77:823-827. Abstract
26. Sanders JO, Little DG, Richards BS. Prediction of the crankshaft phenomenon by peak height velocity.
Spine. 1997;22:1352-1356. Abstract
27. Harrop JS, Birknes J, Shaffrey CI. Noninvasive measurement and screening techniques for spinal
deformities. Neurosurgery. 2008;63(3 suppl):46-53. Abstract
28. Grossman TW, Mazur JM, Cummings RJ. An evaluation of the Adams forward bend test and the
scoliometer in a scoliosis school screening setting. J Pediatr Orthop. 1995;15:535-538. Abstract
29. Ashworth MA, Hancock JA, Ashworth L, et al. Scoliosis screening. An approach to cost/benefit
analysis. Spine. 1988;13:1187-1188. Abstract
30. Bunnell WP. An objective criterion for scoliosis screening. J Bone Joint Surg Am. 1984;66:1381-1387.
Abstract
31. Zaoussis AL, James JI. The iliac apophysis and the evolution of curves in scoliosis. J Bone Joint Surg
Br. 1958;40-B:442-453. Full text Abstract
32. Cobb JR. The problem of the primary curve. J Bone Joint Surg Am. 1960;42-A:1413-425. Abstract
33. Yawn B, Yawn RA. Efficacy of school scoliosis screening. Orthopedics. 2001;24:317. Abstract
REFERENCES
34. Yawn BP. School-screening for scoliosis. A prospective epidemiological study in northwestern and
central Greece. J Bone Joint Surg Am. 1998;80:1244. Abstract
35. Yawn BP. Reassessing scoliosis screening: new definitions, new criteria. Adm Radiol J.
2000;19:14-17. Abstract
36. Yawn B, Yawn RA. The estimated cost of school scoliosis screening. Spine. 2000;25:2387-2391.
Abstract
37. Lonstein JE. Why school screening for scoliosis should be continued. Spine. 1988;13:1198-1200.
Abstract
38. Fong DY, Lee CF, Cheung KM, et al. A meta-analysis of the clinical effectiveness of school scoliosis
screening. Spine (Phila Pa 1976). 2010;35:1061-1071. Abstract
39. Sabirin J, Bakri R, Buang SN, et al. School scoliosis screening programme-a systematic review. Med J
Malaysia. 2010;65:261-267. Full text Abstract
40. Weinstein SL, Dolan LA, Spratt KF, et al. Health and function of patients with untreated idiopathic
scoliosis: a 50-year natural history study. JAMA. 2003;289:559-567. Full text Abstract
41. Bagnall KM, Beuerlein M, Johnson P, et al. Pineal transplantation after pinealectomy in young
chickens has no effect on the development of scoliosis. Spine. 2001;26:1022-1027. Abstract
42. Goldberg MS, Mayo NE, Poitras B, et al. The Ste-Justine Adolescent Idiopathic Scoliosis Cohort
Study. Part II: Perception of health, self and body image, and participation in physical activities. Spine.
1994;19:1562-1572. Abstract
43. Weinstein SL. Idiopathic scoliosis. Natural history. Spine. 1986;11:780-783. Abstract
44. Weinstein SL, Ponseti IV. Curve progression in idiopathic scoliosis. J Bone Joint Surg Am.
1983;65:447-455. Abstract
45. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow-up and prognosis in
untreated patients. J Bone Joint Surg Am. 1981;63:702-712. Abstract
46. Sponseller PD. Bracing for adolescent idiopathic scoliosis in practice today. J Pediatr Orthop.
2011;31:S53-S60. Abstract
47. Kotwicki T, Durmala J, Czaprowski D, et al. Conservative management of idiopathic scoliosis:

