Scoliosis: A Literature Review

Abstract

Scoliosis is a condition in which the spine has a lateral curve and rotation, which can cause prominence of the thorax, shoulder blade, shoulders and pelvis are asymmetrical. It is more common in adolescent females and usually has no known cause. Scoliosis in young children is more likely to have a known cause. Risk factors for progression include: type of abnormality, location of abnormality, and patient age. Plain radiographic images are still the standard for diagnosis. MRI evaluation may be considered. Scoliosis management aims to achieve body and spinal balance while maintaining as much normal spinal growth as possible and preventing neurological deficits. Treatment focuses on identifying and monitoring curves that may worsen and treating them if necessary.

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Hong Kong Journal of Orthopaedic Research 2023; 6(1): 4-11
Review Article
Hong Kong J Orthop Res
2023; 6(1): 4-11
ISSN (e): 2663-8231
ISSN (p): 2663-8223
© 2023, All rights reserved
www.hkorthopaedicjournal.com
DOI: 10.37515/ortho.8231.6102
*Corresponding author:
Febyan
Resident of Orthopaedics and
Traumatology, Faculty of
Medicine, University of
Udayana, Prof Ngoerah General
Hospital, Denpasar, Indonesia
Email: febyanmd@gmail.com
Scoliosis: A Literature Review
I Gusti Ngurah Paramartha Wijaya Putra1, Febyan2
1 Department of Orthopaedics and Traumatology, Faculty of Medicine University of Udayana, Udayana Hospital, Bali,
Indonesia
2 Resident of Orthopaedics and Traumatology, Faculty of Medicine, University of Udayana, Prof Ngoerah General
Hospital, Denpasar, Indonesia
Abstract
Scoliosis is a condition in which the spine has a lateral curve and rotation, which can cause prominence of the thorax,
shoulder blade, shoulders and pelvis are asymmetrical. It is more common in adolescent females and usually has no
known cause. Scoliosis in young children is more likely to have a known cause. Risk factors for progression include: type
of abnormality, location of abnormality, and patient age. Plain radiographic images are still the standard for diagnosis.
MRI evaluation may be considered. Scoliosis management aims to achieve body and spinal balance while maintaining as
much normal spinal growth as possible and preventing neurological deficits. Treatment focuses on identifying and
monitoring curves that may worsen and treating them if necessary.
Keywords: Spine, Scoliosis, Deformity, Review.
INTRODUCTION
Scoliosis is a deformity of the spine has a lateral curvature of more than 10 degrees. There are different
types of scoliosis, such as idiopathic and secondary, and it can also be classified by the side of the curve and
the age at which it occurs [1]. The prevalence of scoliosis ranges from 2-13.6% across different countries [2,3].
The rate of occurrence of adolescent idiopathic scoliosis among students aged 9-16 in Surabaya, Indonesia
elementary and junior high schools is 2.93% out of a total of 784 students [4]. Scoliosis is still considered as
idiopathic condition, but it is thought to be influenced by a mixture of genetic, growth, hormonal, and
neurological factors, as well as changes in bone mass density (BMD), abnormalities in body tissue, and
imbalances in certain chemicals in the body [5].
Scoliosis can be treated by addressing the underlying cause. The treatment of scoliosis depends on
understanding the natural mechanism of the curve and its complication [6]. However, it's important to note
that there is no exact characteristic of the illness, but rather varying subjective complaints that can vary
depending on the type of curve [7]. This literature review discusses on various forms of scoliosis, the potential
for the condition to worsen, and the methods used for evaluating and treating scoliosis.
Natural History of Scoliosis
Scoliosis is considered to be a inherited disease with siblings and parents to child coincidence [8]. When first
diagnosed, the primary focus is usually determining if the cause is idiopathic or non-idiopathic. Non-
idiopathic reasons typically manifest earlier, advance faster, and may exhibit neurological signs [9,10].
Scoliosis typically manifests as a deformity that the patients, their family, or friends first notice. This
deformity may be a curvature of the spine, rib protrusion, or an asymmetry of the pelvis or shoulders [7]. In
adolescent females, breast asymmetry may also be noticed. Pain is not a common symptom of scoliosis, but
some patients may experience back pain or pain from rib prominence [2].
