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Scoliosis: A Literature Review

Article in Hong Kong Journal of Orthopaedic Research · April 2023

DOI: 10.37515/ortho.8231.6102

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 Hong Kong Journal of Orthopaedic Research 2023; 6(1): 4-11

Review Article
Scoliosis: A Literature Review
Hong Kong J Orthop Res
2023; 6(1): 4-11 I Gusti Ngurah Paramartha Wijaya Putra1, Febyan2
ISSN (e): 2663-8231 1 Department of Orthopaedics and Traumatology, Faculty of Medicine University of Udayana, Udayana Hospital, Bali,
ISSN (p): 2663-8223 Indonesia
© 2023, All rights reserved 2 Resident of Orthopaedics and Traumatology, Faculty of Medicine, University of Udayana, Prof Ngoerah General
www.hkorthopaedicjournal.com Hospital, Denpasar, Indonesia
DOI: 10.37515/ortho.8231.6102
Abstract

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

Keywords: Spine, Scoliosis, Deformity, Review.

INTRODUCTION

Scoliosis is a deformity of the spine has a lateral curvature of more than 10 degrees. There are different
types of scoliosis, such as idiopathic and secondary, and it can also be classified by the side of the curve and
the age at which it occurs [1]. The prevalence of scoliosis ranges from 2-13.6% across different countries [2,3].
The rate of occurrence of adolescent idiopathic scoliosis among students aged 9-16 in Surabaya, Indonesia
elementary and junior high schools is 2.93% out of a total of 784 students [4]. Scoliosis is still considered as
idiopathic condition, but it is thought to be influenced by a mixture of genetic, growth, hormonal, and
neurological factors, as well as changes in bone mass density (BMD), abnormalities in body tissue, and
imbalances in certain chemicals in the body [5].

Scoliosis can be treated by addressing the underlying cause. The treatment of scoliosis depends on
understanding the natural mechanism of the curve and its complication [6]. However, it's important to note
that there is no exact characteristic of the illness, but rather varying subjective complaints that can vary
depending on the type of curve [7]. This literature review discusses on various forms of scoliosis, the potential
for the condition to worsen, and the methods used for evaluating and treating scoliosis.

Natural History of Scoliosis

Scoliosis is considered to be a inherited disease with siblings and parents to child coincidence [8]. When first
diagnosed, the primary focus is usually determining if the cause is idiopathic or non-idiopathic. Non-
idiopathic reasons typically manifest earlier, advance faster, and may exhibit neurological signs [9,10].
Scoliosis typically manifests as a deformity that the patients, their family, or friends first notice. This
deformity may be a curvature of the spine, rib protrusion, or an asymmetry of the pelvis or shoulders [7]. In
adolescent females, breast asymmetry may also be noticed. Pain is not a common symptom of scoliosis, but
some patients may experience back pain or pain from rib prominence [2].
*Corresponding author:
Febyan Pain should alarm the clinician to exclude spinal infections, particularly if the patient complains about fever.
Resident of Orthopaedics and Imaging should be ordered to rule out a spinal tumor because nighttime pain in one location is uncommon.
Traumatology, Faculty of
Other crucial characteristics to be aware of include imbalance and gait disturbance, poor or paralysis of
Medicine, University of
Udayana, Prof Ngoerah General bowel and bladder, and any other neurological deficits, as these can indicate other pathological causes, such
Hospital, Denpasar, Indonesia as tumors or central causes like syringomyelia [1]. The risk of deterioration depends on the timing of growth
Email: febyanmd@gmail.com spurts and how much growth left in each patient, so curve deterioration needs to be closely monitored.

