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Adolescent idiopathic scoliosis

110 citationsUpdated Sep 2026

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Overview

Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine that affects approximately 2% to 3% of children [2]. Successful management of this condition requires a comprehensive understanding of its etiology, natural history, evaluation, and the available nonsurgical and surgical management options [1]. The primary goals of treatment are aimed at minimizing deformity and maximizing functional outcomes [2].

Juvenile idiopathic scoliosis is considered a separate and distinct entity from adolescent idiopathic scoliosis due to rapid progression during the adolescent growth spurt and a high need for early operative management [4]. Regarding surgical planning, no definite guideline for fusion level selection has been established for corrective surgery in adolescent idiopathic scoliosis [10].

Preoperative assessment must account for pulmonary status, as obstructive lung disease is present in 21% to 39% of patients scheduled for surgical correction of thoracic adolescent idiopathic scoliosis [42].

Anatomy & Pathophysiology

Definition and Epidemiology

Adolescent idiopathic scoliosis (AIS) is defined by an age at presentation of 11 to 18 years [20]. AIS accounts for approximately 90% of all cases of idiopathic scoliosis [20] and constitutes about 80% of all cases of scoliosis [21]. The prevalence of AIS is 0.47% [20], affecting approximately 2% to 3% of patients between the ages of 10 and 14 years [43]. Late-onset (adolescent) idiopathic scoliosis makes up 90% of cases and is mostly found in girls [21]. The female-to-male ratio for AIS is 1:1 for small curves but increases to 10:1 for curves exceeding 30° [53]. Primary thoracic curves in AIS are usually convex to the right, while lumbar curves are usually convex to the left [21]. The population incidence of serious AIS curves (over 30 degrees) is 3 per 1000 [21].

Etiology and Pathogenesis

The exact aetiology of AIS remains unknown despite decades of research [20]. AIS is the result of a complex interplay of genetic, internal, and environmental factors [20], with genetic variants hypothesized to act as the initial trigger that allows epigenetic factors to propagate AIS [20]. AIS is a three-dimensional spinal deformity producing deviations in the coronal, sagittal, and axial planes [43]. Scoliosis is a complex rotational deformity which may manifest with a thoracic or lumbar prominence, shoulder imbalance, coronal shift, and infrequently pain [27]. In structural scoliosis, there is a non-correctable deformity of the affected spinal segment, an essential component of which is vertebral rotation [27]. The spinous processes swing round towards the concavity of the curve and the transverse processes on the convexity rotate posteriorly [27]. In thoracic structural scoliosis, the ribs on the convex side stand out prominently, producing a classical rib hump [27]. Secondary (compensatory) curves nearly always develop to counterbalance the primary deformity in structural scoliosis and may become fixed [27].

Scoliosis has four fundamental characteristic features seen on roentgenograms: penetration or transverse shift of the spine, contracture of the spine, rotation of the vertebrae, and compression of the vertebrae on the concave side [145]. Penetration and compression are essential scoliotic signs not encountered under physiological conditions [145]. The universal mechanical factor of all forms of acquired scoliosis is human gait, which brings about the deformity in the presence of a definite pathological process [145]. Compression on the concave side is a primary characteristic of idiopathic scoliosis in the thoracic spine [145]. The separation of the vertebral cortex from the intravertebral system, notably the separation of the epiphyseal ring and its partial displacement, represents the basic pathological process of idiopathic scoliosis in the thoracic spine [145]. Separation of the epiphyseal ring is preceded by the infantile (juvenile) form of osteoporosis of the spine [145].

Histological and ultrastructural analyses of the vertebral end plates and vertebral bodies in patients with scoliosis have been shown to be normal [91]. Enneking and Harrington found no abnormalities in enchondral growth at the apex of the primary curve of patients with idiopathic scoliosis [91]. The deformity in idiopathic scoliosis may be secondary to an extraosseous cause, with observed changes in bone and cartilage being secondary adaptations [91]. Genetic studies indicate the familial nature of scoliosis and lend support to the proposal that the etiology is genetically related [91]. A polygenic threshold model with sex dimorphism exists in adolescent idiopathic scoliosis, referred to as the Carter effect [15].

Genome-wide association studies suggest candidate susceptibility genes for adolescent idiopathic scoliosis [49]. A genome-wide association study identifies common variants near LBX1 associated with adolescent idiopathic scoliosis [49]. A meta-analysis identifies an association between adolescent idiopathic scoliosis and the LBX1 locus in multiple ethnic groups [49]. A PAX1 enhancer locus is associated with susceptibility to idiopathic scoliosis in females [49]. Genetic variants in GPR126 are associated with adolescent idiopathic scoliosis [49]. Gpr126/Adgrg6 deletion in cartilage models idiopathic scoliosis and pectus excavatum in mice [49]. The growth hormone receptor did not appear to be a predisposing gene or disease modifier gene of adolescent idiopathic scoliosis [187]. Disordered leptin and ghrelin bioactivity is present in adolescent idiopathic scoliosis [192]. Emerging pathogenetic mechanisms in AIS include interconnected mechanisms linking immune dysregulation, musculoskeletal remodeling, and curve progression [167]. Causal relationships between inflammation, gut microbiota, and AIS remain to be fully established [167]. The potential role of the elastic fiber system in adolescent idiopathic scoliosis has been investigated [91].

Asymmetry in the onset of paraspinal muscles activity differs in adolescents with idiopathic scoliosis compared with those with a symmetrical spine [193]. Differences in paraspinal musculature activation are seen even in very small curves, hinting that changes in muscle activation may be related to the etiology of adolescent scoliosis [193]. The coronal Cobb angle and the symmetry index of paraspinal muscle activity in AIS patients vary with posture changes [138]. Compensatory strategies are potentially seen at lower levels of the spine in subjects presenting an idiopathic scoliosis [146]. Morphometric characteristics of vertebral bodies differ according to the pathogenesis of scoliosis, and the pathology of wedging in idiopathic scoliosis could not be a result only of asymmetric loading to the vertebral bodies [150]. Cervical kyphosis is among the most prevalent morphological alterations in patients with AIS and is closely associated with curve severity [136]. The biomechanical parameters of the lower limbs are affected in cases of scoliosis with altered coronal balance, with the lower limb on the side of decompensation becoming shorter, having a lower collodiaphyseal angle, and increased varus at the knee joint [151]. The coexistence of dynamic plantar pressure asymmetries and weak associations with static pelvic alignment suggests that structural deformities alone may not adequately explain functional loading behavior in AIS [161].

Natural History and Progression

Progression of AIS is not inevitable; most curves of less than 20 degrees either resolve spontaneously or remain unchanged [21]. If an AIS curve starts to progress, it usually continues to do so until skeletal maturity and, to a much lesser degree, beyond that [21]. Reliable predictors of AIS progression include very young age at onset, marked curvature, and an incomplete Risser sign [21]. In prepubertal children, rapid progression of scoliosis is liable to occur during the growth spurt [21]. After an adolescent reaches skeletal maturity, the natural history of scoliosis appears to be dependent on the deformity magnitude [22].

A long-term study at the University of Iowa reported little deformity progression over time if the curvature was less than 30° at skeletal maturity [22]. The maximal risk of progression of deformity occurs with curvatures greater than 50° at the time of skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of thoracic deformity was 2.6° for curves less than 30° at skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of thoracic deformity was 10.2° for curves 30° to 50° at skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of thoracic deformity was 29.4° for curves 50° to 75° at skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of lumbar deformity was 0° for curves less than 30° at skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of lumbar deformity was 15.4° for curves 30° to 50° at skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of lumbar deformity was 18.5° for curves 50° to 75° at skeletal maturity [22]. Radiographic outcomes for patients with curves between 30° and 50° at skeletal maturity are dependent on the location of the deformity, with lumbar curves being at increased risk for progression compared with thoracic curves [22].

