{
  "id": "scoliosis",
  "title": "Scoliosis",
  "lang": "en",
  "source_lang": "en",
  "summary": "Scoliosis is a three-dimensional lateral deformity of the spine, most often idiopathic and emerging in adolescence; this entry covers its causes, diagnosis, classification and treatment.",
  "category": "health",
  "subcategory": "diseases",
  "type": "concept",
  "aliases": [
    "Spinal curvature",
    "Lateral spinal curvature",
    "Spinal deformity"
  ],
  "generated_at": "2026-10-09",
  "model": "pro/claude-haiku-5-5",
  "url": "https://aiwiki.page/en/scoliosis/",
  "translations": {
    "zh-Hans": {
      "url": "https://aiwiki.page/zh/scoliosis/",
      "json": "https://aiwiki.page/zh/scoliosis.json"
    }
  },
  "sections": [
    {
      "heading": "",
      "text": "Scoliosis is a deformity of the spine in which it curves sideways and, in most cases, also rotates around its own long axis. Clinicians measure it on radiographs with the Cobb angle, and a lateral curve greater than 10 degrees with vertebral rotation is generally regarded as scoliosis. The condition is three-dimensional, affecting the coronal, sagittal and axial planes at once, so it is studied across medicine, genetics, physiology and public health. Most cases are idiopathic, meaning no single cause is identified, and adolescent idiopathic scoliosis is the most common form in children and young people.\n\nIts importance lies in three areas. First, a minority of curves progress during growth, and severe curves can impair breathing, cause back pain, and affect appearance and psychological wellbeing. Second, the disorder has no fully established cause, and research has examined genetic, hormonal, neurological and mechanical explanations without reaching consensus. Third, treatment choices range from observation and bracing to surgical spinal fusion, and decisions depend on curve size, skeletal maturity and the patient's age, which makes classification and diagnosis central to care.\n\nThis entry first defines scoliosis and its main types, then reviews its epidemiology, proposed causes and natural history. It next covers clinical features, diagnosis and screening, and the classification systems used for measurement and surgical planning. The final sections address conservative and surgical treatment, adult scoliosis, the history of research, psychosocial and public-health aspects, and questions that remain open."
    },
    {
      "heading": "Definition and diagnostic criteria",
      "text": "Scoliosis is usually defined as a lateral curvature of the spine that is accompanied by rotation of the vertebrae. Clinical sources describe it as a deformity in three dimensions rather than a simple bend in one direction. The gold-standard method to assess scoliosis is the Cobb angle measured on coronal-plane radiographs. The angle is formed by drawing lines along the endplates of the most tilted vertebrae at the upper and lower ends of the curve, and then reading the angle where those lines, or lines perpendicular to them, meet. A diagnosis is generally made when a lateral curve with rotational deformity reaches a Cobb angle of at least 10 degrees. The measurement was introduced by the American orthopaedic surgeon John Robert Cobb, and the Scoliosis Research Society later adopted it as the standard. Below 10 degrees, the finding is generally labelled a spinal curve or asymmetry rather than scoliosis.\n\nMeasurement conditions matter. Angles are preferably measured while standing, since lying down decreases Cobb angles by around 7–10°. The Cobb angle is also a radiographic measure of one plane only. A single 2D image reflects the curvature in a single plane, so the true deformity may be larger; one source estimates the actual angle might be up to 20% greater than that estimated from the radiographs. Reported measurement error also varies between sources. One review cites intra-observer variation of 5°-10°, while another gives interobserver and intraobserver error of approximately 3 to 5 degrees. Because of this spread, a change of a few degrees between two films may not represent true progression.\n\nThe coronal Cobb angle captures only the frontal plane. The sagittal profile is assessed separately, using a Cobb angle measured in the sagittal plane such as on lateral radiographs. Axial rotation of the vertebrae is recognised clinically through the rib hump, a prominence of the ribs on the convex side of the trunk. Structural curves also are identified by the presence of marked rotation that manifests clinically by the rib hump. This three-dimensional view explains why a curve with a modest Cobb angle can still look asymmetric to an examiner.\n\nScoliosis must also be separated from related findings. Postural asymmetry, which can produce a curve that disappears when the patient bends or sits differently, is classed as a nonstructural curve. Kyphosis, an excess of backward curvature, is measured in the sagittal plane and is not scoliosis, although the two can coexist. Leg-length discrepancy can tilt the pelvis and produce an apparent lateral curve; clinicians must determine whether the discrepancy is anatomical or functional, because a nonstructural curve may be secondary to leg length discrepancy or muscle spasm.\n\nStructural versus nonstructural curves\n\nThe key distinction is whether a curve is fixed. A curve can be nonstructural when the curvature corrects on bending to the convex side. A structural curve, by contrast, does not correct fully and is typically accompanied by vertebral rotation. The main test is the side-bending radiograph. A structural curve may be reliably defined as one with a Cobb angle of 25° or more on ipsilateral side-bending radiographic views. A curve of 25 degrees or more on the standing film that does not fall below 25 degrees on side-bending films is generally considered structural, and a curve below 25 degrees may still be structural if the sagittal profile shows enough kyphosis.\n\nThe distinction determines treatment. Nonstructural curves are often compensatory: other curvatures may be inflexible, structural curves or flexible, nonstructural curves that are present to maintain truncal balance. In surgical planning, if a curve is considered structural, it should be included in the fusion surgery. Including a nonstructural curve in a fusion can lengthen the operation unnecessarily, while omitting a structural curve can leave a residual deformity. For this reason, side-bending views are obtained when surgery is contemplated, and their interpretation is central to the classification systems discussed elsewhere in this article."
    },
    {
      "heading": "Types by cause",
      "text": "Scoliosis is commonly grouped by etiology into idiopathic, congenital, neuromuscular, syndromic and degenerative forms. The first three are the principal categories in most clinical descriptions, while syndromic and degenerative curves are recognized as additional groups. The boundaries between them are not always sharp, and a curve's assigned category can change as the cause is clarified.\n\nIdiopathic scoliosis\n\nIdiopathic scoliosis is a diagnosis of exclusion: it is diagnosed only when the history and the clinical and radiological findings do not provide clear evidence for any specific etiology. Reported shares of all scoliosis cases differ by source: one review gives approximately 75-85% of all cases, while another puts the figure at about 80 percent of all cases.\n\nIdiopathic curves are subdivided by the age at which they are first identified. Infantile scoliosis has an onset before three years of age. Juvenile scoliosis is first detected between three and 10 years of age. Adolescent idiopathic scoliosis is found between age 10 and skeletal maturity, and it is the largest subgroup. The cutoffs are not uniform. Some sources define the juvenile period as 4-9 years old, and the age used is one of detection, not necessarily onset: this is not necessarily the same as the time the curve first appears. The infantile form is rare, accounting for fewer than 1 percent of all cases, and the juvenile form occurs in 12 to 21 percent of all patients with idiopathic scoliosis.\n\nCongenital scoliosis\n\nCongenital scoliosis is caused by vertebral anomalies causing an imbalance in the longitudinal growth of the spine. Surgeons often describe the underlying defect as a \"failure of segmentation,\" in which vertebrae do not separate properly or are abnormally joined on one side. Common forms include single or multiple hemivertebrae and segmentation defects, which produce block vertebrae of variable length. Because the deformity is present at birth, the condition is usually recognized early, although the curve should be classified as congenital, even if the deformity is not apparent until adolescence.\n\nCongenital vertebral anomalies are frequently accompanied by abnormalities in other organ systems. Estimates vary with study design. One review reports that about 20 to 40% of patients with congenital vertebral malformations have renal anomalies, and that about 10-15% of patients with congenital scoliosis have congenital heart defects. A retrospective series of 305 patients reported a higher cardiac rate, with cardiac anomalies documented in 54% of patients. The anomalies are linked to the MRI and renal and cardiac screening recommended for these patients, and they are also part of the VATER or VACTERL associations, which combine vertebral, anorectal, cardiac, renal and limb defects.\n\nNeuromuscular scoliosis\n\nNeuromuscular scoliosis is secondary to neurological or muscular diseases. The associated conditions include cerebral palsy, spinal cord trauma, muscular dystrophy, spinal muscular atrophy and spina bifida. The mechanism is primarily muscular imbalance around the spine, which allows the trunk to deform as the child grows. Its clinical course differs from other types. These curves typically are long and involve the entire spine. In addition, NMS curves progress more rapidly and may continue to worsen even into adulthood. For this reason the condition generally progresses more rapidly than idiopathic scoliosis and often requires surgical treatment.\n\nSyndromic and degenerative scoliosis\n\nSyndromic scoliosis occurs as part of a recognized genetic or systemic disorder. Some syndromes are associated with a high incidence of scoliosis including Marfan syndrome and neurofibromatosis. Scoliosis also appears in several congenital malformation syndromes, and Goldenhaar and VACTERL being the commonest associations followed by Klippel-Feil, Alagille, Jarcho Levin, Joubert, basal cell naevus, trisomy18 and diabetic embryopathy.\n\nDegenerative scoliosis is an adult-onset form. It results from age-related degeneration in the spine. In older patients, a degenerative curve is often hard to tell apart from pre-existing idiopathic scoliosis with superimposed degenerative changes. The distinction therefore depends on the patient's history as well as on imaging."
