Seminar

Adolescent idiopathic scoliosis

Stuart L Weinstein, Lori A Dolan, Jack C Y Cheng, Aina Danielsson, Jose A Morcuende

Adolescent idiopathic scoliosis (AIS) affects 1–3% of children in the at-risk population of those aged 10–16 years. The Lancet 2008; 371: 1527–37
aetiopathogensis of this disorder remains unknown, with misinformation about its natural history. Non-surgical Department of Orthopaedic
treatments are aimed to reduce the number of operations by preventing curve progression. Although bracing and Surgery and Rehabilitation,
University of Iowa, Iowa City,
physiotherapy are common treatments in much of the world, their effectiveness has never been rigorously assessed.
Iowa, IA, USA (S L Weinstein MD,
Technological advances have much improved the ability of surgeons to safely correct the deformity while maintaining L A Dolan PhD,
sagittal and coronal balance. However, we do not have long-term results of these changing surgical treatments. Much J A Morcuende MD);
has yet to be learned about the general health, quality of life, and self-image of both treated and untreated patients Department of Orthopaedics
and Traumatology, Chinese
with AIS.
University of Hong Kong, Hong
Kong SAR, China
Introduction measurement of the degree of curvature in each affected (J C Y Cheng MD); and
Adolescent idiopathic scoliosis (AIS) is a structural, individual and identification of any scoliosis in the family Department of Orthopaedics,
Sahlgrenska University
lateral, rotated curvature of the spine that arises in are of paramount importance for future genetic studies. Hospital, Göteborg University,
otherwise healthy children at or around puberty. The Several investigators have reported candidate-gene Gothenburg, Sweden
diagnosis is one of exclusion, and is made only when analyses of connective tissue genes. Results of these (A Danielsson MD)
other causes of scoliosis, such as vertebral malformation, studies have excluded genes for fibrillin 1 (FBN1) and Correspondence to:
neuromuscular disorder, and syndromic disorders, have 2 (FBN2); collagen type I (COLα1) and II (COLα2); elastin Dr Stuart L Weinstein,
Department of Orthopaedic
been ruled out. Patients are generally screened with (ELN); aggrecan (ACAN); and heparan sulfotransferases
Surgery and Rehabilitation,
Adams’ forward bend test and a scoliometer, although a (HS3ST3A1 and HS3ST3B1) as causes of AIS.8,12–14 Inoue University of Iowa, Hospitals and
definitive diagnosis cannot be made without measuring and colleagues15 studied polymorphisms in the genes for Clinics, 200 Hawkins Drive, Iowa
the Cobb angle on a standing coronal radiograph vitamin D receptor (MED4), oestrogen receptor (ESR1), City, Iowa, IA 52242, USA
stuart-weinstein@uiowa.edu
(figure 1). When defined as a Cobb angle of at least 10°, and CYP17A1 in relation to curve progression. The results
epidemiological studies estimate that 1–3% of the at-risk suggested that XbaJ site polymorphism in ESR1 was
population (children aged 10–16 years) will have some associated with curve progression.15,16 However, Tang and
degree of spinal curvature, although most curves will colleagues17 did not show an association between ESR1
need no intervention.1,2 In this Seminar we discuss and AIS.
present notions about aetiopathogenesis, natural history, On the basis of the hypothesis that AIS is related to an
non-operative treatment, and surgery. abnormality in melatonin metabolism, Morcuende and
colleagues18 investigated several known receptors, such as
Aetiopathogenesis hMel1A, hMel1B, and ROR-α, but reported no evidence
Despite much clinical, epidemiological, and basic science of mutations in the coding regions of these genes.
