When is treatment indicated in adolescent idiopathic scoliosis?

Updated: Dec 02, 2020
  • Author: Charles T Mehlman, DO, MPH; Chief Editor: Jeffrey A Goldstein, MD  more...
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Answer

Treatment recommendations for adolescent idiopathic scoliosis are driven almost totally by curve magnitude (the only caveat being that brace treatment is thought to be effective only in patients who are still growing). It is thus somewhat ironic to note that stated recommendations urge observation for curves less than 30°, bracing of curves that reach the 30-40° range, and consideration of surgery for curves that exceed 40°. This amounts to a 10° window between observation and major spinal surgery. It is even more ironic to note that 10° is a commonly discussed margin of error for measuring such scoliotic curves.

Additional patient factors may also influence some orthopedic surgeons to brace patients with curves measuring less than 30° or in excess of 40°. For instance, a rapidly progressive curve in a 12-year-old child that suddenly goes from 16º to 26° may easily prompt bracing.

When it comes to surgical considerations, patients with adolescent idiopathic scoliosis may be functionally subdivided into those patients in whom significant anterior spinal growth is a concern and those in whom it is not. This amounts to a quantification of risk of development of the complication known as crankshaft phenomenon. [98] This can have a major impact on the surgical treatment plan in that a child at significant risk for crankshaft phenomenon will require an anterior spinal fusion procedure.

Much effort has been devoted to predicting which patients may suffer from this continued anterior spinal growth that results in progressive angulation and rotation of the spine. [98, 99, 100, 101, 102] In fact, a hierarchy of risk can be constructed in which progressively more precise estimates can be made. In this hierarchy, the presence of a radiographic Risser sign and reaching menarche are somewhat predictive but less so than closure of the triradiate cartilage, and reaching one's peak height velocity is perhaps the most powerful predictor of being at rather low risk for the crankshaft phenomenon.


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