CLINICAL ARTICLE

J Neurosurg Spine 38:84–90, 2023

Surgical treatment of young adults with idiopathic scoliosis

Corey T. Walker, MD,1 Nitin Agarwal, MD,2 Robert K. Eastlack, MD,3 Gregory M. Mundis Jr., MD,3
Nima Alan, MD,2 Tina Iannacone, MPH,3 Behrooz A. Akbarnia, MD,3 and
David O. Okonkwo, MD, PhD2
1
Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; 2Department of Neurosurgery, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and 3Division of Orthopedics, Scripps Clinic, San Diego, California

OBJECTIVE  In this study, the authors report on their experience with the surgical treatment of young adults with idio-
pathic scoliosis (YAdISs) who did not have surgical treatment in adolescence but did require intervention after skeletal
maturity.
METHODS  The medical records of YAdISs between 18 and 40 years of age who had been surgically treated at two
institutions between 2009 and 2018 were retrospectively evaluated. Pre- and postoperative clinical and radiographic
information was gathered and compared at 2 years after treatment.
RESULTS  Twenty-eight patients (9 male, 19 female) with a median age of 25 years (range 18–40 years) met the study
inclusion criteria. Five patients (18%) had postoperative complications, including 2 deep venous thromboses, 1 ileus,
and 2 reoperations, one for implant failure and the other for pseudarthrosis. The mean maximum coronal curve angle
improved from 43° ± 12° to 17° ± 8° (p < 0.001), but there were no significant differences in sagittal vertical axis, lumbar
lordosis, pelvic tilt, or thoracic kyphosis (p > 0.05). There was no relationship between the amount of correction obtained
and patient age (p = 0.46). Significant improvements in the Oswestry Disability Index (31 vs 24, p = 0.02), visual analog
scale score for both back pain (6.0 vs 4.0, p = 0.01) and leg pain (2.6 vs 1.1, p = 0.02), and self-image score (Δ1.1, p <
0.001) were seen.
CONCLUSIONS  YAdISs can present with pain, deformity progression, and/or appearance dissatisfaction because of
their scoliosis despite successful nonoperative management during adolescence. Once the scoliosis becomes symp-
tomatic, surgical correction can result in significant clinical and radiographic improvements at the 2-year follow-up with a
relatively low complication rate compared to that for other types of adult spinal deformity.
https://thejns.org/doi/abs/10.3171/2022.7.SPINE2298
KEYWORDS  idiopathic scoliosis; young adult; spinal deformity; malalignment; spine surgery

T
hesurgical treatment of adolescent idiopathic sco-
liosis (AIS) has been heavily studied and advanced
significantly over the past several decades. More re-
cently, a significant focus of outcomes research in spinal
surgery has been the correction of adult spinal deformity
(ASD).1 Deformity in this population is predominantly de-
generative in nature, but ASD also includes a small subset
of AIS patients who enter young adulthood without prior
surgical treatment for their deformity (Aebi type 2 adult
scoliosis).2 Unlike adolescents who present with idiopathic
scoliosis, AIS patients who enter adulthood may present
similarly to degenerative scoliosis patients, with superim-
posed spondylosis, kyphosis, and loss of compensatory
mechanisms. This in turn can result in back pain, radicu-
lopathy, leg pain,3–6 and consequential disability necessi-
tating surgical treatment.
It has been shown in long-term natural history studies
that if the surgical treatment of AIS can be avoided during
adolescence, most patients can have relatively normal adult
lives, become employed, get married and have children,
and function as active older adults.7 Still, a number of these
patients, particularly those with substantial curve magni-
tudes, can develop pain and progression of their deformity
into adulthood, even before the onset of the aforementioned
degenerative processes. The decision to surgically treat
this subset of patients has been historically based on the
development of progressive deformity, symptoms refrac-
tory to conservative therapies, or neurological symptoms.

