Scoliosis in Children and Adolescents: When Observation Is Enough and When Surgery Is Needed—A Contemporary Evidence-Based Review

Scoliosis in Children and Adolescents: When Observation Is Enough and When Surgery Is Needed—A Contemporary Evidence-Based Review

Kassem El Houcheimi *, Muhieddine Hamie, M.D

*Correspondence to: Kassem El Houcheimi.

Copyright
© 2026 Kassem El Houcheimi is an open access article distributed under the Creative Commons Attribution   License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 09 August 2026

Published: 01 September 2026

DOI: https://doi.org/10.5281/zenodo.22249902

Abstract 

Scoliosis is among the most prevalent spinal deformities in childhood and adolescence, affecting approximately 2–4% of the global pediatric population. (Wang et al., 2025) Despite extensive clinical experience and research, significant controversy remains regarding optimal management strategies, particularly in determining the appropriate timing for transitioning from observation to active intervention or surgical correction. (R. et al., 2013) Although Cobb angle thresholds continue to inform treatment decisions, recent evidence indicates that curve magnitude alone is insufficient to predict progression risk and long-term outcomes. (Development and Validation of Transformer- and Convolutional Neural Network-Based Deep Learning Models to Predict Curve Progression in Adolescent Idiopathic Scoliosis, 2023) Scoliosis progression is now understood to result from a complex interplay of skeletal maturity, growth velocity, curve morphology, biomechanical factors, genetic susceptibility, and environmental influences. (Lenz et al., 2021) As a result, contemporary management emphasizes individualized risk stratification over rigid radiographic criteria. (Addai et al., 2020) Observation is suitable for most mild curves, while bracing may reduce progression in selected skeletally immature patients with moderate deformities. Surgical intervention is typically reserved for progressive curves that exceed established treatment thresholds or are associated with significant functional, cosmetic, or physiological consequences. This review critically evaluates current evidence on scoliosis progression, conservative management, surgical indications, emerging technologies, and ongoing controversies, highlighting the need to balance overtreatment with the risks of delayed intervention.

Keywords: Adolescent idiopathic scoliosis, Pediatric scoliosis, Spinal deformity, Cobb angle, Bracing, Spinal fusion, Vertebral body tethering, Curve progression.

Introduction

Scoliosis is traditionally defined as a three-dimensional spinal deformity, characterized by a coronal curvature of at least 10° measured by the Cobb method and accompanied by vertebral rotation. While this definition is clinically useful, it does not fully capture the complexity of scoliosis as a dynamic developmental disorder. The primary clinical challenge lies not in identifying spinal curvature, but in determining which curves will remain stable and which are likely to progress to clinical significance.

This distinction is crucial, as the majority of children diagnosed with scoliosis do not require surgical intervention. Large epidemiological studies indicate that while scoliosis affects approximately 2–4% of adolescents, only a minority develop deformities severe enough to necessitate active treatment. (Dunn et al., 2018, pp. 173-187) However, progressive scoliosis can lead to significant cosmetic deformity, chronic pain, pulmonary compromise, psychological distress, and diminished health-related quality of life. (Sanders et al., 2018) Therefore, both undertreatment and overtreatment present potential risks.

Historically, management decisions have been largely guided Historically, management decisions have primarily relied on curve magnitude. Recent evidence, however, indicates that scoliosis progression is determined by a complex interplay of growth potential, skeletal maturity, biological susceptibility, biomechanical loading, and curve characteristics. This evolving understanding has prompted a shift toward precision-based management strategies that seek to identify patients most likely to benefit from intervention, while minimizing unnecessary treatment in low-risk individuals.

Adolescent idiopathic scoliosis (AIS) accounts for approximately 80–85% of pediatric scoliosis cases and remains the most common form encountered in clinical practice. (Menger & Sin, 2023) Population-based studies consistently report prevalence rates between 2% and 4%, although estimates vary according to screening methodology, diagnostic criteria, and geographic region. (Li et al., 2024)

A notable epidemiological observation is the discrepancy between disease prevalence and the need for treatment. While minor curves occur at similar rates in boys and girls, progression to clinically significant deformity is much more common in females. Girls are estimated to be up to ten times more likely than boys to require treatment for progressive scoliosis, indicating significant biological influences on curve progression. (Scoliosis and Prognosis—a systematic review regarding patient-specific and radiological predictive factors for curve progression, 2021, pp. 1181-1192)

The socioeconomic burden of scoliosis the socioeconomic burden of scoliosis extends beyond direct healthcare costs. Ongoing expenses arise from repeated radiographic surveillance, brace treatment, specialist consultations, physiotherapy, surgical interventions, and long-term follow-up. Additionally, psychological consequences such as altered body image, reduced self-esteem, social anxiety, and emotional distress significantly contribute to the overall disease burden, especially during adolescence when physical appearance becomes increasingly important. (Smith & Doe, 2022, pp. 123-130) oil-based screening programs. Advocates argue that early identification facilitates timely intervention and reduces the need for surgery, whereas critics emphasize low positive predictive values, overdiagnosis, unnecessary radiographic exposure, and increased healthcare costs. Current evidence remains insufficient to establish universal consensus, and screening practices vary considerably between countries. (Labelle et al., 2013)

Understanding Curve Progression: Why Do Some Curves Worsen?