    },
    {
      "heading": "Classification systems",
      "text": "Cobb's scheme and King's 1983 system\n\nThe first systematic grouping of spinal curves is usually traced to John Cobb, whose 1948 scheme set out major and minor curves and distinguished structural from nonstructural ones, attaching treatment guidelines to each category. In 1948 John Cobb was the first to describe a classification system of scoliosis. He was the first to give a description of major and minor curves, structural and non-structural curves and set guidelines for treating these deformities accordingly. The Cobb angle used to quantify curve size is the measurement that later systems adopted as their common reference.\n\nHoward King's 1983 system, published with John Moe, Bradford and Winter, grew out of Moe's surgical work with Harrington rod instrumentation. Curves were divided into five types and guidelines and recommendations for which levels should be instrumented were given according to those different curve types in order to preserve motion as much as possible. King's group also introduced the stable vertebra, defined as the vertebra most closely bisected by the center sacral vertical line, and judged whether a curve was structural or compensatory by its flexibility on side-bending films. The King-Moe classification, published in 1983 after an evaluation of more than 400 patients who had AIS, was the first broadly applied classification of patients in the era of instrumented spinal fusions. Its scope was narrow: it covered only thoracic curves and only the coronal plane. As segmental instrumentation systems began to gain favor over the Harrington rods this classification system failed to give accurate and reliable guidelines for choosing the proper levels for fusion. In addition, several articles showed low inter and intra-observer reliability of this classification system.\n\nLenke's 2001 triad\n\nLawrence Lenke's 2001 system was the first scoliosis classification to incorporate the sagittal profile. It is a triad of curve type, lumbar spine modifier and sagittal thoracic modifier. Curve types 1 to 6 depend on which of the proximal thoracic, main thoracic and thoracolumbar or lumbar regions carry structural curves, and the largest curve is always structural while smaller curves may be either. The lumbar modifier, labelled A, B or C, reflects where the center sacral vertical line lies relative to the apex of the lumbar curve. Modifier C describes a lumbar apex that lies entirely off the midline. The sagittal modifier uses the T5–T12 Cobb measurement on a standing lateral film: values below +10° receive a minus, 10° to 40° receive N, and 40° or more receive a plus. The combination produces 42 curve patterns. A true selective thoracic fusion occurs when selectively fusing the thoracic curve with a C modifier lumbar curve that completely deviates from the midline. Classification requires standing posteroanterior and lateral films along with supine bending films of the whole spine.\n\nReliability and measurement error\n\nReliability is usually expressed as kappa coefficients, which adjust agreement for chance. In a 2002 study of Lenke's system, all five reviewers agreed on the overall classification in 21 (41%) of the 51 patients. A mean kappa value of 0.62 was determined for interobserver reliability, and a mean kappa of 0.73 for intraobserver reliability. The main sources of disagreement were whether an upper thoracic curve was structural and how the lumbar modifier was assigned. In a multisurgeon comparison, King's system reached a mean interobserver kappa of 0.45, which the authors described as poor. A later review reported King interobserver kappa values from about 0.32 to 0.88, and Lenke values from 0.23 to 0.973, a wide spread that partly reflects differences in how observers read the sagittal and lumbar modifiers. Because of this variation, the authors cautioned that directly comparing the overall reliability with other classification systems is not entirely fair.\n\nMeasurement error matters because classifications are used to compare outcomes between series and to guide treatment. If two surgeons assign the same curve to different categories, a difference in results between groups may reflect labelling rather than the treatment itself.\n\nThree-dimensional and treatment-oriented classifications\n\nTwo-dimensional systems capture only projections of a deformity that is three-dimensional. New technologies which provide three-dimensional (3D) reconstruction of the spine may serve as a basis for a truly 3D classification of scoliosis and for new therapeutic concepts. One study derived five subtypes of Lenke 1 curves from coronal and lateral radiographs, reading the sagittal, frontal and axial views. The SRS–Lenke–Aubin system adds two transverse-plane modifiers for each spinal region, creating a modular, four-modifier scheme. Within the thoracolumbar and lumbar segments, a rotation-related value below 70° has been linked to preserved lumbar lordosis above 40°. Automated approaches have also appeared: in one deep-learning study built on 2,082 radiographs from 407 patients, the Cobb measurement reached an intraclass correlation of 0.925. Treatment-oriented schemes are also emerging. The Rigo classification was developed to specify correction principles for brace design, and its interobserver kappa values range from 0.7 to 0.942. Agreement figures for the newer 3D and automated schemes come mainly from individual studies, so they still need independent replication."
    },
    {
      "heading": "Epidemiology and risk factors",
      "text": "Prevalence and regional variation\n\nEstimates of how many children have scoliosis depend on the curve threshold, the population studied and how cases were found. A pooled analysis of 32 studies covering more than 55 million young people produced a prevalence of 3.1% (95% CI: 1.5%–5.2%). For idiopathic cases alone, the pooled figure was lower: prevalence is 1.65%, with girls affected at twice the rate of boys. Older reviews gave wider ranges, from 0.47–5.2 % for adolescent idiopathic scoliosis, and the figure of roughly 2–3% is the one most often quoted in clinical texts.\n\nRecorded rates differ sharply between countries. One global review found that national estimates ran from 0.05% in Ecuador to 16.67% in Romania, and the authors attributed part of this spread to economic, educational and social development, which shapes how far school and community screening is carried out. Chinese data show a similar pattern within one country: a national estimate of about 1.2% is reported, with peaking at ages 13–14 years for girls and 15–16 years for boys.\n\nSex differences\n\nSex is the most consistent demographic correlate. Among small curves the female-to-male ratio is modest, but it rises with severity: one review reported that it rises from 1.4:1 in curves from 10° to 20° up to 7.2:1 in curves >40°. Another older review described near-equal rates for curves of about 10° and roughly ten girls for each boy among curves above 30°. Girls are also more prone to progression. In a prospective cohort, sex (girls) was among the factors linked with a high risk of curve progression, alongside curves of 30° or more and early pubertal maturity. The mechanical explanation that the likelihood of progression scales with height has been proposed, but it remains a hypothesis.\n\nReported risk factors\n\nLarge meta-analyses have linked several exposures to a higher prevalence. One review reported that scoliosis was significantly associated with sex (girls), family history (1.92), sedentary behavior (≥ 11 h, 1.64), poor sitting posture (3.48), along with short outdoor time and long screen time. Poor sitting posture in this context refers to desk-related forward flexion, asymmetrical sitting, cross-legged positions or kyphotic alignment. The evidence for body mass index is inconsistent. The same review found that prevalence did not differ significantly by BMI, daily sleep duration, or desk height, while its summary elsewhere lists low BMI as a possible marker of risk. Individual studies have also disagreed about whether underweight or overweight adolescents are more affected. Most of these findings come from cross-sectional or cohort data, and the causal status of such factors is uncertain. Mendelian randomization analyses, which are designed to reduce confounding, have found that almost no evidence exists to support their causal association with AIS. Some researchers have suggested that reduced sunlight at higher latitudes might affect melatonin secretion and vitamin D metabolism, but this remains speculative and is discussed in the hormonal hypotheses section.\n\nRising recorded prevalence\n\nSeveral recent reports describe an increase in recorded cases. A Chinese meta-analysis noted a notable upward trend observed in recent years, particularly exhibiting marked increases between 2016 and 2024, and a global review suggested that the prevalence may increase since 2020 year (3.02%). Whether this reflects a true rise in incidence or simply more complete detection is still debated. Because prevalence estimates depend heavily on screening intensity and diagnostic thresholds, the same underlying population can produce markedly different figures across studies, and the available data cannot yet separate these influences."