guidelines based on SOSORT 2006 Consensus. Ortop Traumatol Rehabil. 2009;11:379-395. Abstract
48. Dolan LA, Wright JG, Weinstein SL. Effects of bracing in adolescents with idiopathic scoliosis. N Engl
J Med. 2014;370:681. Full text Abstract
33
49. Negrini S, Minozzi S, Bettany-Saltikov J, et al. Braces for idiopathic scoliosis in adolescents. Cochrane
Database Syst Rev. 2015;(6):CD006850. Full text Abstract
REFERENCES
50. Dickson JH, Mirkovic S, Noble PC, et al. Results of operative treatment of idiopathic scoliosis in adults.
J Bone Joint Surg Am. 1995;77:513-523. Abstract
51. Kim YJ, Lenke LG, Kim J, et al. Comparative analysis of pedicle screw versus hybrid instrumentation in
posterior spinal fusion of adolescent idiopathic scoliosis. Spine. 2006;31:291-298. Abstract
52. Lenke LG. Debate: Resolved, a 55 degrees right thoracic adolescent idiopathic scoliotic curve should
be treated by posterior spinal fusion and segmental instrumentation using thoracic pedicle screws:
Pro: Thoracic pedicle screws should be used to treat a 55 degrees right thoracic adolescent idiopathic
scoliosis. J Pediatr Orthop. 2004;24:329-234. Abstract
53. Suk SI, Lee CK, Kim WJ, et al. Segmental pedicle screw fixation in the treatment of thoracic idiopathic
scoliosis. Spine. 1995;20:1399-1405. Abstract
54. Suk SI, Lee SM, Chung ER, et al. Selective thoracic fusion with segmental pedicle screw fixation in
the treatment of thoracic idiopathic scoliosis: more than 5-year follow-up. Spine. 2005;30:1602-1609.
Abstract
55. Muschik MT, Kimmich H, Demmel T. Comparison of anterior and posterior double-rod instrumentation
for thoracic idiopathic scoliosis: results of 141 patients. Eur Spine J. 2006;15:1128-1138. Abstract
56. Turi M, Johnston CE 2nd, Richards BS. Anterior correction of idiopathic scoliosis using TSRH
instrumentation. Spine. 1993;18:417-422. Abstract
57. Newton PO. The use of video-assisted thoracoscopic surgery in the treatment of adolescent idiopathic
scoliosis. Instr Course Lect. 2005;54:551-558. Abstract
58. Newton PO, Faro FD, Gollogly S, et al. Results of preoperative pulmonary function testing of
adolescents with idiopathic scoliosis. A study of six hundred and thirty-one patients. J Bone Joint Surg
Am. 2005;87:1937-1946. Abstract
59. Newton PO, Marks M, Faro F, et al. Use of video-assisted thoracoscopic surgery to reduce
perioperative morbidity in scoliosis surgery. Spine. 2003;28:S249-S254. Abstract
60. Newton PO, Parent S, Marks M, et al. Prospective evaluation of 50 consecutive scoliosis patients
surgically treated with thoracoscopic anterior instrumentation. Spine. 2005;30:S100-S109. Abstract
61. Newton PO, Wenger DR, Mubarak SJ, et al. Anterior release and fusion in pediatric spinal deformity.
A comparison of early outcome and cost of thoracoscopic and open thoracotomy approaches. Spine.
1997;22:1398-1406. Abstract
62. Newton PO, White KK, Faro F, et al. The success of thoracoscopic anterior fusion in a consecutive
series of 112 pediatric spinal deformity cases. Spine. 2005;30:392-398. Abstract
63. Reddi V, Clarke DV Jr, Arlet V. Anterior thoracoscopic instrumentation in adolescent idiopathic
scoliosis: a systematic review. Spine (Phila Pa 1976). 2008;33:1986-1994. Abstract
64. Betz RR, Harms J, Clements DH 3rd, et al. Comparison of anterior and posterior instrumentation for
correction of adolescent thoracic idiopathic scoliosis. Spine. 1999;24:225-239. Abstract
REFERENCES
65. Lenke LG. Anterior endoscopic discectomy and fusion for adolescent idiopathic scoliosis. Spine.
2003;28:S36-S43. Abstract
66. Lowe TG, Alongi PR, Smith DA, et al. Anterior single rod instrumentation for thoracolumbar
adolescent idiopathic scoliosis with and without the use of structural interbody support. Spine.
2003;28:2232-2241. Abstract
67. Mayo NE, Goldberg MS, Poitras B, et al. The Ste-Justine Adolescent Idiopathic Scoliosis Cohort
Study. Part III: back pain. Spine. 1994;19:1573-1581. Abstract
68. Collis DK, Ponseti IV. Long-term follow-up of patients with idiopathic scoliosis not treated surgically. J
Bone Joint Surg Am. 1969;51:425-445. Abstract
69. Ascani E, Bartolozzi P, Logroscino CA, et al. Natural history of untreated idiopathic scoliosis after
skeletal maturity. Spine. 1986;11:784-789. Abstract
70. Nachemson A. A long term follow-up study of non-treated scoliosis. Acta Orthop Scand.
1968;39:466-476. Abstract
71. Branthwaite MA. Cardiorespiratory consequences of unfused idiopathic scoliosis. Br J Dis Chest.
1986;80:360-369. Abstract
72. Edgar MA, Mehta MH. Long-term follow-up of fused and unfused idiopathic scoliosis. J Bone Joint
Surg Br. 1988;70:712-716. Full text Abstract
73. Pehrsson K, Bake B, Larsson S, et al. Lung function in adult idiopathic scoliosis: a 20 year follow up.
Thorax. 1991;46:474-478. Full text Abstract
74. Pehrsson K, Danielsson A, Nachemson A. Pulmonary function in adolescent idiopathic scoliosis: a 25

year follow up after surgery or start of brace treatment. Thorax. 2001;56:388-393. Full text Abstract
75. Dickson RA. Spinal disorders and low back pain. J Bone Joint Surg Br. 1999;81:378-379. Full text
Abstract
76. Newton PO, Upasani VV, Lhamby J, et al. Surgical treatment of main thoracic scoliosis with
thoracoscopic anterior instrumentation. a five-year follow-up study. J Bone Joint Surg Am.
2008;90:2077-2089. Abstract
77. Lehman RA Jr, Lenke LG, Keeler KA, et al. Operative treatment of adolescent idiopathic scoliosis with
posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases.
Spine (Phila Pa 1976). 2008;33:1598-1604. Abstract
35
Scoliosis Images
Images
IMAGES
Figure 1: Scoliometer measurement of a right thoracic prominence