research, the aetiopathogenesis of AIS remains Gao and colleagues19 discovered a potentially functional
unknown.3,4 AIS is often seen in multiple members of polymorphism in CHD7 that is over-transmitted to affected
one family, which strongly suggests that it has a genetic offspring and predicts disruption of a caudal-type (Cdx)
component. A meta-analysis of studies of twins showed transcription-factor binding site. They suggest that this gene
concordance for AIS in 73% of monozygotic twins and is associated with the susceptibility of AIS and propose an
36% of dizygotic twins.2 Several studies that assessed overlap of causes between the rare, early onset CHARGE
large pedigrees showed different methods of inheritance,
such as autosomal dominance, maternal factors, multiple
gene inheritance, multifactorial inheritance, and X-linked Search strategy and selection criteria
dominance.3,5 However, Axenovich and colleagues6 We searched the Cochrane Library and Medline from 1996
analysed pedigrees of 101 families (778 individuals) and to 2006 for relevant literature and entered the following
undertook a complex segregation analysis. They noted search terms: “adolescent idiopathic scoliosis”, “late onset
that genetic control of severe forms of AIS could be scoliosis”, “scoliosis” AND “bracing” or “orthotic treatment”,
attributed to an autosomal dominant, major gene diallele “natural history”, “aetiology”, “pathogenesis”, “operative
model with incomplete sex-dependent penetrance of the treatment”, “spinal fusion”, “surgical stapling”, “surgical
genotypes. Moreover, four genome-wide screens of AIS stapler” or “thoracoscopy” or “video-assisted thoracic
have been reported. surgery” or “pedicle screw”. We mainly selected literature
Overall, results from these studies are disappointing from the past 10 years, but did not exclude commonly
since no one locus has been identified.7–11 This absence referenced and highly regarded older studies. We also
can be explained by phenotypic or genotypic heterogeneity, searched the reference lists of articles identified by this search
incomplete penetrance, and variable expressivity. strategy and selected those we judged relevant. Pertinent
Multiple genes could be implicated in the disorder and a review articles and book chapters were also included.
phenocopy could also arise in some families. Precise

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A B
Figure 1: Screening and diagnosis of scoliosis by scoliometer and radiography
(A) Measurement of trunk rotation with a scoliometer with patient in forward bend position; and
(B) posterior-anterior standing film of a 13-year-old boy, Risser 2, presenting with a Cobb angle of 30°.
syndrome (coloboma of the eye; heart defects; atresia of
the choanae; retardation of growth and development, or
both; genital and urinary abnormalities, or both; and ear
abnormalities and deafness) and AIS.19
Szappanos and colleagues20 reported a family with
multiple familial occurrences of AIS coupled with the
same anomaly of the karyotype [inv(10)(p11q26)].
However, analysis of restriction fragment length
polymorphism showed no abnormality. Bashiardes and
colleagues21 investigated another family in whom a
pericentric inversion of chromosome 8 seemed to
cosegregate with AIS in three generations. They used
fluorescent in-situ hybridisation and established that the
p-arm break did not interrupt any known gene, but the
q-arm break took place between exons 10 and 11 of the
syntrophin, gamma-1 (SNTG1) gene. Mutational analysis
of SNTG1 exons revealed a 6-bp deletion in exon 10, but
this deletion did not consistently cosegregate with the
disease in this family.21
What is the role of melatonin in the development of AIS?
Several investigators have shown that pinealectomy in
chickens, rats, and hamsters leads to scoliosis, and have
attributed this effect to decreased melatonin production.
However, other reports have failed to show this development
of scoliosis.22–26 Additionally, patients with AIS do not have
an inability to form melatonin, or impaired sleep or
immune function. Moreover, several diseases associated
with an abnormal melatonin rhythm do not have an
obvious effect on the development of scoliosis. Thus
scoliosis is unlikely to result from a simple absence of
melatonin; rather, it might be the result of melatonin’s
effect on other unknown growth mechanisms.3
Abnormalities in the structure and function of platelets
have been noted in patients with AIS. Evidence suggests
that raised concentrations of calmodulin result in altered
skeletal muscle activity and subsequent progressive
curvatures.27 Burwell4 formulated an integrative
platelet-skeletal hypothesis whereby a small curve loads
1528
intervertebral discs and vertebral body growth plates
creating mechanical microinsults, vascular damage, and
platelet activation with changes in calmodulin, leading to
the release of growth factors that affect the compromised
vertebral endplate. The end result of this postulated chain
of events is a relative anterior spinal overgrowth and
curve progression. However, the key questions of how
and why the initial small curve develops have not been
answered.