    },
    {
      "heading": "Genetic hypotheses",
      "text": "Genetic factors are among the most widely supported explanations for idiopathic scoliosis, although no single causal gene has been established. The evidence comes first from family and twin studies, then from molecular studies that have tried to locate specific variants.\n\nFamilial clustering has been recognized for a long time. Almost a century of literature describes familial forms of AIS, and in the case of twin research, the usual comparison is concordance (both twins affected) in identical versus fraternal pairs. Reported figures vary by study. One source gives monozygotic concordance of about 73% and dizygotic concordance of about 36%, while another reports more than 70% and about 30%. A 2022 systematic review found that pairwise concordance in monozygotic twins ranged from 0.11 to 1.00 across studies. Its meta-analysis of three studies produced a narrow-sense heritability of 0.57 (95% CI 0.29–0.86), but the authors judged heterogeneity to be large. Estimates were higher in family-based studies than in twin studies, and higher when diagnosis was confirmed radiographically rather than self-reported. Some individual estimates diverge sharply: one Chinese sibling cohort gave about 0.88, and a Swedish twin cohort about 0.38. Discordant twins and twin pairs whose curves differ in magnitude or apex are also documented, which is usually read as evidence that the environment modifies a heritable susceptibility.\n\nMolecular studies began with linkage analysis. In 2005, a linkage study of 202 families identified candidate regions on chromosomes 6, 9, 16 and 17. Subsequent genome-wide association studies (GWAS) were more productive but produced inconsistent results. A 2011 GWAS of 419 AIS families found its strongest signal near the CHL1 gene on chromosome 3p26.3, but the association was not confirmed in a separate GWAS, and this illustrates the replication problem that has persisted in the field. By contrast, several loci have been replicated across populations. Variants near LBX1 on chromosome 6q25 were associated with AIS in Japanese, Chinese Han and European-ancestry samples, and a 2013 Chinese case-control study reported odds ratios of roughly 1.5 to 1.7 for three of these variants. The GPR126 (ADGRG6) locus on chromosome 6q24.1 has also been replicated in several East Asian and European-ancestry populations, and knockdown of this gene in zebrafish delayed spinal ossification. A variant in BNC2, a zinc finger transcription factor, has been replicated in Japanese and Chinese cohorts, and its overexpression in zebrafish produced body curvature in a dose-dependent manner. A Japanese two-stage GWAS of roughly 12,000 individuals linked a common variant near SOX9 to severe curves. Whole-exome and genome sequencing have added rare variants in extracellular matrix and connective tissue genes, such as COL11A1, COL11A2, FBN1 and CHD7, although these studies are smaller and their findings are less consistent.\n\nThe genetic model that has gained the most acceptance is polygenic. Under this view, many variants each contribute a small amount of risk, and their combined effect, together with environmental influences, determines whether a curve develops and how it progresses. Replicated common variants confer only modest increases in risk, and the rarity of clearly causal genes supports this interpretation. Incomplete penetrance, in which carriers of a risk variant often remain unaffected, fits the same model. A 2025 whole-genome sequencing study of 119 patients reported a potentially relevant candidate variant in most individuals, but only a small minority carried a variant rated as clinically relevant, which suggests that candidate lists remain large and difficult to interpret.\n\nSeveral gaps remain between statistical association and biological mechanism. Most associated variants lie in non-coding regions, and it is often unclear which gene they affect or in which tissue. Animal models support roles for some genes in spinal development, but these findings have not yet been connected to the cellular or biomechanical processes that produce a curve in humans. Genetic testing can identify rare variants associated with syndromes in which scoliosis is a feature, such as those in ROBO3 linked to horizontal gaze palsy with progressive scoliosis, but it cannot currently predict which individuals with idiopathic scoliosis will develop a severe curve. Clinical genetic testing for idiopathic scoliosis is therefore not established as a routine tool for diagnosis or risk stratification."
    },
    {
      "heading": "Hormonal, neurological and mechanical hypotheses",
      "text": "No single cause of adolescent idiopathic scoliosis (AIS) has been established. Three broad lines of inquiry have shaped research: hormonal regulation of growth, disturbances of postural control originating in the inner ear and brain, and asymmetric mechanical loading acting on a growing spine. These hypotheses overlap, and each has been tested with mixed results.\n\nMelatonin and estrogen\n\nThe melatonin hypothesis grew out of animal work. Removing the pineal gland in young chickens produced a spinal curve resembling AIS, and melatonin supplementation could prevent it. Later experiments in rats and mice showed that pinealectomy alone did not reliably produce curves in quadrupedal animals, while bipedal posture appeared to be a necessary condition for the deformity to develop. Hormone studies in humans have been less supportive. In one small comparison of nine patients with AIS and ten matched controls, circadian serum melatonin and urinary metabolite levels did not differ significantly between the groups, and the authors concluded that the data did not support melatonin deficiency as a cause. Other reports described lower serum melatonin in adolescents with progressive curves, so the findings remain contested. Reviewers have generally concluded that permanent melatonin deficiency is unlikely to be a primary cause.\n\nEstrogen has been proposed as a contributor because AIS is more frequent in girls, with incidence reported to be about 1.44 times higher in women in one systematic review. Sex hormones are known to influence growth-plate activity and skeletal physiology, and it has been suggested that they could modify bone metabolism and paraspinal muscle tone during puberty. Direct evidence linking estrogen levels to curve initiation is limited, and the sex difference is also explained in part by mechanical models, discussed below.\n\nVestibular and central nervous system theories\n\nA major neurological hypothesis holds that AIS begins with impaired postural control. The inner-ear vestibular organ, consisting of three semicircular canals, helps the brain sense head position and orientation. Some researchers proposed that a vestibular imbalance precedes the spinal deformity and influences the muscles of the trunk. Studies have reported that adolescents with AIS sway more than controls when visual or somatosensory cues are removed, and that galvanic vestibular stimulation evokes larger lateral postural responses in these patients. However, only about 42.5% of patients in one classification study showed clearly impaired sensorimotor responses, which suggests the abnormality is not universal. Imaging studies have reported inner-ear asymmetry, such as a more vertically oriented left lateral semicircular canal in some patients, but a systematic review concluded that the evidence was insufficient to link an isolated unilateral vestibular lesion with AIS. An alternative formulation attributes the deformity to an inaccurate central internal representation of verticality, in which the brain misjudges the body's axis relative to gravity. Within this framework, sensorimotor mismatch could lead to inappropriate motor commands and asymmetric back muscle tone, which in turn would deform the growing spine. Some researchers have also proposed that genetic variation affecting inner-ear development could link these two sets of findings, but this remains a hypothesis.\n\nGrowth asymmetry and mechanical loading\n\nThe mechanical theories focus on why a spine that is already slightly curved might continue to deviate during adolescence. The Hueter-Volkmann principle states that compression slows growth at a growth plate, while reduced pressure allows faster growth. Applied to the spine, asymmetric compression would be expected to slow vertebral growth on the concave side of a curve and allow normal or accelerated growth on the convex side, which could produce wedging of the vertebral bodies. Early studies on the vertebral growth plates, and a later histological study comparing the concave and convex sides, supported the idea that differential growth contributes to deformity, although the exact role of the neurocentral synchondroses remains uncertain. Asymmetric loading of immature animal spines has been shown to produce wedging and scoliotic changes.\n\nThe most widely cited version is the \"vicious cycle\" theory, which proposes that an initially small lateral curve produces asymmetric loading, that this loading alters growth, and that the altered growth then increases the curve. Computational models based on this idea suggested that neuromuscular control of trunk muscles could influence whether a curve progresses, and this is one reason the theory has been linked to rapid progression during the growth spurt. The theory has also been challenged. Some researchers argue that mechanical loading explains progression but not initiation, and that the initial asymmetry must come from another source, such as disc, costal, vertebral or neuromuscular factors. Another group has proposed that hip asymmetry during gait and habitual standing posture drive rotational asymmetry in the first place. A further model, based on buckling mechanics, suggests that taller and thinner spines are more prone to lateral deviation, which has been offered as one explanation for the sex difference.\n\nWhy no unifying theory has been accepted\n\nHormonal, vestibular and mechanical hypotheses are not mutually exclusive, and they can be arranged as a chain of events in which an initial disturbance in one system affects the others. For example, altered sensory input could change trunk muscle activity, which could produce asymmetric loading during the growth spurt, which could then drive asymmetric growth. Hormonal changes during puberty could modulate each step. Evidence for each link is uneven, and most studies are small, cross-sectional or animal-based, making it hard to determine whether observed differences are causes, consequences or markers of the deformity. Some reviews distinguish intrinsic factors, such as genetic and biomechanical ones, from extrinsic factors, such as neurological, muscular and hormonal abnormalities, and propose several parallel pathogenic mechanisms rather than a single pathway. Recent biomechanical reviews continue to describe the etiology and progression of AIS as not fully explained."