Long-term data suggest the clinical effect of slowly progressing thoracic scoliosis continuing into adulthood may not be as important as originally suspected [22]. Moderate progression of smaller magnitude lumbar scoliosis into adulthood may be associated with more negative functional outcomes, such as increasing back pain, than previously thought [22]. Up to 19% of patients with AIS have moderately impaired pulmonary function (<65% predicted forced expiratory volume in 1 second) preoperatively, with a mean thoracic curve magnitude of 70° [22]. A 50-year long-term data comparison found no significant difference in reported shortness of breath with activity between untreated patients with scoliosis and control subjects [22]. Higher rates of shortness of breath compared with control subjects were noted in patients with thoracic curves greater than 80° [22]. Thoracic curves exceeding 50° and lumbar curves exceeding 40° have been shown to progress at a rate of up to a mean of 1° per year after skeletal maturity [53]. Curves exceeding 60° can adversely affect pulmonary function tests, but symptomatic cardiopulmonary changes are traditionally seen with curves exceeding 90° [53]. With untreated scoliosis, an increase in the incidence of back pain is likely in adulthood, as well as lower self-reported physical function [53]. Long-term studies for patients with untreated AIS have demonstrated relatively few functional differences compared with normal control subjects [43].

Strong and consistent evidence supports Cobb angle, curve type, flexibility, and correction rate as predictors of curve progression in patients with AIS undergoing conservative treatment [133]. Variations of spinal growth velocity exerted more direct influence over changes in angle velocity as compared with height velocity in peri-pubertal girls with idiopathic scoliosis [142]. At the onset of the pubertal growth spurt, curves greater than 30 degrees have a 100% risk of progressing over 45 degrees [95]. Peak height velocity (PHV) is reported to be approximately 8.0 cm/yr for girls and 9.5 cm/yr for boys [95]. The reported average age at PHV in North American girls is approximately 11.5 years [95]. Closure of the triradiate cartilage occurs after PHV and before Risser grade 1 and menarche [95]. In boys, use of PHV to predict the period of remaining growth is superior to the Risser sign and chronologic age [95]. A scoliotic curve that exceeds 30° at peak height velocity is likely to require surgery [53]. Girls at greatest risk for AIS progression are premenarchal, have a Risser grade of 0, have a Tanner stage of less than 3, and have open triradiate cartilage [53]. Peak height velocity in adolescence is approximately 10 cm per year and occurs just before the onset of menses in girls [53]. The simplified skeletal maturity scoring system (Sanders grade) can be used to predict risk of progression for a given curve magnitude [53]. The digital skeletal maturity scoring system correlates more strongly with the behavior of idiopathic scoliosis than does the Risser sign [95]. Increasing spinal deformity occurs after Sanders stage 7 in females with AIS [15]. The natural history of AIS is dependent on the magnitude of the deformity at skeletal maturity [22]. An absolute correlation between larger spinal deformity and decreased health is lacking [22].

Associated Conditions and Screening

A family history of scoliosis is not uncommon [27]. Pain is a rare complaint in scoliosis and should alert the clinician to the possibility of a neural tumour and the need for MRI [27]. MRI is used to rule out intraspinal anomalies such as tethered cord, syringomyelia, Chiari 1 malformation, dysraphism, and spinal cord tumor [53]. Indications for MRI of the spine include atypical curve patterns such as left thoracic curve, short angular curves, absence of apical thoracic lordosis, absence of rotation, congenital scoliosis, and hyperkyphosis [53]. MRI is indicated for patients younger than 10 years with a scoliotic curve exceeding 20° [53]. MRI is indicated for patients with abnormal neurologic findings on examination, abnormal pain, rapid progression of scoliotic curve (more than 1° per month), and asymmetric umbilicus reflex [53]. A syrinx is commonly associated with scoliosis without rotation and an asymmetric umbilicus reflex [53]. Asymmetric abdominal reflexes are associated with a syrinx and are an indication for MRI of the entire spine [53]. Hairy patches, dimples, nevi, or masses overlying the spine may indicate spinal dysraphism [53]. Dimples outside the gluteal fold are generally benign [53]. Evaluation of the lower extremities should rule out cavovarus foot, particularly unilaterally, which is associated with neural axis abnormalities [53]. Skin evaluation should include inspection for café-au-lait spots (neurofibromatosis) and hairy patches (diastematomyelia) [53].

Scoliosis is the most common skeletal manifestation of neurofibromatosis [135]. The reported incidence of scoliosis in neurofibromatosis is between 10% and 60%, with a 10% to 20% incidence more accurately reflecting the entire population [135]. Dystrophic scoliosis in neurofibromatosis is more common, has a greater tendency to progress, and includes a subgroup of patients at risk for neurologic deficits [135]. Nondystrophic scoliosis in neurofibromatosis more closely resembles idiopathic scoliosis in both curve patterns and behavior [135]. Nondystrophic curves in younger children with neurofibromatosis can modulate into the dystrophic type over the course of several years [135]. The overall modulation rate from nondystrophic to dystrophic scoliosis in neurofibromatosis is 65% [135]. Modulation occurs in 81% of NF-1 patients with scoliosis before age 7 years, and 25% of those after the age of 7 years [135]. Early screening for incorrect postures and angle of trunk rotation could be an effective and economical strategy to predict the severity of AIS [116]. Radiographic analysis provides limited information about the spine's overall alignment because it does not reflect the trunk's dynamic position during daily activities [102].

Classification

Adolescent idiopathic scoliosis (AIS) is defined by an age at presentation of 11 to 18 years [20]. The condition has a prevalence of 0.47% [20] and accounts for approximately 90% of all cases of idiopathic scoliosis [20]. Prognosis varies considerably by curve pattern and age at onset [30], with main thoracic curves increasing to greater deformities than other patterns [30]. Juvenile idiopathic scoliosis warrants consideration as a separate and distinct entity from AIS due to its rapid progression during the adolescent growth spurt and the high need for early operative management [4].

Moe and King: In 1983, Moe and King developed a method of classifying AIS curves that included five curve types and relied on PA radiographs [190]. This system helped surgeons determine when to fuse the thoracic curve alone and when to include an associated lumbar curve [190]. However, the current method of classification does not appear to have sufficient intraobserver or interobserver reliability among scoliosis surgeons to portray curve types accurately [29].

Lenke: The Lenke classification system was designed to improve upon the King classification by addressing limitations such as the lack of sagittal plane assessment and poor reliability [178]. Updated in 2001 to include both sagittal and coronal plane assessments [190], the system achieved good-to-excellent intraobserver and interobserver reliability in multiple studies [178]. It includes six curve types (1 to 6) with modifiers for lumbar curve apical vertebral translation (A, B, and C) [190]. The classification also includes modifiers for hyperthoracic, normal, or hypothoracic kyphosis (1,N,2) [190]. Primary lumbar and thoracolumbar curves as well as triple curves are added as distinct curve types [190]. The Lenke classification relies on additional bending radiographs to determine curve flexibility [190]. Curves that do not bend to less than 25° are considered “structural” and should be considered for inclusion within the fusion construct [190]. Additional sagittal plane structural criteria address potential proximal and distal junctional kyphosis [190]. Rotational, or axial plane deformity, was not considered in the published Lenke classification criteria because considerable observer variability occurred in the assessment of this 3D phenomenon with 2D radiographs [190].