A central unresolved question in scoliosis research is why some curves progress significantly while others remain stable. Despite advances in imaging, biomechanics, and molecular biology, no single theory fully accounts for disease progression.

The Hueter–Volkmann principle remains one of the most influential biomechanical concepts. According to this theory, increased compression inhibits vertebral growth, whereas reduced mechanical loading accelerates growth. Once a spinal curvature develops, asymmetrical loading across vertebral growth plates may perpetuate further deformity through a self-reinforcing cycle. Although this model explains many aspects of progression, it fails to clarify the initial development of curvature or the substantial variability observed among patients.

Genetic factors clearly contribute to disease susceptibility. Family history remains one of the strongest predictors of AIS, and numerous candidate genes have been implicated in spinal growth regulation, connective tissue development, melatonin signaling, and neuromuscular control. (Adolescent idiopathic scoliosis: MedlinePlus Genetics, 2013) Nevertheless, no single genetic pathway explains disease progression, suggesting a polygenic and multifactorial etiology.

Recent evidence implicates abnormalities in bone mineral density, vertebral growth regulation, proprioceptive control, hormonal signaling, and neuromuscular coordination. Collectively, these findings support the view that scoliosis is a systemic developmental disorder rather than an isolated spinal abnormality. (Yang et al., 2023, pp. 149-166)

Progression predominantly occurs during periods of rapid skeletal growth. This explains why identical curves may behave differently depending on a patient’s age and maturity status. Therefore, growth potential is a critical factor in treatment planning.

Predicting Progression: The Central Question in Clinical Management

Modern scoliosis manaContemporary scoliosis management prioritizes predicting progression over relying solely on curve measurement. Although the Cobb angle remains the most widely used parameter, evidence indicates that curve magnitude is only one aspect of a broader risk profile.gle strongly influences progression probability. Larger curves at presentation possess greater likelihood of worsening, particularly in skeletally immature patients. However, substantial heterogeneity exists among patients with comparable curve magnitudes, highlighting the limitations of relying solely on radiographic thresholds.

Assessment of skeletal maturity has therefore become increasingly important. The Risser classification, Sanders maturity staging system, and evaluation of peak height velocity provide valuable information regarding remaining growth potential. Numerous studies have demonstrated that growth status frequently predicts progression more accurately than Cobb angle alone. (Coillard et al., 2013)

Curve pattern further influences risk. Thoracic curves generally exhibit greater progression potential than lumbar curves, while double major curves often demonstrate distinct progression behavior compared with isolated thoracolumbar deformities.

Recent advances in predictive modeling have resulted in multivariable risk assessment tools that incorporate curve magnitude, skeletal maturity, sex, age, and growth velocity. These approaches are an important step toward personalized treatment strategies and may help reduce both overtreatment and delayed intervention. (Johnson et al., 2021, pp. 543-548)

When Observation Is Enough: Avoiding Overtreatment

Observation is the most appropriate management strategy for most children diagnosed with scoliosis. Evidence consistently shows that many mild curves remain stable throughout growth and adulthood, without resulting in significant functional impairment. (Asher & Burton, 2006)

The challenge lies in distinguishing low-risk curves from those requiring intervention. Current practice generally favors observation for curves below 20–25° in patients without evidence of rapid progression. (Adolescent Idiopathic Scoliosis: Indications and Efficacy of Nonoperative Treatment, 2010, pp. 2262-2268) However, this threshold should not be interpreted rigidly. A 20° curve in a near-mature adolescent may possess negligible progression risk, whereas an identical curve in a rapidly growing premenarchal girl may warrant closer surveillance.

The risk of overtreatment requires careful consideration. Assigning a diagnosis of spinal deformity can impose a significant psychological burden, especially when treatment is unlikely to change outcomes. Repeated radiographic monitoring, unnecessary activity restrictions, and parental anxiety may reduce quality of life even when the physical disease burden is minimal.

Long-term outcome studies support the effectiveness of observation strategies. Most individuals with mild, untreated scoliosis maintain normal employment, physical function, and life expectancy. (Farshad et al., 2022) Therefore, observation should be regarded as an active, evidence-based approach that minimizes unnecessary intervention while preserving the opportunity for timely treatment if progression occurs.

Bracing: Effective Treatment or Delayed Surgery?

