SECTION
Idiopathic Scoliosis
CHAPTER
71
Introduction to Adolescent
Idiopathic Scoliosis
The last 100 years have seen the birth and maturation of the
field of surgical treatment for adolescent idiopathic scoliosis
(AIS). In 1914, Hibbs described the method of operative fusion
and cast correction with extended recumbence for the treat-
ment of AIS. While the outcomes achieved by using this tech-
nique were modest at best, the age of surgical treatment for
scoliosis had begun. The inertia of surgical innovation that
started with Hibbs has grown at an expanding rate and scope
ever since.
Since the publication of the second edition of the Textbook
of Spinal Surgery, many significant advances have been intro-
duced to the evaluation and surgical management of patients
with AIS. The chapters contributed by the expert authors in
this section reflect the current state of the art. Because of the
rapidly changing field, it is important for all involved in the
care of patients with AIS to remain knowledgeable of recent
advances and areas of ongoing controversy. The purpose of this
chapter is to highlight some of the major shifts to our evalua-
tion and surgical paradigms for AIS and to introduce the chap-
ters that follow in this section.
The fundamental rationale for surgical intervention for AIS
remains prevention of scoliosis curve progression and, in select
cases, cosmetic improvement. Although there have been tre-
mendous advances in the methods for treating AIS, the basis for
determining which patients will actually benefit from surgical
intervention over the course of their lifetimes remains largely
undetermined. Curve progression into adulthood is expected
for larger curves with the potential for major morbidity for
patients with curves greater than 100. In remains unclear, how-
ever, which specific curve types and of what magnitude are at
the greatest risk for significant progression and clinically signifi-
cant impact to patients during their adult years. The ability of
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V II
Charles C. Edwards II
Keith H. Bridwell
surgical intervention to improve the quality of life for individu-
als with moderate curves also remains unclear. Does AIS surgical
management prevent symptomatic degeneration of remaining
mobile segments later in life, or does a long fusion segment
make such changes more likely? Simply stated, are there suffi-
cient benefits later in life to justify the risks, expense, inconve-
nience, and future activity restrictions associated with the per-
formance of a long fusion in a healthy and minimally symptomatic
child? The answers to these challenging questions are not avail-
able today. Prospective long-term studies of surgically treated
and nonsurgically managed individuals with AIS are urgently
needed to help answer these fundamental questions.
The recent development of validated functional outcomes
measures for spinal deformity is a major step forward. The
Scoliosis Research Society-22 Outcomes Questionnaire
(SRS-22) has been broadly adopted over the past 10 years as the
standard functional outcomes metric for spinal deformity.
Patient responses to its 22 questions provide a measured assess-
ment of four domains (pain, function, self-image, and satisfac-
tion). The metric allows for comparison of an individual to nor-
mative values for the population, assessment of changes in
status over time, and comparison of outcomes among different
centers. All clinicians treating AIS are encouraged to use the
SRS-22 as a valuable clinical assessment and outcomes instru-
ment. Chap. 78 discusses the development of this and other
questionnaires used in spinal deformity, their utility, and limita-
tions. It is through prospective data collection with validated
outcomes instruments that our understanding of the natural
history of adolescent scoliosis and its surgical management will
expand in the years ahead.
Idiopathic scoliosis tends to progress most during the years
of peak skeletal growth. Once skeletal maturity is reached, the
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 710 Section VII Idiopathic Scoliosis
scoliosis curve magnitude remains relatively stable, with grad-
ual progression during adulthood occurring in many patients.
Assessment of skeletal maturity thus has important implications
for decision making regarding surgery.11 Chap. 76 provides the
current state of knowledge regarding idiopathic scoliosis pro-
gression and its natural history into adulthood. A thorough
understanding of such concepts in essential to appropriate
decision making regarding observation, bracing, and surgery
for idiopathic scoliosis.
When surgery is recommended, classification systems help
to guide the determination of the appropriate fusion levels,
Chap. 79. Classifications also provide a language through which
physicians and researchers can communicate about distinct AIS
curves. The King classification, introduced in 1983,6 was
groundbreaking for its differentiation of various thoracic curve
types and the role for selective fusion in patients with false
double major curves. In 2001, Lenke et al8 introduced an
expanded surgical classification for AIS. Its unique contribu-
tions include a description of the full spectrum of thoracic and
lumbar idiopathic curves, incorporation of the sagittal plane
and specific criteria for differentiating major and minor curves.
The Lenke classification includes six curve types and two
modifiers (sagittal alignment and lumbar apical translation).
Its intuitive design and high reliability have led to its broad
acceptance and adoption into clinical practice and research
studies. Although radiographic classification systems provide
valued guidance regarding surgical management,9 the ultimate
decisions of surgical approach, fusion levels, and desired cor-
rection need to take into account each patients clinical defor-
mity, the goals of surgery, and the surgeons experience.