Several MRI studies have renewed interest in abnormal
neuroanatomy associated with AIS. Chiari type-I
malformations and spinal cord syrinx have been noted in
cases of AIS; and in younger patients, drainage of the
syrinx leads to resolution of the deformity.28–31 Additionally,
the relation between impaired autonomous nervous
system function and aetiopathogenesis of AIS has
received some attention. Sympathectomy of intercostal
nerves in growing rabbits results in hypervascularity of
the soft tissues, increased rib growth on the side of the
operation, and thoracic scoliosis convex to the opposite
side.32,33
The hypothesis that an abnormality of the paravertebral
muscles contributes to the development of AIS has been
discussed for many years. Several have been recorded,
including decreased number of type-II fibres
(fast-twitched), fibre splitting, tubular bodies, myofilament
disarray consistent with myopathy, and generalised
membrane defect (namely, impaired calcium pump).
However, no definitive conclusion can be reached about
these abnormalities, though they are likely to be
secondary to the deformity itself.
Progressive AIS is attributed to relative anterior spinal
overgrowth during the adolescent growth spurt. MRI
studies of vertebral thoracic morphometry show that
longitudinal growth of the vertebral bodies in patients
with AIS is disproportionate and faster than age-matched
and sex-matched controls, and takes place mainly by
endochondral ossification. By contrast, the circumfer-
ential growth by membranous ossification is slower in
both the vertebral bodies and pedicles.34–38 However, the
mechanisms of this growth asymmetry are not well
understood.
Natural history
The natural history of scoliosis varies with the
aetiopathogenesis and curve pattern. Early long-term
studies of so-called idiopathic scoliosis presented a grim
prognosis, perpetuating the common misperception that
all types of idiopathic scoliosis inevitably lead to disability
from back pain and cardiopulmonary compromise.39–42
Shortcomings of these earlier studies were (1) the
inclusion of patients with other causes of scoliosis or of
early onset idiopathic scoliosis; and (2) failure to assess
the outcomes related to the location of the curvature.
Patients with AIS and their families are often unneces-
sarily upset by the long-term picture painted by these
early studies. Although the natural history of scoliosis
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clearly varies according to the aetiopathogenesis and
curve pattern,43–48 screening and treatment policy for AIS
has been formed on the basis of this misinformation.
Treatment of any disorder is an attempt to alter its
natural history; therefore, long-term studies of both the
natural history and treatment outcomes are necessary.
Treatment should be proven to prevent the negative
outcomes of natural history without introducing
iatrogenic complications. The outcomes of untreated AIS
through adulthood have been studied in Britain,43 Italy,44
Sweden,47 and the USA.45,49–52 The most frequently noted
long-term sequelae of untreated AIS are curve
progression, back pain, cardiopulmonary problems, and
psychosocial concerns. Although present in most
untreated patients, the severity of these sequelae and
their effect on overall health and function is very
variable.
The size of the curve tends to increase over the entire
lifetime, but the degree of progression over a lifetime and
the time-at-risk varies with many factors. Clinicians and
patients need to be aware of the risk of curve progression
as they make treatment decisions. Factors predicting
curve progression include maturity (age at diagnosis,
menarchal status, and the amount of skeletal growth
remaining), curve size, and position of the curve apex.
Many investigators agree that curves with a thoracic apex
have the highest prevalence of progression, ranging
from 58%53 to 100%.54 The more skeletally and sexually
immature the patient is, the greater the probability of
curve progression.44,49,54–56 Likewise, the larger the curve at
presentation, the higher the likelihood of progression
both before54 and after maturity.49 Table 1 summarises the
risk of progression that results from the combined effects
of maturity and curve size.56 Progression equations have
also been developed to quantify the risk of progression.
