1Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
2Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
3School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
4Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan
Correspondence: Tsui-Fen Yang Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan. Tel: +886-2-28757363 Fax: +886-2-28757359 E-mail: tsuifenyang1@gmail.com
• Received: July 24, 2025 • Revised: September 16, 2025 • Accepted: October 14, 2025
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Adolescent idiopathic scoliosis (AIS) is the most encountered spinal deformity in growing children, which may bring significant impacts on patients’ physical function, appearance, and overall quality of life. A physiatrist plays a crucial role in the early diagnosis of AIS and longitudinal management through continuous care. Contemporary management for AIS is according to the skeletal maturity, the magnitude of the spinal curves, and the risk of progression. For mild curves, therapeutic exercises, particularly physiotherapeutic scoliosis-specific exercises (PSSE), are employed as a conservative approach to improve postural symmetry and reduce the risk of curve progression. Bracing is required for moderate curves from 25 to 45 degrees in skeletally immature cases. Strict compliance with bracing is critical for therapeutic success. In cases that are rapidly progressive or in severe curves exceeding 40 to 45 degrees, spinal fusion surgery is considered the definitive treatment. Recent advancements in non-fusion and motion-preserving techniques provide alternative options to traditional fusion surgery. To protect maximal neurological function, intraoperative neurophysiological monitoring (IONM) is currently the trend for spinal deformity correction surgery. The care for AIS patients is an individualized, multidisciplinary, patient-centered, growth-sensitive approach, aiming to optimize outcomes and minimize long-term complications. This review outlines a comprehensive rehabilitation-oriented strategy for AIS patients from the perspective of a physiatrist, encompassing clinical assessment, conservative management with observation, therapeutic exercises, bracing, and further considerations in referral to spinal surgery.
Scoliosis is an ancient medical concept that derives from the era of Classical Greece, when Hippocrates (460–370 BC) mentioned the spinal deformities and misalignment in several of his treatises. Centuries later, Galen (129–200 AD), influenced by Hippocratic thoughts, first proposed the term skolios, from which the modern term scoliosis originates [1]. Among several types of scoliosis, adolescent idiopathic scoliosis (AIS) is the most encountered in clinical practice, with its onset from age 10 until skeletal maturity without specific underlying etiologies [2-5]. AIS affects approximately 0.47% to 5.2% of adolescents worldwide and accounts for 80%–90% of all idiopathic scoliosis cases, with disproportional female predominance [4,6,7]. The clinical significance of AIS extends beyond mere structural deformity, as uncontrolled curve progression can profoundly impact a patient’s life in every aspect [8,9]. The cause of AIS is thought to be multifactorial and is still not fully unraveled despite extensive research. Current management of AIS integrates a comprehensive, multidisciplinary team-based and patient-centered approach, including observation with therapeutic exercises for mild curves, bracing for moderate deformities, and surgical correction for severe cases. The primary aim of this article is to give a detailed overview of the assessment and management of AIS from a physiatrist’s perspective, with the focus on clinical practice.
DEFINITION AND CLASSIFICATIONS OF SCOLIOSIS
Scoliosis is marked by lateral curvatures of the spine that exceed 10 degrees in the coronal plane and typically involves a rotational component [5,10,11]. It is widely classified into the following five major types. Congenital scoliosis is a spinal condition caused by vertebral malformations present at birth. Neuromuscular scoliosis, however, is a spinal distortion from pre-existing disorders that impact the neuromuscular systems, causing an imbalance in muscle strength around the spine. Idiopathic scoliosis is a spinal deformity without identifiable causes and is the most prevalent type of scoliosis. It is further categorized by the age at which it begins: infantile scoliosis is from birth to 3 years, juvenile scoliosis occurs between the ages of 4 and 10, and adolescent scoliosis begins after age 10. Syndromic scoliosis is associated with specific genetic or systemic diseases. Functional scoliosis is a non-structural curvature secondary to temporary or external factors [5,10,12]. Table 1 presents a summary of various types of scoliosis along with their corresponding conditions.
Certain terms are frequently mentioned in the clinical context of scoliosis. Scoliosis Research Society (SRS) and Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) have established guidelines regarding the terminology associated with scoliosis [13,14]. A clear understanding of key terminology is crucial for managing patients with scoliosis, as it empowers effective communication among the multidisciplinary care team, which includes physiatrists, orthopedic surgeons, pediatricians, therapists, nurses, patients, and their caregivers. An organized summary of these terms is presented in Table 2, while Fig. 1 illustrates representative examples in a patient with AIS.
EPIDEMIOLOGY AND CURVE PROGRESSION OF AIS
AIS takes up 80%–90% of primary scoliosis cases and is more prevalent in girls than in boys. The gender disproportion is even more pronounced in groups with larger curve sizes. The most common pattern of curve observed is a right thoracic curve [4,6,7,15].
