An In Depth Review of Scoliosis: Treatment of Adolescent Idiopathic Scoliosis

Treatment choice in adolescent idiopathic scoliosis is determined by a complex equation which includes the patient's physiologic (not chronologic) maturity, curve magnitude and location and potential for progression. Thoracic curves are at higher risk for progression than thoracolumbar curves or lumbar curves. Patients whose curves are of consequential magnitude prior to onset of their adolescent growth spurt are at significant risk for curve progression. Treatment options include observation, bracing or surgery. General guidelines include re-evaluation every 4-6 months (often including a PA erect T-L spine radiograph) for patients who are skeletally immature (but still not fully skeletally mature) and have curves less than 25° . In patients who are more skeletally mature with curves less than 45° similar observation should be carried out to assess any evidence of interval change at 6 months.

Brace (orthotic) management of adolescent idiopathic scoliosis is used in children with spinal deformity and curve magnitudes of 25-40° who are skeletally immature and with significant growth remaining. The primary goal of brace management is to stop curve progression. Any amount of curve correction at the end of brace treatment must be considered a "bonus." The orthoses used are usually underarm or higher reaching Milwaukee-type styles (Fig.15). The type of braces and amount of time the braces are worn daily vary according to the orthopaedist's choice (Fig.16).

Figure 15 Brace types

Figure 16 Radiograph of a patient with
AIS undergoing brace treatment

Brace removal for participation in sports is strongly encouraged. An alternative to full-time brace wear is the use of a night time "bending" brace for management of a single curve. The termination of successful brace use is determined by the achievement of skeletal maturation, usually indicated by the patient not having further changes in height (and no curve progression) and evidence of maturity on skeletal radiographs.

Surgery for idiopathic scoliosis is suggested when curve magnitude is 50° or more in either the previously untreated patient or in one who fails brace treatment. Surgery is undertaken with two goals in mind. The primary one is to prevent spine deformity progression and the secondary one is to diminish spinal deformity. The natural history of idiopathic scoliosis during adulthood is one of continued progression if the curves tend to be more than 50° at the end of growth. The surgical procedure most often used to correct idiopathic adolescent scoliosis is a posterior spinal fusion with instrumentation and bone grafting (Fig.17).

Figure 17a Radiograph of patient with AIS (Pre-op)

Figure 17bc Radiograph of patient with AIS (Post-op)

With current instrumentation techniques, post-operative casting and bracing are not required in most idiopathic scoliosis cases. Patients are rapidly ambulatory and usually discharged from hospital within 5-7 days postoperatively with progressive resumption of routine daily activities, including return to school (Fig.18).

Figure 18a Clinical photos of patient with AIS (Pre-op)

Figure 18b Clinical photos of patient with AIS (Post-op)

There is no scientifically documented role for exercises, manipulation or electrical stimulation in the management of scoliosis.