Peterson and Nachemson57 include Risser sign, level of
apex, presence of trunk imbalance, and chronological
age; the equation developed by Lonstein and Carlson55
includes the Cobb angle, Risser sign, and chronological
age. These methods could be helpful to clinicians and
patients who want to base their treatment decisions on
the risk of progression.
The goal of non-operative treatment during adolescence
is to prevent curve progression; the goal of surgical
treatment is curve correction and maintenance. However,
the only negative outcome of AIS strongly and
consistently associated with curve size is pulmonary
function. Besides the degree of lateral curvature, other
factors such as high degrees of thoracic lordosis and
vertebral rotation and decreased respiratory muscle
strength affect pulmonary function.58–60 Unlike early
onset (age 0–8 years) idiopathic scoliosis,41,43,46,47,61 in which
substantial loss of vital capacity and forced expiratory
volume in 1 s could cause pulmonary hypertension, right
heart failure, and death, these problems rarely arise in
AIS. Large curves (greater than 50°) with a thoracic apex
have been associated with reduced vital capacity and
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Seminar
10–12 years 13–15 years 16 years
<19° 25% 10% 0%
20–29° 60% 40% 10%
30–39° 90% 70% 30%
>40° 100% 90% 70%
*Data reproduced from reference 56 with permission of authors.
Table 1: Percentage of curve progression: magnitude of curve at initial
detection vs age*
more frequent shortness of breath, but rarely, severe
cardiopulmonary compromise.44,48,52,62
Most adults have back pain in some form during their
lifetime. About 50% of adults have an episode of low
back pain in any particular year and 15% report frequent
back pain or pain lasting for more than 2 weeks in a
year.63 Ascani and others44 reported the frequency of pain
in adults with AIS (61%) to be similar to that of the
general population, whereas another report52 showed
that chronic pain was more frequent and of greater
intensity and duration in scoliotics than in the general
population. However, both groups of investigators agreed
that back pain does not seem to cause excessive disability
and, overall, patients work and undertake everyday
activities similarly to their peers.44,52 Over a lifetime, most
patients with AIS, as well as the general population, will
develop clinically important radiographic osteoarthritic
changes.52 However, history of backache seems to be
unrelated to the presence or absence of osteoarthritis or
curve severity. Back tenderness on palpation has not
been related to the curve type or severity of osteoarthritis
on radiography except for areas of lateral listhesis in
lumbar and thoracolumbar curves. These curves,
especially those with lateral listheses at the caudal end,
tend to cause a higher frequency of back pain than do
other curve patterns.44,48
Untreated AIS, and its possible sequelae such as back
pain and pulmonary limitations, affects overall function
and self-esteem. In this respect, publications are sparse
and research is conflicting. Some studies show that
patients perceive themselves to be less healthy and
restricted in physical and social activities. Ascani and
colleagues44 reported “real psychological disturbances”
in 19% of their sample, 94% of whom had curves greater
than 40°. Other studies have noted no significant
difference between people with AIS and controls in their
ability to undertake activities or in quality of life.64 With
respect to psychosocial aspects of AIS and presence of
clinical depression, scoliosis patients fare as well as
age-matched and sex-matched controls.65 However older,
untreated AIS patients are much less satisfied than are
controls with their body image, and appearance in clothes
and swimsuits. About a third of patients believe that their
curvature has restricted their life in some way, such as
difficulty in purchasing clothes, reduced physical ability,
and self-consciousness.52,65
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As they age, most patients with untreated AIS can have

Total sample size Surgical rate (%)
back pain and cosmetic concerns. Patients with untreated
AIS can function well as young adults, become employed, Wilmington84 brace 147 31%

get married, have children, and become active older Wilmington94 brace 79 11%
adults. Unfortunately, patients can develop substantial Providence75 brace 102 18%
deformity, and the cosmetic aspect of this disorder cannot Boston86 brace 212 13%
be disregarded. Treatment recommendations—watchful TLSO89 brace 54 26%
waiting, physiotherapy, bracing, and surgery—should be Boston vs Charleston95 brace 319 22%
made on an individual basis, and the patient and family TLSO96 brace 24 13%
should be well informed about the natural history of the Boston or Charleston97 brace 120 43%
disease. Boston98 brace 276 30%
Charleston99 brace 95 18%
Non-operative treatment Rosenberger100 brace 71 31%
Although AIS is diagnosed and treated worldwide, Charleston93 brace 42 7%
treatment approaches vary internationally. In patients Boston101 brace 151 13%
who still have growth remaining, watchful waiting Boston102 brace 50 30%
(observation), followed by bracing if the curve progresses
TLSO=thoracolumbosacral orthosis.