    },
    {
      "heading": "Natural history and progression",
      "text": "Course of mild curves and the growth spurt\n\nMany curves never reach a treatment threshold. A review in American Family Physician estimates that only 10 percent of diagnosed adolescents have curves that advance enough to need medical intervention. Curves of about 10–20° often stay static in children, and the rest tend to keep advancing (many children will have curves of 10-20 degrees that remain static). Progression is concentrated in periods of fast skeletal growth, when the spine and trunk lengthen quickly, and the risk is highest during rapid skeletal growth. The adolescent growth spurt and the hormonal changes of puberty are often cited together as the reason for this pattern, although the mechanism is not established (see hormonal hypotheses).\n\nSkeletal maturity and the Risser sign\n\nThe Risser sign grades skeletal maturity on a 0–5 scale, based on ossification and fusion of the iliac apophysis, a growth plate on the pelvis. Lower grades indicate more remaining growth, and adolescents with Risser 0 or 1 have a higher risk of progression compared to those with Risser 3, 4, or 5. Its predictive value is limited. Comparisons of predicted and measured change suggest that the Risser system is variably accurate, and alternative staging such as Sanders staging can classify the same patient differently. In a cohort of 135 patients treated with night-time bracing, progression occurred in 60% of those at Risser 0–2 and 37% of those at Risser 3–4, but the authors concluded that Risser stage did not clearly separate patients by risk and recommended other measures of growth potential (see surgical and radiographic assessment).\n\nLate-stage data illustrate the same limits. In a minimum five-year follow-up of 97 patients with curves of 40–50° at Risser IV or V, the mean Cobb angle rose from 42.6° to 45.1°, and curve progression was observed in 38 patients (39.2%). Younger age and Risser stage IV were significantly associated with curve progression. A larger baseline curve was also linked to a final Cobb angle of 50° or more.\n\nCurve size, sex and location\n\nCurve magnitude at presentation is widely considered the strongest long-term predictor, ahead of age, Risser stage and menarchal status, and a curve magnitude of 25° at presentation may be predictive of a greater risk of curve progression. Sex is also a major factor: the main risk factors for curve progression are a large curve magnitude, skeletal immaturity and female gender. Curve location is recorded in most natural-history studies because the apex position alters the mechanics of the deformity, but the evidence for location as an independent predictor is less consistent. In the degenerative setting, lumbar curves are typically associated with facet and disc degeneration that drives later progression.\n\nProgression in adulthood and later complications\n\nCurve size at skeletal maturity is the main guide to adult behaviour. One clinical summary states that curves of less than 30° at maturity are unlikely to progress, while curves of 30-50° progress at an average of 10-15° over a lifetime. Rates reported for adults with idiopathic curves vary, and clinical sources commonly cite roughly 0.5 to 1 degree per year. In older adults, degenerative change adds to the process. The AAPMR describes adult degenerative scoliosis as primarily a disease of aging populations, with most cases diagnosed in individuals over the age of 50, and faster progression in those with osteoporosis, degenerative disc disease, or pre-existing instability. Published rates differ across sources: one clinical website gives 1 to 3 degrees per year in symptomatic patients, while the AAPMR overview cites a typical rate of 3º-4° per year.\n\nProgression in adulthood matters mainly because of its consequences. Curve progression in adulthood is a key factor in chronic pain and disability. Clinically significant rib cage distortion can result in respiratory insufficiency and cor pulmonale, which links the magnitude reached at maturity to later cardiopulmonary risk."
    },
    {
      "heading": "Clinical features and symptoms",
      "text": "Most scoliosis is recognised from its appearance before it causes any symptoms. In adolescents with idiopathic curves, the earliest signs are usually postural: one shoulder sits higher than the other, one shoulder blade projects, one hip looks higher or more prominent, and the head may not sit centrally over the pelvis. Because the spine rotates in three dimensions, the vertebrae in a thoracic curve turn toward the convex side, which pushes the ribs backward and outward on that side and produces the familiar rib prominence, or \"rib hump,\" that becomes most obvious when the patient bends forward. Trunk asymmetry also changes the waistline, so the flank on the concave side can look shortened and the hip line may tilt. Pelvic obliquity can make one leg look longer than the other even when true limb length is equal. These visible features are often noticed by parents, teachers or sports staff rather than by the patient, and they are the reason school screening and the forward bend test focus on the trunk rather than on pain (see diagnosis).\n\nPain is a more complicated feature. In adolescents, back and low-back pain is reported fairly often, but studies disagree about whether it tracks with curve size. Some reports find that larger curves are associated with more pain, cosmetic concern and subjective breathlessness, while others find that pain does not necessarily lead to disability or that curve magnitude has little influence on its severity. In adults, pain is more typical and tends to have a mechanical pattern. It is usually worse with standing, walking or prolonged loading, improves with sitting or flexing forward, and is often stiff in the morning. The source of the pain is generally degeneration of the discs and facet joints on the concave side, rather than the curve itself. Adults may also develop leg pain, numbness or weakness from narrowing of the spinal canal (stenosis) or from compressed nerve roots, and may find that they can walk only short distances before symptoms appear. Pain of this kind is closely related to general pain management and rehabilitation pathways.\n\nCardiopulmonary effects are mainly a concern in severe thoracic curves. Because the thoracic cage is deformed, the lungs have less room to expand, and the restrictive pattern that results is usually measured as a reduced forced vital capacity. Studies have found that in moderate to severe curves the vital capacity tends to fall as the Cobb angle increases, whereas curves below about 35° often produce little measurable change in resting lung volumes. The location of the curve also matters: a higher apex compresses the lung on the convex side more directly, so thoracic curves generally carry more risk than lumbar ones of the same size. Long-term follow-up has not always confirmed a simple dose–response relationship. In one cohort followed for about forty years, patients with thoracic curves had slightly lower lung function than those with thoracolumbar or lumbar curves, but the values remained within the normal range and the curve size did not correlate linearly with lung impairment. In very severe deformity, typically curves above roughly 90° to 100°, the risks are more serious: impaired exercise tolerance, chronic carbon dioxide retention, pulmonary hypertension, cor pulmonale and right heart failure. Children with early-onset deformity face the greatest concern because the chest cannot grow normally, and their respiratory function is harder to assess directly (see physiology).\n\nNeurological symptoms are uncommon in idiopathic scoliosis, but their presence changes management. Most patients have no deficits, and when they occur they usually point to a cause other than the curve. Clinicians pay particular attention to a left-sided thoracic or thoracolumbar curve, which is much less common than a right-sided one and is associated with an increased rate of underlying abnormalities. Large series have reported neural axis abnormalities such as syringomyelia, Chiari malformation or a tethered cord on MRI in a substantial proportion of such patients, although other studies have found the association to be weaker, so the indication remains debated. Other warning signs include curves that progress rapidly, unusual rotation or a curve without marked apical rotation, age of onset before about ten years, male sex, excessive thoracic kyphosis, pain at rest or at night, asymmetric abdominal reflexes, foot deformities, gait change, weakness, and bladder or bowel dysfunction. Any of these features may prompt MRI of the whole spine to exclude a central nervous system lesion before surgical planning. Where an abnormality is found, treating it, for example by neurosurgical decompression, can improve the spinal deformity, which is why the investigation matters.\n\n<!-- no new keywords -->"
    },
    {
      "heading": "Diagnosis and imaging",
      "text": "Clinical examination\n\nDiagnosis usually begins with a hands-on examination. In the forward bend test, the patient bends at the waist with feet together and arms hanging, and the examiner looks for rib humps and uneven contours along the back. The test is less sensitive for low-back curves because it does not involve rib rotation.\n\nA scoliometer, a handheld inclinometer, can be placed over the back during the bend to record the angle of trunk rotation. An angle of trunk rotation of 5° to 7° is the recommended threshold for referral to radiography. The device is a screening aid rather than a diagnostic one. In a large school study of girls, the scoliometer flagged many children whose forward bend test appeared normal, and the low positive predictive values at these cut-offs have led to concerns about over-referral (123 and 13 children were abnormal on scoliometer at thresholds of 5 and 7 degrees but appeared normal on the Adams test).\n\nStanding radiographs and the Cobb angle\n\nA positive examination is followed by full-spine standing radiographs. The Cobb angle is measured from the endplates of the most tilted vertebrae at each end of a curve. A diagnosis of scoliosis is reached when the imaging shows a lateral curvature greater than 10 degrees together with vertebral rotation. The same films show curve type, the vertebral levels involved and skeletal (bone) age, which is commonly estimated with the Risser sign from the iliac crest. Plain radiography remains the gold standard for evaluating and classifying adolescent idiopathic scoliosis.\n\nMagnetic resonance imaging\n\nMRI is not routine for every patient. Its main role is to exclude an underlying neural axis anomaly such as syringomyelia or a tethered cord. In the presence of atypical features, MRI is recommended to exclude a neural axis anomaly. The usual triggers are a left-convex thoracic curve, short-segment or double curves, rapid progression, pain, and abnormal neurological signs (10% of patients with an atypical curve pattern and 6% of those with an isolated neurological finding showed abnormalities on MRI). The yield is higher when features co-occur (the highest yield, 25%, occurred when both an atypical curve and neurological indicators were present). Neural anomalies are also more common in congenital curves, involving up to one-third of cases. Whether MRI should be used routinely before surgery in neurologically normal adolescents with typical curves remains debated, because the individual indicators have shown inconsistent predictive value in different series.\n\nRadiation-sparing imaging and 3D reconstruction\n\nChildren with scoliosis may need many radiographs over several years, which raises the cumulative radiation concern. The EOS system uses two perpendicular X-ray beams to capture frontal and lateral views simultaneously while the patient stands. It lowers the radiation dose needed for a 2D spine radiograph by eight to ten times compared with conventional methods. In a 2016 protocol study, a micro-dose protocol cut the mean dose-area product for posteroanterior views from about 300 to about 41 mGy·cm², but image quality was lower with the micro-dose protocol. The same system supports 3D modelling of the spine from the two planar images, and low-dose EOS imaging was found to yield a very accurate 3D reconstruction of the spine. Its limits include cost and the fact that EOS does not provide information on soft tissues.\n\nRepeated imaging is also a practical burden. Children in brace treatment often need scans at the design stage, at delivery and throughout follow-up, which can last for years. Non-ionizing or lower-dose options therefore remain a priority. Surface topography and 3D ultrasound are being studied as alternatives, but a reliable and valid 3D ultrasound system ready for clinical scoliosis assessment has not yet been reported."