Pain should alarm the clinician to exclude spinal infections, particularly if the patient complains about fever.
Imaging should be ordered to rule out a spinal tumor because nighttime pain in one location is uncommon.
Other crucial characteristics to be aware of include imbalance and gait disturbance, poor or paralysis of
bowel and bladder, and any other neurological deficits, as these can indicate other pathological causes, such
as tumors or central causes like syringomyelia [1]. The risk of deterioration depends on the timing of growth
spurts and how much growth left in each patient, so curve deterioration needs to be closely monitored.

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Untreated severe or deteriorating scoliosis in younger children can
cause burden the respiratory system [6].
The patient's perception of their appearance is also crucial in
therapeutic planning, as unhappiness with self-image could eventually
result in psychological impairment. Long-term scoliosis results are
primarily based on observational studies involving diverse patient
populations; generally, curves over 90 degrees are thought to increase
the risk of morbidity and mortality [11]. If not properly treated, these
consequences in curves with congenital or early onset can be disastrous
[6]. Scoliosis in adults can arise spontaneously, usually as a result of a
degenerative disease, or it can be brought on by an untreated or
overlooked adolescent deformity [12]. Treatment goal in all cases is to
prevent curve progression [7] .
Upon spinal physical examination, a severe form of scoliosis would be
easily noticeable without much of an effort, even with clothing. For
milder form, disrobing the patient would be necessary. Through
inspection, shoulder and pelvic should appear level, as well as spinal
process’ protrusion. Palpation gives examiner more detailed contour of
the back. Spinous processes from cervical to coccyx needs to be palpated
to feel the alignment. Forward bending test or Adam’s forward bend test
is an exam specifically designed to recognize any coronal tilt of patient’s
posture. To measure the angle of the tilt, a scoliometer can be placed on
the apex of the spinal curvature (Figure 1) [6].
Figure 1: Forward bending test and angle measurement with scoliometer
Classification
Scoliosis can be classified based on the cause, such as idiopathic
(primary) or secondary. Idiopathic scoliosis is divided into subtypes
based on age of onset, such as infantile, juvenile, and adolescent or early
and late onset. It can also be caused by other underlying medical
conditions like congenital disorders, neuromuscular conditions,
tumours, trauma, or syndromic conditions [1,6,10]. Additionally,
scoliosis can be classified by the side of the curve, whether it is left or
right sided [7]. Scoliosis curves can be further classified based on the
apical vertebral level as seen in Table 1.
Table 1: Scoliosis classification by apex location [5,7].
Cervical
C1-C6
Cervicothoracic
C7-T1
Thoracic
T2-T12
Thoracolumbar
T12-L1
Lumbar
L2-L4
Lumbosacral
L5-S1
The different types of scoliosis are as follows:
1. Idiopathic
a. Congenital scoliosis
Congenital scoliosis curves present at birth but may not be noticeable
for many years. Genetic mutations in the HOX group are the cause for
many cases. These types are classified into three groups: failure of
formation, failure of segmentation, and mixed groups. Each group is
further divided based on the location of the pathology. The classification
helps to understand the natural progression of these curves. Generally,
failures of segmentation have a more favourable outcome compared to
failures of formation and mixed anomalies. The prognosis is generally
worse for anomalies in junctional regions, like the thoracolumbar
junction. These curves are usually associated with neurological, cardiac,
and urinary anomalies and are often discovered through a prenatal
ultrasound [6]. Congenital scoliosis can range from minor to severe
depending on the probability of progression and the chance of spinal
cord compression and paralysis. It is advised that children with
congenital scoliosis have brain and spinal cord MRIs (magnetic
resonance imaging), as about 20% of cases have abnormalities in these
areas. Conditions such as Chiari malformations, Syringomyelia, and
spinal cord tethering are commonly associated with congenital and
earlier onset of the disease [1]. Other factors that may be associated with
congenital scoliosis include old age, an increased incidence of congenital
heart anomaly, hip dysplasia, and disabilities. Additionally, conditions
such as Diastematomyelia and VACTERLS syndrome may be associated
with congenital scoliosis. Plagiocephaly and rib malformations may also
be present and can indicate that the scoliosis was caused by intrauterine
molding [7].
b. Infantile and juvenile scoliosis
Curves that develop in children between the age of 0-3 and 4-10 years
are referred to as infantile and juvenile idiopathic scoliosis, respectively.