to greater than 25°, is the general course of care in
North America.1,2 Physical therapy (outpatient and Table 2: Surgery rates after TLSO treatment
inpatient rehabilitation) has been recommended as the
first line of treatment for small curves and those with a Blount first used the Milwaukee brace (originally a
low risk of progression by various, mostly European, postoperative orthotic) in 1958.73 Thoracolumbosacral
clinicians.66,67 No definite evidence has shown that orthoses (TLSO) were then developed, which improved
physical therapy or bracing reduces the risk of curve on the Milwaukee brace by removal of the cervical
progression, corrects the existing deformity, or component; use of lighter materials; and customisation
decreases the need for surgery. Patients should be aware to improve comfort, cosmesis, and compliance.74 Some
of the absence of evidence for these treatments, and be braces have been developed for use only part-time or at
provided with the opportunity to decide for themselves night-time,75,76 whereas most others are worn for 18 or
which treatment, if any, they believe will best fit with more hours per day.
their own personal assessment of risk, side-effects, and Modifications to the typical rigid TLSO include the
benefits. Cheneau bracing programme and the SpineCor dynamic
The popularity of physical therapy for AIS has waxed brace (SpineCorporation, Chesterfield, UK). The Cheneau
and waned over time, but it continues to be favoured in brace77,78 delivers a higher degree of initial correction
France, Germany, and Spain. The aim of physiotherapy through the use of a hypercorrected mould and pads to
is to prevent aggravation of the deformity in mild scoliosis provide derotational forces throughout the trunk than
(ie, curves less than 25°) and to enhance the effect of a did the original braces. Novel to this brace is the addition
brace and counteract its side-effects in moderate scoliosis of expansion room to allow for active correction by
(ie, curves between 25° and 45°). These aims are met, respiratory movements.79 The SpineCor and TrIAC
theoretically, by a combination of prescribed and (Boston Brace International, Avon, MA, USA) are
monitored sports activities and kinesitherapy to increase non-rigid braces for AIS treatment. Straps are placed to
coordination, spinal proprioception, and movement coincide with a specific correcting movement for each
control.68 kind of curve, producing a progressive positional change,
The expectation of treatment with bracing is to dynamic curve correction, and more appropriate muscle
prevent progression of the curve until the patient balance.80,81 Neither of these braces have been widely
reaches skeletal maturity, at which time the risk of tested, but the inclusion of dynamic forces in addition to
curve progression (and hence the risk of surgery) the traditional three-point control shows a more
greatly diminishes. Over the years, the medical sophisticated understanding of the growing spine.
community has arrived at two different conclusions. The nature of the dose–response relation between
On the one hand, some believe that the weight of brace wear and outcome is not well established, most
evidence favours a positive effect of bracing on the probably because of previous inability to accurately and
natural history of AIS. On the other hand, the US reliably measure time that a brace is worn. On the basis
Preventive Services Task Force,69 its Canadian counter- solely of review of records and other subjective
part,70 and many individual practitioners worldwide indicators of compliance, in a meta-analysis Rowe and
believe that evidence to support bracing is poor or colleagues82 reported that a 23-h per day protocol was
inconclusive. In fact, the effectiveness of bracing is more successful than 16-h or night-time protocols.
being tested in two randomised trials in North America Mechanical devices—mainly measuring temperature,
and the Netherlands.71,72 pressure, and proximity sensors—to measure brace

1530 www.thelancet.com Vol 371 May 3, 2008


wear are now available. These devices create the
opportunity to critically assess the relation between
brace dose (ie, wear time) and curve response.