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 Hong Kong J Orthop Res
Untreated severe or deteriorating scoliosis in younger children can The different types of scoliosis are as follows:
cause burden the respiratory system [6].
1. Idiopathic
The patient's perception of their appearance is also crucial in
therapeutic planning, as unhappiness with self-image could eventually a. Congenital scoliosis
result in psychological impairment. Long-term scoliosis results are
primarily based on observational studies involving diverse patient Congenital scoliosis curves present at birth but may not be noticeable
populations; generally, curves over 90 degrees are thought to increase for many years. Genetic mutations in the HOX group are the cause for
the risk of morbidity and mortality [11]. If not properly treated, these many cases. These types are classified into three groups: failure of
consequences in curves with congenital or early onset can be disastrous formation, failure of segmentation, and mixed groups. Each group is
[6]. Scoliosis in adults can arise spontaneously, usually as a result of a further divided based on the location of the pathology. The classification
degenerative disease, or it can be brought on by an untreated or helps to understand the natural progression of these curves. Generally,
overlooked adolescent deformity [12]. Treatment goal in all cases is to failures of segmentation have a more favourable outcome compared to
prevent curve progression [7] . failures of formation and mixed anomalies. The prognosis is generally
worse for anomalies in junctional regions, like the thoracolumbar
Upon spinal physical examination, a severe form of scoliosis would be junction. These curves are usually associated with neurological, cardiac,
easily noticeable without much of an effort, even with clothing. For and urinary anomalies and are often discovered through a prenatal
milder form, disrobing the patient would be necessary. Through ultrasound [6]. Congenital scoliosis can range from minor to severe
inspection, shoulder and pelvic should appear level, as well as spinal depending on the probability of progression and the chance of spinal
process’ protrusion. Palpation gives examiner more detailed contour of cord compression and paralysis. It is advised that children with
the back. Spinous processes from cervical to coccyx needs to be palpated congenital scoliosis have brain and spinal cord MRIs (magnetic
to feel the alignment. Forward bending test or Adam’s forward bend test resonance imaging), as about 20% of cases have abnormalities in these
is an exam specifically designed to recognize any coronal tilt of patient’s areas. Conditions such as Chiari malformations, Syringomyelia, and
posture. To measure the angle of the tilt, a scoliometer can be placed on spinal cord tethering are commonly associated with congenital and
the apex of the spinal curvature (Figure 1) [6]. earlier onset of the disease [1]. Other factors that may be associated with
congenital scoliosis include old age, an increased incidence of congenital
heart anomaly, hip dysplasia, and disabilities. Additionally, conditions
such as Diastematomyelia and VACTERLS syndrome may be associated
with congenital scoliosis. Plagiocephaly and rib malformations may also
be present and can indicate that the scoliosis was caused by intrauterine
molding [7].

b. Infantile and juvenile scoliosis

Curves that develop in children between the age of 0-3 and 4-10 years
are referred to as infantile and juvenile idiopathic scoliosis, respectively.
Recently, curves that occur before the age of 10 years have been
referred to as having "early onset" [10]. Children with earlier onset of the
deformity are at a higher risk of impaired lower respiratory system,
which can impact their life expectancy. The risk of respiratory
complications is identified by measuring the rib-vertebral angle
difference (RVAD) and comparing it to the Cobb angle [13]. If the
Figure 1: Forward bending test and angle measurement with scoliometer difference between the two angles is more than 20 degrees, it suggests
a likelihood of deterioration. Therefore, it's important to measure both
Classification angles in these patients. If the Cobb angle is less than 25 degrees and
RVAD is less than 20 degrees, they should be observed every 4-6 months
Scoliosis can be classified based on the cause, such as idiopathic with radiographs. If the Cobb angle increases by 5-10 degrees
(primary) or secondary. Idiopathic scoliosis is divided into subtypes independent to the changes to RVAD, then treatment is recommended
[7]. Early intervention aims to improve lung development, encourage
based on age of onset, such as infantile, juvenile, and adolescent or early
and late onset. It can also be caused by other underlying medical healthy spine growth, and stop the progression of deformity, control the
conditions like congenital disorders, neuromuscular conditions, spine and thoracic cavity [14].
tumours, trauma, or syndromic conditions [1,6,10]. Additionally,
scoliosis can be classified by the side of the curve, whether it is left or c. Adolescent scoliosis
right sided [7]. Scoliosis curves can be further classified based on the
apical vertebral level as seen in Table 1. Adolescent idiopathic scoliosis is the most common form of scoliosis
seen, accounting for about 80% of cases [2]. The incidence of small curves
Table 1: Scoliosis classification by apex location [5,7]. is equal in both sexes, but larger curves are more common in females.
These curves frequently appear when the disease has advanced to the
Cervical C1-C6 point where a other people observes asymmetry in the shoulder, waist,
or back. Adolescent idiopathic curve progression risk can be predicted
Cervicothoracic C7-T1
by several factors, including first presentation magnitude of the curves,
Thoracic T2-T12 the presence of double curves, and the rate of growth during the
Thoracolumbar T12-L1 adolescent growth spurt. Premenarchal status and skeletal immaturity,
Lumbar L2-L4
as assessed by the Risser grade, also increase the potential for
progression [15]. However, the likelihood of progression decreases as
Lumbosacral L5-S1 growth slows down following the onset of menarche in girls and puberty
in boys [7]. Two classification systems have been developed to determine
the fusion area for these types of curves: the King & Moe classification,

