If a diagnosis of scoliosis is made, Risser staging should be completed. Risser sign is a growth marker noted in adolescents by viewing iliac apophyseal ossification on radiograph. The progress of bone fusion over the iliac apophysis reflects remaining skeletal growth and is graded from 0 to 5, with 0 representing no ossification of the iliac apophysis and 5, complete ossification. The lower the grade noted at curve detection, the greater the risk for curve progression.3,4
Other tests may be warranted. If a patient has persistent back or side pain, especially pain that wakens the patient at night, and/ or pain not relieved by aspirin or NSAIDs, then a bone scan should be ordered to rule out discitis, rib or spine osteoid osteoma, spinal or intradural tumors, osteomyelitis, or other abnormalities.7 An MRI is warranted in children younger than 10; those who have left-sided curves, headaches, or neck pain; patients with quickly progressing curves; and those with any abnormality on neurologic exam. This test is generally not necessary in those with AIS if no family history is present and physical exam findings are unremarkable.1,2,5,7 Laboratory tests are generally not ordered for patients with idiopathic scoliosis unless inflammatory or infectious processes are suspected; standard laboratory tests would then follow. The ScoliScoreTM (Axial Biotech, Salt Lake City), a newer genetic screening test, can be used along with clinical and radiographic testing in patients with AIS. It is felt that specific genes are associated with AIS, and this test may help detect them and determine any associated risk for curve progression.1,3
There are several genetic tests for conditions associated with congenital neuromuscular or syndrome-related scoliosis.12,32 These may be ordered by the primary care provider, an orthopedist, or the geneticist.
REFERRAL
According to some researchers, any child with scoliosis greater than 10° should be referred to an orthopedist, preferably a pediatric spine orthopedist, especially when the patient is younger than 10. Referral is also recommended when the curve is left thoracic, or if any abnormal physical findings or a positive family history is present.4,5,7 There is also support for a strategy in which the practitioner closely observes the patient older than 10 with scoliosis but no other abnormalities, then refers the child once the curve reaches 20° to 25°.7 Referral within three months is most likely indicated for those with typical scoliosis and within one month for atypical scoliosis.7
Each practitioner will develop his or her own comfort level in the management of idiopathic scoliosis. Once a referral has been made, the practitioner should follow up to be sure the patient has seen the specialist in a timely fashion, with no appointments missed. Curve progression can develop rapidly, possibly making treatment more difficult once it begins.
TREATMENT
Three main types of treatment are provided for scoliosis: observation, bracing, and surgery.3,5,7 Observation is generally considered sufficient for immature patients whose curves measure less than 25°; usually no treatment will be needed for mature patients with curves less than 25°. Depending on risk stratification, children will initially need serial radiographs every four to six months.2
Most children will be seen by an orthopedist at this point.2,3,22 Oftentimes orthopedists with adult patients will order radiographs every three to five years to be sure the scoliosis has not progressed.3 Treatment of children with neuromuscular or syndrome-related scoliosis is lengthy and will not be addressed in this review.
Orthotic management (bracing or casting) is usually started once the immature patient's curve is between 25° and 45°. Brace treatment is not used to alter or correct scoliosis, but rather to halt its progression until the patient is skeletally mature (more common), a spinal fusion occurs (less common), or both.5 A 20% to 24% risk for eventual surgery has been reported in patients treated with braces.25,33 In infants or young children with congenital (or other) scoliosis, several temporary management options can be used to prevent curve progression while allowing the child's thorax to grow and expand.2
Several surgical interventions are appropriate for scoliosis. For infants or young children, one surgical intervention is the vertical expandable prosthetic titanium rib (VEPTRTM [Synthes, Inc, West Chester, Pennsylvania]). This is a longitudinal rib distraction device that can attach from rib to rib, rib to spine, or rib to pelvis. The device is indicated in the presence of a constrictive chest wall syndrome, which can decrease lung volumes and cause severe deformity if untreated. The device is lengthened every 4 to 6 months, with the goal to delay a final fusion until skeletal maturity.2
The growing rod, a comparable temporary device, is inserted spine to spine and lengthened similarly at various intervals. Growing rods are usually used in older children with scoliosis who await maturity before undergoing a definitive spinal fusion.2