Treatment of adolescent idiopathic scoliosis and evaluation of the adolescent patient

Abstract

Adolescent idiopathic scoliosis (AIS) is a three-dimensional, multi-faceted deformity of the vertebral column. Although screening is mandated by several states, debate exists surrounding the efficacy or utility of in-school scoliosis screenings. Detailed history and physical examination are crucial to this diagnosis of exclusion. Assessment of curves has long been limited to static radiography; however, use of MRI may permit detection of associated spinal anomalies, while three-dimensional gait analysis may permit improved understanding of functional improvement in AIS patients before and after treatment. Nonoperative management includes bracing, which is a complex, yet important, component to treatment of AIS. The Bracing in Adolescents with Idiopathic Scoliosis Trial (BrAIST) and other studies have revealed the potential for halting curve progression and a positive dose-response relationship of bracing. Surgical management has focused on the mainstay of posterior spinal fusion with pedicle screw fixation and rod instrumentation, with new techniques under development that modify fusion and fixation or focus on different approaches altogether (i.e. vertebral body tethering). This article details evaluation and treatment of AIS, supplemented by a review of the historical progression of management, to equip readers with an appreciation for the complex nature of this pathology and its treatment.

Current concepts in the diagnosis and management of adolescent idiopathic scoliosis

“…The pathophysiology of AIS is largely unknown; however, several studies suggest a genetic aspect [4]. Studies indicate an increased risk of developing AIS in people who have first degree relatives affected by AIS (prevalence of 6-11%) [9].…”

“…Standard radiological images include upright standing posteroanterior (PA) and lateral views [43]. The location of the apex vertebrae should be determined and corresponds to the curves name: cervical, thoracic, thoracolumbar or lumbar curves [43,45].The main Cobb angle is measured by identifying the largest curve and its two end vertebrae (EV), defined as the maximally tilted vertebrae cephalad and caudal to the curve's apex [4]. The Cobb method is then utilised by drawing lines along the superior border of the upper EVand the inferior border of the lower EV to form the Cobb angle [4,43].…”

“…The location of the apex vertebrae should be determined and corresponds to the curves name: cervical, thoracic, thoracolumbar or lumbar curves [43,45].The main Cobb angle is measured by identifying the largest curve and its two end vertebrae (EV), defined as the maximally tilted vertebrae cephalad and caudal to the curve's apex [4]. The Cobb method is then utilised by drawing lines along the superior border of the upper EVand the inferior border of the lower EV to form the Cobb angle [4,43]. Additional imaging, such as magnetic resonance imaging, is reserved for patients with an atypical presentation of AIS suggestive of other underlying aetiologies [43].…”

“…Although a method for classifying scoliosis was first described by John Cobb in 1948, further advances in surgical techniques meant that Lawrence Lenke published a new set of guidelines in 2001 allowing surgeons to decide the best method of treatment depending on curve pattern [3]. Whilst recent research largely maintains that AIS is a multifactorial etiological disease, further studies have advanced our understanding of this deformity as multifaceted with a polygenetic background [4]. Surgery for AIS aims to relieve pain and improve function and cosmetics with minimal rates of complications [5].…”

Ahead of the Curve: Pediatric Scoliosis

“…Although some controversy exists, it is generally reserved for children with remaining growth potential but who are at least 10 years of age. 37 Vertebral body tethering allows correction of the deformity while preserving motion that is lost with posterior spinal fusion. This is accomplished using vertebral body screws connected with a polyester cable.…”