Other Considerations: Scoliometer measurement and radiographic rib index measurements can provide a crude measurement of vertebral rotation [190]. The method developed by Nash and Moe using pediculae is perhaps the most widely adopted surrogate measure of vertebral rotation [190]. A new two-dimensional classification of AIS was shown to be much more reliable than the King system [96]. A new 3D classification has the potential to identify the subtypes of the Lenke 1 AIS without a need for quantitative 3D image post-processing [143].

Clinical Presentation

Definition and Epidemiology

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity affecting approximately 2% to 3% of children [2]. In a cross-sectional prevalence study of children aged six to fourteen years, a lateral spinal curve with a Cobb angle of more than 5 degrees was observed in 2.7% of the population [28]. However, only 0.5% of this age group met the strict definition of idiopathic scoliosis, characterized by a curve of more than 10 degrees with concordant apical rotation [28]. The point-prevalence rate of idiopathic scoliosis is higher in girls and increases with age [28]. Specifically, prevalence was 0.1% in children aged six to eight years, 0.3% in those aged nine to eleven years, and 1.2% in those aged twelve to fourteen years [28]. Two to three percent of children younger than sixteen years will develop a curvature of 10 degrees or greater [40]. Furthermore, 0.3% to 0.5% of children younger than sixteen years will develop a curvature of 20 degrees, the magnitude at which treatment is generally recommended [40]. More than 620,000 adolescents in the United States have AIS [40]. The population incidence of serious curves exceeding 30 degrees is 3 per 1000 [21]. Late-onset adolescent idiopathic scoliosis predominantly affects girls [21].

Clinical Features and Physical Examination

Deformity is the usual presenting symptom of structural scoliosis [27]. Clinical features include an obvious skew back or rib hump in thoracic curves, and asymmetrical prominence of one hip in thoracolumbar curves [27]. Pain is a rare complaint in structural scoliosis; its presence should alert the clinician to the possibility of a neural tumour and necessitate MRI [27]. Forward flexion demonstrates spinal deviation from the midline if the deformity is not obvious on inspection [27]. During examination, the level and direction of the major curve convexity must be noted [27]. In thoracic scoliosis, rotation causes the rib angles to protrude, producing a rib hump on the convex side [27]. In balanced deformities, the occiput is over the midline; in unbalanced or decompensated curves, it is not [27]. The diagnostic feature of fixed scoliosis is that forward bending makes the curve more obvious [27]. Spinal mobility should be assessed, and the effect of lateral bending on the curve noted [27]. Neurological examination is critical, and any abnormality suggesting a spinal cord lesion requires CT and/or MRI [27]. General examination includes a search for possible causes and an assessment of cardiopulmonary function, which is reduced in severe curves [27]. Skin pigmentation and congenital anomalies such as sacral dimples or hair tufts are also sought [27]. Back pain is common in patients with AIS, but chronic back pain is seen in fewer than 10% of patients [111]. When a patient with scoliosis presents with back pain, a careful history, thorough physical examination, and good-quality plain radiographs should be performed [14]. If initial evaluation reveals normal findings, a diagnosis of idiopathic scoliosis can be made and non-operative treatment initiated [14]. There is a high level of agreement between telehealth and in-person spine measurements, suggesting that telehealth visits may be reliably used to evaluate AIS [130].

Curve Characteristics and Patterns

Primary thoracic curves are usually convex to the right, while lumbar curves are convex to the left [21]. Vertebral wedging is present in mild scoliosis and increases as the condition progresses [63]. The spinous processes swing round towards the concavity of the curve, and the transverse processes on the convexity rotate posteriorly [27]. Secondary compensatory curves nearly always develop to counterbalance the primary deformity and may become fixed [27]. The prognosis in idiopathic scoliosis varies considerably by curve pattern and age at onset, with main thoracic curves increasing to greater deformities than other patterns [30].

Natural History and Progression

Progression of scoliosis is not inevitable; most curves of less than 20 degrees either resolve spontaneously or remain unchanged [21]. If a curve starts to progress, it usually continues to do so until skeletal maturity and, to a much lesser degree, beyond that [21]. Reliable predictors of progression include very young age at onset, marked curvature, and an incomplete Risser sign [21]. In prepubertal children, rapid progression is liable to occur during the growth spurt [21]. Curve magnitude, Risser sign, and chronological age are the strongest predictors of progression in untreated idiopathic scoliosis [13]. A long-term study reported little deformity progression over time if the curvature was less than 30° at skeletal maturity [22]. In 102 patients with an average follow-up of 40 years, the average progression of deformity was 2.6° for thoracic curves of less than 30° at skeletal maturity [22]. The average progression was 10.2° for thoracic curves of 30° to 50° at skeletal maturity [22]. The average progression was 29.4° for thoracic curves of 50° to 75° at skeletal maturity [22]. The average progression of lumbar curves was 0° for curves less than 30° at skeletal maturity [22]. The average progression of lumbar curves was 15.4° for curves of 30° to 50° at skeletal maturity [22]. The average progression of lumbar curves was 18.5° for curves of 50° to 75° at skeletal maturity [22]. Lumbar and thoracolumbar scoliosis may be strongly progressive after skeletal maturity [16]. Scoliosis is a life-long condition with potentially significant poor health-related quality of life scores many years after diagnosis [9]. Patients with scoliosis may need to be followed up in a timely and appropriate manner for decades rather than for just a few years [9]. The stability of the scoliosis was not related to the age of the patient [70]. There is no evidence that untreated mild idiopathic scoliosis occurs or progresses in girls of ages 10 to 16 because of increased joint flexibilities [24].

Associated Conditions and Comorbidities

An abnormality of the central nervous system is present in approximately 10% of patients with presumed AIS in whom only subtle abnormalities are identified based on clinical history, physical examination, or radiographic examination [17]. Children with AIS have a higher prevalence of psychiatric disorders compared to children without AIS [118]. Spondylolysis is a clinically impactful comorbidity in AIS, associated with increased postoperative pain, dysfunction, and distal junctional complications [33]. Physical activity is strongly associated with AIS [119]. Clinically actionable pathogenic mutations in genes associated with AIS and aortic aneurysm are rare in patients with AIS who are not suspected of having these disorders [122]. Variants of unknown significance are relatively common in patients with AIS regarding genes associated with aortic aneurysm [122].

Pulmonary and Functional Impact

Higher rates of shortness of breath compared with control subjects were noted in patients with thoracic curves greater than 80° [22]. There appears to be a type of patient with idiopathic scoliosis in whom there is an excessive loss of pulmonary function relative to the amount of scoliosis [73]. Early onset scoliosis would have a severe impact on pulmonary function if not treated properly [109].

Investigations

Physical Examination and Screening

Scoliosis is a complex rotational deformity that may manifest with a thoracic or lumbar prominence, shoulder imbalance, coronal shift, and infrequently pain [27]. In structural scoliosis, the deformity is non-correctable and includes vertebral rotation, where spinous processes swing toward the concavity and transverse processes on the convexity rotate posteriorly [27]. In thoracic structural scoliosis, this rotation causes the rib angles to protrude, producing a rib hump on the convex side [27]. When a patient with scoliosis presents with back pain, a careful history, thorough physical examination, and good-quality plain radiographs should be performed [14]. The physical examination must include a detailed neurologic assessment of the lower extremities, covering sensory, motor, and reflex functions [53]. Skin evaluation should include inspection for café-au-lait spots and hairy patches to screen for neurofibromatosis and diastematomyelia [53]. All patients with 'idiopathic' scoliosis deserve a careful neurological evaluation, even if they have minimal muscle symptoms in the extremities [35].