    },
    {
      "heading": "Screening programs and public policy",
      "text": "Evidence on benefit\n\nMost of the evidence on population-level scoliosis screening comes from observational programs. The 2018 review for the US Preventive Services Task Force located seven fair-quality screening programs, including 447,243 adolescents. Six of these were run in schools, and the screening tests and examiner training differed considerably between them (Seven fair-quality screening programs (13 articles) including 447,243 adolescents met our inclusion criteria. Six of the seven programs were conducted in school settings, and there was heterogeneity in the screening tests used and in the training of the practitioners conducting screening.).\n\nAccuracy depends heavily on the test used. The combination of the forward bend test, a scoliometer and moiré topography gave the best results in one clinic-based program, with sensitivity of 93.8% and specificity of 99.2% (The accuracy of screening was highest (93.8% sensitivity and 99.2% specificity) when 3 separate screening tests were used (the forward bend test, scoliometer measurement, and Moiré topography).). Single-modality screening performed far worse on predictive value, with positive predictive values of only 5.0 to 17.3 percent for a single screening modality.\n\nWhether screening changes long-term outcomes remains unresolved. The Scoliosis Research Society's international task force judged that screening brings detection at an earlier stage, meaning younger age or smaller Cobb angle, and that screened patients are less likely to need surgery (There is moderate evidence that the use of scoliosis screening allows for detection and referral of patients with AIS at an earlier stage of the clinical course, in terms of younger age and/or lower Cobb angle.; There is evidence that scoliosis patients detected by screening are less likely to need surgery than those patients who did not have screening.). The USPSTF reached a more cautious view, finding no direct evidence of a benefit of screening for adolescent idiopathic scoliosis on health outcomes. The earlier detection gained through screening is therefore inferred from intermediate measures, not shown to improve health in adulthood.\n\nArguments for and against routine screening\n\nProponents emphasize that bracing can halt curve progression if started early, and that brace treatment can interrupt or slow scoliosis progression. Critics stress the costs of finding curves that would never have caused harm. The USPSTF noted that the harms of treatment as moderate (eg, unnecessary brace wear or unnecessary referral to specialty care). This is the core of the overdiagnosis concern: a large share of detected curves are mild and unlikely to progress, yet the child is still referred, imaged and monitored.\n\nThe harms of screening itself are poorly documented. The 2018 review found little or no evidence on long-term outcomes for AIS treated in adolescence, the association between curvature at skeletal maturity and adult health outcomes, the harms of AIS screening or treatment. False positives create a follow-up burden of clinic visits and repeated radiographs. A Norwegian regional program in 12-year-olds illustrates the scale of the problem: School screening identified 5 of the 9 children treated for scoliosis but resulted in referrals for another 87 children who were not treated.\n\nThe USPSTF's position has changed over time. In 2004 it recommended against routine screening, but its 2018 update concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis, leading the USPSTF to issue an I statement. The recommendation does not cover children who present with back pain or breathing difficulties, or with obvious deformity (It does not apply to children and adolescents presenting for evaluation of back pain, breathing difficulties, abnormal radiography findings or other imaging studies, or obvious deformities in spinal curvature.). Because the evidence on benefit and harm is incomplete, the outcome of this debate depends partly on how much weight is given to unproven benefits and to avoided surgery.\n\nDivergent national policies\n\nScreening policy varies widely between countries. Japan is the most frequently cited example of a legal mandate, but the program is run locally: In Japan, school-screening program for scoliosis is mandatory by law. But actual program depends on local educational committees, as they take charge of their own program. Local practice also differs in its methods. In one survey of Tokyo committees, the committees which use moiré surface topography are less than half. In Europe the picture is similarly fragmented, with SSS is not a national policy in the United Kingdom and Poland, while in Greece, Italy, Spain, Israel, Turkey, the Netherlands and Bulgaria, it is provided on a voluntary basis. In the United States, school screening was regulated state by state; as of 2003, 21 States had legislated school screening; 11 States recommended school screening without legislation. Canada adopted school screening in the 1970s but discontinued it about a decade later, on the advice of a national body. In China, a SSS program is not included in the Chinese School Health Service, and there is no recommendation to include one.\n\nThe sharpest divergence is between the USPSTF and certain specialist bodies. Some professional societies, such as the Scoliosis Research Society and the American Academy of Pediatrics, have advocated screening at specific ages, which conflicts with the USPSTF's I statement. Guidelines therefore reflect different weightings of the same incomplete evidence, and evidence-based reasoning alone has not produced a consensus.\n\nImplications for health systems and minors\n\nScreening programs depend on the workforce and budgets of the health system and the education sector. Staffing is a practical constraint: Some states have ratios of one school nurse for every 700 students, which limits the capacity of nurse-led programs. Programs must also decide who performs the examination, how positive results are reported to families, and who is responsible for follow-up, which affects costs and the quality of care.\n\nScreening involves healthy minors, so informed consent raises particular questions. Parents or guardians must be informed about the purpose of screening, the likelihood of false positives, and the possibility that a finding will lead to observation without treatment. Because the benefits of early detection are still debated, consent materials that explain uncertainty are important. Any policy decision also has to weigh resource allocation against other public health priorities and the psychosocial effects of labeling a healthy child as having a spinal condition."
    },
    {
      "heading": "Observation and bracing",
      "text": "Treatment thresholds\n\nPatients with a Cobb angle under 25 degrees are typically reviewed clinically and radiographically every four to six months, alongside exercise and posture work. Bracing is usually directed at skeletally immature patients with moderate curves, and one review gives the range as 25 to 45 degrees. The Scoliosis Research Society has been cited as supporting bracing for curves of 20° to 40°, with surgery considered above 45° when growth remains, although some clinicians set the surgical cut-off at 40° instead. The boundaries are therefore not uniform across authorities.\n\nEvidence from BrAIST\n\nThe Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) is the principal source of high-level evidence. It enrolled patients with curves of 20° to 40° and Risser grades 0 to 2, and it combined a randomized cohort with a preference cohort. Its primary outcome was progression to 50° or more, a commonly used indicator for surgery. In the combined analysis, the rate of treatment success was 72% after bracing, as compared with 48% after observation. The trial was stopped early because of the apparent efficacy of bracing.\n\nThe benefit was dose-dependent. Patients who wore the brace for 13 hours or more a day had success rates above 90%, while those in the lowest wear quartile, at 0 to 6 hours daily, reached only 42%. Average wear in the trial was about 12 hours per day, and a substantial minority stopped using the brace before the trial ended.\n\nBrace designs\n\nThe brace used in BrAIST was a rigid thoracolumbosacral orthosis (TLSO). Alternatives include night-time designs worn mainly in bed. One comparison found that the Providence nighttime orthosis was more effective than a TLSO at avoiding surgery in curves of 25° to 40°. Another reported surgery rates of 11% with the Charleston brace and 13.5% with a TLSO, without a statistically significant difference. SOSORT classifies part-time rigid bracing as 12 to 20 hours per day and full-time bracing as 20 to 24 hours per day. Brace type also influences adherence: in one analysis, compliance was higher with one design than with the Lyon or Milwaukee braces.\n\nWear schedules and adherence\n\nSOSORT guidance recommends that braces be worn full time, or for no less than 18 hours daily, at the start of treatment, with wear gradually reduced after vertebral growth ends. Compliance is the most variable element in practice. In one cohort, curves did not progress in 82% of patients who wore the brace more than 12 hours daily, compared with 31% of those who wore it fewer than 7 hours. Self-reported wear is unreliable, and studies using temperature sensors found both reported and estimated hours inaccurate. In an SOSORT-linked cohort, overnight-only wear was associated with a high rate of progression, whereas interruptions of up to one month did not change the outcome. Prolonged brace use may also reduce spinal mobility and affect body image, which bears on adherence.\n\nGuidelines and consensus\n\nThe 2014 SRS–SOSORT consensus broadened its target population to all idiopathic patients and added recommendations on reporting wear. A newer SRS–SOSORT consensus on bracing research calls for objective wear measurement, such as thermal sensors, and for specifying brace type in accordance with SOSORT-SRS-ISPO-POSNA guidance. It also notes that the field has not reached agreement on definitions of compliance and adherence."