Recently, curves that occur before the age of 10 years have been
referred to as having "early onset" [10]. Children with earlier onset of the
deformity are at a higher risk of impaired lower respiratory system,
which can impact their life expectancy. The risk of respiratory
complications is identified by measuring the rib-vertebral angle
difference (RVAD) and comparing it to the Cobb angle [13]. If the
difference between the two angles is more than 20 degrees, it suggests
a likelihood of deterioration. Therefore, it's important to measure both
angles in these patients. If the Cobb angle is less than 25 degrees and
RVAD is less than 20 degrees, they should be observed every 4-6 months
with radiographs. If the Cobb angle increases by 5-10 degrees
independent to the changes to RVAD, then treatment is recommended
[7]. Early intervention aims to improve lung development, encourage
healthy spine growth, and stop the progression of deformity, control the
spine and thoracic cavity [14].
c. Adolescent scoliosis
Adolescent idiopathic scoliosis is the most common form of scoliosis
seen, accounting for about 80% of cases [2]. The incidence of small curves
is equal in both sexes, but larger curves are more common in females.
These curves frequently appear when the disease has advanced to the
point where a other people observes asymmetry in the shoulder, waist,
or back. Adolescent idiopathic curve progression risk can be predicted
by several factors, including first presentation magnitude of the curves,
the presence of double curves, and the rate of growth during the
adolescent growth spurt. Premenarchal status and skeletal immaturity,
as assessed by the Risser grade, also increase the potential for
progression [15]. However, the likelihood of progression decreases as
growth slows down following the onset of menarche in girls and puberty
in boys [7]. Two classification systems have been developed to determine
the fusion area for these types of curves: the King & Moe classification,

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6
which describes five distinct curve patterns but has poor intra/inter
observer reliability and only evaluate the coronal plane, and the Lenke
system, which combines six curve types with coronal and sagittal plane
modifiers and identifies minor and major structural curves [15]. Figure 2
shows the Lenke classification system. Nevertheless, not all curves fall
into these categories, and each curve should be treated according to its
own merits because it might be necessary to combine treatment
approaches [1].
Lenke classification system is used to classify scoliosis based on the type
of curve and its location in the spine. It includes 6 curve types, a sagittal
thoracic and a lumbar spine modifier. These definitions were established
by the Scoliosis Research Society and are used to order appropriate
vertebral levels for an arthrodesis. The classification system is based on
the location of the curve's apex, with thoracic curves having an apex
from T2 to T11/T12, thoracolumbar curves having an apex at T12 to L1,
and lumbar curves having an apex from L1/L2 to L4. The lumbar
modifiers (A, B, and C) are used to indicate the position of the lumbar
curve apex in relation to the center sacral vertical line (CSVL). Type A is
when the line is between the pedicles on apical level of the lumbar, Type
B is when the CSVL touches the apical vertebral body, and Type C is when
the CSVL is completely medial to the vertebral body. The thoracic sagittal
modifier describes the degree of thoracic kyphosis between T5 and T12,
with less than 10 degrees being designated with a "-", more than 40
degrees designated with a "+", and "N" indicating a kyphosis between
10 and 40 degrees [16].
Figure 2: Lenke classification system for adolescent idiopathic scoliosis [16].