Screening protocols vary in sensitivity. Adoption of a trunk inclination angle (ATI) threshold of 5° in screening tests for children aged 6–12 years may be more effective in the early detection of scoliosis [41]. A scoliometer measurement of more than 7° has a false-negative rate for a curvature of more than 20° ranging from 2% to 5% [53]. Conversely, the false-positive rate for a scoliometer measurement for a curvature of less than 20° is 50% [53].

Radiographic Evaluation

Plain radiography: Radiographic assessment of patients with suspected spinal deformity should start with PA and lateral radiographs performed on a full-length (36 × 14 inch) cassette in the weight-bearing position [126]. PA and lateral upright views should be obtained using a 36-inch cassette or biplanar radiography [53]. Appropriate breast and gonadal shielding should be used to limit radiation exposure to radiosensitive areas during scoliosis radiography [126]. Digital radiography is the current standard in radiographic imaging because it leads to a substantial decrease in radiation exposure [126]. A novel imaging system using biplanar digital slot scanning substantially further decreases radiation exposure compared with traditional digital radiography, with no difference in image quality [126]. Bending or traction films are useful for surgical planning but are not necessary for evaluation [53].

CT: Findings suggested that scoliotic curvatures in preoperative adolescent idiopathic scoliosis patients can be largely represented by both biplanar low-dose stereoradiography and computed tomography despite the difference in body positioning [82].

Other Considerations: The proximal femoral epiphysis is visible in routine spine radiographs, allowing skeletal maturity assessment through convenient viewing and thus avoiding additional radiation exposure [206]. The risk of progression in adolescent idiopathic scoliosis is related to curve size and remaining skeletal growth, which is assessed using Tanner stage, Risser grade, age of menarche, and presence of open triradiate cartilages [53]. Bone age and simplified skeletal maturity scoring (Sanders grade) can be used to predict risk of progression for a given curve magnitude [53]. Peak height velocity generally occurs before Risser grade 1 [53]. There is clinically important asymmetry in the morphologic features of pedicles in individuals with adolescent idiopathic scoliosis, with the concave side being smaller in height and width periapically and having a more acute trajectory compared to the convex side [207]. Coronal curve severity is associated with reduced axial and coronal range of motion in adolescent idiopathic scoliosis patients [79].

Magnetic Resonance Imaging (MRI)

MRI: MRI is used to assess the spinal cord for evidence of intraspinal abnormalities in patients with abnormal physical examination findings or, occasionally, for patients with substantial scoliosis-related pain [126]. Routine evaluation of the spinal cord using MRI before surgical intervention in patients with normal physical examination or radiographic findings is a debated issue [126]. The incidence of intraspinal abnormality in patients with suspected adolescent idiopathic scoliosis can be up to 10% [126]. Findings including limited axial plane rotation, abnormal reflexes on examination, lack of thoracic hypokyphosis, atypical curve direction (left thoracic or right thoracolumbar/lumbar), rapid deformity progression, and substantial back or radicular pain warrant further investigation of the spine with MRI [126]. MRI is indicated for patients with abnormal neurologic finding on examination, abnormal pain, rapid progression of scoliotic curve (more than 1° per month), and asymmetric umbilicus reflex [53]. MRI should include the entire spine from the skull base to the sacrum [53]. If surgery is planned, MRI evaluation of the spinal axis can identify dural ectasia in patients with neurofibromatosis, Ehlers-Danlos syndrome, and Marfan syndrome [53]. Magnetic resonance is an excellent modality for imaging pathologic processes in the pediatric spine, allowing high-resolution views of osseous and soft-tissue structures [160].

This study reports the lowest rates to date of intraspinal anomalies in patients with early onset idiopathic scoliosis, suggesting geographical variation [23]. Of patients with scoliotic curves of 20° or more, 22% have a neural axis abnormality; approximately 80% of these patients will require neurosurgical care [53]. The incidence of abnormalities of the neural axis in juvenile idiopathic scoliosis is 20% to 25%; hence, MRI is indicated for curves of 20° or greater [53].

Other Investigations

Laboratory: Idiopathic scoliosis patients seemed to have lower BMD at central skeletal sites and less evident differences at peripheral skeletal sites when compared with controls [200]. Because there was no significant difference between readings from the concave and convex sides, it is unlikely that a lesion of the posterior column is responsible for idiopathic scoliosis [199].

Treatment

General Principles and Goals

The primary goals of treating adolescent idiopathic scoliosis (AIS) are preventing spinal deformity progression and avoiding physical impairment, pain, and disfigurement [47]. Long-term objectives include maximizing spinal flexibility and movement over time while avoiding malalignment to prevent future spondylotic degeneration [47]. Because scoliosis is a life-long condition associated with potentially significant poor health-related quality of life scores many years after diagnosis, patients require follow-up for decades rather than just a few years [9]. Management should pursue a holistic approach that considers the psychological impact and quality of life of the patient [195].

Non-Operative

Conservative treatment is the first-line approach for most cases of early-onset scoliosis due to fewer complications compared with surgery [117]. In patients with substantial remaining growth, observation is indicated when the deformity is less than 20° [43, 47]. A spinal orthotic is used to decrease the risk of progression when the deformity is between 20° and 45° [43, 47]. Patients with little growth remaining or those who have reached skeletal maturity are typically not candidates for brace treatment; observation and reassurance are indicated unless the deformity is greater than 50° [47]. Most curves of less than 20 degrees either resolve spontaneously or remain unchanged [21]. The population incidence of serious curves requiring treatment (over 30 degrees) is 3 per 1000 [21]. Reliable predictors of curve progression include very young age at onset, marked curvature, and an incomplete Risser sign [21].

Exercise and Physical Therapy: Active self-correction demonstrated superior short-term benefits compared to other exercise interventions in ameliorating spinal deformity and improving quality of life for adolescents with idiopathic scoliosis [44]. A meta-analysis of Schroth exercises shows limited statistical improvements in both Cobb angle and self-reported quality of life [49]. A literature review found no evidence to suggest physiotherapy scoliosis-specific exercises are more effective at reducing Cobb angle compared with observation [49]. However, a randomized controlled trial of Schroth physical therapy showed a number needed to treat of 3.1 to decrease the risk of scoliosis progressing beyond 5° [49]. There is no evidence to support the efficacy of chiropractic manipulation, electrical stimulation, and traction in the management of spinal deformity [47].

Bracing and Casting: In skeletally immature patients with idiopathic scoliosis, braces designed by an automated generative algorithm were noninferior to those designed by expert orthotists for immediate in-brace correction [93]. Nonoperative management of moderate idiopathic curves remains a realistic option in early-onset scoliosis and can be proposed as a 'delaying tactic' for surgery until adolescent years [3]. Juvenile scoliosis is more likely to progress, less likely to respond to bracing, and more likely to require surgical treatment than AIS [38]. If the rib-vertebral angle difference (RVAD) does not improve following bracing of a progressive juvenile curve, spinal fusion will probably be required as definitive treatment [38]. In a study of 54 children with early-onset scoliosis treated with Mehta Casting, 49% had improved scoliosis to less than 15° and 73% improved by at least 20° at minimum 5-year follow-up [22]. In a study of 21 patients with an average age of 2.1 years who underwent serial casting for early-onset scoliosis, body mass index and age younger than 1.8 years at the initiation of casting were important predictors of success [23].

