Adolescent Idiopathic Scoliosis: Management and Prognosis

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Adolescent idiopathic scoliosis: Management and prognosis
Author: Susan A Scherl, MD

Section Editor: William Phillips, MD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2018. | This topic last updated: Mar 14, 2018.
INTRODUCTION — Scoliosis, lateral curvature of the spine, is a structural alteration that occurs in a variety of
conditions. Progression of the curvature during periods of rapid growth can result in significant deformity, which
may be accompanied by cardiopulmonary compromise.
The treatment and prognosis of adolescent idiopathic scoliosis (AIS) will be reviewed here. The clinical features,
diagnosis, and initial evaluation are discussed separately. (See "Adolescent idiopathic scoliosis: Clinical features,
evaluation, and diagnosis".)
TERMINOLOGY — AIS is scoliosis with Cobb angle ≥10° (image 1), age of onset ≥10 years, and no underlying
etiology (eg, congenital, neuromuscular, syndromic). (See "Adolescent idiopathic scoliosis: Clinical features,
evaluation, and diagnosis".)
RISK FOR PROGRESSION — The risk for progression of AIS has implications for management. However, it is
impossible to predict with complete accuracy which curves will progress and which will not [1].
Clinical predictors — Curves progress in approximately two-thirds of skeletally immature patients before they
reach skeletal maturity [1,2]. Natural history studies indicate that the magnitude of progression is increased in:
● Patients <12 years [3]
● Girls compared with boys [3,4]
● Premenarchal compared with postmenarchal girls [5]
● Curves with initial Cobb angle ≥20°, independent of age [6-9]
● Double and thoracic curves compared with nonthoracic curves [1,3,9,10]
● Risser grade 0 or 1 (figure 1) compared with Risser grade ≥2 [9]
In a review of 123 skeletally immature patients (mean age 14 years) with idiopathic scoliosis and Cobb angles
<50° who were followed without treatment until skeletal maturity, the average curve measured 33° (range 10 to
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49°) at the time of diagnosis and 49° (range 12 to 97°) at skeletal maturity [2]. The curves progressed by:
● <5° in 32 percent
● ≥5° in 68 percent
● >10° in 34 percent
● >20° in 18 percent
● >30° in only 8 percent
Genetic testing — We do not use genetic testing (ie, the AIS prognostic test [AIS-PT], marketed as ScoliScore)
to assess the risk for scoliosis progression. AIS is a complex disorder that appears to result from the interaction
of multiple genetic loci and the environment, but the details of these interactions are not fully understood [11].
The AIS-PT is expensive (approximately $2950), and results are applicable only to certain Caucasian patients
[12]. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Etiology'.)
The AIS-PT is an algorithm developed to predict the risk of scoliosis progression to a Cobb angle >40° in
skeletally immature Caucasian adolescents age 9 to 13 years who present with a Cobb angle between 10 and
25° [13]. It neither confirms nor refutes the diagnosis of AIS. The algorithm incorporates the initial Cobb angle
and saliva-based DNA testing for 53 genetic markers of severe scoliosis progression. The genetic markers were
identified in as yet unpublished case-control genome-wide association studies [12].
In an independent cohort of 91 patients whose risk of progression was assessed clinically (including Cobb angle
and Risser sign) and with the AIS-PT, the risk stratification varied according to the method of assessment, with
clinical assessment categorizing more patients as high-risk (47 versus 9 percent) and AIS-PT categorizing more
patients as low risk (36 versus 2 percent) [14]. This suggests that the AIS-PT may differ from traditional clinical
predictors in determining the risk of progression. However, the cohort was not followed longitudinally to
determine the validity of risk categorization.
The AIS-PT was independently evaluated in a retrospective review of 126 Caucasian patients with AIS and Cobb
angle between 10 and 25° who underwent AIS-PT testing and were followed clinically and radiographically to
skeletal maturity [15]. Mean AIS-PT scores did not differ between patients with and without curve progression to
>40° or spinal fusion; nor was there a difference in curve progression between patients with high-risk and low-
risk AIS-PT scores. Independent studies in other populations have also failed to replicate the association
between the genetic markers used in the AIS-PT and curve progression [16,17].
Lack of validation of the AIS-PT in independent cohorts may be related to differences in the test population,
genetic variability [18], or loss to follow-up of patients with nonprogressive scoliosis [15,19]. Until these issues
are resolved, we continue to use clinical predictors rather than the AIS-PT to predict the risk for progression in
patients with AIS.
INDICATIONS FOR REFERRAL — Indications for referral to an orthopedic surgeon for patients with AIS vary
geographically. Our suggested indications for referral to an orthopedic surgeon include [20-22]:
● Angle of trunk rotation (ATR), as measured with the scoliometer, of ≥7° in patients with body mass index
th th
(BMI) <85th percentile or ATR ≥5° in patients with BMI ≥85th percentile
● Cobb angle between 20 and 29° in premenarchal girls or boys age 12 to 14 years
● Cobb angle >30° in any patient
● Progression of Cobb angle of ≥5° in any patient
Adolescents with idiopathic scoliosis and low risk for progression (eg, postmenarchal girls; boys age ≥15 years)
may be followed by their primary care provider if the provider is comfortable doing so. However, referral to an
orthopedic surgeon may be warranted if the patient or parents have questions that are beyond the scope of the
primary care provider.
At the time of referral, it is important to specify whether the curve was measured by Cobb angle or scoliometer
because the two measures are not directly equivalent. (See "Adolescent idiopathic scoliosis: Clinical features,
evaluation, and diagnosis", section on 'Use of a scoliometer' and "Adolescent idiopathic scoliosis: Clinical
features, evaluation, and diagnosis", section on 'Cobb angle'.)
MANAGEMENT — The goal of the treatment is a curve with a Cobb angle of <40° at skeletal maturity. Natural
history studies indicate that curves <40° do not progress after skeletal maturity [6,23-26]. Options for treatment of
AIS include observation, bracing, and surgery [1,10,27,28]. Physical therapy or exercise programs such as
Schroth exercises have been increasing in popularity, but the evidence for their efficacy is limited [29].
Management is individualized according to the magnitude of the curve (Cobb angle or scoliometer