There are two main focuses on the natural course of AIS: the initial curve and its progression. While the contributing factors for the initial curve remain unclear, curve progression has been closely linked to a patient’s growth spurt. The phase of rapid growth is typically associated with an increased risk of scoliosis curve progression [4,16-18]. Furthermore, the greatest risks for curve progression are the age of onset and the magnitude of the curve [19,20]. For instance, young patients with AIS in considerable curves are at the highest risk for accelerated progression. Most cases of scoliosis remain mild in curves; however, approximately 10% of AIS patients may need conservative management, including observation, therapeutic exercise, and bracing. A small proportion of AIS patients, about 0.1%, may experience significant curve progression in the following years that disrupts balance in both the coronal and sagittal planes, potentially requiring surgical intervention [21].
Most institutes of health in developed countries provide school screening programs emphasizing surveillance of schoolchildren’s physical condition in basic anthropometry, physical examinations, vision, and hearing. School screenings are particularly valuable for the early detection of scoliosis [22]. Schoolchildren suspected of having scoliosis are referred to a physiatrist, a pediatric orthopedic surgeon, or a pediatrician’s clinic for further investigation. The earlier scoliosis is identified, the easier it can be effectively managed conservatively through observation, therapeutic exercises, and bracing, ultimately minimizing the need for surgical intervention. Overall, early detection through school screening facilitates better curve control, eventually maintaining the spinal curvature at a smaller magnitude after skeletal maturity.
Encouragingly, the majority of scoliosis patients can lead everyday lives with minimal effects from the disease condition. From the perspective of female reproductive health, future pregnancy and childbirth are generally not problematic. However, there may be an increased risk of experiencing lower back pain and possible curvature progression during pregnancy [23].
ETIOPATHOGENESIS OF AIS
Although by definition, there are no identifiable etiologies to AIS, multiple hypotheses have been postulated for the etiopathogenesis of AIS, which reflects its complexity and multifactorial nature. Potential contributing factors include dysregulation in hormones(melatonin, estrogen), vitamin D, and calmodulin, asymmetrical skeletal growth, imbalances in paraspinal muscle development, osteopenia, and even other undiagnosed neuromuscular conditions [4]. Moreover, genetic factors are believed to have a significant influence on AIS. About 25% of AIS patients have a family history of scoliosis, and studies show a higher concordance rate of AIS heritability in monozygotic twins compared to dizygotic twins [24,25]. Nevertheless, no single culprit gene has been definitively identified. Instead, out-of-state studies suggest a polygenic model in AIS that interacts with environmental and biomechanical factors, contributing to both the onset of scoliosis and the progression of spinal curvature. Research using the genetic analysis of genome-wide association studies (GWAS) and candidate gene studies has highlighted several loci potentially associated with the susceptibility to idiopathic scoliosis. These genomic findings are still under investigation as further replication in diverse cohorts is required [24-26]. Overall, the etiopathogenesis of AIS is beyond our current understanding and still remains a significant area for ongoing research.
ASSESSMENTS: HISTORY, PHYSICAL EXAMINATION, AND IMAGE
History
The very first step in approaching a patient with suspected scoliosis is to obtain a comprehensive medical history. In a clinical setting, clinicians should inquire about any neurological symptoms, reports of back pain, past medical history, pertinent family history, and any concerns from parents or patients regarding appearance and functional impairment. It is essential to review potentially related conditions and to identify if the patient meets the developmental milestones. Additionally, the patient’s current growth status and stage of puberty must be taken into account.
Generally, girls experience the peak height velocity (PHV) around one to two years before the menarche, and the growth typically ceases approximately two to three years after the first period. In boys, puberty tends to end about two years later than in girls. As menstruation is not a developmental feature in males, the presence of axillary and facial hair may serve as an alternative clinical indicator of pubertal stage. During history taking, the five-stage Tanner scale provides a comprehensive assessment of pubertal development and prediction for PHV in pediatric patients [27,28].
Physical examination
Physical examination includes observing a patient’s appearance to check for any truncal asymmetry or abnormal skin markings. Moreover, it is pivotal to monitor if the patient has entered a rapid growth phase by measuring the patient’s height upon each clinic visit. A thorough neurologic examination with motor and sensory tests has to be conducted to exclude any underlying diseases, especially intraspinal lesions.
Adam’s forward bending test is a commonly used examination to assess the angle of trunk rotation (ATR). It is performed by instructing a patient to bend forward from a standing position with their feet shoulder-width apart. This test allows examiners to discover any truncal asymmetry or prominence on either side of the back through visual inspection from the back of the patient. A scoliometer is a common measuring tool used to quantify the ATR. A reading larger than 5 degrees is considered the cutoff to prompt referral for further radiographic survey [29].