Operative

Indications: Surgery is indicated for progressive deformities with magnitudes greater than 50° in patients with substantial remaining growth [43, 47]. For adolescents presenting with curves greater than 50° or curves progressing past 45° in immature patients, traditionally, posterior spinal fusion is recommended [54]. Curves of magnitude greater than 50° tend to progress 1° per year even after skeletal maturity [54]. The literature does not support routine definitive fusion of thoracic spinal deformity at an early age in children with scoliosis [37]. As the child approaches 8 to 10 years of age, a definitive surgical procedure should be considered for juvenile idiopathic scoliosis [38].

Surgical Approach / Technique: Most spinal fusions for AIS are now performed using a posterior approach [54]. The use of pedicle screws that provide three-column fixation combined with wide posterior releases allows the posterior approach to provide similar radiographic outcomes as achieved with the anterior approach [54]. Anterior spinal fusion produces good long-term functional outcomes in adolescent idiopathic scoliosis with satisfactory and sustained correction [6]. A thoracoscopic approach for anterior vertebral tethering is a reproducible and effective treatment that takes advantage of continued spinal growth in pediatric patients with adolescent idiopathic scoliosis who would otherwise require spinal arthrodesis [77]. Anterior vertebral body tethering (AVBT) is associated with satisfactory correction of deformity and an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis [83]. The use of the single Harrington distraction rod is a safe and effective treatment for patients who have adolescent idiopathic scoliosis with a curve in the thoracic spine and for patients with a thoracolumbar curve that does not require fusion below the fourth lumbar vertebra [155]. Cotrel traction did not improve the results of treatment of idiopathic scoliosis of 40 to 90 degrees in patients less than twenty years old [156].

Implant Selection: All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis, offering superior deformity correction and shorter fusions compared with hook instrumentation [52]. There is no clear advantage in using a high number of implants per operated vertebra in the surgical treatment of patients with idiopathic scoliosis [87].

Alignment / Balancing Strategy: The primary goal of surgery for AIS is to prevent further progression by obtaining fusion while maintaining spinal balance in the coronal and sagittal planes [54]. Secondary goals include decreasing the size of the curve and reducing associated deformities such as trunk shift, waist asymmetry, shoulder height differences, and rotational prominences [54]. Objective criteria using spinopelvic parameters and preoperative three-dimensional planning can guide sagittal plane correction during posterior spinal fusion for adolescent idiopathic scoliosis [26].

Classification and Fusion Levels: The Lenke classification provides guidance on the selection of fusion levels in the surgical management of AIS [54]. The Lenke classification includes six curve types, three lumbar modifiers, and three sagittal modifiers, resulting in 42 different possible patterns [54]. Supine bending radiographs are required to use the Lenke classification system to distinguish structural curves (that do not bend out to <25°) from nonstructural curves (that bend out to <25°) [54]. For Lenke types 1A and 1B, the upper instrumented vertebra is typically the proximal end vertebra, often T4 [54]. If the proximal thoracic curve is structural (Lenke type 2), the left shoulder is elevated, or there is kyphosis greater than 20° from T2 through T5, then T2 or T3 should be considered for the upper instrumented vertebra [54]. Thoracolumbar and lumbar curves (Lenke type 5) are typically fused from the proximal end vertebra to the distal end vertebra [54]. Commonly used criteria for selective thoracic fusion include a thoracic-to-lumbar curve magnitude ratio greater than 1.2, an apical vertebral translation ratio greater than 1.2, and a preoperative lumbar curve less than 45° [54]. In a 20-year follow-up study that included Lenke type 1B, 1C, and 3C curves, lumbar curve correction and overall balance were maintained over time with selective thoracic fusion; however, patients had lower scores in self-image on the SRS-24 questionnaire compared with patients treated with fusions that included the lumbar spine [54].

Early-Onset Scoliosis Strategy: A realistic long-term goal for the management of early-onset scoliosis appears to be spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation [12]. Therapeutic strategies for early-onset scoliosis must preserve the growing spine and thorax while correcting deformity [8]. Treatment goals and strategies in patients with early-onset scoliosis are directed at preserving the growth of the spine and thoracic cavity to maximize lung function [85]. Surgical interventions using growth-friendly instrumentation, tethers, or a growth guidance system can control a curve while preserving growth of the spine and thoracic cavity [85]. VEPTR treatment resulted in similar deformity control and thoracic growth in patients younger than 3 years and in those 3 to 6 years of age, with lower complication rates reported in the older age group [5].

Adjuncts: High-dose tranexamic acid appears to be effective and safe for adolescent idiopathic scoliosis surgery [31]. Leaving out the subfascial drain after correction of adolescent idiopathic scoliosis is non-inferior to using a drain regarding blood loss, haemoglobin drop, and opioid consumption [159].

Complications and Outcomes: Junctional kyphosis, surgical site infection, and implant failure are common complications in early-onset scoliosis surgery and areas of current research interest [85]. Traditionally reported radiographic outcomes may not be good surrogates for actual patient outcomes or improvement in pulmonary function in early-onset scoliosis [85]. Surgical treatment for adult lumbar and thoracolumbar scoliosis in patients over 50 is associated with a high rate of complications (44%) and a significant risk of requiring a second operation (50% at 6 years) [18]. Operative treatment of idiopathic scoliosis in adults resulted in a significantly greater decrease in pain and fatigue and significantly more improvement in self-image and functional ability compared to untreated patients [80]. Back pain alone is not a surgical indication, and surgical correction of AIS does not have a clear association with improvement or worsening of pain [170]. Patients who have surgery for idiopathic scoliosis are likely to have better long-term outcomes than are patients who have surgery for spondylolisthesis [25].

Other Considerations: Patients and families seeking treatment for idiopathic scoliosis value appearance and preservation of spinal motion and, to a lesser extent, reoperation rates when considering fusion versus non-fusion surgery [76].

Complications

Surgical Complications

Junctional kyphosis, infection, and implant failure: Junctional kyphosis, surgical site infection, and implant failure are common complications in the management of early-onset scoliosis [85]. Neurologic deficits: Neurologic deficits following spinal surgery have been reported in patients with neural axis abnormalities that were not recognized preoperatively [38]. Anterior vertebral body tethering: Anterior vertebral body tethering is associated with an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis [83]. VEPTR implantation: VEPTR implantation after age 3 is associated with fewer complications compared to implantation in patients younger than 3 years [5]. Ponte osteotomies: Ponte osteotomies increase the risk of neuromonitoring alerts in adolescent idiopathic scoliosis correction surgery [46].

Respiratory and Pulmonary Complications

Thoracic insufficiency syndrome: Thoracic insufficiency syndrome is defined as an inability of the thorax to support normal respiration and lung growth [19]. Patients presenting under age 6 with early-onset scoliosis comprise the high-risk group for developing this syndrome [19]. Pulmonary function deficits: Up to 19% of patients with adolescent idiopathic scoliosis have moderately impaired pulmonary function (<65% predicted forced expiratory volume in 1 second) preoperatively, with a mean thoracic curve magnitude of 70° [22]. Additionally, 52% of patients with mild to moderate idiopathic scoliosis had significant reduction of pulmonary volume, best reflected by vital capacity [144]. The greater the curve magnitude, the greater the deficit in vital capacity in patients with idiopathic scoliosis [144]. Management goals: A realistic long-term goal for the management of early-onset scoliosis is spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation [12].