    },
    {
      "heading": "Exercise-based and other conservative therapy",
      "text": "Scoliosis-specific exercise, called physiotherapeutic scoliosis-specific exercise (PSSE) in the SOSORT literature, differs from general physiotherapy because it targets the three-dimensional deformity rather than general fitness. The best-known approach is the Schroth method, which works on postural alignment in all three planes, breathing patterns and sensorimotor control (a scoliosis-specific exercise program focusing on three-dimensional corrective postural training, breathing techniques, and sensorimotor re-education). In trials, a typical course begins with a few individual teaching visits, followed by weekly supervised group sessions of about an hour and daily home practice; in one trial, the home routine was selected with an algorithm matched to the curve pattern (five individual visits to learn the exercises, followed by weekly supervised group sessions of one hour each, with daily home exercises prescribed using an algorithm).\n\nSchroth-based exercise has been compared mainly with other exercise types and with standard care. In a 10-week trial of 28 adolescents with mild curves of 10–26°, Schroth exercise produced larger improvements in Cobb angle, thoracic trunk rotation and quality of life than core stabilization, whereas core stabilization better improved peripheral muscle strength (patients in the Schroth group showed greater improvement in Cobb angles, thoracic trunk rotation angle, cosmetic trunk deformity, spinal mobility, and quality of life than those in the core group; peripheral muscle strength improvement was greater in the core group). Larger trials against standard care have followed. A six-month randomized trial of 124 participants aged 10–18 with curves of 10–45° and Risser stage ≤3 compared standard care with and without Schroth sessions (124 participants with AIS (age: 10–18, Cobb: 10°-45°, Risser: ≤3) were randomly assigned to the control (Standard care only) or Schroth (Standard care + Schroth treatment) group). A separate 12-month trial added supervised Schroth exercise to bracing; its authors reported significant gains in Cobb angle, trunk rotation and SRS-22 scores relative to bracing alone (a 12-month supervised Schroth exercise program in AIS patients undergoing brace treatment significantly improves scoliosis severity (Cobb angle and ATR maximum) and quality of life). Because the control arm also wore a brace, this design cannot isolate the contribution of exercise alone.\n\nThe evidence on whether exercise slows curve progression remains weak. The Cochrane review of exercise for adolescent idiopathic scoliosis identified low-quality evidence from 1 randomized controlled study that exercises as an adjunctive to other conservative treatments to increase the efficacy of these treatments. The same review found very low-quality evidence from a prospective controlled cohort study that SSEs structured within an exercise program can reduce brace prescription, and concluded that there is a lack of high-quality evidence to recommend the use of SSE for AIS. Subsequent syntheses have been more favorable but remain limited in quality. An earlier meta-analysis of nine randomized trials reported that very-low-quality evidence indicated that SSE improved some measures of spinal deformity, function, pain and overall health-related quality of life, while bracing was more effective than SSE on measures of spinal deformity. Pain results were inconsistent: the same review also reported no differences ... for pain or trunk rotation. A recent network meta-analysis found that exercise interventions were consistently superior to control conditions, but the differences among specific exercise modalities were limited in most comparisons, and that the overall quality of evidence was low. Its authors also noted that the balance of structural evidence favors Schroth, while cautioning that larger multicenter trials are needed.\n\nEvidence on quality of life, muscle endurance and symptoms comes largely from small trials. A preliminary analysis of a six-month Schroth trial suggested a small but positive influence on self-efficacy, self-image, pain and back muscle endurance. The assessor- and statistician-blinded trial published as a SOSORT award winner examined quality-of-life outcomes and back muscle endurance compared to standard of care alone in patients with AIS. Exercise is also used alongside bracing for higher-risk curves. A prospective matched-control study compared patients diagnosed with AIS who fulfilled the Scoliosis Research Society (SRS) criteria for bracing who received Schroth exercise during bracing with a 1:1 matched historical control group who were treated with bracing alone. Because this design is non-randomized, its results are hypothesis-generating.\n\nGuideline positions reflect this mixed evidence. The 2011 SOSORT guidelines recommended that PSSE be the first step to treat idiopathic scoliosis to prevent/limit progression of the deformity and bracing, and that it are performed during brace treatment. Later SOSORT material, however, advises that bracing is recommended in patients with evolutive idiopathic scoliosis above 25° during growth; in these cases, PSSEs alone (without bracing) should not be performed unless prescribed by a physician expert in scoliosis. The Scoliosis Research Society has said that it has supported and will continue to support pilot research studies for the role of exercises in the treatment of scoliosis, and it has worked with SOSORT on research standards for non-operative methods. Observation of small curves, bracing of intermediate curves and surgery of large curves form the standard framework within which exercise is placed (standard treatment is observation, bracing, and surgery for small, moderate, and large curves, respectively).\n\nAdjunctive therapies have been studied even less. The Cochrane review noted one very low-quality study suggested that these exercises may be more effective than electrostimulation, traction, and postural training to avoid scoliosis progression. Newer protocols, such as a planned trial of traditional Chinese medicine manipulation added to Schroth exercise in 60 adolescents, have yet to report results (sixty adolescents (aged 10–18) with idiopathic scoliosis and Cobb angle 10°–45° will be randomized 1:1 to: (1) Schroth therapy alone (control) or (2) TCM manipulation combined with Schroth exercise). After surgery, the evidence is also thin: the application of Schroth exercises in postoperative scoliosis management lacks support from randomized controlled trials (RCT), underscoring a critical research gap."
    },
    {
      "heading": "Surgical treatment",
      "text": "Indications\n\nSurgery is usually considered for curves that are large or still progressing. In adolescent idiopathic scoliosis, a common threshold is a Cobb angle above roughly 45 to 50 degrees, although practice varies. Fusion is recommended for growing adolescents at various Cobb angles, but typically around 45º to 50º, and some surgeons operate on curves as low as 40º. One guideline framework generally recommends surgery when the Cobb angle exceeds 50 degrees even after skeletal maturity, or 40 degrees with remaining growth potential. The evidence base is thin: no long-term study provides Level I evidence in favor of surgery when compared to the natural history of scoliosis.\n\nActual practice differs by location. In a multicenter database of 4,229 patients, the median indication for posterior spinal fusion in the thoracic curve cohort was 55°, and in the lumbar curve cohort was 51°. The same study found that increasing maturity, female sex, and lumbar curve location are independent risk factors for fusion under 50°.\n\nPosterior spinal fusion\n\nPosterior fusion is the most common operation for established deformity. Posterior spinal fusion is the mainstay of treatment for a Cobb angle over 50 degrees with satisfactory long-term results. Surgeons use pedicle-screw and rod constructs to straighten the spine and then fuse the segments that form the structural curve, while leaving flexible, nonstructural segments unfused where possible so that more of the spine keeps its motion. Fusion levels are chosen according to the curve pattern, which is why classification matters for planning.\n\nSevere deformities have historically required additional work. For severe (Cobb angle 45° to 59°) and very severe (Cobb angle > 60°), posterior instrumentation along with anterior release was traditionally the preferred method. Anterior approaches are less attractive for the most rigid curves, because these patients frequently have cardiopulmonary limitations. Some surgeons use internal distraction or preoperative traction to obtain improved correction, but preoperative traction is associated with a heightened risk of perioperative complications, including cranial nerve palsies, pin infections, and pin loosening.\n\nGrowth-friendly surgery for early-onset scoliosis\n\nEarly-onset scoliosis, which begins before age ten, presents a different problem because the spine and chest are still growing. Early fusion can leave a small fixed thoracic cage with underdeveloped lungs causing pulmonary complications, which is why fusionless methods were developed. Growing rods use tandem or domino connectors designed to allow periodic distractions (e.g., every few months) via surgical approach under anesthesia. Their drawback is the repeated operation: it requires surgical lengthening every 4 to 6 months as the spine grows in length, which raises the risk of wound infection, repeated anesthetic exposure, spontaneous fusion, and eventual definitive fusion.\n\nVertebral body tethering (VBT) applies a flexible cord across the convex side of the curve to guide growth in skeletally immature patients. Because it works through growth modulation, timing matters. The ideal skeletal age for anterior tethering is defined by a Risser score of ≤ 2 and a Sanders score of 3-4, and if the vertebral tethering is performed too early, a higher risk of curve overcorrection should be considered. Outcomes are still being defined. One systematic overview reported that 73.9% achieving clinical success. However, 15.8% required unplanned reoperations, and 52.2% experienced complications with 22% tether failure rate. Reviewers have described the evidence as limited and advised that high reoperation and complication rates be discussed with patients.\n\nComplications\n\nComplications affect every surgical pathway. Fusionless growing-rod treatment is associated with implant related, wound related, and anesthetic complications. In anterior tethering series, it has moderate success and perioperative complications, revision and conversion to PSF, meaning that some patients later need conversion to posterior fusion. Pulmonary problems such as atelectasis, pneumonia and pneumothorax have been reported after tethering, usually managed without further surgery. Neurological injury, deep infection, implant failure and the need for revision are recognized risks of instrumented spinal surgery in general, and they are a central part of the informed-consent discussion for families."