Bracing remains Bracing is the most extensively studied nonoperative treatment for scoliosis and occupies an intermediate position between observation and surgery. However, considerable debate remains regarding its effectiveness, optimal indications, and long-term outcomes.al represented a landmark advance in scoliosis research by providing high-quality evidence supporting brace treatment. The study demonstrated significantly lower progression rates among brace-treated patients compared with observation alone, particularly among individuals demonstrating high compliance. (Costa et al., 2021)

Despite these findings, several important limitations persist. The effectiveness of bracing is highly dependent on adherence, yet compliance often declines during adolescence due to discomfort, cosmetic concerns, social embarrassment, and reduced quality of life. As a result, treatment success is influenced by behavioral factors as much as by biomechanical correction. (Clinical, Psychological, and Social Determinants of Brace Compliance in Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis, 2024)

Moreover, bracing does not permanently correct scoliosis. Rather, it functions as a growth-modulating intervention designed to prevent progression during skeletal development. Once growth ceases, the brace no longer influences spinal alignment.

The psychological impact of brace treatment is also significant. While many patients adapt successfully, some experience body image concerns, reduced self-esteem, and emotional distress. Consequently, modern management emphasizes shared decision-making, realistic expectations, and psychosocial support in addition to mechanical correction. (Lark et al., 2022)

When Surgery Is Needed: Balancing Risks and Benefits

Surgical decision-making is the most consequential aspect of scoliosis management. Traditionally, curves greater than 45–50° have been considered candidates for surgical correction due to increased progression risk after skeletal maturity. (Factors Related to Curve Progression in Adolescent Idiopathic Scoliosis Girls at Skeletal Maturity, 2024) However, this threshold is partly historical and remains a subject of ongoing debate.

Arguments supporting surgical intervention include prevention of further progression, improvement of cosmetic deformity, restoration of spinal balance, and potential protection against long-term cardiopulmonary compromise. Modern surgical techniques achieve substantial deformity correction with favorable functional outcomes and high patient satisfaction rates. (Techniques of Deformity Correction in Adolescent Idiopathic Scoliosis—A Narrative Review of the Existing Literature, 2022)

However, surgery should not be viewed solely as a corrective procedure. Spinal fusion permanently alters spinal biomechanics and carries inherent risks, including infection, neurological injury, implant failure, pseudarthrosis, and the need for revision surgery. Although complication rates are relatively low in experienced centers, these risks remain clinically significant. (Reames et al., 2011, pp. 1484-1491)

Recent discussions increasingly emphasize patient-centered outcomes rather than radiographic correction alone. Factors such as cosmetic concerns, psychological distress, self-image, functional limitations, and quality of life may influence treatment decisions as much as curve magnitude. Therefore, surgical indications should integrate radiographic findings with patient preferences, expectations, and overall disease burden.

Table 1. Major Determinants of Scoliosis Progression and Their Clinical Significance

Table 2. Observation Versus Intervention: Evidence-Based Treatment Thresholds

Table 3. Benefits and Limitations of Current Management Strategies

Emerging Technologies and Future Directions

Technological innovation is rapidly transforming scoliosis management. Low-dose EOS imaging systems have significantly reduced radiation exposure during long-term surveillance, addressing a major concern associated with repeated radiography. (Newton et al., 2016, pp. 138-144)

Vertebral body tethering (VBT) has emerged as a motion-preserving alternative to fusion for selected skeletally immature patients. By utilizing differential growth modulation, VBT aims to correct deformity while preserving spinal mobility. Early outcomes are promising, but higher revision rates and limited long-term evidence currently limit widespread adoption. (Imbeault et al., 2026)

Artificial intelligence and machine learning are also areas of considerable interest. Predictive algorithms that incorporate radiographic, demographic, and growth-related variables may improve progression prediction and facilitate personalized treatment planning in the future. (He et al., 2026)

Wearable technologies, digital monitoring systems, and advanced biomechanical modeling may further refine future managementstrategies by, enabling earlier identification of high-risk patients and more individualized interventios.

Conclusion

The management of scoliosis in children and adolescents is evolving from a primarily radiographic discipline to a more individualized, evidence-based approach. Although Cobb angle remains an important factor in decision-making, current evidence shows that progression risk is determined by a complex interplay of skeletal maturity, growth velocity, curve morphology, biological susceptibility, and psychosocial factors.

Observation is appropriate for most mild curves and should be recognized as an active treatment strategy rather than as therapeutic inaction. Bracing offers meaningful benefits for carefully selected patients, especially those with significant growth remaining and moderate deformities at risk of progression. Surgical intervention is the most effective treatment for severe or progressive scoliosis but should be reserved for patients in whom the anticipated benefits outweigh the procedural risks.

Future advances in predictive modeling, genetic risk stratification, motion-preserving technologies, and personalized rehabilitation may further enhance clinical decision-making. Ultimately, the goal of modern scoliosis management is not only curve correction but also the optimization of long-term function, quality of life, and patient-centered outcomes.

References

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