Long-Term Health and Functional Outcomes

Quality of life: Patients with idiopathic scoliosis have significantly decreased health-related quality of life and capacity to work 40 years after diagnosis [56]. Functional outcomes: Even moderate progression of smaller magnitude lumbar scoliosis into adulthood may be associated with more negative functional outcomes, such as increasing back pain, than previously thought [22].

Diagnostic and Preoperative Considerations

Neural axis abnormalities: An abnormality of the central nervous system is present in approximately 10% of patients with presumed adolescent idiopathic scoliosis in whom only subtle abnormalities are identified on clinical history, physical examination, or radiographic examination [17]. The incidence of neural axis abnormalities in patients with juvenile idiopathic scoliosis is 18% to 26% [38].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living following adolescent idiopathic scoliosis treatment.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing progression, or timing for sling or brace removal.

Functional milestones: The provided evidence does not report validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks for recovery.

Other Considerations: The natural history of scoliosis is dependent on deformity magnitude after skeletal maturity [22]. In a long-term study with an average follow-up of 40 years, the average progression of thoracic curves less than 30° at skeletal maturity was 2.6° [22]. For thoracic curves between 30° and 50° at skeletal maturity, the average progression was 10.2° [22]. Thoracic curves between 50° and 75° at skeletal maturity progressed an average of 29.4° [22]. Lumbar curves less than 30° at skeletal maturity showed 0° average progression [22]. Lumbar curves between 30° and 50° at skeletal maturity progressed an average of 15.4° [22], while lumbar curves between 50° and 75° progressed an average of 18.5° [22]. Radiographic outcomes for patients with curves between 30° and 50° at skeletal maturity are dependent on the location of the deformity, with lumbar curves at increased risk for progression compared with thoracic curves [22]. A general indication for surgery is a deformity greater than 50° due to the risk of progressive deformity into adulthood [22].

The population incidence of serious curves (over 30 degrees) in adolescent idiopathic scoliosis is 3 per 1000 [21]. If a curve starts to progress, it usually continues to do so until skeletal maturity and, to a much lesser degree, beyond that [21]. Reliable predictors of progression in untreated idiopathic scoliosis include very young age at onset, marked curvature, and an incomplete Risser sign [21]. The prognosis in idiopathic scoliosis varies by curve pattern and age at onset, with main thoracic curves increasing to greater deformities than other patterns [30]. Scoliotic deformity increases as long as vertebral growth continues, with the average age of growth cessation being 14.5 years in girls and 16.3 years in boys [202]. Completion of vertebral growth, indicated by the completion of iliac epiphyseal ossification, results in the arrest of the curvature [202]. Patients with idiopathic scoliosis may need to be followed up in a timely and appropriate manner for decades rather than for just a few years [9]. In a long-term follow-up study, patients with idiopathic scoliosis had significantly decreased health-related quality of life and capacity to work 40 years after diagnosis [56]. The stability of scoliosis was not related to the age of the patient in the context of pregnancy [70].

Early-onset scoliosis is defined as a spinal curvature in the coronal plane of greater than 10° with onset under 10 years of age [34]. Children with early-onset scoliosis are at risk for impaired pulmonary function from their spinal deformity due to constraints on the thorax during a critical time of lung development [34]. The natural history of untreated early-onset scoliosis is associated with significant morbidity and potential for cardiopulmonary compromise, including respiratory failure and cor pulmonale [34]. A Swedish study demonstrated more than double the mortality rate by the age of 40 years in patients with early-onset scoliosis compared with that of the general population [34]. Patients presenting under age 6 comprise the high-risk group for developing thoracic insufficiency syndrome [19]. Correcting the spinal deformity permitted longer-term improvement in pulmonary function in patients with severe early-onset scoliosis [176]. Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their early-onset scoliosis than children with idiopathic early-onset scoliosis [71]. Children with skeletal dysplasia had significantly lower health-related quality of life both preoperatively and at final follow-up than children with idiopathic early-onset scoliosis [71]. Approximately 18% of early-onset scoliosis patients experienced proximal junctional kyphosis after traditional growing rods treatment [189]. Long-term follow-up after final fusion is necessary to determine true final results in patients treated with growing rods for early-onset scoliosis [173].

In a study of 54 children with early-onset scoliosis treated with Mehta Casting, 49% had improved scoliosis to less than 15° at minimum 5-year follow-up [22]. In the same study, 73% improved by at least 20° at minimum 5-year follow-up [22]. The initial Cobb angle, first-cast Cobb angle, rib-vertebral angle difference, and traction Cobb angle were predictive of sustained scoliosis of ≤15° in children treated with Mehta Casting [22]. Relapse of scoliosis was seen in 3 patients with continued growth after Mehta Casting treatment [92]. In a study of 21 patients with an average age of 2.1 years who underwent serial casting for early-onset scoliosis, the patient’s body mass index and age younger than 1.8 years at the initiation of casting were important predictors of success [23]. Full-time and part-time bracing were equally effective in preventing progression of curves of 40 degrees or less in skeletally immature patients who had adolescent idiopathic scoliosis [201]. It is currently impossible to state that bracing effectively alters the natural history of scoliosis in immature patients who are at high risk for progression [66]. There is no evidence to support the efficacy of chiropractic manipulation, electrical stimulation, and traction for the management of spinal deformity [47].

Scoliosis correction after anterior spinal growth tethering was associated with overall height changes and occurred primarily within 2 to 3 years after surgery in a cohort of largely Risser stage-0 patients [51]. At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent anterior vertebral body tethering had a residual curve of <35 degrees compared with 97.4% of patients who underwent posterior spinal fusion [86]. Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation, even if patients with lumbar curves were excluded [182]. VEPTR treatment resulted in similar deformity control and thoracic growth in patients younger than 3 years and in those 3 to 6 years of age [5]. Lower complication rates were reported for VEPTR treatment in the older age group (3 to 6 years) compared to patients younger than 3 years [5].