2. Neuromuscular scoliosis
Neuromuscular scoliosis is a type of scoliosis triggered by neurological
or muscular conditions that disrupt the normal alignment and support
of the spine. In the past, Polio was the main cause of this type of
scoliosis, but presently, the most common causes are Cerebral Palsy and
Spina Bifida [17]. This type of scoliosis is also seen in various progressive
neuromuscular disorder such as Duchenne muscular dystrophy and
Spinal muscular atrophy. Children with neuromuscular scoliosis often
present with muscle coordination and sitting difficulties rather than
pain, and as their trunk muscles weaken, their spine gradually collapses,
resulting in a long, C-shaped curve. These curves are often progressive,
worsening at periods of rapid growth like puberty, particularly in
children with severe CP [18,13]. Children with GMFC 4 and 5 need close
monitoring by pediatricians and physiotherapists to detect scoliosis, and
specialist surgeons use sitting or standing X-rays to monitor the
progression. Progressive curvature might make it difficult for children
who are wheelchair-dependent or immobile to sit comfortably [19]. Lung
issues, such as volume loss and recurring infections, are more prevalent
in people with severe deformities and are more common in people with
thoracic spine curves of 80 degrees or more [20].
3. Developmental or syndromic scoliosis
Syndromic scoliosis refers to a type of scoliosis that is associated with
various syndromes, including skeletal dysplasias, connective tissue
disorders, and neuromuscular conditions [7]. Examples of common
syndromes that can cause scoliosis include neurofibromatosis and
Marfan syndrome, as well as Rett syndrome, Prader-Willi syndrome,
osteogenesis imperfecta, and Ehler-Danlos syndrome. Children with
syndromic scoliosis tend to have worse risk of medical complications and
complications from surgery when compared to children with idiopathic
scoliosis [21,22].
Scoliosis is not a common occurrence in type 2 Neurofibromatosis (NF),
but it can happen in 10-40% of patients with type 1 NF. There are two
types of scoliosis associated with NF: 1. Dystrophic scoliosis, which is
typically a severe, short curve with a significant kyphosis. 2. Non-
dystrophic scoliosis, which is alike to an idiopathic curve. An MRI is
needed to rule out the presence of an intraspinal neurofibroma, which
is more abundant in dystrophic curves [23]. Treatment may require a
combination approach as pseudoarthrosis is a known complication of
scoliosis associated with neurofibromatosis[24].
Clinical Assessment
It is crucial to have a thorough medical history. Include the time of start
and the person who first noted the curvature when diagnosing scoliosis,
as well as any history of progression or pain [7]. Pain may be an indication
of an underlying pathology, such as tumors, neurological conditions, or
syndromic conditions like Arnold Chiari malformation or cord tethering.
The onset of menarche in females and the characteristics of puberty in
males are significant indicators for determining the likelihood of
deterioration and the interventions timing. Obtaining specifics about the
deformity's secondary effects is necessary, such as issues with body
image or functional restrictions at school due to coordination or cardio-
respiratory problems [25]. A birth history, family history, and examination
must contain height and weight measurements, as well as observation
for skin stigmata, lower limb anomalies, dysmorphic facial features,
shoulder or pelvic asymmetry, truncal balance, scapular prominence,
flexibility of the curve, thoracic kyphosis, lordosis, range of motion, gait
pattern, and a full neurological examination [1,6]. In younger children, the
spine can be examined while the child is suspended in the air to check
for flexibility and pelvic obliquity, as well as while the child performs
everyday activities like walking and squatting. Always check the lower
extremities for deformity or length discrepancies [26].
A scoliosis is characterized by two curves, a primary and a secondary
curve, each with a convex and concave side. The primary curve is
typically more rigid and its location on cervical, thoracic, or lumbar
depends on where vertebral apex lies in the coronal plane. A junctional
curve appears where two areas converge. The end vertebrae are the
most cephalad and caudal vertebrae with surfaces that incline toward
the concavity of the curve, and the apical vertebra is the most rotated
vertebra in the curve. The Cobb angle, which is typically expressed in the
concavity direction, is used to calculate the curve size. The Cobb angle is
helpful in evaluating the first curve, tracking the curves' escalating
magnitude, and determining when an operative intervention might be
most advantageous for the child. Unlike the Cobbometer, which was
previously in use, this measurement can be performed using computer
software [27, 28].