measurement), remaining growth potential, best estimate of risk for progression, and patient and family
preferences. Individual patients and families may place a different value on the potential risks and benefits of the
various treatment options [30]. Our approach is described below. Other centers may use different thresholds for
bracing or surgery.
The margin of errors for the angle of trunk rotation (ATR) and Cobb angle are factored in to the thresholds for
intervention described below.
Substantial growth remaining — We use the Risser sign (figure 1) to estimate remaining growth potential in
children with AIS if they have had posteroanterior (PA) spine radiographs. Children at Risser grade 0 to 2 have
substantial growth remaining.
For patients who have not had PA spine radiographs or in whom the Risser sign cannot be determined due to the
radiographic technique, remaining growth potential can be estimated by a combination of chronologic age, height
velocity, and sexual maturity rating (Tanner stage). Some also use hand radiographs to help determine skeletal
maturity and growth remaining [31,32]. Patients with substantial growth remaining generally are younger than 12
years, have not undergone their pubertal growth spurt, and have sexual maturity rating ≤2 (figure 2A-B). (See
'Clinical predictors' above and "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis",
section on 'Other methods'.)
Normal ATR rotation — Patients with normal ATR as measured with a scoliometer (picture 1) can be
followed clinically approximately every six months [33]. For patients with body mass index (BMI) <85th percentile,
th
we consider <7° to be the normal ATR. For patients with BMI ≥85th percentile, we consider <5° to be the normal
ATR. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Use of a
scoliometer'.)
Scoliosis radiographs (standing, full-length PA and lateral views of the spine [C7 to the sacrum and iliac crest])
should be obtained if the ATR increases to ≥7° in patients with BMI <85th percentile or if the ATR increases to
≥5° in patients with BMI ≥85th percentile. The Cobb angle determines subsequent management, as described in
the sections that follow. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis",
section on 'Radiographic evaluation'.)
Cobb angle <10 degrees — Curves with Cobb angle <10° do not meet the Scoliosis Research Society's
definition of scoliosis (curves with Cobb angle ≥10°). The family should be told that such a small curve is
common and has no clinical significance; no follow-up other than routine screening at well-child visits is needed.
Repeat imaging is not indicated unless there is clinical progression of the curve or significant pain (pain that
limits activities or requires frequent analgesia).
Cobb angle 10 to 19 degrees — We recommend observation for patients with Cobb angles of <20° and
Risser grade 0 to 2. Patients are followed clinically every six to nine months until skeletal maturity (six months for
younger children with more growth remaining; nine months for older children with less growth remaining). Curves
<20° may progress approximately one degree per month during the adolescent growth spurt [34]. In a natural
history study, among skeletally immature patients with a Cobb angle between 5 and 19°, the risk for progression
(defined by increase of ≥10° with final curve ≥20°) was 22 percent if the Risser grade was ≤1 at the time of
presentation and approximately 2 percent if the Risser grade was ≥2 [9].
Decisions about radiographs in such patients are made on a case-by-case basis. The limited added benefit of
serial radiographs for observation of small curves must be balanced against the cost and cumulative radiation
exposure. We obtain follow-up radiographs if there is an increase in the scoliometer reading or worsening clinical
appearance of the curve.
If ordered, follow-up radiographs should include standing, full-length PA views of the spine [35]. The lateral view
need not be repeated if the initial radiograph demonstrated the normal configuration of thoracic kyphosis and
lumbar lordosis. (See "Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on
'Radiographic evaluation'.)
If follow-up radiographs are obtained and the Cobb angle has progressed by ≥5° or measures ≥20°, bracing may
be indicated, and a referral to an orthopedic surgeon should be made. (See 'Bracing' below.)
Cobb angle 20 to 29 degrees — We suggest initial observation for patients with Cobb angles of 20° to 29°
and Risser grade 0 to 2. However, some patients and families may choose bracing as initial therapy [36].
Observed patients are followed clinically and often radiographically every five to six months until skeletal maturity
(five months for younger children with more growth remaining; six months for older children with less growth
remaining). Bracing may be indicated if the Cobb angle increases by ≥5° over a three- to six-month period. In a
natural history study, among skeletally immature patients with a Cobb angle 20 to 29°, the risk of progression of
≥5° was 68 percent if the Risser grade was ≤1 and 23 percent if the Risser grade was ≥2 [9].
Initial observation for skeletally immature patients with AIS and Cobb angle 20 to 29° is supported by the
multicenter Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), which compared thoraco-lumbar-sacral
orthosis and observation in skeletally immature adolescents (10 to 15 years) with Cobb angle 20 to 40° [36].
Treatment success (defined by Cobb angle <50° at skeletal maturity) was achieved in 40 to 50 percent of
patients assigned to observation or who wore their brace ≤6 hours per day [36].
Cobb angle 30 to 39 degrees — We suggest bracing for patients with Cobb angles of 30 to 39° and Risser
grade 0 to 2. We monitor patients who are braced clinically and radiographically every six months until skeletal
maturity (Risser grade 4 in girls; Risser grade 5 in boys). Surgical correction may be indicated if the curve
progresses to ≥50° despite bracing or if the curve progresses rapidly (≥10° in one year).
Bracing does not correct curvature that is present at the time of diagnosis [37-39] but reduces the risk of curve
progression to >50°at skeletal maturity (the usual threshold for surgery) [36]. The efficacy of bracing is directly
related to the number of hours per day that the brace is worn. (See 'Bracing' below.)
In the multicenter BrAIST study, which compared thoraco-lumbar-sacral orthosis wear and observation in
skeletally immature adolescents (10 to 15 years) with Cobb angle 20 to 40°, more adolescents treated with
bracing had Cobb angle <50° at skeletal maturity (72 versus 48 percent, odds ratio [OR], adjusted for nonrandom
assignment 1.9, 95% CI 1.1-3.5) [36]. The proportion of patients who had Cobb angle <50° at skeletal maturity
increased with increasing duration of brace wear (93 percent among those averaging ≥12.9 hours/day versus 41