Generally, the more severe the scoliosis is, the greater the degree of ATR that a scoliometer would measure. Although the reading from a scoliometer does not directly convert to a specific Cobb angle, a measurement of approximately 7 degrees typically corresponds to a Cobb angle of around 20 degrees [30]. However, due to the unsatisfactory prediction value and limitation of inter-observer variability in using scoliometers, emerging techniques using optical engineering and deep machine learning are being developed for better prediction of the Cobb angle in AIS patients, to avoid excessive radiation exposure for young cohorts [31]. Fig. 2 demonstrates the Adam’s forward bending test and the application of the scoliometer.
Image
Radiologic evaluation for scoliosis should include standing full-length posteroanterior, standing lateral, and side-bending spine radiographs, commonly referred to as triple films in a clinical setting. These serial images facilitate measurement of the Cobb angle across the coronal and sagittal planes and assist in evaluating whether scoliosis impacts coronal or sagittal balance. Imaging is also helpful in unraveling structural abnormalities that may be the underlying causes of scoliosis [32]. The side-bending radiographs help assess how flexible or rigid the spinal curve is, as the information is critical in guiding the appropriate treatment strategy and estimating prognosis. Additionally, a standing full-length anteroposterior radiograph of bilateral lower extremities, including the pelvic level, should be reviewed if leg length discrepancy is suspected during the inspection [33].
Further advanced imaging tools are warranted for specific clinical conditions. Abnormal neurological findings, particularly upper motor neuron signs, may suggest the presence of neuraxial abnormalities. Eight percent of patients with AIS are reported to have combined with these abnormalities [34]. In such cases, magnetic resonance imaging (MRI) should be conducted to assess for occult pathologies, such as syringomyelia, Arnold–Chiari malformation, tethered cord, split cord malformation, or spinal tumors [35]. On the other hand, computed tomography (CT) is typically reserved for preoperative planning or in complex cases involving multiple organ systems other than the spine.
Radiographs are useful for evaluating skeletal maturity. The Risser stage and the closure of the triradiate cartilage serve as practical indicators of skeletal maturity, both of which can be reviewed on the triple films of the spine. The Risser stage evaluates the ossification of the iliac apophysis, providing an estimate of remaining growth potential. Similarly, closure of the triradiate cartilage in the acetabulum suggests the end stage of peak growth. They are strongly associated with the likelihood of curve progression in scoliosis patients [36]. In the past, the SRS relied solely on the Risser staging system as the only resource for skeletal maturity to guide the management of patients with AIS [37]. However, studies have pointed out the limitations of Risser staging due to its insensitivity to peak growth velocity and its weak correlation with curve progression in AIS patients. Therefore, it is now recommended to use combined assessment tools when evaluating a patient’s skeletal maturity. These may include the Sanders scale, which evaluates hand ossification stages, and the distal radius and ulna (DRU) classification. Both provide more precise estimates of growth potential and risks associated with curve progression [38-41].
Various systems have been proposed to evaluate the severity and location of spinal curvature via radiographs of patients with AIS. The Lenke classification [11,42,43], King-Moe classification [44], Moe-Nash classification [45,46] are widely used imaging assessment instruments. Lonstein and Carlson developed a well-known formula using components of the Cobb angle, Risser sign, and chronological age to calculate a progression factor, which estimates the likelihood of curve progression [47]. However, in the past two decades, the accuracy of Lonstein and Carlson’s formula has faced challenges. Instead, numerous prediction tools are being developed to address the insufficiency in the accurate prediction of curve progression.
DIAGNOSIS OF AIS
This article focuses on AIS, and the diagnosis is based on both clinical and radiographic features. The following three diagnostic criteria must be met: onset of scoliosis after the age of 10 years; a Cobb angle greater than 10°, typically accompanied by vertebral rotation; and the exclusion of other identifiable causes of scoliosis [5].
MANAGEMENTS
There are three principles guiding the management of AIS. First, it is critical to identify each patient’s risk of curve progression. Second, the medical team should make every effort to stabilize the underlying driving forces contributing to scoliosis. Third, treatment should aim to support the child in maintaining a healthy, normal, and enjoyable daily life.
Contemporary treatment for AIS is categorized into four main approaches:
1. Observation,
2. Therapeutic exercises,
3. Bracing, and
4. Surgical intervention.
The proper treatment choice is according to the magnitude of the spinal curvature and the likelihood of curve progression.
