Evaluation and Management of Thoracic Scoliosis

Initial Evaluation and Assessment

The American College of Radiology recommends beginning with standing posteroanterior (PA) and lateral radiographs of the complete spine to measure the Cobb angle, assess curve severity, classify the deformity, and evaluate skeletal maturity using the Risser index 1, 2
Measuring the Cobb angle on PA radiographs is crucial to quantify curve magnitude, which is the primary determinant of management strategy 1, 3
Assessing skeletal maturity using the Risser index is essential to predict progression risk 1
Evaluating for neurologic deficits, including focal weakness, abnormal reflexes, sensory changes, or pes cavus, is necessary 4

Screening for atypical features such as left thoracic curves, short segment curves, rapid progression, or pain is crucial, as these warrant MRI evaluation 3, 5
MRI of the complete spine without contrast is mandatory before any surgical intervention and should be obtained in specific high-risk scenarios 2, 3
MRI is indicated when there is any congenital scoliosis, left thoracic curve pattern, short segment curves, rapid curve progression, pain or neurologic symptoms, or early onset scoliosis (age 0-9 years) 3, 5

For curves <20° in skeletally immature patients, observation with serial radiographs every 12 months for Risser 0-3, or every 18 months for Risser 4-5, is recommended 3, 5
For curves 20-50° in skeletally immature patients, high progression risk (>70%) if Cobb angle >20°, and consideration of bracing for curves 20-40° with remaining growth potential is necessary 5, 6
Surgical intervention is typically indicated when curves reach 40-50° with remaining growth potential to prevent further progression 5

MRI of the entire spine is mandatory before surgery to rule out neural axis abnormalities (present in >20% of severe curves) 3
CT with multiplanar reconstruction for presurgical planning reduces screw misplacement from 15.3% to 6.5% 2, 5
Assessing curve flexibility using side bending, push prone, fulcrum bending, or traction radiographs is necessary to guide surgical approach 3

Preoperative evaluation by pulmonology and cardiology at least 2 months before surgery is essential to allow time for intervention 7, 8, 3
Required preoperative assessments include pulmonary function testing, sleep study or nocturnal oximetry, cardiology evaluation, and nutritional optimization 7, 8, 3

Aggressive airway clearance and respiratory support are critical postoperatively, with follow-up by a pulmonologist specializing in respiratory care 7, 8, 3
Key postoperative considerations include titrating pain management to promote airway clearance while minimizing respiratory suppression, and monitoring for mucus plugs if tracheostomy is present 7, 8, 3

MRI of the complete spine is mandatory before any treatment decision in congenital scoliosis due to the 21-43% prevalence of intraspinal anomalies 5
Unilateral bar with contralateral hemivertebra has extremely high progression risk (>10° per year), and isolated hemivertebra has 28% intraspinal anomaly rate 1, 5

Do not assume pain is solely from scoliosis, as thoracic disc herniations can present with burning pain and require different management 4
Do not skip MRI in congenital scoliosis or atypical presentations, as up to 43% have intraspinal anomalies that alter surgical planning 5
Do not delay evaluation of new neurologic symptoms, as development of myelopathic signs requires urgent imaging and potential surgical evaluation 4