Adolescent Idiopathic Scoliosis
Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and, in the vast majority of cases, is a manageable condition that never requires surgery. At Maryland Orthopedic Specialists, our non-operative spine team provides expert evaluation, curve monitoring, and bracing to keep your child's spine on track through the critical growth years. Most families leave their first visit with reassurance, a clear monitoring plan, and confidence about the path ahead.
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What is adolescent idiopathic scoliosis?
Adolescent idiopathic scoliosis is a curvature of the spine that generally occurs during the adolescent growth spurts. There are also infantile and juvenile forms. It is usually discovered by routine screening by pediatricians or possibly by parents/family. Treatments include observation, bracing, and occasionally surgery.
Scoliosis is a lateral (sideways) curvature of the spine that, by definition, measures greater than 10° on a standing X-ray using the Cobb angle method. In adolescent idiopathic scoliosis, the "idiopathic" label means that no single identifiable cause has been established. It is not caused by injury, a neurological condition, or a congenital vertebral anomaly. AIS affects approximately 2 to 3% of all adolescents and is the most prevalent musculoskeletal condition diagnosed in the school-age population. While the exact etiology remains under investigation, genetic factors, asymmetric growth plate loading, and connective tissue differences are all thought to play a role.
Girls and boys develop scoliosis at similar rates, but girls are significantly more likely to have curves that progress to a degree requiring treatment: roughly 8 to 10 times more likely than boys. The most common curve pattern is a right thoracic curve, in which the thoracic spine bows to the right and the spine rotates such that the ribs on the right side are pushed posteriorly, forming the characteristic "rib hump" visible on forward bending. Thoracolumbar and lumbar curves also occur and carry their own natural history considerations.
Understanding the natural history of AIS is central to good care. The most important predictor of curve progression is skeletal maturity. The more growth remaining, the higher the risk that a curve will worsen. Skeletal maturity is staged using the Risser sign, a radiographic grading of iliac apophysis ossification from 0 (fully open growth plates, maximum growth remaining) to 5 (complete fusion, growth complete). Curves under 25° in patients nearing skeletal maturity are very unlikely to progress and require only observation. Larger curves (particularly those exceeding 25 to 30° in a Risser 0 to 2 patient) carry meaningful risk of progression and warrant active intervention. Once skeletal maturity is reached, curves under 30° rarely progress further; curves over 50° at skeletal maturity may continue to progress slowly into adulthood.
Symptoms — do you recognize these?
- Uneven shoulders — one shoulder appears higher than the other, or one collar sits differently on shirts and jackets.
- Uneven shoulder blades — one scapula appears more prominent or "winged" compared to the other.
- Asymmetric waist or hips — the waistline looks uneven from behind, or one hip appears higher or more prominent.
- Rib hump on forward bending — when the child bends forward at the waist with arms hanging (the Adam's forward bend test), a visible hump or ridge appears on one side of the back due to rib cage rotation.
- Clothes not fitting evenly — pants hems hang at different lengths, shirt collars sit asymmetrically, or school uniforms require consistent adjustment.
- Usually no pain — AIS is most often a painless deformity; significant back pain in an adolescent with a known curve should prompt evaluation for other causes rather than being attributed to scoliosis itself.
How we diagnose it
Evaluation at MOS begins with a thorough clinical examination, review of growth history, and any prior imaging. The goal is to accurately measure the curve, stage skeletal maturity, and identify any atypical features that warrant additional workup.
Adam's Forward Bend Test The child stands with feet together and bends forward at the waist, arms hanging freely. The examiner views the spine from behind, looking for trunk asymmetry: a rib hump on the right (in thoracic curves) or a lumbar prominence on the left (in lumbar curves). A scoliometer (an inclinometer placed along the spine at the apex of the curve) is used to measure the angle of trunk rotation (ATR). An ATR of 5 to 7° or greater is the standard threshold for referral for standing X-rays, as it correlates with a Cobb angle approaching 20°.
Standing Spine X-Rays Weight-bearing posteroanterior (PA) and lateral full-length spine X-rays are the definitive diagnostic study. The PA view is taken to minimize breast radiation dose in girls. Cobb angle is measured by drawing lines along the endplates of the most tilted vertebrae above and below the curve apex; the angle between these lines is the Cobb angle. Curves are classified as mild (10–24°), moderate (25–44°), or severe (≥ 45°). The lateral view assesses sagittal alignment. Normal thoracic kyphosis and lumbar lordosis should be preserved.
Risser Staging Skeletal maturity is assigned at the time of each X-ray using the Risser sign (grades 0–5 based on iliac apophysis ossification). This is critical for treatment decisions: a Risser 0 or 1 patient with a 30° curve is at very different risk than a Risser 4 patient with the same curve.
MRI: When Indicated MRI of the full spine is ordered when atypical features are present, including: a left thoracic (rather than right thoracic) curve pattern, onset of significant pain, neurological symptoms (weakness, gait changes, bladder/bowel concerns), or unusually rapid progression. These features raise suspicion for an underlying spinal cord abnormality (most commonly a syrinx (syringomyelia) or a Chiari I malformation) which must be identified before any treatment decisions are made.
Treatment options
Treatment depends on the size of the curve and how much growing the patient has left to do.
Observation
Curves under 25° in growing patients are monitored with standing spine X-rays every 4 to 6 months during active growth phases. Most small curves stay stable through adolescence and never need active treatment. Once skeletal maturity is reached, curves under 30° can be discharged from active monitoring.
Bracing
Bracing is recommended for curves between 25 and 45° in skeletally immature patients (Risser 0–2) to prevent further progression during the remaining growth period, not to correct the existing curve. The landmark BrAIST trial showed bracing was significantly more effective than observation alone, with success rates around 72% in the braced group. Scoliosis-specific exercises (the Schroth method) are integrated alongside bracing to build strength and body awareness throughout treatment.
Surgical Referral
Curves greater than 45 to 50° in a still-growing patient, or curves that continue to progress despite consistent bracing, are referred by MOS to a pediatric spinal deformity surgeon for evaluation. MOS coordinates the referral and supports the family through the process. The surgical decision is made in partnership with the consulting surgeon. The vast majority of patients who undergo spinal fusion return to full activity, including competitive sports, and report excellent outcomes.
Recovery & rehabilitation
Observed patients have no activity restrictions. School sports, physical education, and recreational activities are all encouraged; there is no evidence that activity causes curve progression, and keeping adolescents active supports overall spine health. Regular monitoring appointments continue on the schedule outlined above.
Braced patients are encouraged to remain as active as possible. Most sports and physical activities can be performed while wearing the brace, and brace removal for sports participation (when prescribed) is factored into the daily wear-hour plan. Physical therapy and Schroth exercises are pursued in parallel with bracing and do not require activity limitation.
After surgical fusion (referral): Recovery timelines are guided by the treating surgeon, but most patients are up and walking within 1 to 2 days of surgery. Return to light activity and school typically occurs within 4 to 6 weeks. Full return to unrestricted activity, including contact sports, is generally achieved at 6 to 12 months post-fusion, once fusion consolidation is confirmed.
Frequently Asked Questions
Q: Will my child need surgery?
Q: Does scoliosis cause pain?
Q: How often does my child need to be seen?
Q: What is the Schroth method?
Q: Can scoliosis get worse after treatment ends?
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