percent among those averaging ≤6 hours/day). Other types of braces, such as night time bending braces (eg,
Charleston, Providence, etc) or strapping systems (eg, SpineCor) were not used in the BrAIST study and remain
of unproven efficacy.
Cobb angle 40 to 49 degrees — We suggest either bracing or surgery for patients with substantial growth
remaining (Risser grade 0 to 2) and Cobb angles between 40 and 50° at the time of presentation. We monitor
patients who are braced clinically and radiographically every six months until skeletal maturity (Risser grade 4 to
5 for girls; Risser grade 5 for boys). Surgical correction may be indicated if the curve progresses to ≥50° despite
bracing (See 'Bracing' below and 'Surgery' below.)
Little growth remaining — Patients at Risser grade 3 (figure 1) have little growth remaining and are not
candidates for bracing. Management depends upon the magnitude of the curve at the time of presentation.
We suggest that patients at Risser grade 3 and Cobb angle <40° be followed yearly until one year after skeletal
maturity. For these patients, we determine skeletal maturity clinically: two years after menarche for girls; shaving
every day (or need to shave every day) for boys.
We suggest observation for patients at Risser grade 3 and Cobb angle 40 to 49° at the time of presentation.
Such patients are near the threshold for surgery but are not candidates for bracing. We follow them with
radiographs every six to nine months until at least one year after skeletal maturity (Risser grade 4 in girls, Risser
grade 5 in boys). If the curve progresses to 50° before full skeletal maturity, surgery is indicated. In consultation
with their orthopedic surgeon, some patients may opt for earlier surgery.
Skeletally mature patients — Skeletal maturity is defined by Risser grade 4 in girls and Risser grade 5 in boys.
Cobb angle <40 degrees — Skeletally mature patients with AIS and Cobb angle <40° can be reassured and
discharged from care. They do not need regular follow-up because their curves are not likely to progress. (See
'Outcome' below.)
Cobb angle 40 to 49 degrees — Skeletally mature patients with AIS and Cobb angle 40° to 49° are
assessed and managed on an individual basis according to patient preferences. Factors to be considered in the
decision include the benefits and risks of spine surgery and the patient's concerns about appearance, risk of
progression in adulthood (typically 1° per year), and back pain in adulthood.
Cobb angle ≥50 degrees — Surgery should be discussed for patients with Cobb angles ≥50° at the time of
presentation or later, regardless of skeletal maturity. (See 'Surgery' below.)
Curves with Cobb angles ≥50° at skeletal maturity may progress approximately one degree per year after
cessation of growth [6]. Over 30 years, such curves may progress to Cobb angles >80°. Thoracic curves with
Cobb angle ≥70° have been associated with compromised pulmonary function [24,40]. (See 'Outcome' below.)
TREATMENT MODALITIES — Options for treatment include observation, bracing, and surgery [1,10,27,28].
There is a lack of high-quality evidence from randomized trials that physical therapy (scoliosis-specific
exercises), chiropractic treatment, electrical stimulation, or biofeedback is effective [41-43].
Observation — Observation is recommended for patients with AIS and Cobb angle <20° and is an option for
patients with Cobb angle between 20 and 40°. Patients who are observed are followed clinically and/or
radiographically until skeletal maturity or curve progression that requires bracing or surgery. The frequency of
clinical and radiographic follow-up depends upon the severity of scoliosis and remaining growth potential. (See
'Substantial growth remaining' above.)
Bracing — In skeletally immature patients with AIS, bracing reduces the risk of curve progression to ≥50° (the
usual threshold for surgery) at skeletal maturity [36,44,45]. The efficacy of bracing is directly related to the
number of hours per day that the brace is worn.
We suggest bracing for skeletally immature patients (Risser sign 0 to 2) whose Cobb angle is 30 to 39° at the
time of presentation and skeletally immature patients whose Cobb angle is between 20 and 29° and progresses
≥5° over any six- to nine-month period during observation.
Bracing also is an option for skeletally immature patients with Cobb angle between 20 to 29° or 40 to 49° who
choose bracing over observation or surgery, respectively.
In the multicenter Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), which compared thoraco-lumbar-
sacral orthosis and observation in skeletally immature adolescents (10 to 15 years) with Cobb angle 20 to 40°,
more adolescents treated with bracing had Cobb angle <50° at skeletal maturity (72 versus 48 percent, odds
ratio [OR], adjusted for nonrandom assignment 1.9, 95% CI 1.1-3.5) [36]. The proportion of patients who had
Cobb angle <50° at skeletal maturity increased with increasing duration of brace wear (93 percent among those
averaging ≥12.9 hours/day versus 41 percent among those averaging ≤6 hours/day).
The rate of brace failure appears to be increased in patients at Risser stage 0 (particularly those with open
triradiate cartilage) and in patients with thoracic curves [46,47]. In an observational study of 168 patients who
were treated with braces for AIS with Cobb angles of 25 to 45°, the rate of brace failure (ie, surgery or curve
progression to ≥50°) was 44 percent in 120 patients at Risser stage 0, 7 percent in 29 patients at Risser stage 1,
and 0 percent in 19 patients at Risser stage 2 [47]. The rate of brace failure was 34 percent in patients with
thoracic curves and 15 percent in those with lumbar curves [46].
● Contraindications – Contraindications to bracing include:
• Little growth remaining or skeletal maturity (Risser grade 3 to 5 and fusion of the vertebral ring
apophyses)
• Cobb angle ≥50°
• Cobb angle <20°
Thoracic lordosis is a relative contraindication [48]. Some authors maintain that thoracic lordosis is a
component of all structural scolioses [49].
● Types – Most curves can be managed with an underarm brace (a thoraco-lumbar-sacral orthosis [TLSO],
also known as the Boston brace) (picture 2). The TLSO is relatively easy to hide under clothing and fairly
well accepted by most patients. Other types of underarm braces include the Charleston brace and the
Providence brace, which are designed to be worn only at night [50-53]. A nonrigid brace (SpineCor), which
consists of a series of straps, is also available [54]. Data regarding the efficacy of the different types of
braces are mixed; differing inclusion criteria preclude direct comparisons [55-57].
A small percentage of curves require a brace with an under-chin extension (a cervico-thoraco-lumbar-sacral

