Scoliosis is often defined as an abnormal curvature of the spine in the coronal plane accompanied by a variable degree of rotation.
If a child is finished growing and the spine does not curve a lot, treatment is usually not needed.
If a child is not finished growing, the Cobb angle determines subsequent management.
The main options for treatment of idiopathic adolescent scoliosis include observation, bracing, and surgery as following:
Cobb angle 10 degrees or less:
no follow-up other than routine screening at well-child visits is needed.
such a small curve is common and has no clinical significance.
We recommend observation for patients with Cobb angles of less than 25°.
Patients are followed clinically every 6 to 9 months until skeletal maturity.
we suggest exercises to strengthen the back.
Although evidence for the efficacy of scoliosis-specific exercise therapy is limited, it is unlikely to be harmful.
If follow-up radiographs are obtained and the Cobb angle has progressed by more than 5°
or the curvature measures more than 25°,
bracing may be indicated.
Bracing is only effective for flexible deformity in skeletally immature patient.
Bracing does not correct curvature that is present at the time of diagnosis.
but reduces the risk of curve progression to more than45° at skeletal maturity,
the usual threshold for surgery.
The efficacy of bracing is directly related to the number of hours per day that the brace is worn.
We instruct the patient to wear the brace 18 hours per day,
acknowledging that 13 hours may be adequate.
Most curves can be managed with an underarm thoraco-lumbar-sacral brace,
also known as the Boston brace.
it is relatively easy to hide the brace under clothing and fairly well accepted by most patients.
Other types of braces include:
the Charleston brace,
and the Providence brace, which are designed to be worn only at night.
and Milwaukee brace,
Many sports can be played while wearing the brace,
but it may be removed for sports that cannot be performed while wearing it, such as swimming or gymnastics.
Patients should be seen shortly after the first fitting for a radiograph in the brace to make sure that the brace fits appropriately.
A properly fitting brace will improve the Cobb angle while the brace is being worn.
We monitor patients who are braced clinically and radiographically every 5 to 6 months until skeletal maturity.
brace fit have to be assessed and radiographs (in and out of brace) should be obtained to assess curve progression.
The family needs to understand that the in-brace correction is only transitory while the brace is being worn
and the Cobb angle will return to the original curve magnitude (assuming no progression) with subsequent out-of-brace radiographs.
Surgical correction may be indicated if the curve progresses to more than 45° despite bracing
or if the curve progresses rapidly (more than 10° in one year).
The primary goal of surgical treatment is prevention of curve progression.
Secondary goals include curve correction and improving quality of life.
Procedures for correction of scoliosis involve growth modulation techniques.
these techniques include vertebral body tethering
and unilateral periapical distraction.
These techniques preserve motion, and do not preclude spinal fusion if they are unsuccessful.
Vertebral body tethering devices are intended to gradually correct scoliosis by slowing growth on the convex side of the curve.
vertebral body tethering appears to be safe,
though overcorrection is a concern.
Unilateral periapical distraction implant.
This device is implanted on the concave side of the curve.
it corrects the deformity through incremental ratchet lengthening that is activated by exercise.
Posterior spinal fusion is the most common surgical procedure for idiopathic adolescent scoliosis.
During this surgery, the spine is straightened with rigid rods,
followed by spinal fusion and bone grafting which creates a solid union between two or more vertebrae.
The metal rods attached to the spine ensure that the backbone remains straight while the spinal fusion takes effect.
Although a large percentage of scoliosis patients benefit from surgery,
there is no guarantee that surgery will stop curve progression and symptoms in every individual.
Postoperative care
Neurologic function must be monitored closely for 48 hours after surgery because delayed neurologic injury may occur.
most patients are released within a week of surgery and do not require post-surgical bracing.
most patients are able to return to school or work in two to four weeks post-surgery,
and are able to resume all pre-surgical activities within 4 to 6 months.
Once the spine has fused, all sports are permitted
with the possible exception of collision sports such as football or hockey.
Routine removal of spinal implants used in correction of scoliosis is not usually performed.
MRI studies can be safely performed following spinal instrumentation for scoliosis.