Surgical techniques for the treatment of AIS have improved
and expanded dramatically since the era of Harrington
distraction rods.2 For most cases of AIS, more than one surgical
technique is reasonable. Anterior approaches are often utilized
for thoracolumbar curves as they result in similar correction
with fewer fusion levels, Chap. 86. For single thoracic curves,
the optimal approach remains hotly debated, Chap. 86A. For
anterior approaches, the benefit of one to two fewer fusion lev-
els must be weighed against the measurable (although rarely
symptomatic) negative impact on pulmonary function,4 Chap.
82. Posterior instrumented fusion avoids violation of the chest
and its attendant risks with similar curve correction. Limitations
of the posterior approach are the need for a longer fusion
segment in many cases and concern about an increased
incidence of adjacent segment kyphosis and late degeneration.
For double major curves, posterior instrumented fusion is the
standard, Chap. 85.
The last 10 years have seen the emergence of pedicle screws
as a viable alternative to hooks as a rod anchor, Chap. 84. Pedicle
screws offer the benefits to the treatment of AIS including supe-
rior curve correction capability, improved control of the sagittal
plane, and decreased postoperative bracing needs. Questions
have been raised regarding the relative safety of thoracic pedicle
screws relative to hooks. Thoracic pedicle screw placement in the
presence of a scoliosis requires advanced training and safeguards
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to minimize the risk of complications. Such safeguards include
careful attention to anatomic landmarks, surgeon experience,
radiographic confirmation, and electrophysiologic monitoring.
While anecdotal cases of neurologic injury due to aberrant screw
placement have surfaced, several large clinical series reflecting
an excellent safety profile have been published.3,5,7 Important
outstanding questions include: (1) How much correction is nec-
essary? (2) What is the optimal density of screw/hook anchors?
In decades past, large and stiff curves were typically treated
with circumferential procedures (anterior discectomies with
posterior instrumented fusion). Recent experience with pedi-
cle screw constructs has demonstrated their corrective power
and low nonunion rate. Accordingly, there seems to be a shift
away from circumferential procedures, except in the largest
and stiffest curves.1,10
We are on the cusp of several other diagnostic and technical
advances in the treatment of AIS. An improved understanding
of the natural history of idiopathic scoliosis has led to the ear-
lier identification of patients who are at an especially high risk
for progression. Genetic testing in particular shows promise in
predicting whether a childs curve will remain stable during
their adolescence or whether they would be best served with
early intervention, including bracing and fusionless correction
surgery, Chaps. 80 and 81. Improvements in derotation surgical
techniques are pursued with the hope of diminishing the need
for thoracoplasty (Chap. 83) and improving the cosmetic
benefit of scoliosis surgery. The development of various bone
graft substitutes has reduced reliance on the traditional gold
standard: iliac crest bone graft. While bone morphogenic pro-
teins are not approved by the Food and Drug Administration
for use in adolescents in the posterior spine, such may prove to
be useful to the treatment of scoliosis in the future.
REFERENCES
1. Dobbs MB, Lenke LG, Kim YJ, et al. Anterior/posterior spinal instrumentation versus
posterior instrumentation alone for the treatment of adolescent idiopathic scoliotic curves
more than 90 degrees. Spine 2006;31:23862391.
2. Harrington PR. Treatment of scoliosis: correction and internal fixation by spine instrumen-
tation. J Bone Joint Surg Am 1962;44A:591634.
3. Kim YJ, Lenke LG, Bridwell KH. Freehand pedicle screw placement in the thoracic spine:
is it safe? Spine 2004;29(3):333342.
4. Kim YJ, Lenke LG, Bridwell KH, et al. Pulmonary function in adolescent idiopathic
scoliosis relative to the surgical procedure. J Bone Joint Surg Am 2005;87A(7):15341541.
5. Kim YW, Lenke LG, Kim YJ, et al. Free-hand pedicle screw placement during revision spinal
surgery: analysis of 552 screws. Spine 2008;33:11411148.
6. King HA, Moe JH, Bradford DS, et al. The selection of fusion levels in thoracic idiopathic
scoliosis. J Bone Joint Surg Am 1983;65:13021313.
7. Kuklo TR, Lenke LG, OBrien MF, et al. Accuracy and efficacy of thoracic pedicle screws
in curves more than 90 degrees. Spine 2005;30:222226.
8. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification
system to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:
11691181.
9. Lenke LG, Edwards CC II, Bridwell KH. The Lenke classification of adolescent idiopathic
scoliosis: how it organizes curve patterns as a template to perform selective fusions of the
spine. Spine 2003;28:S199S207.
10. Luhmann SJ, Lenke LG, Kim YT, et al. Thoracic adolescent idiopathic scoliosis curves
between 70 and 100 degrees: is anterior release necessary? Spine 2005;30(18):20612067.
11. Sanders JO, Khoury JG, Kishan S, et al. Predicting scoliosis progression from skeletal
maturity: a simplified classification during adolescence. J Bone Joint Surg 2008;90(3):
540553.
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