Editing Scoliosis (section)

==Management==
{{Main|Management of scoliosis}}
Our lack of understanding of the etiology and pathogenesis of scoliosis makes it difficult to manage. <ref>{{Cite journal |last1=Schreiber |first1=Sanja |last2=Whibley |first2=Daniel |last3=Somers |first3=Emily C |date=2023-05-27 |title=Schroth Physiotherapeutic Scoliosis-Specific Exercise (PSSE) Trials—Systematic Review of Methods and Recommendations for Future Research |journal=Children |language=en |volume=10 |issue=6 |pages=954 |doi=10.3390/children10060954 |doi-access=free |issn=2227-9067 |pmc=10297476 |pmid=37371186}}</ref> Scoliosis curves do not straighten out on their own. Many children have slight curves that do not need treatment. In these cases, the children grow up to lead normal body posture by itself, even though their small curves never go away. If the patient is still growing and has a larger curve, it is important to monitor the curve for change by periodic examination and standing x-rays as needed. The rise in spinal abnormalities require examination by a neurosurgeon to determine if active treatment is needed.<ref>{{Cite web|title=Treatment Options {{!}} Scoliosis Research Society|url=https://www.srs.org/patients-and-families/common-questions-and-glossary/frequently-asked-questions/treatment-and-coping|access-date=2022-02-11|website=www.srs.org}}</ref> Although AIS normally does not cause health problems throughout development, the observable changes in appearance can have a substantial impact on teenagers, leading to quality-of-life concerns and, in extreme cases, emotional stress.<ref>{{Cite journal |last1=Romano |first1=Michele |last2=Minozzi |first2=Silvia |last3=Bettany-Saltikov |first3=Josette |last4=Zaina |first4=Fabio |last5=Chockalingam |first5=Nachiappan |last6=Kotwicki |first6=Tomasz |last7=Maier-Hennes |first7=Axel |last8=Arienti |first8=Chiara |last9=Negrini |first9=Stefano |date=2024-02-28 |title=Therapeutic exercises for idiopathic scoliosis in adolescents |journal=The Cochrane Database of Systematic Reviews |volume=2 |issue=2 |pages=CD007837 |doi=10.1002/14651858.CD007837.pub3 |issn=1469-493X |pmc=10900302 |pmid=38415871}}</ref>

The traditional medical management of scoliosis is complex and is determined by the severity of the curvature and [[Bone age|skeletal maturity]], which together help predict the likelihood of progression.
The conventional options for children and adolescents are:<ref name="NHS-child">{{cite web |url=http://www.nhs.uk/Conditions/Scoliosis/Pages/Treatment.aspx |title=Treating scoliosis in children |publisher=NHS Choices |date=19 February 2013 |access-date=14 May 2014 |url-status=live |archive-url=https://web.archive.org/web/20140514182026/http://www.nhs.uk/Conditions/Scoliosis/Pages/Treatment.aspx |archive-date=14 May 2014}}</ref>

# Observation
# [[Back brace|Bracing]]
# Surgery
# Physical therapy. Evidence suggests use of scoliosis specific exercises might prevent the progression of the curve along with possible bracing and surgery avoidance.<ref name="Effects of corrective, therapeutic">{{cite journal | vauthors = Ceballos Laita L, Tejedor Cubillo C, Mingo Gómez T, Jiménez Del Barrio S | title = Effects of corrective, therapeutic exercise techniques on adolescent idiopathic scoliosis. A systematic review | journal = Archivos Argentinos de Pediatria | volume = 116 | issue = 4 | pages = e582–e589 | date = August 2018 | pmid = 30016036 | doi = 10.5546/aap.2018.eng.e582 | doi-access = free }}</ref>

For adults, treatment usually focuses on relieving any pain:<ref name="NHS-adult">{{cite web |url=http://www.nhs.uk/Conditions/Scoliosis/Pages/treatment-adults.aspx |title=Scoliosis – Treatment in adults |publisher=NHS Choices |date=19 February 2013 |access-date=14 May 2014 |url-status=live |archive-url=https://web.archive.org/web/20140514180521/http://www.nhs.uk/Conditions/Scoliosis/Pages/treatment-adults.aspx |archive-date=14 May 2014}}</ref><ref name="srs-adult-nonoperative">{{cite web |url=http://www.srs.org/patient_and_family/scoliosis/idiopathic/adults/nonoperative_management.htm |title=Idiopathic Scoliosis – Adult Nonoperative Management |publisher=Scoliosis Research Society |access-date=14 May 2014 |archive-url=https://web.archive.org/web/20140701132729/http://www.srs.org/patient_and_family/scoliosis/idiopathic/adults/nonoperative_management.htm |archive-date=1 July 2014}}</ref>