Weinstein SL, et al. Adolescent idiopathic scoliosis. Lancet. 2008;371:1527-1537. Used with permission
Scoliosis Images
IMAGES
Figure 2: Posteroanterior scoliosis radiograph of a 13-year-old girl with a 49° right thoracic curvature with
apex at the T9-T10 disc space
From the collection of Stuart Weinstein, MD, University of Iowa; used with permission
37
IMAGES Scoliosis Images
Figure 3: Lateral scoliosis radiograph of a 13-year-old girl with a 49° right thoracic curvature
Scoliosis Images
IMAGES
Figure 4: Typical thoracic-lumbar-sacral orthosis (TLSO) scoliosis brace
Weinstein SL, et al. Adolescent idiopathic scoliosis. Lancet. 2008;371:1527-1537. Used with permission
39
IMAGES Scoliosis Images
Figure 5: Thirteen-year-old girl post-posterior spinal instrumentation and fusion for progressive scoliosis
Scoliosis Images
IMAGES
Figure 6: Thirteen-year-old girl post-posterior spinal instrumentation and fusion for progressive scoliosis
41
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UK
Contributors:
// Authors:
Ryan M. Ilgenfrit z, MD, MS

Pediatric Orthopaedic Surgeon
Department of Orthopaedics, Nemours Children’s Hospital, Orlando, FL
DISCLOSURES: RMI declares that he has no competing interests.
Stuart L. Weinstein, MD
Ignacio V. Ponseti Chair and Professor of Orthopaedics
Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
DISCLOSURES: SLW is a former board member of the Journal of Bone and Joint Surgery (ended in
2013); he was involved in a NIH RO1 research grant programme until 2015; and he is an author of several
references cited in this monograph.
// Peer Reviewers:
John M. (Jack) Flynn, MD

Associate Chief of Orthopaedic Surgery
The Children's Hospital of Philadelphia, Philadelphia, PA
DISCLOSURES: JMF declares that he has no competing interests.
Amer Samdani, MD
Director
Pediatric Spine Surgery, Shriners Hospitals for Children, Philadelphia, PA
DISCLOSURES: AS is a paid consultant for Synthes Spine, Depuy Spine, and SpineVision.
Andre Tomasino, MD
Neurosurgeon
Department of Neurosurgery, Hospital Munich-Bogenhausen, Munich, Germany
DISCLOSURES: AT declares that he has no competing interests.

Scoliosis: The Right Clinical Information, Right Where It's Needed

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Scoliosis

The right clinical information, right where it's needed

Last updated: Jun 11, 2018

◊ AIS accounts for approximately 90% of idiopathic scoliosis cases.

◊ It is uncertain whether non-surgical management (i.e., bracing) is efficacious in the treatment of

Early onset idiopathic scoliosis

• Develops before 10 years of age.

• Develops after 10 years of age.

Infantile versus juvenile versus adolescent[2]

Infantile idiopathic scoliosis

• Develops before 3 years of age.

• Develops between 3 and 10 years of age.

• Develops between 10 and 18 years of age.

• Cervical: curve apex located between C2 and C6

There are 4 curve types described within this classification system.

• Type I: lumbar dominant and S-shaped (approximately 10% of curves).

Lenke and associates system

Adams' forward bend test

Step-by-step diagnostic approach

• Involves examination of all 4 extremities.

[18] [19] The true inheritance pattern of AIS is likely to be multifactorial.

peak adolescent growth spurt

History & examination factors

age >10 years (common)

6 to 12 months post puberty (common)

postural asymmetry (common)

absent or minimal pain (common)

absence of neurological symptoms with normal neurological exam

scoliometer measurement of >5° at paraspinal prominence (common)

symmetric abdominal reflexes (common)

Other diagnostic factors

waist-line asymmetry (common)

thoracic wall or breast asymmetry (common)

normal gag reflex (uncommon)

truncal decompensation (uncommon)

Other tests to consider

Condition Differentiating signs / Differentiating tests

Neuromuscular scoliosis • Spinal deformity presenting • EMG and nerve conduction

Syringomyelia • May present in a very similar • MRI: in patients where

Condition Differentiating signs / Differentiating tests

Arnold-Chiari • Clinical features range from • MRI of the entire spine: to

Leg-length discrepancy • Results in the development • Orthoroentgenogram: to

Step-by-step treatment approach

Screening scoliometer measurement <5° or standing coronal

Standing coronal Cobb angle measurement of 11° to 20°

Standing coronal Cobb angle measurement of 21° to 45°

Standing coronal Cobb angle measurement of >45°

Treatment details overview

1st regular exercise

with worsening postural plus observational monitoring

standing coronal Cobb angle

1st observational monitoring

standing coronal Cobb angle

plus regular exercise

standing coronal Cobb angle

1st surgical spinal arthrodesis

plus regular exercise

screening scoliometer 1st regular exercise

1st observational monitoring

» Follow-up standing PA and lateral scoliosis

» The patient should be advised to maintain

» Many brace options are available, and the

» Several brace-wearing schedules exist,