In young children, the Adams forward bending test (to identify the
prominence of the rib on the thoracic or transverse process on the
lumbar spine) may not be possible. However, the test can be simulated
by placing the child in a prone position on the examiner's knees. The
flexibility of the curve can be examined by placing the child in a lateral
position on the examiner's knees or by holding the baby on the
examiner's arm. The balance of the spine in the coronal and sagittal

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dimensions should be evaluated. Truncal imbalances, head tilt, shoulder
asymmetry and pelvic balance should be evaluated. Motor, sensory and
reflex (including abdominal reflexes) examination should be done
thoroughly [6, 7]. Vital capacity screening is recommended for patients
with severe curves. Treatment is recommended if surgery is planned for
patients with a vital capacity less than 60% of normal [14].
Radiological Examinations
Plain X-rays are the foundation of initial assessment, in addition to
physical examination, and are widely available and inexpensive. They are
also useful for monitoring the curve. However, standard X-rays are not
sufficient at the initial appointment, a standing PA and lateral views of
the entire spine are required for assessing adolescent scoliosis. On
subsequent visits, only a PA view is necessary to diagnose congenital
deformities and assess the sagittal profile [29]. Additional views, such as
supine active bending films to examine curve flexibility, traction views in
neuromuscular or syndromic patients who are unable to bend actively,
hyperextension views to assess flexibility in kyphotic deformities, and
the Ferguson view which allows assessment of the L5-S1 junction. In
wheelchair-bound patients, sitting films will reveal pelvic obliquity and
spinal deformity [30].
It is measured how severe the curve is and how it changes over time by
the Cobb angle [31]. The maturity of the skeletal structure can be
estimated by the ossification of the iliac apophysis, from front to back,
which is graded using the Risser classification (1-5). A Risser 5 represents
complete skeletal maturity and no further growth. Grade 0-2 have the
maximum risk of progression should be closely monitored, and radiation
exposure should be minimized, so X-rays should only be taken when
clinically necessary. A PA film reduces radiation exposure. In some
institutions, superficial topography of the back is used to monitor curves
instead of X-rays to reduce radiation exposure [7].
Magnetic Resonance Imaging (MRI) of the complete spine is
recommended for all infant and children with large or progressive
curves, as around 25% of these patients may have neuroaxial anomalies.
These anomalies may include Arnold-Chiari malformations, syrinx,
tumors and cord tethering. The use of MRI in young patients is more
debated due to the low rate of abnormalities detected. Congenital
scoliosis, pain, rapid curve progression, a left-sided thoracic curve, and
neurofibromatosis are all indications for an MRI. The entire spine,
including the cranio-cervical junction, should be scanned [32, 33, 34].
Computed tomography can be helpful for planning surgeries for
complex cases by showing the bony anatomy. It is especially useful for
children with small or absent pedicles, as this information can be used
to plan alternative forms of stable fixation. Children with congenital
conditions should undergo an echocardiogram and a renal ultrasound as
part of their pre-operative planning because these children are more
likely to have cardiac and renal anomalies [35, 36]. As bronchio-alveolar
development continues until the age of 8, it is also crucial to evaluate
respiratory function in younger children. For older, more cooperative
patients, measuring forced vital capacity as a percentage of normal can
be a useful guide to pulmonary function [7].
Treatment
The treatment for curves over 20 degrees in all groups, additional follow-
up is usually necessary. A 5 degree increase in curve size within a 6-
month period or a 10-degree increase within a 12-month period is
regarded as progression. When there is progression or if the curve is
significant upon initial presentation, treatment should start. Surgery can
be the initial treatment of choice in circumstances where deteioration
with serious consequences is anticipated, such as in congenital
deformities [1, 7]. With curves between 20 and 40 degrees, observation
or bracing may be a viable option for older kids. A growth spurt, growth
potential, curve pattern, curve magnitude, unusual curve pattern,
thoracic hypokyphosis, and female sex are risk factors for severity. The
objectives of treatment include halting the progression of the curve,
achieving satisfactory coronal and sagittal correction, enhancing
aesthetic appeal, achieving solid fusion, and avoiding long-term
disability [28].