ABBREVIATIONS  AIS = adolescent idiopathic scoliosis; ASD = adult spinal deformity; HRQOL = health-related quality of life; MCID = minimal clinically important differ-
ence; ODI = Oswestry Disability Index; SRS = Scoliosis Research Society; VAS = visual analog scale; YAdIS = young adult with idiopathic scoliosis.
SUBMITTED  January 22, 2022.  ACCEPTED  July 6, 2022.
INCLUDE WHEN CITING  Published online September 2, 2022; DOI: 10.3171/2022.7.SPINE2298.

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TABLE 1. Summary of demographics and surgical characteristics
in 28 YAdISs
Characteristic Value
Median age in yrs (range) 25 (18–40)
No. of M/F patients 9/19
Mean BMI 23.8 ± 4.5
Lenke curve type classification
  1, main thoracic 11 (39)
  2, double thoracic 3 (11)
  3, double major 4 (14)
  4, triple major 1 (4)
  5, thoracolumbar/lumbar 6 (21)
  6, thoracolumbar/lumbar–main thoracic 3 (11)
Mean length of stay in days 5.5 ± 2.0
Mean estimated blood loss in ml 839 ± 658
Op duration in mins 299 ± 94
Mean no. of levels fused per patient 11 ± 2
Mean no. of osteotomies per patient 6±2
Values are expressed as number (%) or mean ± standard deviation, unless
indicated otherwise.
It is generally believed that adult scoliosis remains
more difficult to treat than AIS, as advancing age means
worse bone quality, stiffer curves, increased kyphosis, and
a higher risk of medical complications.8,9 Thus, surgery
for patients in their 2nd and 3rd decades of life may be
addressed much differently than for those in their 5th, 6th,
and 7th decades. Younger adult patients have a lower risk
of perioperative complications, have fewer spondylotic
changes, require fewer osteotomies, and can potentially be
treated with fewer fusion levels and shorter constructs.10,11
Similarly, the decision-making process about surgical in-
tervention is also different.12 In the aforementioned older
group of patients, the choice to perform surgery is typi-
cally determined on the basis of documented curve pro-
gression, evidence of decompensated sagittal or coronal
alignment, back pain or radicular symptoms associated
with asymmetrical disc degeneration and stenosis, or sig-
nificant pulmonary dysfunction that cannot be attributed
to an underlying pulmonary disease.13 In contrast, the
indications for treatment in adult idiopathic scoliosis pa-
tients under the age of 40 years remain more nebulous and
controversial, with refractory axial pain and unacceptable
cosmesis being the major drivers of treatment.
Few studies have focused on this relatively small popu-
lation of young adults with idiopathic scoliosis (YAdISs)
who have reached adulthood and then develop symptoms
warranting surgical treatment, and most of these studies
are outdated. In 2002 Takahashi et al., in a series of 58
adult idiopathic scoliosis patients treated with posterior
surgery using Cotrel-Dubousset instrumentation, demon-
strated that curve patterns and surgical indications var-
ied across decades of patients aged between 30 and 60
years.12 Moreover, these authors noted significantly worse
radiographic correction in patients over 50 but greater sat-
isfaction in their pain reduction. More recent studies com-
paring patients treated during young adulthood (age < 30
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Walker et al.
years) have suggested that they may have slightly worse
outcomes in terms of radiographic curve correction11,14 and
potentially more treated levels11 than AIS patients treated
before the age of 18 years. In the present study, we sought
to describe our surgical experience with YAdISs between
the ages of 18 and 40 who had presented with untreated
scoliosis to better characterize clinical and radiographic
surgical outcomes in this unique clinical population.
Methods
Patients were retrospectively identified from the case
logs of consecutively treated surgical patients from two
institutions. The patients were treated between 2009 and
2018. Inclusion criteria were patients with an age between
18 and 40 years who had primary untreated idiopathic
scoliosis with a curve angle > 20°. Only patients whose
major scoliotic curve(s) had been corrected were included
in the analysis. Patients with neuromuscular, congenital,
or degenerative scoliosis were excluded from the analysis.
Prospectively collected data were retrospectively ob-
tained and analyzed. Patient demographic data and surgi-
cal variables were obtained and compared pre- and post-
operatively. Patients were followed up for a minimum of 2
years. Indications for surgery were retrospectively collect-
ed based on preoperative consultation notes. Patients were
treated with posterior-only and combined anterior-poste-
rior approaches as determined by the surgeons at the time
of correction, and this information was recorded. Patients
were grouped according to their Lenke scoliosis clas-
sification.15 Radiographic analysis was performed using
standing anteroposterior and lateral radiographs (36-inch),
and comparisons were made between the preoperative
and 2-year follow-up time points. Captured radiographic
parameters included the maximum coronal curve angle,
thoracic kyphosis (T2–12), sagittal vertical axis, lumbar
lordosis (L1–S1), and pelvic tilt.
Health-related quality-of-life (HRQOL) measures in-
cluded the Oswestry Disability Index (ODI) and visual
analog scale (VAS) scores for both back pain and leg pain.
These patient-reported outcome measures were completed
before surgery and at the 2-year follow-up.
GraphPad Prism software (version 8.4.3) was used for
statistical analysis. Descriptive analysis was performed for
demographic data and radiographic parameters. A paired
t-test was performed to compare each radiographic param-
eter and HRQOL measurements pre- and postoperatively
for the cohort analysis. A p value < 0.05 was considered
statistically significant.
Results
A total of 28 patients were identified and included in
the analysis, 17 from one institution and 11 from the other.
The median age was 25 years (range 18–40 years), and 19
of the patients were female. The breakdown of the Lenke
scoliosis classification and specific operative details are re-
ported in Table 1. The mean hospital length of stay was 5.5
± 2.0 days, estimated blood loss was 839 ± 658 ml, and op-
erative duration was 299 ± 94 minutes for these cases. No
patients required a three-column osteotomy to achieve the
desired correction, and all patients had posterior column
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Walker et al.