    },
    {
      "heading": "Adult scoliosis",
      "text": "Two groups with different origins\n\nAdult scoliosis is usually divided by when the curve began. Adult idiopathic scoliosis begins during adolescence and continues throughout adulthood, while adult degenerative scoliosis develops after adulthood. The diagnostic threshold is a Cobb angle above 10° in people with mature skeletons, and the deformity is regarded as a three-dimensional complex deformity of the spine.\n\nAdolescent idiopathic scoliosis carried into adulthood\n\nCurves that persist from adolescence are the more heterogeneous group. Their progression is slow but continuous. In one study with a mean follow-up of 25.7 years, the median major curve grew from 36.5° at skeletal maturity to 45.5° at the survey, a progression rate of 0.5°/year. Over 40% of the curves were above 50° during the mean 25-year follow-up period. Outcomes diverge: some patients experience curve stabilization while others have further progression, chronic pain, osteoporosis or fractures, and declines in pulmonary and functional capacity. In a 10-year retrospective analysis of unoperated adults, most adults functioned well, while a subset experienced increased disability correlated with age, body mass index, and curve magnitude. Pregnancy does not reliably accelerate curvature, although it may intensify pain and functional limitations.\n\nAdult degenerative scoliosis\n\nDegenerative scoliosis, discussed in more detail in its own entry, typically appears in a spine that was previously straight. Its onset usually occurs around age 50, with a mean clinical presentation age of approximately 70 years. Prevalence rises steeply with age: in a large DXA-based study of adults aged 40 and older, the prevalence was 3.14% for those aged 40 to 50, and 50% for those aged 90 or older. Women are more often affected, and postmenopausal osteoporosis is thought to accelerate vertebral degeneration and ligamentous laxity. The mechanism is generally attributed to asymmetrical degeneration of disc and facet joints, which places an asymmetric load on the spine. The degenerative sequence starts with loss of disc hydration and disc space height, followed by increased loads on the facets leading to facet degeneration.\n\nSymptoms differ by type. Back pain and deformity are the main indications for surgery in adult idiopathic scoliosis, whereas radiating leg pain caused by foraminal stenosis often prompts surgery in degenerative scoliosis. Common complaints also include neurogenic claudication, postural instability, and chronic back pain. Larger curves, particularly those above 30°, and curves with sagittal imbalance are more likely to become symptomatic and require intervention.\n\nTreatment approaches\n\nNon-operative care is aimed mainly at pain and function. Recent literature suggests that a lack of evidence exists to support the effectiveness of nonoperative treatment for adult scoliosis. Surgical decisions weigh deformity severity against comorbidity. Patients who undergo operations are typically older, carry more comorbidities, and have greater disability and poorer sagittal alignment than those managed non-operatively. Operative patients had more co-morbidities, greater disability and worse sagittal spinopelvic alignment. Reported outcomes vary: current literature reports a varying range of improved clinical outcomes, curve correction, and complication rates. In adults operated for adolescent curves, re-operation rates appear to be 14–15% with follow-up periods of 2–17 years. These figures come from relatively short follow-up series, so long-term data remain limited.\n\nClassification of adult deformity\n\nThe SRS-Schwab classification is the most widely used system for adult deformity. It includes a curve type descriptor and three sagittal spinopelvic modifiers: sagittal vertical axis, pelvic tilt, and the pelvic incidence–lumbar lordosis mismatch. Its reliability has been measured in inter- and intra-observer studies, where the mean κ value was 0.73 for interobserver reliability and 0.83 for intraobserver reliability. Clinically, significant differences in health-related quality of life were identified based on curve type, with thoracolumbar and primary sagittal deformities associated with greater disability.\n\nNewer systems focus on adolescent curves that persist. One proposal divides adolescent idiopathic scoliosis persisting into adulthood into Young Adult Idiopathic Scoliosis (19–30 years) and Adult Idiopathic Scoliosis (over 30 years), with further subdivision of the younger group into mild, flexible curves and severe, stiff curves. Its validation so far rests on a retrospective review of patients who underwent surgical correction between 2018 and 2022, so its predictive value in other populations has not yet been established."
    },
    {
      "heading": "History of research",
      "text": "Early descriptions and non-operative methods\n\nEfforts to correct spinal curvature predate any systematic measurement of it. In the fifth century BC, Hippocrates described scoliosis for the first time, and designed a distraction apparatus for correction of the deformity. Galen's second-century work is also documented: In the second century AD, Galen coined the terms scoliosis, kyphosis, and lordosis, and described their treatment by chest binding and the application of spinal jackets.\n\nIn the sixteenth century, the French surgeon Ambroise Paré first described congenital scoliosis and understood spinal cord compression as a cause of paralysis. He is also associated with the first metal brace, but sources disagree on its date: one places it in 1564 The first brace for scoliosis, developed in 1564, while another dates the first metal brace to 1575 The 1st metal brace was developed under Ambroise Pare in 1575. Paré also recommended that growing patients receive new breastplates roughly every three months.\n\nIn 1741, Nicolas André introduced the word orthopedia, which meant \"straight child\" In 1741, Nicholas Andre coined the word \"orthopedia\" meaning \"straight child\". André linked the condition to muscle imbalance and poor sitting posture, André felt that scoliosis was the result of muscle imbalance and poor sitting posture. Plaster-of-Paris jackets, moulded on patients suspended in a frame, became the signature treatment of Lewis Sayre around 1890 In 1890, Lewis Sayre popularized plaster of Paris casts that he applied to patients while they were standing in a vertical suspension device.\n\nEarly surgery and the twentieth century\n\nSurgical correction began to take shape in the early twentieth century. Russell Hibbs carried out what is recorded as the first spinal fusion meant to correct scoliosis in 1911 Dr. Hibbs performed the first spinal arthrodesis in 1911, a procedure designed to fuse the spine and correct scoliosis. Fred Albee later applied the method to tuberculous spinal deformity. These early fusions had a serious weakness: Over time, they frequently led to a loss of correction, and patients often experienced pseudoarthrosis, a condition where the bone fusion fails to heal correctly. Fritz Lange had earlier tried internal stabilisation with steel wire, borrowing the logic of splinting long-bone fractures Drawing inspiration from the use of splints in long bone fractures, Lange adapted this concept to the treatment of spinal deformities. In 1908, he introduced an innovative technique to stabilize deformed or scoliotic spines using steel wire.\n\nConservative care changed in parallel. Bracing superseded traction as the primary means to treat spinal deformities in the 1900s. Later designs such as the Milwaukee and Boston Brace reshaped bracing practice.\n\nThe Harrington rod\n\nBefore the Harrington rod, fusion offered limited protection: such fusions required many months in plaster casts, and large curvatures could progress despite fusion. Paul Harrington's work, carried out from the late 1940s to late 1950s, grew out of earlier failures. An internal fixation method would not hold. The hooks and threaded rods used would corrode and break, causing curvature to return to the spine.\n\nSources give differing dates for the device. Its introduction is variously given as 1947, while another account states it was developed in 1953, and a third gives 1955. Its public debut was less than warmly received: He first presented the Harrington Rods at the American Academy of Orthopaedic Surgeons Annual Meeting in 1958, which was met with skepticism. The method anchored the rod to the spine, and the rod is positioned along the concavity (inside) of the spinal curve and attached to the spine using two hooks. Then, employing the ratcheting mechanism, the surgeon stretches the spine to straighten the curve and fuses into position.\n\nThe implant spread quickly. Up to one million people had Harrington rods implanted for scoliosis between the early 1960s and the late 1990s. From the early 1960s until the early 1980s, Harrington rod instrumentation (HRI) was considered the standard of care for the surgical management of idiopathic scoliosis (IS). Later instrumentation that avoided flatback deformity gradually replaced it, advances in surgical techniques and technology in the late 1990s were eventually able, in most cases, to correct scoliosis without causing flatback syndrome, leading to the gradual phasing out of the Harrington Rod. Subsequent systems, such as the Cotrel-Dubousset screw-based instrumentation of the 1980s, extended fixation to multiple levels and improved control of rotation.\n\nCobb's measurement and early classification\n\nIt was introduced in 1948 (see Cobb (1948) \"Outline for the study of scoliosis\", The American Academy of Orthopedic Surgeons Instructional Course Lectures. The angle became the reference measure for coronal curves: The Cobb angle constitutes the gold standard and most frequently performed curvature measurement in the coronal plane. Its reliability is imperfect, and measurements of the Cobb angle bare an intra- and interobserver variability of approximately 4° to 8°. Critics also noted its planar limits: This is due to the three dimensional (3D) nature of a scoliotic curvature, which may include a displacement, a rotation and/or a deformation of each vertebra. Early classification schemes of the mid-century were built around this angle, and later systems are covered elsewhere in this entry.\n\nThree-dimensional measurement followed. In analytical method for 3D Cobb angle measurement, which was introduced by the Scoliosis Research Society, the vertebral body line is defined as the curve that best fits the centroids (geometric centers) of each vertebra.\n\nProfessional societies and guidelines\n\nSurgeons organised themselves into specialist bodies that shaped the field. Harrington himself served as president of the SRS from 1972 to 1973, and Levine was president of the society from 1978 to 1979. Current membership primarily includes spinal deformity surgeons, as well as some researchers, physician assistants, and orthotists who are involved in research and treatment of spinal deformities. A focus on early identification eventually produced school screening, intrauterine detection of congenital spinal deformities, and genetic markers. Subsequent national and international guidelines, discussed in the sections on screening and treatment, drew these strands together into modern practice."