1. Conservative treatment
Bracing and casting are recommended for younger children and are less
certain for adolescents. The goal is to keep the curve stable up until the
child reaches skeletal maturity. As the brace must be worn for up to 23
hours per day, the results of bracing are less certain than those of
surgery and heavily dependent on the child's compliance [7]. Under
general anesthesia, a cast is applied to young children with flexible
curves; it must be changed frequently every 3-4 months to
accommodate growth. Once the curve is under control, which typically
takes 12-18 months, a molded brace is worn for until skeletal maturity
[37]. In stable patients, the brace can be gradually discontinued as the
child nears maturity. If bracing is unsuccessful, surgery should be
considered [9]. Table 2 shows the various methods of conservative
approaches for scoliosis.
Table 2: Conservative treatment options [9, 38, 39, 40]
Milwaukee
brace
This brace is used for postoperative treatment of post-polio
scoliosis, it includes a pelvic section (usually plastic), front
and back uprights, and a neck ring with a throat mold in the
front and occipital pads in the back. It is commonly used for
patients with a curve apex higher than T8. Another type of
brace used to treat scoliosis is the TLSO, which was first used
for patients with deteiorating AIS and a curve apex below T8
Boston brace
It is commercially available in six sizes to increase
production efficiency. This is a back-opening TLSO that
passively corrects the scoliotic curve.
Cheneau
brace
The brace has two modes of operation, active and passive,
and while the goal of using orthotics to treat scoliosis is to
prevent the curve deteioration, the Cheneau brace may
actually correct the curvature in some instances.
Rigo Cheneau
brace
This brace is generally recommended for individuals with
mild to moderate pediatric scoliosis. It is built on the idea of
balance at the L4/L5 level. Studies have shown that it can
achieve a 53.7% correction of the main curvature, but for
patients with a single extended dorsal curvature, the
correction rate increases to 76.7%, and 55% for those with
rotational deformity cases.
Gensingen
brace
This brace is utilizing computerized design and is typically
used for curvatures of more than 50 degrees, which cannot
be treated with other orthotics.
Cheneau-
Toulouse-
Munster
brace
This is is a type of thoracolumbosacral orthosis (TLSO) that
opens in the front and exerts pressure on the torso to
change the scoliotic curve and disallowing it from getting
worse. It is usually worn at night, particularly for low
curvature (Cobb angle less than 30).
Triac brace
The Triac brace is designed to provide dynamic force to treat
scoliosis. Because of the hinge position, it can only be used
for curves below T11. The name Triac is based on the three
C's: comfort, control, and cosmesis. The design focuses on
the brace following the patient's motion. It has the unique
feature of being able to achieve an instant correction of 22%
for the primary curve and 35% for the secondary curve.
C-brace
The C-brace is a type of orthosis that addresses single curve
deformities. Its design allows for movement of the trunk,
providing patients with increased ease while wearing the
brace.
Scoliosis Lycra
orthosis
The Scoliosis Lycra orthosis is intended for individuals with
neurological scoliosis. It consists of a panel that is added to

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the convex side of the brace to slow the deterioration. This
orthosis is primarily for patients with cerebral palsy.
SpineCor
orthosis
The SpineCor brace is designed with an active biofeedback
mechanism, and has been found to be effective for minor
scoliosis curves.
Charleston
brace
The Charleston brace is a custom orthosis that positions the
patient in an overcorrection. Studies have shown that by
wearing the brace for 5-10 hours a day, it can change the
course of the scoliosis over time.
Long lever
scoliosis brace
This brace is intended to address large translational
displacement related to idiopathic scoliosis. The force
required to stabilize the curve decreases with the use of its
long lever arm system.
Providence
brace
The Providence brace is an orthosis that is worn at night. It
is designed to put the spine in an overcorrection by applying
opposing forces, and is intended to address abnormalities.
Sforzesco
brace
This is a non-casting alternative, particularly for severe
cases, and is based on the SPoRT (symmetric patient-
oriented, rigid three-dimensional, active) concept. It is made
of two pieces of polycarbonate that are connected in the
front and back by a closure and a vertical aluminum bar
respectively.
Lapadula
brace
The Lapadula brace is similar to the Sforzesco brace in that
it is made of polycarbonate. The main difference is that the
Lapadula brace does not have an above chest pad. It is
primarily recommended for patients with both
hyperkyphosis and scoliosis.
Dynamic
derotational
brace
This is a modified version of the Boston limited pressure
brace, features its lightness and flexible aluminum blades.