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 Hong Kong J Orthop Res
which describes five distinct curve patterns but has poor intra/inter 3. Developmental or syndromic scoliosis
observer reliability and only evaluate the coronal plane, and the Lenke
system, which combines six curve types with coronal and sagittal plane Syndromic scoliosis refers to a type of scoliosis that is associated with
modifiers and identifies minor and major structural curves [15]. Figure 2 various syndromes, including skeletal dysplasias, connective tissue
shows the Lenke classification system. Nevertheless, not all curves fall disorders, and neuromuscular conditions [7]. Examples of common
into these categories, and each curve should be treated according to its syndromes that can cause scoliosis include neurofibromatosis and
own merits because it might be necessary to combine treatment Marfan syndrome, as well as Rett syndrome, Prader-Willi syndrome,
approaches [1]. osteogenesis imperfecta, and Ehler-Danlos syndrome. Children with
syndromic scoliosis tend to have worse risk of medical complications and
Lenke classification system is used to classify scoliosis based on the type complications from surgery when compared to children with idiopathic
of curve and its location in the spine. It includes 6 curve types, a sagittal scoliosis [21,22].
thoracic and a lumbar spine modifier. These definitions were established
by the Scoliosis Research Society and are used to order appropriate Scoliosis is not a common occurrence in type 2 Neurofibromatosis (NF),
vertebral levels for an arthrodesis. The classification system is based on but it can happen in 10-40% of patients with type 1 NF. There are two
the location of the curve's apex, with thoracic curves having an apex types of scoliosis associated with NF: 1. Dystrophic scoliosis, which is
from T2 to T11/T12, thoracolumbar curves having an apex at T12 to L1, typically a severe, short curve with a significant kyphosis. 2. Non-
and lumbar curves having an apex from L1/L2 to L4. The lumbar dystrophic scoliosis, which is alike to an idiopathic curve. An MRI is
modifiers (A, B, and C) are used to indicate the position of the lumbar needed to rule out the presence of an intraspinal neurofibroma, which
curve apex in relation to the center sacral vertical line (CSVL). Type A is is more abundant in dystrophic curves [23]. Treatment may require a
when the line is between the pedicles on apical level of the lumbar, Type combination approach as pseudoarthrosis is a known complication of
B is when the CSVL touches the apical vertebral body, and Type C is when scoliosis associated with neurofibromatosis[24].
the CSVL is completely medial to the vertebral body. The thoracic sagittal
modifier describes the degree of thoracic kyphosis between T5 and T12, Clinical Assessment
with less than 10 degrees being designated with a "-", more than 40
degrees designated with a "+", and "N" indicating a kyphosis between It is crucial to have a thorough medical history. Include the time of start
10 and 40 degrees [16]. and the person who first noted the curvature when diagnosing scoliosis,
as well as any history of progression or pain [7]. Pain may be an indication
of an underlying pathology, such as tumors, neurological conditions, or
syndromic conditions like Arnold Chiari malformation or cord tethering.
The onset of menarche in females and the characteristics of puberty in
males are significant indicators for determining the likelihood of
deterioration and the interventions timing. Obtaining specifics about the
deformity's secondary effects is necessary, such as issues with body
image or functional restrictions at school due to coordination or cardio-
respiratory problems [25]. A birth history, family history, and examination
must contain height and weight measurements, as well as observation
for skin stigmata, lower limb anomalies, dysmorphic facial features,
shoulder or pelvic asymmetry, truncal balance, scapular prominence,
flexibility of the curve, thoracic kyphosis, lordosis, range of motion, gait
pattern, and a full neurological examination [1,6]. In younger children, the
spine can be examined while the child is suspended in the air to check
for flexibility and pelvic obliquity, as well as while the child performs
everyday activities like walking and squatting. Always check the lower
Figure 2: Lenke classification system for adolescent idiopathic scoliosis [16]. extremities for deformity or length discrepancies [26].

