Most patients with an established diagnosis of idiopathic scoliosis do not require treatment. Of patients identified through school screening, only 7% of those with spinal asymmetry on Adams bending test will require treatment.
During the past several decades, a large variety of orthotic devices have been developed for the treatment of scoliosis. The goal of bracing programs is to contain the curve rather than to exact improvement. Patients should be skeletally immature (Risser 0, 1, or 2), have a curve in the range of 20 to 40 degrees, have a deformity that they consider cosmetically acceptable, and be willing to accept brace treatment. Those patients with curves between 20 and 30 degrees can be observed. If curve progression of 5 degrees or more occurs, brace treatment should be initiated. Because bracing is effective in managing smaller curves, some authors advocate initiating treatment for curves of 25 degrees or more, when the Risser is 0. The use of bracing in more mature patients (Risser 3 and 4) should be individualized for each patient. Most studies demonstrate that bracing is ineffective in curves greater than 45 degrees.
The type of curve pattern is also an important determinant for bracing. Most authors believe that curves with the apex at or above the T7 vertebra are not amenable to braces without a cervical extension. Double curves may not be amenable to bracing because maximal correction of one curve may decrease the correction of the adjacent curve.
The indications for surgical intervention are based upon characteristics of the curve and of the patient. Curve factors include location, magnitude, rotation, progression, and balance. The patient's age is of primary importance. In general terms, a skeletally immature patient who presents with a curve beyond the limits of effective brace treatment (40 to 45 degrees) or who demonstrates progression is a candidate for fusion. Mature patients with thoracic curves greater than 50 degrees and thoracolumbar or lumbar curves greater than 30 degrees with marked apical rotation or translatory shift may also be considered surgical candidates.
Surgical treatment involves a posterior spinal fusion in combination with one of the various forms of spinal instrumentation. The purpose of the procedure is to obtain a solid spinal fusion and to have the top and the bottom of the fusion balanced.