FIG. 1. Graphic representations of pre- and postoperative improvements in ODI (A) and VAS scores for back pain (B) and leg pain
(C); indications and presenting symptoms prompting surgical intervention (D); and changes in self-image scores pre- and postop-
eratively (E), with relative improvement differences. *p < 0.05.

osteotomies at the apices of their curves. Only 1 patient
with a primary lumbar curve was treated with circumfer-
ential anterior-posterior fusion; the other 27 patients were
all treated with posterior-only single-stage approaches.
Clinical improvements are graphically shown in Fig.
1. A comparison of preoperative and postoperative out-
come measures revealed significant improvements of 23%
in the ODI (31 vs 24, p = 0.02), 33% in the VAS score
for back pain (6.0 vs 4.0, p = 0.01), and 58% in the VAS
score for leg pain (2.6 vs 1.1, p = 0.02). The percentage of
patients attaining the minimal clinically important differ-
ence (MCID)16 for ODI and VAS back pain was 55% and
67%, respectively. There was no identified preoperative
ODI threshold above which patients were more likely to
have a significant improvement in clinical outcomes. Only
86 J Neurosurg Spine  Volume 38 • January 2023
9 patients presented with significant leg pain (preopera-
tive VAS score ≥ 3), and 7 of these patients (78%) met the
MCID in their leg pain improvement.
The clinical indications for surgery were recorded and
are shown in Fig. 1. All patients except 1 (96%) presented
with clinically significant refractory back pain, and this
was the main indication for surgery in most instances.
Eighteen patients (64%) presented with deformity or curve
progression radiographically, and 14 patients (50%) were
dissatisfied with their appearance. Scoliosis Research So-
ciety (SRS) self-image scores significantly improved, with
a mean improvement of 1.1 (p < 0.001).
Surgical complications were identified in 5 cases (18%;
Table 2). This included 3 minor medical complications (1
ileus, 2 deep venous thromboses) and 2 major complica-

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 Walker et al.