2. Neuromuscular scoliosis A scoliosis is characterized by two curves, a primary and a secondary

curve, each with a convex and concave side. The primary curve is
Neuromuscular scoliosis is a type of scoliosis triggered by neurological typically more rigid and its location on cervical, thoracic, or lumbar
or muscular conditions that disrupt the normal alignment and support depends on where vertebral apex lies in the coronal plane. A junctional
of the spine. In the past, Polio was the main cause of this type of curve appears where two areas converge. The end vertebrae are the
scoliosis, but presently, the most common causes are Cerebral Palsy and most cephalad and caudal vertebrae with surfaces that incline toward
Spina Bifida [17]. This type of scoliosis is also seen in various progressive the concavity of the curve, and the apical vertebra is the most rotated
neuromuscular disorder such as Duchenne muscular dystrophy and vertebra in the curve. The Cobb angle, which is typically expressed in the
Spinal muscular atrophy. Children with neuromuscular scoliosis often concavity direction, is used to calculate the curve size. The Cobb angle is
present with muscle coordination and sitting difficulties rather than helpful in evaluating the first curve, tracking the curves' escalating
pain, and as their trunk muscles weaken, their spine gradually collapses, magnitude, and determining when an operative intervention might be
resulting in a long, C-shaped curve. These curves are often progressive, most advantageous for the child. Unlike the Cobbometer, which was
worsening at periods of rapid growth like puberty, particularly in previously in use, this measurement can be performed using computer
children with severe CP [18,13]. Children with GMFC 4 and 5 need close software [27, 28].
monitoring by pediatricians and physiotherapists to detect scoliosis, and
specialist surgeons use sitting or standing X-rays to monitor the In young children, the Adams forward bending test (to identify the
progression. Progressive curvature might make it difficult for children prominence of the rib on the thoracic or transverse process on the
who are wheelchair-dependent or immobile to sit comfortably [19]. Lung lumbar spine) may not be possible. However, the test can be simulated
issues, such as volume loss and recurring infections, are more prevalent by placing the child in a prone position on the examiner's knees. The
in people with severe deformities and are more common in people with flexibility of the curve can be examined by placing the child in a lateral
thoracic spine curves of 80 degrees or more [20]. position on the examiner's knees or by holding the baby on the
examiner's arm. The balance of the spine in the coronal and sagittal