Key Evidence

• [L5] Successful management of idiopathic scoliosis requires understanding the etiology, natural history, evaluation, and available nonsurgical and surgical management options for these patients. [1] (10.5435/00124635-200602000-00005)
• [L4] Nonoperative management of moderate idiopathic curves remains a realistic option in early onset scoliosis, and can be proposed as a 'delaying tactic' for surgery until adolescent years. [3] (10.1016/j.otsr.2014.05.024)
• [L4] Juvenile idiopathic scoliosis warrants consideration as a separate and distinct entity from adolescent idiopathic scoliosis due to its rapid progression during the adolescent growth spurt and the high need for early operative management. [4] (10.2106/00004623-199608000-00003)
• [L4] Anterior spinal fusion produces good long-term functional outcomes in adolescent idiopathic scoliosis with satisfactory and sustained correction. [6] (10.1016/j.otsr.2015.12.011)
• [L4] This review elucidates early-onset scoliosis in terms of its aetiology, pathogenesis, pathology and treatment, highlighting that therapeutic strategies must preserve the growing spine and thorax while correcting deformity. [8] (10.1186/s13018-023-03665-0)
• [L5] Scoliosis is a life-long condition with potentially significant poor health-related quality of life scores many years after diagnosis, indicating that patients may need to be followed up in a timely and appropriate manner for decades rather than for just a few years. [9] (10.1302/0301-620x.105b2.bjj-2022-1298)
• [L5] Although several difficult problems in the diagnosis and treatment of adolescent idiopathic scoliosis have been resolved by understanding its mechanism and via technical advancement, no definite guideline for fusion level selection has been established. [10] (10.1016/j.spinee.2017.03.020)
• [L4] A realistic long-term goal for the management of early-onset scoliosis appears to be spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation. [12] (10.2106/jbjs.16.00796)
• [L3] The study identified curve magnitude, Risser sign, and chronological age as the strongest predictors of progression in untreated idiopathic scoliosis. [13] (10.2106/00004623-198466070-00013)
• [L3] When a patient with scoliosis has back pain, a careful history, thorough physical examination, and good-quality plain radiographs should be performed; if initial evaluation reveals normal findings, a diagnosis of idiopathic scoliosis can be made and non-operative treatment initiated. [14] (10.2106/00004623-199703000-00007)
• [L4] Lumbar and thoracolumbar scoliosis may be strongly progressive after skeletal maturity, arguing for more aggressive management during adolescence. [16] (10.1016/j.otsr.2015.05.004)
• [L3] An abnormality of the central nervous system is present in approximately 10% of patients with presumed adolescent idiopathic scoliosis in whom only subtle abnormalities are identified on the basis of the clinical history, physical examination, or radiographic examination. [17] (10.2106/00004623-200410000-00009)
• [L4] Surgical treatment for adult lumbar and thoracolumbar scoliosis in patients over 50 is associated with a high rate of complications (44%) and a significant risk of requiring a second operation (50% at 6 years). [18] (10.1016/j.otsr.2012.04.014)
• [L5] [20] (10.1302/0301-620x.104b8.bjj-2021-1638.r1)
• [L4] This study reports the lowest rates to date of intraspinal anomalies in patients with early onset idiopathic scoliosis, suggesting geographical variation. [23] (10.1302/0301-620x.99b6.bjj-2016-1159.r1)
• [L3] The study provides no evidence that untreated mild idiopathic scoliosis occurs or progresses in girls of ages 10 to 16 because of increased joint flexibilities. [24] (10.1002/jor.1100010108)
• [L3] Patients who have surgery for idiopathic scoliosis are likely to have better long-term outcomes than are patients who have surgery for spondylolisthesis. [25] (10.2106/jbjs.g.00114)
• [L5] Objective criteria using spinopelvic parameters and preoperative three-dimensional planning can guide sagittal plane correction during posterior spinal fusion for adolescent idiopathic scoliosis. [26] (10.5435/jaaos-d-21-01060)
• [L4] [28] (10.2106/00004623-199609000-00006)
• [L4] The current method of classification of adolescent idiopathic scoliosis does not appear to have sufficient intraobserver or interobserver reliability among scoliosis surgeons to portray curve types accurately. [29] (10.2106/00004623-199808000-00002)
• [L3] The prognosis in idiopathic scoliosis varies considerably by curve pattern and age at onset, with main thoracic curves increasing to greater deformities than other patterns. [30] (10.2106/00004623-195032020-00017)
• [L1] Therefore, a high dose appears to be effective and safe for adolescent idiopathic scoliosis surgery. [31] (10.1186/s13018-020-02158-8)
• [L3] This study establishes spondylolysis as a clinically impactful comorbidity in adolescent idiopathic scoliosis, associated with increased postoperative pain, dysfunction, and distal junctional complications. [33] (10.1186/s13018-025-06356-0)
• [L4] All patients with 'idiopathic' scoliosis deserve a careful neurological evaluation, even if they have minimal muscle symptoms in the extremities. [35] (10.1186/s12891-015-0629-8)
• [L4] The literature does not support routine definitive fusion of thoracic spinal deformity at an early age in children with scoliosis. [37] (10.1007/s11999-010-1622-z)
• [L1] [40] (10.2106/jbjs.o.00330)
• [L3] Adoption of the threshold of ATI 5° in screening tests for children aged 6–12 years, as well as for lower locations of scoliosis, may be more effective in the early detection of scoliosis. [41] (10.1186/s12891-021-04965-4)
• [L3] Obstructive lung disease is present in 21% to 39% of patients scheduled for surgical correction of thoracic adolescent idiopathic scoliosis. [42] (10.2106/jbjs.20.01714)
• [L1] Active self-correction demonstrated superior short-term benefits compared to other exercise interventions in ameliorating spinal deformity and improving quality of life for adolescents with idiopathic scoliosis. [44] (10.1186/s12891-024-08223-1)
• [L3] Scoliosis correction was associated with overall height changes and occurred primarily within 2 to 3 years after surgery in this cohort of largely Risser stage-0 patients. [51] (10.2106/jbjs.20.02071)
• [L5] All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis, offering superior deformity correction and shorter fusions compared with hook instrumentation. [52] (10.5435/00124635-200909000-00002)
• [L3] In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis. [56] (10.1302/0301-620x.105b2.bjj-2022-0897.r1)
• [L4] Vertebral wedging was present in mild scoliosis and increased as the scoliosis progressed. [63] (10.1371/journal.pone.0071504)
• [L4] It is currently impossible to state that bracing effectively alters the natural history of scoliosis in immature patients who are at high risk for progression. [66] (10.2106/00004623-199604000-00009)
• [L4] The stability of the scoliosis was not related to the age of the patient. [70] (10.2106/00004623-198062070-00005)
• [L3] Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their early-onset scoliosis and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic early-onset scoliosis. [71] (10.1302/0301-620x.101b12.bjj-2019-0735.r1)
• [L4] There appears to be a type of patient with idiopathic scoliosis in whom there is an excessive loss of pulmonary function relative to the amount of scoliosis. [73] (10.2106/00004623-197557070-00016)
• [L4] Patients and families seeking treatment for idiopathic scoliosis value appearance and preservation of spinal motion and, to a lesser extent, reoperation rates when considering fusion versus non-fusion surgery. [76] (10.2106/jbjs.23.00503)
• [Paper] This thoracoscopic approach is a reproducible and effective treatment that takes advantage of continued spinal growth in pediatric patients with adolescent idiopathic scoliosis, who would otherwise require spinal ardesis. [77] (10.1016/j.eats.2020.11.003)
• [L4] Coronal curve severity is associated with reduced axial and coronal range of motion in adolescent idiopathic scoliosis patients. [79] (10.1186/s12891-017-1423-6)
• [L3] Operative treatment of idiopathic scoliosis in adults resulted in a significantly greater decrease in pain and fatigue and significantly more improvement in self-image and functional ability compared to untreated patients. [80] (10.2106/00004623-199504000-00003)
• [L3] Findings suggested that scoliotic curvatures in preoperative AIS patients can be largely represented by both imaging modalities despite the difference in body positioning. [82] (10.1186/s12891-020-03561-2)