TABLE 2. Postoperative complications among 28 YAdISs

Complication No. (%)
Surgical revision
  Implant failure 1 (4)
  Proximal or distal junctional failure 0 (0)
 Pseudarthrosis 1 (4)
Infection 0 (0)
CSF leak 0 (0)
Deep venous thrombosis 2 (7)
Ileus 1 (4)
Total 5 (18)

tions, both of which required surgical revision (1 for hard-

ware failure in a 27-year-old patient with a T2–L2 fusion,
and 1 for symptomatic pseudarthrosis in a 23-year-old pa-
tient with a T9–L4 fusion).
Radiographically, patients had significant improve-
ments in the major coronal curve angle (from 43° to 17°, p
< 0.001; Table 3). There were no corresponding significant
differences in the sagittal vertical axis, lumbar lordosis,
pelvic tilt, or thoracic kyphosis in this patient cohort. We
saw no difference in the amount of coronal correction at-
tained across the age range treated (p = 0.46; Fig. 2). We
attempted a subgroup analysis to compare patients with
primarily thoracic curves (Lenke type 1 to 4) to those with
thoracolumbar curves (Lenke type 5 and 6) but saw no
differences for age, sex, BMI, length of stay, operative du-
ration, number of treated levels, or number of osteotomies
(all p > 0.05).
Discussion
As AIS patients present much later in adulthood, the
decision to perform deformity correction is often influ-
enced more directly by neurological compromise or other
degenerative condition progression. That is, these patients
tend to present with symptoms associated with spondylo-
sis, stenosis, degenerative progression of their deformity
(coronal and sagittal), and decompensation. Therefore,
despite the increasing surgical risks associated with an ad-
vanced age, surgical decision-making in this older popu-
TABLE 3. Radiographic outcomes of surgical treatment for
idiopathic scoliosis in 28 YAdISs
Surgical Data Preop Last FU
Coronal
  Max curve angle in ° 43 ± 12 17 ± 8
Sagittal
  SVA in mm 4 ± 31 6 ± 32
  Lumbar lordosis in ° 37 ± 18 35 ± 25
  Pelvic tilt in ° 14 ± 8 15 ± 8
  Thoracic kyphosis in ° 38 ± 18 35 ± 10
FU = follow-up; SVA = sagittal vertical axis.
Values are expressed as mean ± standard deviation, unless indicated other-
wise. Boldface type indicates statistical significance.
FIG. 2. Graph showing the amount of coronal correction obtained as
measured by % change in major scoliosis angle against patient age. No
statistical correlation was noted (p = 0.46).
lation is often more straightforward. In contradistinction,
these decisions are more challenging in YAdISs who are
younger than 40 years of age, as they may present with
less compelling indications for surgery, such as chronic
refractory pain, curve progression, or dissatisfaction with
their appearance (Fig. 3).
When treating AIS patients, the goal is typically to
keep curves from progressing while patients approach
skeletal maturity, through close follow-up and bracing.17
Nonoperative measures that allow the slowing of disease
advancement are thus thought to be successful if they
make surgical intervention unnecessary. While many of
these patients go on to prosper in adulthood, a portion of
them experience chronic pain, likely at a higher rate than
the nonscoliotic population.7 In this study, we examined
the clinical and radiographic outcomes of scoliosis correc-
tion in YAdISs who had not been surgically treated during
adolescence. While many historical articles have included
some of these patients in their cohorts of adult idiopathic
scoliosis patients, most are significantly outdated and few
consider these patients to be a population distinct from
older idiopathic scoliosis patients, despite known differ-
ences in presentation and surgical outcomes across the
various age ranges treated.12,13,18,19
In our series, we specifically limited inclusion to pa-
tients who were 18–40 years of age. The mean preopera-
p Value tive curve angle was only 43°, which is smaller than the
angle typically defined in the AIS world to indicate a need
for surgery. We believe this reflects the self-selection of
<0.001 patients who had curves too small to require surgery as
adolescents but large enough to become symptomatic in
0.29 early adulthood. Nearly all patients presented with refrac-
tory back pain, and a significant number demonstrated
0.58
concomitant adult progression of their scoliosis and/or
0.07 dissatisfaction with their appearance. It is important to
0.11 note that while we made the assumption that these patients
had idiopathic curves, we did not have radiographs from
adolescence for every patient to disprove the unlikely pos-
sibility that their curves developed de novo in young adult-