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 Hong Kong J Orthop Res
dimensions should be evaluated. Truncal imbalances, head tilt, shoulder thoracic hypokyphosis, and female sex are risk factors for severity. The
asymmetry and pelvic balance should be evaluated. Motor, sensory and objectives of treatment include halting the progression of the curve,
reflex (including abdominal reflexes) examination should be done achieving satisfactory coronal and sagittal correction, enhancing
thoroughly [6, 7]. Vital capacity screening is recommended for patients aesthetic appeal, achieving solid fusion, and avoiding long-term
with severe curves. Treatment is recommended if surgery is planned for disability [28].
patients with a vital capacity less than 60% of normal [14].
1. Conservative treatment
Radiological Examinations
Bracing and casting are recommended for younger children and are less
Plain X-rays are the foundation of initial assessment, in addition to certain for adolescents. The goal is to keep the curve stable up until the
physical examination, and are widely available and inexpensive. They are child reaches skeletal maturity. As the brace must be worn for up to 23
also useful for monitoring the curve. However, standard X-rays are not hours per day, the results of bracing are less certain than those of
sufficient at the initial appointment, a standing PA and lateral views of surgery and heavily dependent on the child's compliance [7]. Under
the entire spine are required for assessing adolescent scoliosis. On general anesthesia, a cast is applied to young children with flexible
subsequent visits, only a PA view is necessary to diagnose congenital curves; it must be changed frequently every 3-4 months to
deformities and assess the sagittal profile [29]. Additional views, such as accommodate growth. Once the curve is under control, which typically
supine active bending films to examine curve flexibility, traction views in takes 12-18 months, a molded brace is worn for until skeletal maturity
neuromuscular or syndromic patients who are unable to bend actively, [37]. In stable patients, the brace can be gradually discontinued as the