Investigators used objective measures to show
compliance to be much lower than that reported by the
patient. However, a positive correlation between the
time that a brace is worn and outcome is partly evident.
In Rahman and colleagues’ study,83 34 patients had
temperature monitors mounted in their braces for the
duration of treatment. Of those patients who were
highly compliant, 11% had progressive curves compared
with 56% of those patients who were less compliant.
Many investigators have examined radiographic
outcomes of TLSOs for AIS over the past half-century.
Many regard a progression of greater than 5° to suggest a
true change in curvature status, and often use this
radiographic benchmark as their definition of treatment
failure. This outcome has been used in many case series
reports,84–88 although a few studies used improved designs
such as case–control comparison89–91 and one prospective
cohort study92 has been reported. The only prospective
trial92 showed a lower rate of curve progression in the
group with braces as compared with the non-treated
group. Although the most rigorous so far, this study was
non-randomised, non-blinded, with baseline differences
between the groups not statistically adjusted for, and the
results have not been replicated.
Another definition of brace treatment failure is the
number of surgical procedures required despite treatment.
The results of studies tracking surgical rates vary widely,
most probably caused by different sample characteristics.
Table 2 gives an overview of the studies of patients who
meet present indications for bracing treatment with the
rate of surgery despite bracing. The surgical rate ranges
from 7%93 to 43%.97
A B
Figure 2: Radiographs of a teenager with progressive AIS treated by posterior instrumentation by hybrid (rods, hooks, and screws)
(A) Preoperative standing posterior-anterior (PA); (B) preoperative standing lateral; (C) postoperative standing PA; and (D) postoperative standing lateral.
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Surgery
The primary objectives of surgical treatment with
instrumentation are to (1) arrest progression, (2) achieve
maximum permanent correction of the deformity in
three dimensions, (3) improve appearance by balancing
the trunk, and (4) keep short-term and long-term
complications to a minimum. The generally agreed
indication for surgery in adolescents is a primary curve
greater than a Cobb angle of 45°. In adults, the surgical
indications are pain related to the curvature that is
unresponsive to non-operative management, curve
progression that has exacerbated symptoms, and
functional capabilities.103 Although adolescent patients
can choose to delay surgery until they are adults, adults
often have less flexible curves that than seen in children,
which could need anterior and posterior (staged or
sequential) procedures. Additionally, the rate of
complications in adults is much higher for the same
procedures than it is in the adolescent population.
Complications in adults are pseudarthrosis, proximal
and distal junctional kyphosis, and extended recovery.104
Improved preoperative assessments supplemented by
intraoperative neurophysiological monitoring and
blood salvage techniques have made modern scoliosis
surgery safer than previously. Enhancement of solid
bony fusion over the surgical instrumentation can now
be achieved through autogenous bone graft, allograft,
demineralised bone matrix, or the latest biological bone
substitutes.
Posterior instrumentation remains the mainstay of
treatment for most idiopathic curves. From the first
generation of Harrington instrumentation introduced in
the 1960s105 to modern third-generation instrumentation
evolved from the Cotrel-Dubousset system in the 1980s,106
much progress has been achieved by improved multi-
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planar (coronal, sagittal, and transverse plane) correction,
stable fixation, reduced levels of fusion, and avoidance of
postoperative immobilisation with a cast or brace. Such
progress has been possible through combinations of
wires, hooks, and lumbar pedicle screw constructs over
contoured rods, and interconnecting systems applied
over several purchase sites posteriorly (the lamina,
pedicle, transverse processes, and spinous processes)107,108
(figure 2).