orthosis [CTLSO], also known as the Milwaukee brace). The CTLSO is more difficult to hide under clothes
and less well-tolerated by patients. Indications for CTLSO bracing include thoracic curve with apex at or
above T8, and double thoracic curves (high-left and lower-right thoracic curve pattern and right thoracic/left
thoracolumbar pattern) [10].
● Patient instructions – We instruct the patient to wear the brace 18 hours per day, acknowledging that 13
hours may be adequate. Many sports can be played while wearing the brace, but it may be removed for
sports that cannot be performed while wearing it (eg, swimming, gymnastics). In the past, wearing the brace
23 hours per day was recommended. However, in the BrAIST trial, 93 percent of patients who wore their
brace an average of ≥12.9 hours per day had a successful outcome (ie, Cobb angle <50° at skeletal
maturity) [36].
Adherence to brace wear can be monitored with temperature or pressure sensors embedded in the brace.
Several studies demonstrate that patients may not adhere to the bracing schedule and patient-reported
brace wear may be overestimated [36,58-60]. In observational studies that monitored adherence (eg, with a
temperature sensor), braces were worn for an average of 65 percent of the prescribed hours [58,59].
Awareness of monitoring and counseling may increase adherence [61]. In a small randomized trial,
adherence to an 18-hour schedule was greater among patients who were told that their adherence was
being monitored with a temperature sensor than among those who were not told (85.7 percent versus 56.5
percent) [62].
● Monitoring – Patients who are treated with braces should be seen immediately after the first fitting to make
sure that the brace fits appropriately [27]. The author of this topic review typically obtains the first in-brace
radiograph to determine curve-correction after four weeks, but there is no accepted standard. Some
surgeons prefer to get the initial in-brace radiograph within a few days of the first fitting. Patients whose in-
brace Cobb angle is at least 20 percent lower than the prebrace Cobb angle measurement have an
increased chance of successful bracing [63].
After the initial in-brace radiograph, we monitor brace treatment clinically and radiographically every six
months. During these visits, brace fit should be assessed and radiographs (in or out of brace) should be
obtained to assess curve progression [27]. There is no consensus on the best way to monitor the scoliosis in
patients wearing a brace. The BrAIST study obtained radiographs in the brace. If obtaining out-of-brace
radiographs, we generally ask the patient to remove the brace the night before the study, but there is no
accepted standard. In a small observational study, maximum change in Cobb angle was achieved after at
least 120 minutes out of the brace [64]. Progression of the Cobb angle of ≥5° despite adequate bracing is a
poor prognostic sign that surgery may be necessary. If documented curve progression is observed, the
brace should be carefully assessed to be sure it still fits properly, and adherence to the bracing schedule
should be confirmed. (See 'Surgery' below.)
● Discontinuation – Brace use should be continued until the end of growth, typically one to two years
postmenarche with a Risser grade 4 to 5 for girls and until a Risser grade 5 for boys. Some practitioners
wean brace usage to nighttime (sleeping) only, and some simply discontinue it. The author of this topic
review suggests that her patients wean brace use over six months. However, patients often discontinue use
on their own.
Patients typically have clinical and radiologic follow-up six months after discontinuation of the brace and
then yearly for several years. There is often a several-degree increase of the curve in the months just
following discontinuation of the brace, which quickly stabilizes. However, if the Cobb angle progresses to
≥50° surgery may be warranted.
● Adverse effects – Adverse effects of bracing may include psychosocial effects (eg, diminished self-esteem,
disturbed peer relationships), skin irritation, disturbed sleep, restriction of physical and recreational activities,
and difficulty finding clothes that fit properly [29,65-67]. Studies demonstrating the frequency of these effects
are lacking [66]. There is a single case report of compressive injury to the dorsal scapular nerve resulting in
scapular winging in 15-year-old girl after incorrect use of a thoracolumbar orthosis [68].
Surgery — The primary goal of surgical treatment of AIS is prevention of curve progression through spinal
fusion, but there is limited evidence regarding this outcome. Successful fusion occurs in approximately >95
percent of cases [69,70].
Secondary goals include curve correction and improved quality of life. In a meta-analysis, the average coronal
curve correction ranged from 48 to 67 percent with posterior instrumentation and 71 to 93 percent with anterior
instrumentation [71]. In a multicenter study of the outcomes of surgical treatment, patients reported improved
self-image, function, and level of activity on validated measures two years after surgery for AIS [72].
● Indications – Surgical correction is indicated for skeletally immature patients with curves with Cobb angle
≥50° and some skeletally immature patients with Cobb angle between 40 and 50°. Surgical correction also is
an option for skeletally mature patients with Cobb angle ≥50°. Surgery also may be warranted for patients
with lumbar curves with marked trunk shift. (See 'Cobb angle ≥50 degrees' above and 'Cobb angle 40 to 49
degrees' above.)
● Procedures – Procedures for correction of scoliosis involve spinal fusion, which may be performed
posteriorly or anteriorly. Achieving bony fusion is the most important aspect of surgery, and either autograft
or allograft may be used [73]. The off-label use of bone morphogenic protein (a group of purified proteins
that stimulate bone growth) rather than autograft or allograft is not routinely indicated.
• Posterior spinal fusion and instrumentation and bone grafting – Posterior spinal fusion (PSF) with
instrumentation and bone grafting is the most common surgical procedure for AIS. In older patients with
very stiff curves, it is sometimes necessary to release the anterior intervertebral soft tissues before PSF.
This can sometimes be done thoracoscopically [74].
Contemporary implants for PSF are "segmental": a variety of hooks, screws, and wires are used to
attach contoured rods to the spine at multiple vertebrae, or "segments" (image 2). The original implants
for PSF were straight stainless steel rods connected to the cephalad and caudad regions of the spine
with simple hooks (Harrington rods). Segmental instrumentation gives the surgeon greater control over
the position and rotation of the spine [75]. The increased stability of segmental instrumentation permits
early mobilization with ambulation the day after surgery without external support such as a body cast or
brace.
• Anterior spinal fusion and instrumentation – Anterior spinal fusion (ASF) and instrumentation may
be performed for thoracolumbar and lumbar scoliosis. The convex side of the spine is exposed
anteriorly (often with the assistance of a general surgeon) by a thoracotomy and/or retroperitoneal
approach. The curve is corrected by shortening the convex side of the deformity.
The purported advantages of the anterior approach include less blood loss, lower risk of neurologic
injury (because of correction by shortening instead of distraction), and no disturbance of the paraspinal
muscles. Disadvantages include increased complexity and decreased pulmonary function if the thoracic
cavity is entered and/or the diaphragm is opened [76].
With improvements in PSF instrumentation and techniques, there are relatively few indications for
isolated ASF and it is rarely performed [77]. In a retrospective comparison, patients treated with
posterior instrumentation and fusion for lumbar curves had better outcomes and shorter hospital stays
than those treated with anterior instrumentation and fusion [78].
• Thoracoscopic ASF – Anterior instrumentation of the thoracic spine may be performed