• [L3] AVBT is associated with satisfactory correction of deformity and an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis. [83] (10.1302/0301-620x.102b12.bjj-2020-0426.r1)
• [L3] At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent AVBT had a residual curve of <35 degrees compared with 97.4% of patients who underwent PSF. [86] (10.2106/jbjs.22.00127)
• [L3] These findings suggest that there is no clear advantage in using a high number of implants per operated vertebra in the surgical treatment of patients with idiopathic scoliosis. [87] (10.1302/0301-620x.100b8.bjj-2017-1114.r1)
• [L4] [91] (10.2106/00004623-199408000-00010)
• [L4] However, with continued growth, relapse of scoliosis was seen in 3 patients. [92] (10.2106/jbjs.18.01268)
• [L1] In skeletally immature patients with idiopathic scoliosis, braces designed by an automated generative algorithm were noninferior to those designed by expert orthotists for immediate in-brace correction. [93] (10.2106/jbjs.25.00926)
• [L4] This new two-dimensional classification of adolescent idiopathic scoliosis, as tested by two groups of surgeons, was shown to be much more reliable than the King system. [96] (10.2106/00004623-200108000-00006)
• [L3] Radiographic analysis provides limited information about the spine's overall alignment because it does not reflect the trunk's dynamic position during daily activities. [102] (10.1016/j.otsr.2019.12.023)
• [L3] Early onset scoliosis would have a severe impact on pulmonary function if not treated properly. [109] (10.1186/s13018-025-05630-5)
• [L3] Back pain is common in patients with adolescent idiopathic scoliosis (AIS), but chronic back pain is seen in fewer than 10% of patients. [111] (10.1097/corr.0000000000000689)
• [L3] Early screening for incorrect postures and angle of trunk rotation could be an effective and economical strategy to predict the severity of the condition. [116] (10.1186/s13018-024-04767-z)
• [L4] Conservative treatment should be the first-line treatment for most cases of early-onset scoliosis because it has fewer complications associated with it than surgery. [117] (10.1016/j.otsr.2014.06.032)
• [L3] Children with adolescent idiopathic scoliosis have a higher prevalence of psychiatric disorders compared to children without AIS, and surgeons should provide early referral to pediatric psychiatrists. [118] (10.1097/corr.0000000000001716)
• [L1] Physical activity is strongly associated with adolescent idiopathic scoliosis. [119] (10.1186/s12891-023-07114-1)
• [L4] Clinically actionable pathogenic mutations in genes associated with adolescent idiopathic scoliosis and aortic aneurysm are rare in patients with adolescent idiopathic scoliosis who are not suspected of having these disorders, although variants of unknown significance are relatively common. [122] (10.2106/jbjs.o.00290)
• [L2] There was a high level of agreement between telehealth and in-person spine measurements, suggesting that telehealth visits may be reliably used to evaluate adolescent idiopathic scoliosis, thus improving access to specialized care. [130] (10.2106/jbjs.23.01146)
• [L2] Strong and consistent evidence supports Cobb angle, curve type, flexibility, and correction rate as predictors of curve progression. [133] (10.1302/0301-620x.104b4.bjj-2021-1677.r1)
• [L4] Cervical kyphosis is among the most prevalent morphological alterations in patients with AIS and is closely associated with curve severity. [136] (10.1186/s12891-026-10014-9)
• [L3] The coronal Cobb angle and the SI of paraspinal muscle activity in AIS patients vary with posture changes. [138] (10.1186/s12891-024-07329-w)
• [L3] Variations of spinal growth velocity exerted more direct influence over changes in angle velocity as compared with height velocity. [142] (10.1186/s12891-016-1221-6)
• [L4] The new 3D classification has the potential to identify the subtypes of the Lenke 1 AIS without a need for quantitative 3D image post-processing. [143] (10.1186/s12891-020-03798-x)
• [L4] [144] (10.2106/00004623-196446010-00005)
• [L5] [145] (10.2106/00004623-195436030-00017)
• [L4] The results indicate that compensatory strategies are potentially seen at lower levels of the spine. [146] (10.1186/1471-2474-6-14)
• [L3] Morphometric characteristics of vertebral bodies differed according to the pathogenesis of scoliosis, and the pathology of the wedging of vertebral bodies in idiopathic scoliosis could not be a result only of asymmetric loading to the vertebral bodies. [150] (10.1186/s12891-017-1801-0)
• [L3] The biomechanical parameters of the lower limbs are affected in cases of scoliosis with an altered coronal balance, with the lower limb on the side of decompensation becoming shorter, having a lower collodiaphyseal angle, and increased varus at the knee joint. [151] (10.1016/j.otsr.2018.06.002)
• [L4] The use of the single Harrington distraction rod is a safe and effective treatment for patients who have adolescent idiopathic scoliosis with a curve in the thoracic spine and for patients with a thoracolumbar curve that does not require fusion below the fourth lumbar vertebra. [155] (10.2106/00004623-198668090-00004)
• [L3] Cotrel traction did not improve the results of treatment of idiopathic scoliosis of 40 to 90 degrees in patients less than twenty years old. [156] (10.2106/00004623-197759040-00015)
• [L1] Leaving out the subfascial drain after correction of adolescent idiopathic scoliosis is non-inferior to using a drain regarding blood loss, haemoglobin drop, and opioid consumption. [159] (10.1302/0301-620x.104b9.bjj-2022-0391.r1)
• [L5] Magnetic resonance is an excellent modality for imaging pathologic processes in the pediatric spine, allowing high-resolution views of osseous and soft-tissue structures. [160] (10.5435/00124635-200307000-00004)
• [L4] The coexistence of dynamic plantar pressure asymmetries and weak associations with static pelvic alignment suggests that structural deformities alone may not adequately explain functional loading behavior in AIS. [161] (10.1186/s12891-026-10130-6)
• [L4] Although causal relationships remain to be fully established, these interconnected mechanisms provide a coherent framework linking immune dysregulation, musculoskeletal remodeling, and curve progression in AIS. [167] (10.1186/s13018-026-06837-w)
• [L5] [170] (10.5435/jaaos-d-24-00297)
• [L4] Long-term follow-up after final fusion is necessary to determine true final results. [173] (10.2106/jbjs.15.01334)
• [L4] Correcting the spinal deformity permitted longer-term improvement in pulmonary function in patients with sEOS. [176] (10.2106/jbjs.22.01088)
• [L4] The Lenke classification system was designed to improve upon the King classification by addressing limitations such as the lack of sagittal plane assessment and poor reliability, achieving good-to-excellent intraobserver and interobserver reliability in multiple studies. [178] (10.1097/corr.0000000000000405)
• [L5] Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation, even if patients with lumbar curves were excluded. [182] (10.2106/00004623-200408000-00038)
• [L3] [187] (10.1097/blo.0b013e3180986dc2)
• [L3] Approximately 18% of early-onset scoliosis patients experienced proximal junctional kyphosis after traditional growing rods treatment. [189] (10.1186/s12891-022-05564-7)
• [L5] [190] (10.5435/jaaos-d-21-01175)
• [L1] [192] (10.1186/s13018-020-01988-w)
• [Paper] [193] (10.1097/corr.0000000000003387)
• [L5] Management and treatment of early-onset scoliosis should pursue a holistic approach in which the psychological impact and quality of life of the patient are also taken into consideration. [195] (10.1530/eor-22-0040)
• [L3] Because there was no significant difference between readings from the concave and convex sides, it is unlikely that a lesion of the posterior column is responsible for idiopathic scoliosis. [199] (10.2106/00004623-199173080-00010)
• [L3] In the present study, idiopathic scoliosis patients seemed to have lower BMD at central skeletal sites and less evident differences at peripheral skeletal sites when compared with controls. [200] (10.1302/0301-620x.102b2.bjj-2019-1016.r1)
• [L4] The proximal femoral epiphysis is visible in routine spine radiographs, allowing skeletal maturity assessment through convenient viewing and thus avoiding additional radiation exposure. [206] (10.2106/jbjs.21.00747)
• [L4] There is clinically important asymmetry in the morphologic features of pedicles in individuals with adolescent idiopathic scoliosis, with the concave side being smaller in height and width periapically and having a more acute trajectory compared to the convex side. [207] (10.1007/s11999-016-5188-2)

References

[1] Early Onset Idiopathic Scoliosis. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200602000-00005

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