The extended use of many segmental pedicle screws in
the thoracic spine, originally pioneered by Suk,109 allows
even better three-column mechanical fixation,
multiplanar corrections, such as the rib prominence
reduction, and saving of fusion levels compared with
standard hook-wire constructs110–112 (figure 3). The
disadvantages of thoracic pedicle screws are a steep
learning curve, increased cost, safety concerns, and
difficulties associated with accurately placing pedicle
screws within dysplastic pedicles.113–115At present time, no
conclusive evidence exists about improved radiographic
outcomes in patients with AIS correlate with enhanced
function, self-image, or health.104
Anterior instrumentation has been used mainly for
isolated thoracolumbar and lumbar curves. Evolving
from the early Dwyer cable to the vertebral screw
system,116 Zeilke ventral derotation spondylodesis,
screw-single rod system,117 and other similar systems
have been used satisfactorily with good correction of the
frontal and transverse plane, restoration of truncal
balance,118,119 and reduction of fusion levels. The main
disadvantages are the kyphosing tendency of these
systems, higher rates of implant breakage, pseudarthrosis,
and the necessity of postoperative cast or brace
protection.120,121 The latest dual-rod, multiple vertebral
A B
Figure 3: Radiographs of a teenager with progressive right thoracic adolescent idiopathic scoliosis treated by posterior segmental pedicle screws
(A) Preoperative standing lateral; (B) preoperative standing posterior-anterior (PA); (C) postoperative standing lateral; and (D) postoperative standing PA.
Reproduced with permission of Dr Peter Newton, San Diego, CA, USA.
1532
screw system provides good rigid fixation, improved
correction in the sagittal plane, and minimum need for
postoperative protection.122,123
Anterior instrumentation has been extended to thoracic
scoliosis to achieve improved sagittal plane correction
and reduced number of fused levels, and to prevent
crankshafting (continued anterior spinal growth in the
face of a posterior fusion) in the immature patient
(figure 4).124–126 The disadvantages of anterior open
thoracotomy approach are the rate of implant breakage,
pseudarthrosis, the surgical scar, and the unfavourable
effect on lung function.124,127 Video-assisted thoracoscopic
anterior instrumentation has been used to reduce the
surgical scar. Such surgery, however, entails a very steep
learning curve, risk of encroaching on adjacent vital
structures, and problems related to anaesthesia in one
lung.128–132 Hence, whether this method is useful cannot
be addressed without clearly documented advantages
over the latest posterior instrumentation with thoracic
pedicle screws.133
A novel way to modulate the growth of the anterior
vertebral epiphyses through thoracoscopic stapling of the
convex apical vertebrae for scoliosis in skeletally
immature patients is under investigation after promising
preliminary work in animals (figure 5).134,135 The theoretical
advantages are preservation of growth, and motion and
function of the spine caused by non-fusion. However,
apart from very limited experience, the need to refine the
staple design, and other essential improvements, the
most important questions relate to indications. So, who
is the ideal candidate? In the absence of objective
measures to reliably predict curve progression, one might
be unnecessarily treating patients with curves that will
never progress.
C D
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A B C D

Figure 4: Radiographs of a teenager with progressive right thoracic adolescent idiopathic scoliosis treated by anterior spinal instrumentation
(A) Preoperative standing lateral; (B) preoperative standing posterior-anterior (PA); (C) postoperative standing PA; and (D) postoperative standing lateral.
Reproduced with permission of Dr Peter Newton, San Diego, CA, USA.

Treatment outcome versus natural history
Typically, three types of treatment outcomes are reported:
(1) radiographical (coronal and sagittal radiographic
measurements); (2) clinical (complications, pulmonary
function and symptoms, mobility, muscle strength, back
function); and (3) self-reported outcomes (general health
and health concerns specific to scoliosis and its
treatment).
Several workers have reported that curve size or curve
correction do not correlate with quality of life. Moreover
several retrospective long-term studies have established
that patients treated surgically or with a brace have nearly
the same quality of life, both mentally and physically,
after treatment as do healthy controls or national norms.
However, this evidence is not conclusive.