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Walker et al.

FIG. 3. Imaging studies obtained in a 32-year-old female patient treated for severe back pain, with a primary thoracic angle
measuring 60°. Pre- and postoperative anteroposterior (A) and lateral (B) radiographs demonstrating a significant improvement in
deformity. Associated clinical improvements were seen in this patient.

hood. That said, we believed that it was safe to assume that
in this group of patients under 40 years old, the likelihood
of degenerative de novo scoliosis would be incredibly rare.
In Takahashi and colleagues’ study examining age-related
differences for adult idiopathic scoliosis patients, those
over 50 were much more likely to present with significant
back pain, perhaps as a result of superimposed degenera-
tive changes.12 This older cohort also had more significant
improvement in their back pain symptoms despite gener-
ally less significant radiographic corrections. Altogether,
we believe that this older group represents a very different
population of scoliosis patients than that in our series, as
the superimposed degenerative changes in this age group,
particularly in the lower lumbar spinal segments, com-
posed most of the pathology.
Among our patients, we found surgical correction to
come with a lower risk of complications than that reported
in large ASD series.20 This makes sense given the rela-
tively young age of our patients, absence of three-column
osteotomies, and nonrevision nature of the group being
evaluated. We saw significant clinical improvements in
patients’ ODI, VAS for back and leg pain, and SRS self-
image scores. Only a minority of patients (n = 9) had
clinically significant leg pain preoperatively, and 7 (78%)
attained the MCID in improvement of their symptoms.
While we saw a more pronounced percentage of improve-
ment in VAS back pain than in the ODI, this finding is
not entirely unexpected, as this patient population is rela-
tively resilient because of their age and may not manifest
disability symptoms as readily as older adults despite the
dramatic effect that their pain may have on their overall
quality of life. While we did not have a direct compari-
son cohort in this study, we can look at how our results
compare to historical controls of surgically treated AIS
and ASD patients, 61% and 64% of whom obtained the
MCID in pain scores, respectively.21,22 The 67% mark in
our sample appears similar to these other patient groups.
Given our study findings, we believe that in appropri-
ately selected individuals, surgical intervention in young
adulthood is highly effective and relatively low risk com-
pared to waiting until later in life. Moreover, in our expe-
rience, earlier intervention allows a chance to intervene
while curves are still relatively mobile, thereby requiring
fewer fused levels and osteotomies. Nevertheless, one
must consider that fusion early in life may result in an
added risk of adjacent-segment degeneration that could
increase the need for more surgeries at a later stage. The
long-term downsides of surgery must be weighed against
the immediate surgical need and should only be consid-
ered in individuals who have severe, refractory pain that
has failed significant attempts at conservative therapy and/
or those with marked evidence of curve progression into
adulthood.
In our analysis, we saw no differences in the amount
of coronal correction obtained in the major curve angle
across the ages treated. It has been demonstrated in several
studies that corrections in YAdISs are more difficult than
those in AIS patients.10,11,14 Similarly, older patients tend to
be stiffer than younger patients with idiopathic scoliosis.9
Therefore, either our study was not sufficiently powered to

