Observation

 

One traditional approach to scoliosis has been the “wait and see” method of observation. 

This often happens when a scoliosis is detected in a young child, but the curve is not large enough to recommend traditional treatments such as hard bracing or surgery. A doctor or surgeon will periodically monitor the progression of the curve to see if it gets severe enough to do something about.

Observation makes sense when the only treatment options are invasive such as surgery. However with the availability less invasive treatments such as Night time only bracing, dynamic bracing, rigid over-corrective bracing and SEAS and Schroth physical therapy the opportunity for earlier intervention now exists.

The discussion of observation vs. intervention revolves around the ability to be able to predict progression and having an effective treatment that can be used early on.  Progression prediction is complicated and involves different factors such as age, curve magnitude, curve location, maturation, family history and a range of other factors. Currently there are two genetic test under trial that may offer some insight into the strength of the genetic component of the progression. In the future this may lead to a situation where observation and early intervention are selectively chosen based on these test results.

In the absence of these tests we can look to the research on curve progression and curve magnitude at different ages. In 1984  Lonstein and Carlson reviewed 727 children with idiopathic scoliosis. In there study they found that there was a “direct relationship between the incidence of progression and the magnitude of the curve, and an inverse relationship with chronological age and Risser sign”. In other words a larger curve in a younger, less mature child was more likely to progress than a smaller curve in an older, more mature child.

ProgressionAge

Lonstein and Carlson JBJS 1984

The above table shows that even in curves as small as 20° the likelihood of progression in younger children is very high i.e. children with a curve of 20° that were 10 years old or younger, had a 100% rate of progression. Children up to 12 years of age with a 20°curve had a 61% rate of progression. It would therefore seem logical that when an immature child with a small curve of 20° is diagnosed, that conservative treatment should begin immediately rather than observing and waiting for the child to progress before beginning conservative treatment.

Where there is a family history of scoliosis or where genetic testing shows a strong genetic profile for progression, even earlier intervention may be warranted. Some researchers have suggested conservative treatments such as Dynamic bracing be used in curves as small as 15° where these indications exist. By the same token the research shows us that as a child matures the risk of progression is less, i.e. in patients over 15 years of age with a 20° there was only a 16% rate of progression. In these cases it may be overkill to intervene with treatment and observation may be the most sensible choice.

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