The goal of surgical treatment of adolescent idiopathic scoliosis is to partially correct and stabilize the scoliosis, reduce clinical deformity, and re-establish or maintain spinal balance. The indications for surgery for adolescent idiopathic scoliosis should take into account other factors such as skeletal development level, sagittal plane changes, and vertebral rotation in addition to measurement of Cobb angle size. Adolescents with scoliosis over 50o should be treated surgically. scoliosis over 40o should be considered for surgical treatment if it develops after non-surgical treatment. For adolescent scoliosis that does not develop significantly between 40 and 50o, a specific analysis should be made, and the first step should be to observe whether the scoliosis has developed, and if it has, surgery should be considered. The degree of skeletal maturation is also important in deciding on surgery. For example, the same 45o scoliosis should be observed in girls with Risser’s sign grade 3 or 4, after the first menstruation at the age of 14. In contrast, in girls who have not yet reached menarche and have Risser’s sign grade 0 or 1, their natural history suggests that scoliosis will continue to develop and that bracing will not be effective for this type of scoliosis and should therefore be treated surgically. When considering surgery for adolescent idiopathic scoliosis, the sagittal plane changes should also be analyzed. In patients with reduced thoracic physiological lordosis or even anterior thoracic deformity, surgery should be considered when the thoracic anterior lordosis increases or when the anterior lordosis is -10o, regardless of whether the coronal Cobb angle is less than 40o. Yang Cao, Department of Orthopedics, Wuhan Union Medical College Hospital
There are absolute and relative indications for surgical treatment of idiopathic scoliosis after skeletal development has matured. Pain, progressive worsening of the deformity, cardiopulmonary symptoms, neurological dysfunction, and appearance are all factors to consider for surgery. Pain is the most common symptom, yet progressive worsening of the deformity is the most widely accepted indication for surgery. Although cardiopulmonary symptoms are uncommon, they can occur in patients with thoracic lateral convexity greater than 60o. Therefore, patients with thoracic scoliosis greater than 60o should undergo spinal fusion. Appearance is not a major indication for surgical treatment of scoliosis in adults. However, it is an important factor and should be considered along with other factors.
In adult scoliosis, the need for surgery is determined according to the following methods: evaluation and treatment of asymptomatic patients under 25 years of age is similar to that of adolescent scoliosis; surgery is recommended for progressive scoliosis with thoracic scoliosis greater than 60o and greater than 50o; adult scoliosis patients with scoliosis up to 50o and no signs of progression and older than 25 years of age should be examined on x-ray once a year. If there is no progression of scoliosis after 4 to 5 years of follow-up, the patient can stop the follow-up; if it is confirmed that there is no progression of scoliosis and there is no respiratory or neurological dysfunction, annual follow-up is recommended for asymptomatic adult scoliosis with a Cobb angle between 60o and 70o; based on scoliosis alone, surgery should be considered for adult scoliosis with an angle greater than 70o.
Most patients with severe pain but no evidence of scoliosis exacerbation have non-surgical treatment options, including non-narcotic pharmacologic analgesia, medications, local injections, and physical therapy. Geriatric patients may also be treated with bracing. Surgery is considered only in patients with occasional severe pain that does not respond to extensive conservative treatment.
Respiratory failure is rare but can be a serious manifestation of adult scoliosis. Careful preoperative evaluation is required to determine whether surgical or non-surgical treatment is beneficial to the patient. These patients can be treated with cranial traction and should be treated with intensive respiratory therapy. If it is confirmed that the patient’s respiratory function improves and pulmonary function allows, further deterioration of pulmonary and cardiopulmonary function may be prevented by partial orthosis or fixation of the deformity.
Neurological dysfunction is an indication for surgical treatment. If significant spinal cord compression or spinal cord lesions are present, spinal cord decompression and internal fixation and fusion are recommended. Minor spinal cord involvement such as a mild increase in muscle tone or clonus can be decompressed indirectly through spinal orthopedics. Elderly patients with scoliosis often have nerve root involvement, and treatment should be determined by the location of the nerve root involvement. In most cases, the patient will have spinal stenosis at the level of lumbar 3 to 4 and lumbar 4 to 5 below the primary deformity, and the same treatment can be used with or without scoliosis. If the patient has nerve root involvement around the parietal or lumbar scoliosis, simple decompression may aggravate the deformity and nerve root recompression, and care should be taken to perform partial orthopedic and spinal fixation, with or without direct decompression as an option.