Research Review: Why Do We Treat Adolescent Idiopathic Scoliosis?

It is easy for patients and parents of patients to become focused on the Cobb angle as a measure of success or failure of treatment of scoliosis. Indeed, this may often stem from the treating medical team centering all treatment around the Cobb angle. However this paper by Negrini et al (2006) presented a more holistic way to consider the treatment of adolescents with idiopathic scoliosis. Should the focus of treatment extend beyond the Cobb angle (1)? 

This paper was published in 2006, and at the time provided health professionals with the consensus from experts to help guide treatment of adolescent idiopathic scoliosis (AIS). The incentive for the paper was derived from the two schools of thought at the time:

1. Wait for surgery (2-8) 
2. The need to act to treat patients and to avoid more invasive treatments in the future ‘as much as possible’ (9-16)
3. Uncertainty regarding the need for treatment (1). 

The publication of this consensus paper by the International Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) resulted in a great resource to drive further research and treatment of AIS. 

What do we Want to Obtain and to Avoid for our Patients?

Just like any treatment plan, the goals of treatment must be derived with the patient at the centre of care. According to the consensus paper the goals of treatment for AIS include:

• aesthetics 
• quality of life
• disability 
• back pain 
• psychological wellbeing 
• progression in adulthood
• breathing function 
• scoliosis Cobb degrees
• need for further treatment in adulthood (1).

The comprehensive list above really does also justify why the SOSORT guidelines advocate for a multidisciplinary team approach for AIS (17). 

The other major consideration highlighted by this team of authors is the future of the patients. So, while the scoliosis may not be impacting the patient now, or perhaps the treating team (or indeed even the patient) may not see the treatment as a priority at this point, discussions should still be had about the future. There is no demand for dramatisation of the scoliosis. However, the consensus paper did point out that it is important to consider any potential future impacts on the patient, including: 

• breathing function
• the need for further treatment
• progression into adulthood (1).

What Should be the Major Focus of Scoliosis Treatment for AIS? 

Interestingly, the authors of this SOSORT consensus paper pointed out that when working with a adolescent patient with idiopathic scoliosis the current major considerations should include:

• aesthetics
• disability
• quality of life (1).

Engaging the patient to think beyond the Cobb angle may be easy with some patients and not so easy with others. Afterall, medicine is a ‘scientific art’ (18, 19). This means that, as the treating practitioner, it is imperative to use evidence-based practice but also to connect with the patient in a way so that the individual’s beliefs are understood and considered within the treatment plan  (9, 18-20).

Take Home Message

While the Cobb angle is an important part of the treatment considerations, there is so much more to consider in the treatment planning for adolescents with idiopathic scoliosis. Considering the needs of every single patient, and ensuring that the patient is at the centre of the treatment plan, will help to maximise the chances of ‘success’, however that may be defined for each adolescent. 

Reference: 

1. Negrini, S., Grivas, T.B., Kotwicki, T. et al. (2006) Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper. Scoliosis 1, 4. https://doi.org/10.1186/1748-7161-1-4
2. Dickson, RA. (1999). Spinal deformity–adolescent idiopathic scoliosis.Nonoperative treatment. Spine. 24:2601-2606.
3. Dickson, RA. (1989). Idiopathic scoliosis. Bmj 1989, 298:906-907.15. 
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13. Rigo, M., Reiter, C., Weiss, HR. (2003). Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatr Rehabil. 6:209-214.
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16. Weiss, HR., Weiss, G. Schaar, HJ. (2003). Incidence of surgery in conservatively treated patients with scoliosis. Pediatr Rehabil.  6:111-118.
17. Lawn, B. (1996). L’arte perduta di guarire. Italian Edition edition. Milano, Garzanti Editore; 1996:332.
18. Sacks, O. (1985). L’uomo che scambiò sua moglie per un cappello. Volume Italiana edition. Milano, Adelphi Edizioni. 318.
19. Grol, R. and Grimshaw, J. (2003). From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 362:1225-1230.
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