Studies have shown that this brace not only slows the
deteioration of the curve, but also corrects it. It can be
created using traditional casting methods or computer-
aided design and manufacturing technology (CAD-CAM).
Progressive
Action Short
Brace
The design is based on the idea that scoliotic spines can be
corrected by reversing the abnormal load distribution
during growth.
Spinealite soft
brace
Also known as the CMCR brace (Correct Monocoque
Carbone respectant la Respiration) is a monoshell brace.
Unlike traditional pads, the pads of this brace are mobile and
comfortable. The brace is lightweight and reinforced with
carbon blades and can be made without casting
ART brace
The ART brace is a spinal orthosis that was developed using
computer-aided design and manufacturing (CAD-CAM)
technology. The software (OrthenShape) allows overlaying
different CAD-CAM modulus. The brace is based on the Lyon
approach, and the acronym ART stands for Asymmetrical,
Rigid, Torsion brace.
Lyon brace
This is an adjustable, active, decompressive, symmetrical,
stable and transparent orthosis. It is designed to stretch the
ligaments of the spine by using a plaster cast for 4 weeks,
allowing for up to 7 cm of growth. It is mostly recommended
for use during the night to maintain the structure. It is
typically not recommended for patients with juvenile or
infantile scoliosis, severe thoracic lordosis, major
psychological reactions or nonacceptance of the plaster
cast.
Wilmington
brace
The Wilmington brace is a custom-made spinal orthosis that
is designed to be less bulky and lightweight than other
similar braces. It is made from orthoplast, and features an
anterior opening, adjustable straps, and is intended to be
worn for 23 hours per day. It is intended to improve patient
compliance by making the brace more comfortable to wear.
The scoliosis brace can also be divided into soft and rigid
orthoses, and can be classified based on the time of wear
2. Surgical treatment
Surgery is generally recommended for scoliosis when the deformity
exceeds 45 or 50 degrees as measured by the Cobb method. This is due
to these considerations: [7, 14].
a. Curves larger than 50 degrees tend to continue to progress
even after the skeleton has finished maturing. For example,
thoracic curves between 50 and 75 degrees at skeletal
maturity deter at an average rate of 29.4 degrees over a 40.5-
year follow-up period. Curves more than 55 degrees at
maturity progressed more than 0.5 degrees per year [14].
b. Larger curves can cause a loss of lung function and even
respiratory problem. For example, in patients with curves
between 60 and 100 degrees, total lung capacity was 68% of
normal values. Half of patients with thoracic curves larger than
80 degrees experienced shortness of breath at an average age
of 42 years [14].
c. It is more challenging to surgically treat curves that are larger.
This could result in a need for more surgical anchors, a longer
procedure, more blood loss, and a higher rate of surgical
complications [14].
The patient's decision to have surgery to straighten their spine should
sometimes be respected, especially in cases where the Cobb angle is
between 40 and 45 degrees. Surgery is typically more aggressive for
younger patients as scoliosis is a disorder that is related to growth [6, 7].
Congenital, neuromuscular, and syndromic curves are more likely to
need surgery than other types. Surgery's objectives are to stop the curve
from advancing and to treat the malformation in the coronal and sagittal
axis. A short or long fusion may be necessary for this. The impact of a
fusion on the spine's capacity for growth must be considered. Between
the two periods of rapid spinal development 0–5 years and 10–16 years
spinal growth is constant. After spinal fusion, the potential shortening
can be calculated using the following formula: 0.07 x fused segments
multiplied by the years of growth left (cm) [7].
This allows for an approximate calculation of the potential shortening
after surgery. The surgical treatment options for infantile and juvenile
patients and adolescents are as follows: [7, 14].
Surgical options for scoliosis are divided into onset of the disease. In
early onset scoliosis, expandable implant is more preferable due to the
dynamic of the bone growth. Magnetic remotely expandable growing
rods that can be expanded in an outpatient setting using magnets
(Figure 3), other dynamic system is Shilla rod system, which works in a
principle of track and trolley, that allows for matural growth and
correction of the spine at the same time (Figure 4). Other dynamic
device is Vertical Expandable Titatnium Rib Device (VEPTR) which is a
metal rod that is curved to fit the spine and fit vertically while being able
to expand as the child grows (Figure 5). Other option inclide definitive
fusion of the vertebral bodies and fusionless surgery and placing
growing rods [7, 11, 14, 37, 41].