thoracoscopically. The potential advantages of video-assisted thoracoscopic ASF over posterior spinal
fusion with thoracic pedicle screws include reduced blood loss, fewer total levels fused, and the
preservation of nearly one caudad fusion level. The disadvantages include increased operative time
and slightly less improvement in pulmonary function [79]. Thorascopic anterior instrumentation is
technically demanding and applicable to a limited number of curves. Its use seems to be decreasing
[80].
• ASF and PSF – In patients with open triradiate cartilages, it is sometimes necessary to perform an
ASF, as well as a PSF, to prevent the "crankshaft phenomenon," in which the anterior spine continues
to grow after the PSF, causing a severe rotational and sagittal alignment deformity [81,82]. However,
there is some evidence to suggest that modern segmental instrumentation systems make anterior
fusion unnecessary [83].
● Pre-op evaluation – The preoperative evaluation for scoliosis surgery includes posteroanterior and lateral
spinal radiographs and pulmonary function tests for patients with curves ≥60°. Lateral bending films for
surgical planning may be obtained at the discretion of the surgeon. Many hospitals require a preoperative
pregnancy testing in menarchal girls or girls beyond a certain age.
● Complications – Complications of surgery include blood loss, infection, implant failure, neurologic injury,
and pseudoarthrosis (failure of fusion). Because of the risk of blood loss, many centers provide appropriate
patients the option of autologous blood donation before surgery. Intraoperative blood salvage ("cell saver")
and antifibrinolytics (epsilon aminocaproic acid and tranexamic acid) are other means to reduce blood
transfusion requirements [84-86]. (See "Red blood cell transfusion in infants and children: Selection of blood
products", section on 'Autologous donations' and "Surgical blood conservation: Blood salvage", section on
'Intraoperative blood salvage' and "Overview of topical hemostatic agents and tissue adhesives", section on
'Hemostatic agents'.)
Neurologic function must be monitored closely for 48 hours after surgery because delayed neurologic injury
may occur [87]. However, modifications in devices, techniques, and intraoperative monitoring have reduced
the risk of catastrophic complications [77,88,89]. In a multicenter prospective study of 1819 patients who
underwent scoliosis surgery between 1995 and 2013, the two-year major complication rate decreased from
approximately 20 to 5 percent between 1995 to 1999 and 2010 to 2013 [77]. Among the 609 patients who
had surgery during 2010 to 2013, 2.1 percent of patients had neurologic injury, 1.5 percent had surgical site
infection, 0.5 percent had instrumentation problems, 0.2 percent had pseudoarthrosis, and 3 percent
required reoperation. In an earlier multicenter study, 73 percent of patients with neurologic complications
recovered completely and 22 percent recovered partially [90].
Long-term surgical complications were described in a retrospective review of patients treated for AIS who
were followed for 22 to 23 years [70]. Among those who underwent surgery, the average curve deterioration
was 3.5°; pseudoarthrosis developed in 1.9 percent and loss of lumbar lordosis in 2.6 percent; 5.1 percent
needed additional surgery related to implants. The risk of these complications is expected to be lower with
contemporary implants.
● Return to activity – Recommendations for resuming sports participation vary by surgeon, from as little as 4
months to 12 months postoperatively [27,91,92]. We suggest approximately six months. Once the spine has
fused, all sports are permitted, with the possible exception of collision sports (eg, football, hockey, rugby).
The reduced motion of the fused spine may make it more difficult to perform activities such as gymnastics
and dancing at a high level.
● Considerations related to implanted metal – Antibiotic prophylaxis prior to dental procedures is not
necessary following instrumentation for scoliosis [93]. Hypersensitivity reactions to metallic spinal implants
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are rare, and there is no consensus on the utility of testing preoperatively [94].
Magnetic resonance imaging studies can be safely performed following spinal instrumentation for scoliosis,
although some artifact is produced. The amount of artifact depends on the composition of the implants;
greater artifact has been noted with stainless steel than with titanium alloys.
LONG-TERM FOLLOW-UP — Follow-up with the orthopedic surgeon typically is scheduled for one to two years
after the onset of skeletal maturity (Risser 4 in girls, Risser 5 in boys), regardless of treatment.
Most skeletally mature individuals with curves with Cobb angle <40° and/or successful spinal fusion do not need
routine follow-up into adulthood. Curves in such patients are unlikely to progress during adulthood.
Skeletally mature patients with curves with Cobb angle 40 to 49° are assessed and managed on an individual
basis (regardless of treatment) according to patient preference. Some patients prefer to be seen every one to
two years; others prefer to be seen only as needed.
We do not obtain serial radiographs for asymptomatic patients following surgical correction of AIS. In a series of
451 consecutive patients who had surgical correction of scoliosis (73 percent with AIS), findings on routine
radiographs rarely altered clinical management in patients who were asymptomatic [95]. However, some
surgeons obtain infrequent follow-up radiographs, typically at the first postoperative visit, then at one and two
year follow-up, and as needed if the patient presents with signs or symptoms indicative of a postoperative
problem.
OUTCOME — Several studies have examined the long-term outcomes of AIS treated with observation, bracing,
or surgery. Because surgical methods have changed over time, the longer-term outcomes for patients treated
surgically reflect procedures/implants that are no longer used. Twenty-year follow-up is available for patients
treated with Harrington rods, but only 5- to 10-year follow-up for patients with segmental instrumentation.
● Curve progression – Scoliosis can continue to progress after skeletal maturity in untreated patients,
particularly in those with curves measuring >40° at the end of growth. Curves >50° generally progress one
degree per year after skeletal maturity. Curves measuring ≤30° at the end of growth typically do not
progress [6,23-26]. In a long-term study, 133 untreated curves in 102 patients were followed for an average
of 40.5 years after skeletal maturity [6]. Two-thirds of the curves progressed, with an average rate of 0.75 to
1 degree per year. Factors related to progression after skeletal maturity included severity of curve at
diagnosis (curves with Cobb angles >30° tended to progress, whereas smaller curves did not) and curve
location (increased risk with thoracic curves).
Curves also may progress after bracing or surgery. In one study, patients who were treated with surgery or
bracing were followed for an average of 22 to 23 years [70]. Average Cobb angle progression for patients
treated with bracing and followed for 22 years was 7.9°. Average Cobb angle progression for patients
treated surgically and followed for 23 years was 3.5°.
● Back pain – Follow-up studies indicate an association between AIS (treated or untreated) and mild or
moderate back pain or degenerative disc changes in adulthood [24,26,70,96-104]. Some of the studies
suggest a correlation between the initial magnitude of the curve and subsequent complaints of back pain
[100,101]. Despite an increased risk of back pain, most patients with AIS have little, if any, functional
limitation in adulthood, and the risk of neuropathy is low [26,50,96,102].
● Psychosocial – Patients with AIS may have increased concerns related to body development and peer
interactions, and decreased perception of health status, even after treatment [100,103,105,106]. In a review
of outcomes 10 years after treatment for AIS, patients had moderately reduced perceived health status and
activities of daily living compared with age-matched controls [100]. The patients treated surgically were less
