Treatment. Treatment of infantile and juvenile sco-
liosis remains a therapeutic challenge because of
the adverse effects of multisegmental fusion in a
growing spine. If conservative treatment (cast,
braces) has failed to control the curve, spinal instru-
mentation without fusion becomes necessary. Sur-
gery for these curve types is very demanding and
prone to complications often requiring revision sur-
gery.
The natural history of adolescent idiopathic scoli-
osis is benign without significant differences to an
asymptomatic control group regarding physical
functioning and quality of life in adulthood. The
treatment depends on the severity of the curve and
the risk of progression. Conservative treatment is
intended to control progression of smaller curves. It
consists of observation and physiotherapy in
curves less than 10°–25° in skeletally immature
patients. Curves of 25° –40° are usually treated by
bracing. Braces are only effective before skeletal
maturity is reached. Surgery is indicated in curves
larger than 40°– 50° or rapidly progressing curves
despite conservative treatment. The objective of
scoliosis surgery is to stop the progression and to
correct the deformity. Posterior instrumentation
and fusion remains the gold standard and allows
for a correction of the coronal deformity with resto-
ration of the coronal and sagittal balance and pro-
file. Today, pedicle screws are frequently used as
they allow a better correction and shorter fusion
length than systems only using hooks and wires. In

skeletally immature patients an anterior release
and fusion is necessary to avoid further anterior
growth after posterior fusion with a deterioration of
the deformity (crankshaft phenomenon). The
more demanding anterior scoliosis surgery often
allows motion segments to be spared and vertebral
rotation to be better addressed.
In contrast to adolescent scoliosis, adult idiopathic
scoliosis patients often present with symptoms
(pain, neurological deficits) due to secondary
degenerative changes. Surgical decision-making in
adult idiopathic scoliosis strongly depends on the
underlying causes of the pain or neurological defi-
cits. The goal in adult scoliosis is to achieve a bal-
anced spine without pain or neurological deficits.
Decompression of a nerve root compression or sec-
ondary central stenosis is possible in selected
patients with a balanced spine. Fusion in situ (w/o
short-segmental instrumentation) should be added
when extensive decompression is needed to avoid
curve deterioration. The treatment of an imbalanced
spine with secondary degenerative changes often
requires extensive posterior release and in some
cases necessitates multiple spinal osteotomies.
Key Articles
Nachemson A (1968) A long term follow-up study of non-treated scoliosis. Acta Orthop
Scand 39:466 – 476
This is one of the first long-term follow-up studies on the natural course of scoliosis. Dif-
ferenttypes of scoliosis are included. For congenital, thoracogenic and neurogenic scolio-
sis prognosis was found to be worse than for idiopathic, rachitogenic and poliomyelitic

scoliosis.
Weinstein SL, Z avala DC, Ponseti IV (1981) I diopathic scoliosis: long-term follow-up
and prognosis in untreated patients. J Bone Joint Surg Am 63:702 – 712
Thoracic curves of 50°–80° were found to be at a high risk of progressing even after skele-
tal maturity was reached. Curves smaller than 30° did not progress regardless of the curve
pattern. In thoracic curves, the Cobb angle and vertebral rotation were found to be
important risk factors for curve progression.
Lonstein JE, Carlson JM (1984) The prediction of curve progression in untreated idio-
pathic scoliosis during growth. J Bone Joint Surg Am 66:1061 – 1071
In this study of patients with mild idiopathic scoliosis, pattern and magnitude of the
curve, the patient’s age at first diagnosis, menarchal status and the Risser sign were found
to be related to curve progression during growth.
Harrington PR (1962) Treatment of scoliosis. Correction and internal fixation by spine
instrumentation. J Bone Joint Surg 44A:591 – 610
Historical paper on spinal instrumentation for scoliosis describing the technique of scoli-
osis correction by distraction.
Idiopathic Scoliosis Chapter 23 653
Cotrel Y, Dubousset J (1984) A new technique for segmental spinal osteosynthesis using
the posterior approach. Rev Chir Orthop Reparatrice Appar Mot 70:489 – 494
Cotrel and Dubousset describe their technique for the posterior segmental derotation
technique of scoliosis correction.
Dubousset J, Herring JA, Shufflebarger H (1989) The crankshaft phenomenon. J Pediatr
Orthopedics 9:541 – 550
This article first describes the progression of the anterior column deformity despite pos-
terior instrumentation and solid fusion, the so-called crankshaft phenomenon.
KingHA,MoeJH,BradfordDS,WinterRB(1983)Theselectionoffusionlevelsintho-
racicidiopathicscoliosis.JBoneJointSurgAm65:1302 – 1313
Landmark paper on the classification of thoracic curves into five types.
Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K (2001)Ado-
lescent idiopathic scoliosis: a new classification to determine extent of spinal arthrode-

sis. J Bone Joint Surg 83A:1169 – 1181
The King classification only included thoracic curves. Lenke et al. therefore developed a
new more comprehensive classification system. It allows the classification of 42 different
curve patterns including all curve types and the thoracic sagittal profile. This classifica-
tion is helpful for the selection of fusion levels.
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