hyperextension views to assess flexibility in kyphotic deformities, and child nears maturity. If bracing is unsuccessful, surgery should be
the Ferguson view which allows assessment of the L5-S1 junction. In considered [9]. Table 2 shows the various methods of conservative
wheelchair-bound patients, sitting films will reveal pelvic obliquity and approaches for scoliosis.
spinal deformity [30].
Table 2: Conservative treatment options [9, 38, 39, 40]
It is measured how severe the curve is and how it changes over time by
the Cobb angle [31]. The maturity of the skeletal structure can be Milwaukee This brace is used for postoperative treatment of post-polio
estimated by the ossification of the iliac apophysis, from front to back, brace scoliosis, it includes a pelvic section (usually plastic), front
which is graded using the Risser classification (1-5). A Risser 5 represents and back uprights, and a neck ring with a throat mold in the
complete skeletal maturity and no further growth. Grade 0-2 have the front and occipital pads in the back. It is commonly used for
maximum risk of progression should be closely monitored, and radiation patients with a curve apex higher than T8. Another type of
exposure should be minimized, so X-rays should only be taken when brace used to treat scoliosis is the TLSO, which was first used
clinically necessary. A PA film reduces radiation exposure. In some for patients with deteiorating AIS and a curve apex below T8
institutions, superficial topography of the back is used to monitor curves Boston brace It is commercially available in six sizes to increase
instead of X-rays to reduce radiation exposure [7]. production efficiency. This is a back-opening TLSO that
passively corrects the scoliotic curve.
Magnetic Resonance Imaging (MRI) of the complete spine is Cheneau The brace has two modes of operation, active and passive,
recommended for all infant and children with large or progressive brace and while the goal of using orthotics to treat scoliosis is to
curves, as around 25% of these patients may have neuroaxial anomalies. prevent the curve deteioration, the Cheneau brace may
These anomalies may include Arnold-Chiari malformations, syrinx, actually correct the curvature in some instances.
tumors and cord tethering. The use of MRI in young patients is more
Rigo Cheneau This brace is generally recommended for individuals with
debated due to the low rate of abnormalities detected. Congenital
brace mild to moderate pediatric scoliosis. It is built on the idea of
scoliosis, pain, rapid curve progression, a left-sided thoracic curve, and
balance at the L4/L5 level. Studies have shown that it can
neurofibromatosis are all indications for an MRI. The entire spine,
achieve a 53.7% correction of the main curvature, but for
including the cranio-cervical junction, should be scanned [32, 33, 34].
patients with a single extended dorsal curvature, the
correction rate increases to 76.7%, and 55% for those with
Computed tomography can be helpful for planning surgeries for
rotational deformity cases.
complex cases by showing the bony anatomy. It is especially useful for
children with small or absent pedicles, as this information can be used Gensingen This brace is utilizing computerized design and is typically
to plan alternative forms of stable fixation. Children with congenital brace used for curvatures of more than 50 degrees, which cannot
conditions should undergo an echocardiogram and a renal ultrasound as be treated with other orthotics.
part of their pre-operative planning because these children are more Cheneau- This is is a type of thoracolumbosacral orthosis (TLSO) that
likely to have cardiac and renal anomalies [35, 36]. As bronchio-alveolar Toulouse- opens in the front and exerts pressure on the torso to
development continues until the age of 8, it is also crucial to evaluate Munster change the scoliotic curve and disallowing it from getting
respiratory function in younger children. For older, more cooperative brace worse. It is usually worn at night, particularly for low
patients, measuring forced vital capacity as a percentage of normal can curvature (Cobb angle less than 30).
be a useful guide to pulmonary function [7]. Triac brace The Triac brace is designed to provide dynamic force to treat
scoliosis. Because of the hinge position, it can only be used
Treatment for curves below T11. The name Triac is based on the three
C's: comfort, control, and cosmesis. The design focuses on
The treatment for curves over 20 degrees in all groups, additional follow- the brace following the patient's motion. It has the unique
up is usually necessary. A 5 degree increase in curve size within a 6- feature of being able to achieve an instant correction of 22%
month period or a 10-degree increase within a 12-month period is for the primary curve and 35% for the secondary curve.
regarded as progression. When there is progression or if the curve is C-brace The C-brace is a type of orthosis that addresses single curve
significant upon initial presentation, treatment should start. Surgery can deformities. Its design allows for movement of the trunk,
be the initial treatment of choice in circumstances where deteioration providing patients with increased ease while wearing the
with serious consequences is anticipated, such as in congenital
brace.
deformities [1, 7]. With curves between 20 and 40 degrees, observation
Scoliosis Lycra The Scoliosis Lycra orthosis is intended for individuals with
or bracing may be a viable option for older kids. A growth spurt, growth
orthosis neurological scoliosis. It consists of a panel that is added to
potential, curve pattern, curve magnitude, unusual curve pattern,

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

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 Hong Kong J Orthop Res
instrumentation used distraction to apply correction force along the
concave side of the curve. Correction is attempted through the use of a
rod-rotation maneuver. Modern instrumentation systems utilize more
anchors to connect the rod to the spine, resulting in improved correction
and fewer implant failures. The current trend in instrumentation is using
pedicle screw constructs or hybrid constructs that incorporate pedicle
screws, hooks, and wires. A combination of anterior and posterior fusion
is a possible technique for late onset scoliosis (Figure 6, Figure 7) [14, 37,
41].

Figure 5: Vertical Expandable Titanium Rib Device (VEPTR) [41]

Figure 3: Magnetric remotely expandable system [41]

Figure 6: Anterior fusion of the vertebral bodies [14]

Figure 7: Posterior fusion of the vertebral bodies [14]

Figure 4: The Shilla Rod System [41]

Whether to fuse the spine from the front or back during scoliosis surgery
depends on factors such as the location, size, and stiffness of the curve.
Posterior fusion avoids the chest cavity and potential harm to organs,
while anterior techniques result in less blood loss and typically require
fusing fewer levels. The surgeon's expertise and experience also
determinant of the approach. The chance of permanent nerve damage
from the surgery is low, and patients are closely monitored for
complications after the procedure [41]. Scoliosis surgery aims to improve