Some retrospective investigations have shown that AIS
causes disturbances in body image and in other indicators
of mental health and adjustment.136–141 Each investigation
used different instruments to measure psychological
indices and adherence. Despite these shortcomings,
bracing clearly causes some psychological stress to the
patient, at least at the initiation of treatment and possibly
in the long term. Tones and colleagues142 reported a
systematic review of publications about health-related
quality of life and psychosocial issues in AIS. They
concluded that adolescents can have poorer psychosocial
functioning, body image, and health-related quality of
life than have their peers, but that adults generally do not
have psychological distress. However, adults are at risk of
disability and concerns about body image. Stress as a
result of treatment needs to be considered in the
decision-to-treat equation, and the benefits of watchful
waiting, bracing, or surgery should outweigh the risk of
adverse psychological sequelae.
A long-term study from Sweden143,144 corroborates
studies of the natural history of back pain and function.
Danielsson and Nachemson,143,144 compared patients who
previously wore a brace and those who had undergone
surgery each with a set of age-matched controls. They
reported little evidence that either patient group was
greatly impaired relative to their peers when the 36-item
short form health survey and Oswestry low back pain
disability questionnaire was used. The mean curve size
in both groups was greater than 30°. Another follow-up
report of more than 20 years145 showed no difference in
quality of life, including back pain and function, between
AIS patients who had undergone surgery and those who
remained untreated, as inferred from several
instruments, such as the Oswestry, Roland-Morris, and
the EuroQol-5D. This finding is in contrast with that of
Mayo and colleagues’ survey.65 Their sample consisted of
patients who were untreated, had a brace, or had
undergone surgery. The frequency of back pain did not
differ by Cobb angle, and these workers concluded that
A B C
Figure 5: Radiographs of a skeletally immature 10 year old whose right thoracic curve progressed
from 35° to 42° despite bracing
(A) Preoperative but after bracing standing posterior-anterior (PA); (B) 3 years’ postoperative standing PA, Cobb
angle 28°; and (C) 3 years’ postoperative standing lateral. He was treated with vertebral body stapling T6-L1.
Reproduced with permission of Lippincott Williams & Wilkins from reference 134.

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 Seminar
the deformity could induce back pain and that surgery
did not induce additional back pain beyond that caused
by scoliosis itself. However, on the basis of their answers
in the Oswestry questionnaire, people with severe curves
or those who had been surgically treated felt restricted
in their ability to manage pain, lift, and socialise.
Dickson and colleagues103 compared outcomes of
symptomatic, untreated patients who were offered
arthrodesis and fusion as adults with those who had
arthrodesis and fusion. At an average of 5 years after
surgery, 35% had substantial or severe pain compared
with 70% of the patients who declined surgery and 7%
of a non-scoliotic control group. They concluded that
operative intervention, although associated with
improvements in quality of life, self-image, pain, and
disability, did not alleviate all symptoms or restore
function to that of non-scoliotic individuals.
Conclusion
Although many controversies and unanswered questions
surround AIS, the most difficult one is the absence of
information about its aetiopathogenesis. We do not know
if AIS is one entity or a manifestation of several causes.
We are uncertain of all the factors that lead to progression
and secondary manifestations of spinal deformity. The
identification of aetiopathogenetic factors will enable
improved prediction of progression and could aid in the
development of more specific treatments.
Because of this absence of fundamental information,
all treatment efforts are aimed at prevention or correction
of the primary manifestation of the disorder—ie, spinal
deformity. Although bracing has been regarded as the
standard of care for patients at a high risk of progression
(curves between 25° and 40° in skeletally immature
patients), it has never been subjected to rigorous
assessment of either its efficacy or effectiveness. Both the
North American and Netherlands’ clinical trials are
addressing quality of life and other psychosocial issues in
individuals with AIS. If these studies show undue stress
resulting from observation alone or brace treatment, this
stress should be considered in the decision-to-treat
equation.
With respect to surgical management, although
technology has greatly increased the safety with which
we can correct spinal deformity and preserve spinal
balance, long-term results of these changing methods of
management are absent. Surgery can reduce deformity
and prevent further progression; thereby decreasing the
risk of future cardiopulmonary compromise, but its role
in the prevention of other negative long-term effects of
scoliosis is not clear.
Conflict of interest statement
We declare that we have no conflict of interest.
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