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detect a change among this age range of patients or the dif-
ference in flexibility among skeletally mature young adults
was radiographically insignificant. We do not perform any
routine screening or preoperative diagnostic testing, such
as bone density assessments in these patients, but poten-
tially age-related changes in bone density may account for
differences in correction as well.
The limitations of this study lie largely in the retrospec-
tive nature of the clinical evaluation. While we were able
to retrospectively determine from clinic notes the indica-
tions for surgery based on recorded patient complaints and
physician documentation, we did not have consistent ac-
cess to old imaging studies to make reliable assessments of
the magnitude of curve progression over time. Moreover, it
was difficult to determine the exact relative contributions
of each complaint and how that impacted the decision to
perform surgery. Study conclusions were certainly limited
by the small sample size of the pertinent population being
followed. Further, as patients in this series were identified
on the basis of their enrollment in our surgical database,
we had no way of quantifying the rate of YAdISs who later
needed surgery. It may be valuable in future prospective
studies of AIS patients successfully treated with bracing
and without surgery to follow them into adulthood and de-
termine which of them later undergo surgical treatment.
Successful identification of these patients during adoles-
cence may allow for treatment while their curves remain
maximally flexible so that they require the lowest number
of levels in their surgical fusion.11
Conclusions
YAdISs, aged 18 to 40 years, who were successfully
treated nonoperatively during adolescence may require
surgical correction of their scoliosis in early adulthood
because of refractory symptoms. In our study, we exam-
ined the clinical and radiographic outcomes in this spe-
cific set of patients. Surgical intervention resulted in a low
complication rate, in fact much lower than that reported in
the ASD literature. Moreover, patients had clinically sig-
nificant improvements in HRQOL as well as radiographic
measures. No significant differences in the amount of
coronal correction were noted across the age range of our
patients. In summary, we believe that this unique popula-
tion should be identified by spinal deformity surgeons for
their special clinical presentation and should be consid-
ered strong surgical candidates if their symptoms remain
refractory to conservative treatment modalities.
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Disclosures
Dr. Agarwal reports royalties from Thieme Medical Publishers
and Springer International Publishing. Dr. Eastlack reports con-
sulting for and stock, royalties, and fellowship/research support
J Neurosurg Spine  Volume 38 • January 2023 89
Walker et al.
from NuVasive Inc.; royalties from and consulting for SI Bone;
board participation and consulting for Stryker; royalties from
Globus; royalties from and board participation and consulting
for Aesculap; consulting for and stock, royalties, and fellowship/
research support from SeaSpine; stock from Alphatec; consult-
ing for Carevature; stock from and board participation for Spine
Innovation; speakers bureau for Radius; consulting for and
research support from Medtronic; and consulting for ControlRad
and Spinal Elements. Dr. Mundis reports royalties from and con-
sulting for NuVasive; consulting or Stryker, Viseon, Carlsmed,
SI Bone, and SeaSpine; and a patent with Stryker. Dr. Akbarnia
reports royalties from and consulting for NuVasive Inc.; royalties
from DePuy Synthes and Stryker Spine; and stock with NociMed.
Dr. Okonkwo reports royalties from, consulting for, and a patent
with Zimmer Biomet; royalties from and consulting for NuVasive
Inc.; and consulting for Stryker and Siemens Medical.
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Author Contributions
Conception and design: Agarwal, Walker, Eastlack, Okonkwo.
Acquisition of data: Agarwal, Walker, Eastlack, Mundis, Alan,
Iannacone. Analysis and interpretation of data: Agarwal, Walker,
Eastlack, Alan, Okonkwo. Drafting the article: Agarwal, Walker,
Eastlack. Critically revising the article: all authors. Reviewed
submitted version of manuscript: all authors. Administrative/
technical/material support: Eastlack. Study supervision: Eastlack,
Okonkwo.
Correspondence
Robert K. Eastlack: Scripps Clinic, La Jolla, CA. robert.eastlack@
scrippshealth.org.