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the patient's ability to function and live a normal, active lifestyle without 9. Rigo MD, Villagrasa M, Gallo D. A specific scoliosis classification
the negative effects of a progressive spinal curve [7, 14, 37, 41]. correlating with brace treatment: description and reliability. Scoliosis.
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Complication 10. Williams BA, Matsumoto H, McCalla DJ, Akbarnia BA, Blakemore LC,
Betz RR, et al. Development and initial validation of the classification
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Generally without the progression of the disease, scoliosis affect
11. Akazawa T, Minami S, Kotani T, Nemoto T, Koshi T, Takahashi K. Long-
patients’ cosmetic through their posture. However, when progressivity term clinical outcomes of surgery for adolescent idiopathic scoliosis
occurs, pain progresses, and neurological dysfunction will follow. On 21 to 41 years later. Spine. 2012;37(5).
severe thoracic scoliosis, breathing problem may also occur due to 12. Cho KJ, Kim YT, Shin SH, Suk SIL. Surgical treatment of adult
imbalance pulmonary capacity [40]. degenerative scoliosis. Asian Spine J. 2014;8(3):371–81.
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Surgical complications of scoliosis surgery may occur from different in cerebral palsy and risk factors for progression of scoliosis. Journal
aspect of the disease. Implant complication include implant failure such of Orthopaedic Science. 2018;23(4):649–52.
14. Maruyama T, Takeshita K. Surgical treatment of scoliosis: a review of
as breakage or bending of implants. Infection may also occur from
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superficial wound complication to deep wound complication. Blood loss 15. Rose PS, Lenke LG. Classification of operative adolescent idiopathic
from surgery may also occur and create devastating issues on post major scoliosis: treatment guidelines. Orthopedic Clinics of North America.
spine surgery. Spine related complication can also shown in the form of 2007;38(4):521–9.
pseudoarthrosis. Neurological complication is also one devastating 16. Slattery C, Verma K. Classifications in brief: The lenke classification for
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death, it can be caused by autonomic dysfunction, severe blood loss, or 2018;476(11):2271–6.
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39.
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CONCLUSION Rampal V. Risk factors for developing scoliosis in cerebral palsy: a
cross-sectional descriptive study. J Child Neurol. 2017 Apr
In conclusion, scoliosis is a complex spinal disorder that have a 10;32(7):657–62.
significant negative impact on a person's quality of life. The causes of 19. Halawi MJ, Lark RK, Fitch RD. Neuromuscular scoliosis: current
scoliosis are still a confusion among experts and can vary from structural concepts. Orthopedics. 2015;38(6):e452–6.
to neuromuscular. This literature review has provided an overview of 20. Murphy RF, Mooney JF. Current concepts in neuromuscular scoliosis.
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scoliosis typically involves a combination of physical examination and 21. Chung AS, Renfree S, Lockwood DB, Karlen J, Belthur M. Syndromic
scoliosis: national trends in surgical management and inpatient
imaging studies. Imaging studies such as X-rays, CT scans, and MRI used
hospital outcomes: a 12-year analysis. Spine. 2019;44(22):1564–70.
to confirm the diagnosis and to measure the degree of the curve. 22. Ballhause TM, Moritz M, Hättich A, Stücker R, Mladenov K. Serial
However, it is essential to note that early detection is crucial for the best casting in early onset scoliosis: syndromic scoliosis is no
outcome, and regular screenings are important to identify scoliosis at an contraindication. BMC Musculoskelet Disord. 2019;20:1–7.
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Conflicts of interest: Authors declare that, there is no conflict of 24. Cinnella P, Amico S, Rava A, Cravino M, Gargiulo G, Girardo M. Surgical
interest. treatment of scoliosis in neurofibromatosis type I: A retrospective
study on posterior-only correction with third-generation
instrumentation. J Craniovertebr Junction Spine. 2020;11(2):104.
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