The principle of epiphysiodesis is also been able to be used in correcting
scoliosis deformity. By restricting the growth of vertebral body on one
side, imbalance of growth will be happen in the patient with an
expectation of deformation angle change [14, 37, 41].
Late onset scoliosis surgery doesn’t require as much dynamization
copared to early onset due to limited growth available for the patient.
Anterior fusion - has been considered a treatment option for
thoracolumbar and lumbar scoliosis as it can achieve better correction
with fewer fusion levels. Additionally, a technique for performing
anterior instrumentation for thoracic curves using video-assisted
thoracoscopic surgery has been developed. Posterior fusion - with

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9
instrumentation used distraction to apply correction force along the
concave side of the curve. Correction is attempted through the use of a
rod-rotation maneuver. Modern instrumentation systems utilize more
anchors to connect the rod to the spine, resulting in improved correction
and fewer implant failures. The current trend in instrumentation is using
pedicle screw constructs or hybrid constructs that incorporate pedicle
screws, hooks, and wires. A combination of anterior and posterior fusion
is a possible technique for late onset scoliosis (Figure 6, Figure 7) [14, 37,
41].
Figure 3: Magnetric remotely expandable system [41]
Figure 4: The Shilla Rod System [41]
Figure 5: Vertical Expandable Titanium Rib Device (VEPTR) [41]
Figure 6: Anterior fusion of the vertebral bodies [14]
Figure 7: Posterior fusion of the vertebral bodies [14]
Whether to fuse the spine from the front or back during scoliosis surgery
depends on factors such as the location, size, and stiffness of the curve.
Posterior fusion avoids the chest cavity and potential harm to organs,
while anterior techniques result in less blood loss and typically require
fusing fewer levels. The surgeon's expertise and experience also
determinant of the approach. The chance of permanent nerve damage
from the surgery is low, and patients are closely monitored for
complications after the procedure [41]. Scoliosis surgery aims to improve

Hong Kong J Orthop Res
10
the patient's ability to function and live a normal, active lifestyle without
the negative effects of a progressive spinal curve [7, 14, 37, 41].
Complication
Generally without the progression of the disease, scoliosis affect
patients’ cosmetic through their posture. However, when progressivity
occurs, pain progresses, and neurological dysfunction will follow. On
severe thoracic scoliosis, breathing problem may also occur due to
imbalance pulmonary capacity [40].
Surgical complications of scoliosis surgery may occur from different
aspect of the disease. Implant complication include implant failure such
as breakage or bending of implants. Infection may also occur from
superficial wound complication to deep wound complication. Blood loss
from surgery may also occur and create devastating issues on post major
spine surgery. Spine related complication can also shown in the form of
pseudoarthrosis. Neurological complication is also one devastating
complication of spinal surgery. The worst complication that can occur is
death, it can be caused by autonomic dysfunction, severe blood loss, or
spinal shock. Pseudoarthrosis and infection are two most common
complications found on spinal surgery [42].
CONCLUSION
In conclusion, scoliosis is a complex spinal disorder that have a
significant negative impact on a person's quality of life. The causes of
scoliosis are still a confusion among experts and can vary from structural
to neuromuscular. This literature review has provided an overview of
the causes, classification, and management of scoliosis. Diagnosing
scoliosis typically involves a combination of physical examination and
imaging studies. Imaging studies such as X-rays, CT scans, and MRI used
to confirm the diagnosis and to measure the degree of the curve.
However, it is essential to note that early detection is crucial for the best
outcome, and regular screenings are important to identify scoliosis at an
early stage. The management and classification of scoliosis is a complex
and challenging task in the field of orthopedics.
Conflicts of interest: Authors declare that, there is no conflict of
interest.
Authors’ Contribution:
IGNPWP: Expert, concept, review.
F: Writing, review, editing, templating.
Acknowledgments: None
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