affected than those treated with bracing. In another study, at an average of 22 years after nonsurgical
treatment for AIS, the perception of handicap was similar between AIS patients and controls [102].
● Pregnancy – Pregnancy does not appear to affect curve progression, nor does scoliosis appear to affect
pregnancy outcome [107-109]. In a study evaluation the effects of pregnancy in 355 patients with scoliosis,
the risk of progression was not affected by the number of pregnancies, age at first pregnancy, or curve
stability [108]. Women with a history of AIS do not appear to have an increased risk of cesarean delivery or
health problems during pregnancy compared with women without AIS [24,108,110].
● Mortality – In long-term follow-up studies of patients with AIS, the mortality rate is not increased compared
with that of the general population [24,96]. Increased mortality from cor pulmonale and right heart failure is
seen only in patients with severe thoracic curves (>90° to 100°) [24,96,111].
● Breast cancer – The risk of breast cancer in women exposed to diagnostic levels of radiation is discussed
separately. (See "Factors that modify breast cancer risk in women", section on 'Exposure to diagnostic
radiation'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries
and regions around the world are provided separately. (See "Society guideline links: Idiopathic scoliosis in
adolescents".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword[s] of interest.)
● Basics topic (see "Patient education: Scoliosis (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Scoliosis is defined as curvature of the spine in the coronal plane (image 3). It is typically accompanied by a
variable degree of rotation of the spinal column. Adolescent idiopathic scoliosis (AIS) is scoliosis with Cobb
angle ≥10° (image 1), age of onset ≥10 years, and no underlying etiology (eg, congenital, neuromuscular,
syndromic). (See 'Terminology' above.)
● Curves progress in approximately two-thirds of skeletally immature patients before the patient reaches
skeletal maturity. The magnitude of progression is increased in patients younger than 12 years, girls
compared with boys, girls who are premenarchal, curves with initial Cobb angle ≥20°, thoracic curves,
double curves, and patients at Risser grade 0 or 1 (figure 1). (See 'Risk for progression' above.)
● Our suggested indications for referral to an orthopedic surgeon for AIS include Cobb angle between 20 and
29° in premenarcheal girls or boys age 12 to 14 years, Cobb angle >30° in any patient, and progression of
Cobb angle ≥5° in any patient. Adolescents with AIS and low risk for progression (ie, postmenarchal girls,
boys older ≥15 years) may be followed by their primary care provider if the provider is comfortable doing so.
(See 'Indications for referral' above.)
● The goal of the treatment of AIS is a curve with a Cobb angle of <40° at skeletal maturity. Options for
treatment include observation, bracing, and surgery. Management is individualized according to the
magnitude of the curve (Cobb angle or scoliometer measurement), remaining growth potential, best
estimate of risk for progression, and patient and family preferences. (See 'Management' above.)
● For patients with Cobb angles of 10 to 19° and Risser grade 0 to 2 at the time of presentation, we
recommend observation (Grade 1A). Patients are followed every six to nine months until skeletal maturity.
Bracing may be indicated if the Cobb angle increases by ≥5° or progresses to ≥20° during observation. (See
'Cobb angle 10 to 19 degrees' above.)
● For patients with Cobb angles of 20 to 29° and Risser grade 0 to 2 at the time of presentation, we suggest
observation (Grade 2B). Patients are followed clinically every five to six months until skeletal maturity.
Bracing may be indicated if the Cobb angle increases by ≥5° over a three- to six-month period. (See 'Cobb
angle 20 to 29 degrees' above.)
● For patients with Cobb angles of 30 to 39° and Risser grade 0 to 2 at the time of presentation, we suggest
bracing (Grade 2B). We monitor patients clinically and radiographically every six months until skeletal
maturity. Surgery may be indicated if Cobb angles progress to ≥50° during bracing. (See 'Cobb angle 30 to
39 degrees' above and 'Bracing' above.)
● For patients with Cobb angles between 40 and 49° and Risser grade 0 to 2 at the time of presentation, we
suggest either bracing or surgery (Grade 2C). (See 'Cobb angle 40 to 49 degrees' above and 'Bracing'
above and 'Surgery' above.)
● Patients at Risser grade 3 (figure 1) have little growth remaining and are not candidates for bracing.
Management depends upon the magnitude of the curve at the time of presentation. (See 'Little growth
remaining' above.)
● Surgery should be discussed for patients with Cobb angles ≥50° at the time of presentation or later,
regardless of the degree of skeletal maturity. (See 'Surgery' above.)
● Skeletally mature patients (Risser 4 in girls, Risser 5 in boys) with curves with Cobb angle <40° can be
reassured and discharged, with no need for regular follow-up. Skeletally mature patients with curves
between 40 and 50° are assessed and managed on an individual basis. (See 'Long-term follow-up' above.)
● Outcome for patients with AIS is generally favorable, whether they are treated with observation, bracing, or
surgery. They have a slightly increased risk of back pain and degenerative disc changes compared with
patients without AIS but have no increased risk of mortality or adverse pregnancy outcome. (See 'Outcome'
above.)
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111. Pehrsson K, Larsson S, Oden A, Nachemson A. Long-term follow-up of patients with untreated scoliosis. A
study of mortality, causes of death, and symptoms. Spine (Phila Pa 1976) 1992; 17:1091.
Topic 6291 Version 31.0
GRAPHICS
Cobb angle measurement
The Cobb angle (arrow in radiograph) is formed by the intersection of a line parallel to the
superior end plate of the most cephalad vertebra in a particular curve, with the line parallel to the
inferior end plate of the most caudad vertebra of the curve. The intersection of these lines may
occur outside the border of the actual film. Therefore, by convention, perpendiculars to the
parallels are drawn, and the angle between their intersection is measured. The Cobb angle in the
above radiograph is 63°. The most cephalad vertebra is the vertebra that has the greatest tilt
from horizontal of its superior end plate (solid line). The most caudal vertebra is the vertebra that
has the greatest tilt from horizontal of its inferior end plate (dotted line). Drawing lines along
several vertebrae near each end of a curve (dashed lines) is helpful in determining that with the
greatest tilt.
Radiograph courtesy of Susan A Scherl, MD.
Graphic 62495 Version 11.0
Risser sign for skeletal maturity
The iliac apophysis ossifies in a stepwise fashion from anterolateral to posteromedial along
the iliac crest. The Risser sign is a visual grading of the degree to which the iliac apophysis
has undergone ossification and fusion; it is used to assess skeletal maturity. Risser grade 0
corresponds to no ossification. As depicted above, grade 1 describes up to 25 percent
ossification; grade 2 describes 26 to 50 percent ossification; grade 3 describes 51 to 75
percent ossification; grade 4 describes greater than 76 percent ossification; and grade 5
describes full bony fusion of the apophysis.
Sequence of puberty in girls
Sequence of events in girls with average timing of pubertal development in the United States. The
median age for achieving each milestone is younger for African American girls (dashed vertical line)
compared with Caucasian girls (dotted vertical line). The median length of time between the onset of
puberty (breast Tanner stage 2) and menarche is 2.6 years, and the 95 th percentile is 4.5 years.
SMR: sexual maturity rating (also known as Tanner stage).
Data from: Biro FM, Huang B, Lucky AW, et al. Pubertal correlates in black and white US girls. J Pediatr 2006;
148:234, and from: Tanner JM, Davies PS. J Pediatr 1985; 107:317.
Sequence of puberty in boys
Sequence of pubertal events in boys with average timing of pubertal