    },
    {
      "heading": "Quality of life and psychosocial impact",
      "text": "The psychosocial effects of scoliosis depend on how the deformity is perceived, how it is treated, and how long treatment lasts, not only on the measured curve. Changes in appearance are the most consistently affected area. A 2020 review of brace-treated adolescents found that self-image and body configuration were the domains most often reported as impaired, with mental health and stress second. Qualitative syntheses describe the emotional core of this distress as a sudden move from not noticing bodily asymmetry to fixating on it, which triggers anxiety. The diagnosis itself can be a stressor. In a cohort of 179 adolescents referred for suspected scoliosis, self-esteem fell after diagnostic disclosure. In mild cases the drop was immediate, while in moderate and severe cases it appeared one to two months later. Anxiety and depressive symptoms rose in both groups, and depressive symptoms in the more severe group were still elevated at reassessment.\n\nMental health problems occur more often in this population than in healthy peers. A 2022 narrative review of 30 eligible studies concluded that adolescent idiopathic scoliosis is a risk factor for mental disorders, with more frequent anxiety, depressive symptoms and neuroticism than in controls, and an association between brace treatment and raised anxiety. A UK study of 92 adolescents (Sanders et al., 2018) reported that about one-third had clinically significant psychological or emotional difficulties, most often depressive disorders and high anxiety. Other reports note that social anxiety and depression are not routinely screened in scoliosis clinics, which suggests that these needs may be under-identified. Some earlier accounts also describe social withdrawal and eating-related concerns, although the evidence for these is less systematic.\n\nBracing has a measurable but usually modest effect on quality of life. A 2026 systematic review and pooled analysis of 78 studies found that bracing was generally associated with lower scores for psychological issues, physical and social function, and self-image than no treatment, but the pooled differences were small and braced patients still reported good quality of life. Scores improved after brace treatment ended. Longer daily wear and bulkier designs were linked to poorer outcomes, while family support and better adherence were linked to better ones. Non-adherence is itself tied to appearance anxiety, social withdrawal and lower self-esteem. Scoping reviews suggest that cognitive-behavioural therapy, peer support and structured exercise programmes can improve coping and adherence. Family dynamics are also affected: an older review summarizing earlier research described corsets as disrupting body image and the process of separating from parents. Caregivers are affected too, with a meta-synthesis describing exhaustion and sleep loss during postoperative care that can contribute to depressive symptoms.\n\nComparative evidence is mixed. A two-year prospective study found no difference in behavioural and emotional function between patients managed with bracing, surgery or observation. An American Family Physician review noted that bracing and scoliosis-specific physiotherapy showed no clear effect on quality of life, and that there is little evidence that treatments improve patient-reported outcomes. Longer-term surgical data are more favourable. In a series of 1,354 patients, 428 of whom had more than ten years of follow-up, SRS-22r scores improved after surgery in every diagnostic group, although adolescents with idiopathic scoliosis still scored below the general population of 20- to 29-year-olds. A 30-year follow-up of 254 surgically treated patients found scores stable for about ten years and then a gradual decline, with self-image consistently the lowest domain. A ten-year study comparing Lenke types found good overall outcomes, with shorter fusions associated with better self-image and lower disability. In adults with idiopathic scoliosis, surgery improved quality of life at two years, approaching that of untreated people with milder curves, but remained below population norms."
    },
    {
      "heading": "Unresolved questions and research directions",
      "text": "The unexplained cause\n\nThe cause of adolescent idiopathic scoliosis (AIS) remains open after more than a century of study. A systematic review found many abnormalities reported alongside the condition, but strong evidence is lacking for a consistent pattern of occurrence of AIS and any abnormality. A central problem is that associations are hard to interpret: researchers struggle to tell whether a finding contributes to the deformity or is a consequence of it, and the condition is highly variable even among family members and likely has many causes. Some authors therefore suggest that these causes could be similar among homogeneous groups of patients, or they could be individual. Genetic, hormonal and mechanical data have each been studied largely in isolation (see genetics, hormonal regulation and spinal biomechanics), and no accepted model yet links them. The genetic evidence points toward a complex architecture, with a spectrum of genetic risk variants, ranging from very rare or even private to very common. Integrating such findings with growth-related mechanical loading and hormonal signalling is therefore a major unmet task.\n\nComparative effectiveness of observation, bracing and exercise\n\nThe strongest comparative evidence concerns bracing. The Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) compared bracing with observation for preventing progression to 50 degrees, and the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation. Other summaries of the same trial report somewhat different figures, such as 72% and 48%, which reflects differences in how the analyses were reported. Benefit also depended on how much the brace was worn: brace wear for an average of at least 12.9 hours per day was associated with success rates of 90 to 93%, whereas the lowest-wear quartile performed similarly to observation. Enrolment was itself a limitation, since approximately 60% of the participants rejected randomization, which forced a preference cohort into the design.\n\nExercise evidence is less consistent. A randomized trial of moderate curves found that nighttime bracing combined with self-mediated physical activity prevented curve progression of more than 6° to a significantly greater extent than did self-mediated physical activity alone, while scoliosis-specific exercises did not. Other trials of Schroth-based exercise have used it as an add-on, and one study could not determine the effect of only Schroth exercises, because exercises were combined with standard of care. Guideline differences add to the uncertainty. The Scoliosis Research Society's standard of care for growing patients is built around observation, bracing and surgery by curve size, whereas European and recommendations from the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) include scoliosis-specific exercises as a stand-alone therapy, as an add-on to braces, and during the post-surgical period. Trials that compare these approaches on a common protocol, with standardized outcomes and randomized designs that patients accept, are still needed.\n\nScreening strategy, cost and the balance of harm\n\nSchool screening is widely debated. A 2025 systematic review and meta-analysis of 34 studies concluded that school-based screening reliably detects AIS at milder stages, is associated with lower surgical rates, and can be economically defensible under well-designed, multistep protocols. The same authors noted that wide variations in prevalence, screening methods, and cost frameworks highlight the need for standardized programs and contemporary economic evaluations. Cost estimates vary widely: the same review reported costs ranging from $0.47 to $55 per student. A Norwegian health economic model found that screening is cost saving when performed in girls only, and when it leads to reduced treatment rates. Earlier SRS guidance judged that there is scientific evidence to support the value of scoliosis screening with respect to technical efficacy, clinical, program and treatment effectiveness, but there insufficient evidence to make a statement with respect to cost effectiveness. Harms remain central to the debate, including overdiagnosis, false-positive referrals and radiation exposure. Questions of public health policy and consent for minors are therefore closely tied to the evidence on benefit.\n\nPrediction of progression and personalised care\n\nCurrent observation protocols impose a considerable burden. Patients with curves of 25 degrees or less are routinely radiographed to assess the progression every 4–6 months, but no treatment is offered. Average progression values are themselves imprecise, with fast-progressing curves predicted to increase by as much as 9.6 ° over six months. Better predictive models, combining skeletal maturity, curve morphology and early-onset status with three-dimensional imaging (see MRI and computer-based image analysis), could reduce unnecessary radiographs and identify the minority who need intensive care. Approximately 10% of those with AIS develop a more aggressive deformity requiring treatment. Treatment intensity also varies by centre. Some centres begin bracing at curves below 25 degrees, and a registered study in Hong Kong is examining whether early bracing at mild curve magnitudes and surgery at 40 degrees is more cost-effective while maintaining similar health quality of life. Establishing which patients benefit from each strategy, and measuring the effects on quality of life and pain, remains a priority."
    }
  ],
  "links": [
    "medicine",
    "genetics",
    "physiology",
    "public-health",
    "diagnosis",
    "x-ray",
    "magnetic-resonance-imaging",
    "gene",
    "hormone",
    "anatomy",
    "surgery",
    "pain",
    "rehabilitation",
    "central-nervous-system",
    "evidence-based-medicine",
    "health-system",
    "informed-consent",
    "randomized-controlled-trial",
    "computer-vision",
    "quality-of-life"
  ],
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  ],
  "license": "https://creativecommons.org/licenses/by/4.0/"
}