# Pain medication
# Posture checking
# Bracing
# Surgery<ref name=srs-adult-surgical>{{cite web |url=http://www.srs.org/patient_and_family/scoliosis/idiopathic/adults/surgical_treatment.htm |title=Idiopathic Scoliosis – Adult Surgical Treatment |publisher=Scoliosis Research Society |access-date=14 May 2014 |archive-url=https://web.archive.org/web/20140701121525/http://www.srs.org/patient_and_family/scoliosis/idiopathic/adults/surgical_treatment.htm |archive-date=1 July 2014}}</ref>

Treatment for idiopathic scoliosis also depends upon the severity of the curvature, the spine's potential for further growth, and the risk that the curvature will progress. Mild scoliosis (less than 30° deviation) and moderate scoliosis (30–45°) can typically be treated conservatively with bracing in conjunction with scoliosis-specific exercises.<ref name = Neg2018 /> Severe curvatures that rapidly progress may require surgery with spinal rod placement and spinal fusion. In all cases, early intervention offers the best results.{{citation needed|date=October 2020}}

A specific type of [[physical therapy]] may be useful.<ref>{{cite journal | vauthors = Negrini S, Fusco C, Minozzi S, Atanasio S, Zaina F, Romano M | title = Exercises reduce the progression rate of adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature | journal = Disability and Rehabilitation | volume = 30 | issue = 10 | pages = 772–785 | year = 2008 | pmid = 18432435 | doi = 10.1080/09638280801889568 | s2cid = 13188152 }}</ref><ref name = Neg2018 /> Evidence to support its use, however, is weak.<ref name=NIH2015/><ref name=Thom2018/> Low quality evidence suggests scoliosis-specific exercises (SSE) may be more effective than electrostimulation.<ref>{{cite journal | vauthors = Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, Maier-Hennes A, Negrini S | display-authors = 6 | title = Exercises for adolescent idiopathic scoliosis | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD007837 | date = August 2012 | volume = 2012 | pmid = 22895967 | pmc = 7386883 | doi = 10.1002/14651858.cd007837.pub2 }}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/38415871|date = May 2024}} Evidence for the Schroth method is insufficient to support its use.<ref>{{cite journal | vauthors = Day JM, Fletcher J, Coghlan M, Ravine T | title = Review of scoliosis-specific exercise methods used to correct adolescent idiopathic scoliosis | journal = Archives of Physiotherapy | volume = 9 | pages = 8 | date = 2019 | pmid = 31463082 | pmc = 6708126 | doi = 10.1186/s40945-019-0060-9 | doi-access = free }}</ref> Significant improvement in function, vertebral angles and trunk asymmetries have been recorded following the implementation of Schroth method in terms of conservative management of scoliosis. Some other forms of exercises interventions have been lately{{When|date=July 2023}} used in the clinical practice for therapeutic management of scoliosis such as global postural reeducation and the Klapp method.<ref name="Effects of corrective, therapeutic"/>

===Bracing===
[[File:Scoliosis patient in cheneau brace correcting from 56 to 27 deg.png|thumb|upright=1.5|A Chêneau brace achieving correction from 56° to 27° Cobb angle]]
Bracing is normally done when the person has bone growth remaining and is, in general, implemented to hold the curve and prevent it from progressing to the point where surgery is recommended. In some cases with juveniles, bracing has reduced curves significantly, going from a 40° (of the curve, mentioned in length above) out of the brace to 18°. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the person with a device that covers the torso; in some cases, it extends to the neck (example being the Milwaukee Brace).<ref name="Brace2">{{citation|title= The influence of elastic orthotic belt on sagittal profile in adolescent idiopathic thoracic scoliosis: A comparative radiographic study with Milwaukee brace. |date=September 2010 |url= https://www.researchgate.net/figure/The-same-patient-wearing-Milwaukee-brace-The-neck-ring-cause-a-stimulant-effect-on-the_fig2_46412715 |publisher=Research Gate}}</ref>