development in the United States.
Data from:
1. Biro FM et al, Pubertal staging in boys. J Pediatr 1995; 127:100.
2. Karpati AM et al, Stature and pubertal stage assessment in American boys:
the 1988-1994 Third National Health and Nutrition Examination Survey. J
Adolesc Health 2002; 30:205-12.
3. Dore E et al. Gender differences in peak muscle performance during growth.
Int J Sports Med 2005; 26:274.
4. Neu CM et al. Influence of puberty on muscle development at the forearm.
Amer J Physiol Endocrin Metab 2002; 283:E103.
5. Tanner et al. Clinical longitudinal standards for height and height velocity for
North American children. J Pediatr 1985; 107:317.
Use of the scoliometer
The scoliometer is run along the patient's spine from caudad to cephalad
while the patient is in the position assumed for the Adams forward bend test.
In the above photograph, the right thoracic prominence causes the right side
of the scoliometer to deviate upward and the ball to deviate to the left. The
angle of trunk rotation can also be measured with a scoliometer app on a
smartphone.
Courtesy of Susan A Scherl, MD.
Boston brace
The Boston brace is an underarm thoraco-lumbar-sacral orthosis (TLSO).

Such braces can be camouflaged relatively easily under loose-fitting clothes.
Posterior spinal fusion
Preoperative posteroanterior (PA) and postoperative PA and lateral radiographs (panels A, B, and C,
respectively) of a patient who underwent posterior spinal fusion and segmental spinal
instrumentation with pedicle screws. Note on the postoperative lateral how the use of segmental
instrumentation allows contoured rods to be attached to the spine to better maintain normal
physiologic sagittal plane curves (thoracic kyphosis and lumbar lordosis). By orthopedic convention,
scoliosis images are viewed as if looking from the patient's back; the left side of the image is the left
side of the patient.
Courtesy of William Phillips, MD.
Thoracolumbar scoliosis
Posteroanterior radiograph demonstrating right thoracolumbar scoliosis. The

air-fluid level in the stomach confirms that the radiograph was taken with the
patient standing. Scoliosis radiographs are viewed with the patient's heart on
the examiner's left (as if the examiner is standing behind the patient).
Contributor Disclosures
Susan A Scherl, MD Nothing to disclose William Phillips, MD Nothing to disclose Mary M Torchia,
MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
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Adolescent Idiopathic Scoliosis: Management and Prognosis - UpToDate

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Author: Susan A Scherl, MD

● Patients <12 years [3]

● Girls compared with boys [3,4]

● Premenarchal compared with postmenarchal girls [5]

● Curves with initial Cobb angle ≥20°, independent of age [6-9]

● Double and thoracic curves compared with nonthoracic curves [1,3,9,10]

● Risser grade 0 or 1 (figure 1) compared with Risser grade ≥2 [9]

● >30° in only 8 percent

● Cobb angle >30° in any patient

● Progression of Cobb angle of ≥5° in any patient

● Contraindications – Contraindications to bracing include:

• Cobb angle ≥50°

• Cobb angle <20°

A small percentage of curves require a brace with an under-chin extension (a cervico-thoraco-lumbar-sacral

• Thoracoscopic ASF – Anterior instrumentation of the thoracic spine may be performed

limitation in adulthood, and the risk of neuropathy is low [26,50,96,102].

● Basics topic (see "Patient education: Scoliosis (The Basics)")

SUMMARY AND RECOMMENDATIONS

syndromic). (See 'Terminology' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

straight individuals. Spine (Phila Pa 1976) 2001; 26:516.

scoliosis 21 to 41 years later. Spine (Phila Pa 1976) 2012; 37:402.

Topic 6291 Version 31.0

Radiograph courtesy of Susan A Scherl, MD.

Graphic 62495 Version 11.0

Risser sign for skeletal maturity

Graphic 74751 Version 3.0

Sequence of puberty in girls

SMR: sexual maturity rating (also known as Tanner stage).

Graphic 52047 Version 9.0

Sequence of puberty in boys

Sequence of pubertal events in boys with average timing of pubertal

Graphic 72046 Version 3.0

Use of the scoliometer

Courtesy of Susan A Scherl, MD.

Graphic 57756 Version 3.0

The Boston brace is an underarm thoraco-lumbar-sacral orthosis (TLSO).

Courtesy of Susan A Scherl, MD.

Graphic 62578 Version 2.0

Posterior spinal fusion

Courtesy of William Phillips, MD.

Graphic 70369 Version 6.0

Posteroanterior radiograph demonstrating right thoracolumbar scoliosis. The

Courtesy of Susan A Scherl, MD.

Graphic 62029 Version 6.0

Conflict of interest policy

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