[[File:Milwaukee brace - with neck ring and mandible pad.jpg|thumb|Female adolescent (14 years old) patient wearing a Milwaukee brace – with neck ring and mandible (chin) pad showing]]

The most commonly used brace is a [[TLSO]], such as a [[Boston brace]], a [[corset]]-like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is typically recommended to be worn 22–23 hours a day, and applies pressure on the curves in the spine. The effectiveness of the brace depends on not only brace design and [[orthotist]] skill, but also people's compliance and amount of wear per day. An alternative form of brace is a nighttime only brace, that is worn only at night whilst the child sleeps, and which overcorrects the deformity.<ref>{{cite journal | vauthors = Antoine L, Nathan D, Laure M, Briac C, Jean-François M, Corinne B | title = Compliance with night-time overcorrection bracing in adolescent idiopathic scoliosis: Result from a cohort follow-up | journal = Medical Engineering & Physics | volume = 77 | pages = 137–141 | date = March 2020 | pmid = 31992499 | doi = 10.1016/j.medengphy.2020.01.003 | s2cid = 210945485 | doi-access = free }}</ref> Whilst nighttime braces are more convenient for children and families, it is unknown if the effectiveness of the brace is as good as conventional braces. The UK government have funded a large clinical trial (called the BASIS study) to resolve this uncertainty.<ref>{{cite web | url = https://basisstudy.org | title = BASIS study }}</ref> The BASIS study is ongoing throughout the UK in all of the leading UK children's hospitals that treat scoliosis, with families encouraged to take part.

Indications for bracing: people who are still growing who present with Cobb angles less than 20° should be closely monitored. People who are still growing who present with Cobb angles of 20 to 29° should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. People who are still growing who present with Cobb angles greater than 30° should be braced. However, these are guidelines and not every person will fit into this table.

For example, a person who is still growing with a 17° Cobb angle and significant thoracic rotation or [[Harrington rod#Flatback syndrome|flatback]] could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29° Cobb angle and a Risser sign three or four might not need to be braced because the potential for progression is reduced.<ref>{{cite book | vauthors = Wood G | date = 2013 | title = Academy Today (The Edge) | publisher = American Academy of Orthosits and Prosthetist. | chapter = To Brace or Not to Brace: The Three-Dimensional Nature and Growth Considerations for Adolescent Idiopathic Scoliosis | pages = 5–8 }}</ref> The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, [[Risser sign]] 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls.<ref name="Herring JA 2002"/>

Evidence supports that bracing prevents worsening of disease, but whether it changes quality of life, appearance, or back pain is unclear.<ref>{{cite journal | vauthors = Negrini S, Minozzi S, Bettany-Saltikov J, Chockalingam N, Grivas TB, Kotwicki T, Maruyama T, Romano M, Zaina F | display-authors = 6 | title = Braces for idiopathic scoliosis in adolescents | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD006850 | date = June 2015 | volume = 2015 | pmid = 26086959 | doi = 10.1002/14651858.CD006850.pub3 | pmc = 10616811 | hdl-access = free | hdl = 2434/721317 }}</ref>

===Surgery===
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| footer = Preoperative (left) and postoperative (right) [[X-ray]] of a person with [[thoracic vertebrae|thoracic]] dextroscoliosis and [[lumbar vertebrae|lumbar]] levoscoliosis: The X-ray is usually projected anteroposterior, such that the right side of the subject is on the right side of the image; i.e., the subject is viewed from the rear (see left image; the right image is seen from the front). This projection is typically used by spine surgeons, as it is how [[orthopedic surgeon|surgeon]]s see their patients when they are on the operating table (in the prone position). This is the opposite of many [[Chest radiograph]]s, where the image is posteroanterior, i.e. projected as if looking at the patient from the front. The surgery was a fusion with instrumentation.{{citation needed|date=October 2020}}
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Surgery is usually recommended by orthopedists for curves with a high likelihood of progression (i.e., greater than 45–50° of magnitude), curves that would be cosmetically unacceptable as an adult, curves in people with [[spina bifida]] and [[cerebral palsy]] that interfere with sitting and care, and curves that affect physiological functions such as breathing.<ref>{{cite web | vauthors = Alli RA | date = 19 December 2020 |title=Scoliosis Treatment |url=https://www.webmd.com/back-pain/treatment-for-scoliosis#1 |website=WebMD |access-date=11 February 2020}}</ref><ref name=":0">{{Cite journal |last1=Guay |first1=Joanne |last2=Suresh |first2=Santhanam |last3=Kopp |first3=Sandra |last4=Johnson |first4=Rebecca L. |date=2019-01-16 |title=Postoperative epidural analgesia versus systemic analgesia for thoraco-lumbar spine surgery in children |url= |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD012819 |doi=10.1002/14651858.CD012819.pub2 |issn=1469-493X |pmc=6360928 |pmid=30650189}}</ref>

Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45–50°<ref name = Neg2018 /> and by the Scoliosis Research Society (SRS) at a Cobb angle of 45°.<ref name=":1">{{cite web |title=Adolescent Idiopathic Scoliosis |publisher=Scoliosis Research Society (SRS) |url=http://www.srs.org/patient_and_family/scoliosis/idiopathic/ |access-date=2 January 2014 |archive-url=https://web.archive.org/web/20140116090156/http://www.srs.org/patient_and_family/scoliosis/idiopathic/ |archive-date=16 January 2014}} adolescents/surgical_treatment.htm. Accessed 27 January 2013</ref> SOSORT uses the 45–50° threshold as a result of the well-documented, plus or minus 5° measurement error that can occur while measuring Cobb angles.<ref name=":1" />

[[Surgeon]]s who are specialized in spine surgery perform surgery for scoliosis. To completely straighten a scoliotic spine is usually impossible, but for the most part, significant corrections are achieved.<ref>{{cite book | vauthors = Gibson I, Jagdish BN, Zhan G, Hajizedah K, Tho HK, Mengjie H, Dissanayake C | chapter = Development of a human spine simulation system. |chapter-url=https://books.google.com/books?id=ylLNBQAAQBAJ&pg=PA27 |title=Advances in Therapeutic Engineering| veditors = Yu W, Chattopadhyay S, Lim TC, Acharya UR |date = January 2012 |publisher=CRC Press|isbn=978-1-4398-7174-4 |language=en | page = 27 }}</ref>

The two main types of surgery are:<ref>{{Cite journal |last1=Lin |first1=Yang |last2=Chen |first2=Wenjian |last3=Chen |first3=Anmin |last4=Li |first4=Feng |last5=Xiong |first5=Wei |date=March 2018 |title=Anterior versus Posterior Selective Fusion in Treating Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of Radiologic Parameters |url=https://pubmed.ncbi.nlm.nih.gov/29309975/#:~:text=Anterior%20is%20more%20effective%20than,in%20restoring%20the%20sagittal%20curvature. |journal=World Neurosurgery |volume=111 |pages=e830–e844 |doi=10.1016/j.wneu.2017.12.161 |issn=1878-8769 |pmid=29309975}}</ref>
* Anterior fusion: This surgical approach is through an incision at the side of the chest wall.
* Posterior fusion: This surgical approach is through an incision on the back and involves the use of metal instrumentation to correct the curve.

One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, takes four to eight hours.

A new tethering procedure ([[anterior vertebral body tethering]]) may be appropriate for some patients.<ref>{{cite journal |last1= Andreacchio |first1= Antonio |last2= Caretti |first2= Valentina |last3= Colombo |first3= Luca |date= 2022 |title= Anterior vertebral body tethering as a treatment for scoliosis in skeletally immature patients |journal= La Pediatria Medica e Chirurgica |volume= 44 |issue= 1 |pages= 291|doi= 10.4081/pmc.2022.291 |pmid= 37184319 |s2cid= 253212051 |doi-access= free }}</ref>

Spine surgery can be painful and may also be associated with post-surgical pain.<ref name=":0" /> Different approaches for pain management are used in surgery including epidural administration and systemic [[analgesia]] (also known as general analgesia).<ref name=":0" /> Epidural analgesia medication are often used surgically including combinations of local anesthetics and pain medications injected via an epidural injection.<ref name=":0" /> Evidence comparing different approaches for analgesia, side effects or benefits, and which approach results in greater pain relief and for how long after this type of surgery is of low to moderate quality.<ref name=":0" />