Cobb angle less than 25°
Patients with a Cobb angle under 25 degrees should undergo clinic follow-ups every 4 to 6 months for physical examinations and radiographic assessments on a regular basis. In addition, all patients are encouraged to engage in therapeutic exercises and posture training. Though therapeutic exercises alone may not necessarily correct or halt the progression of scoliosis, they still play an important role in improving and preventing secondary issues. As a matter of fact, therapeutic exercises are beneficial not only during the observation phase but also for patients undergoing bracing treatment. The exercises help mitigate complications such as physical deconditioning, muscle atrophy, and body stiffness associated with prolonged brace use. Furthermore, therapeutic exercises are valuable in maintaining patients’ optimal physical function before and after surgery, which may contribute to achieving the best possible surgical outcomes [48,49].
Therapeutic exercises for scoliosis patients fall into two main categories. The first category focuses on generalized physiotherapy exercise, mainly strength training and low-impact stretching. Though the training program boosts overall fitness, its effectiveness is limited in correcting or slowing the progression of the curve. The second category has gained more attention over the past two to three decades: physiotherapeutic scoliosis-specific exercises (PSSE). These are individualized, curve-specific exercise protocols tailored to one’s specific curve location, severity, and clinical presentation. PSSE has shown its worth to temporarily stabilize the progression of spinal curves and effectively reduce the Cobb angle in cases of non-progressive scoliosis from our clinic experiences. Through strategies of three-dimensional (3D) self-correction and maintaining corrected posture, PSSE improves back asymmetry, addresses secondary muscle imbalances, and alleviates pain. Furthermore, in patients with severe thoracic scoliosis, PSSE may contribute to enhanced pulmonary function [48].
Originating in Europe, PSSE has now been widely adopted and promoted globally, including in countries across Asia, the Americas, and beyond. So far, there are at least seven well-established PSSE schools in Europe, each with its unique theoretical framework and treatment methodology. Among various schools of PSSE, the Schroth method stands out as the most widely practiced program in the treatment of scoliosis. Developed by German researchers, the approach emphasizes patients’ own awareness of their bodies and strategies of self-correction through approaches of repetitive 3D asymmetric spinal correction exercises and active 3D stabilization practice. The Schroth method achieves therapeutic goals by using breathing techniques and integrating postural correction movements into patients’ daily lives. The Schroth method is designed as a safe, accessible, and home-based exercise program [50,51].
The value of PSSE is its effect in reducing the progression of spinal curvature, potentially lowering the need for bracing or surgery in the future. Additionally, PSSE can improve postural alignment and physical appearance, bringing a positive impact on the patient’s psychological aspect. When comparing patients with generalized physiotherapy exercises, current research proves that PSSE is more effective in angular improvement. However, the overall strength of the evidence is limited due to variability in the exercise protocols and inconsistencies in the quality of study designs [49].
Electrical stimulation used to be one of the main therapeutic approaches in treating scoliosis patients. The theory is to straighten and stabilize the spine by applying electrical stimulation to the paraspinal muscles of the convex side of the curve. While early studies suggested potential effectiveness [52], more recent long-term follow-up studies comparing treatment groups with the control groups have demonstrated that this modality is ineffective in preventing curve progression [53].
Cobb angle between 25° and 45°
Bracing is recommended as part of a comprehensive treatment plan for AIS patients with a Cobb angle between 25 and 45 degrees, especially when the patient still has considerable growth potential. The skeletal immaturity is often indicated by a Risser sign of less than 3 [54]. The mechanism of bracing is to apply external forces through three-point fixation as a scaffold to guide proper spinal growth. The primary goal of bracing is to slow down curve progression, rather than to achieve curve correction. Smaller curvature is generally more responsive to bracing. Early bracing should be considered in extreme cases with rapid curve progression or a family history of fast progression.
The design and quality of a brace carry a great influence on a patient’s acceptance of wearing it. Dysfunctional bracing may induce pain or discomfort over prolonged use, resulting in skin issues, such as contact dermatitis and fungal infections. Additionally, bracing can be traumatizing to the young patient’s self-image. It is a common phenomenon that many adolescents exhibit strong resistance to braces, not only due to the discomfort but also because of the negative impact on peer interaction and daily activities, leading to social awkwardness and further poor compliance [55,56].
Notably, studies have shown that the failure rate of brace compliance in boys is generally higher than in girls [57,58]. In fact, brace compliance is strongly associated with therapeutic success. Therefore, braces need to be as lightweight and comfortable as possible to maximize patients’ adherence and better control the curve progression. Achieving a balance between effective bracing and patient comfort is challenging yet essential for patients to stay in the treatment plan in the long run.
When selecting a brace for scoliosis patients, the location of the apex is the primary consideration. For patients with the apex situated above T8, a cervico-thoraco-lumbo-sacral orthosis (CTLSO), such as the Milwaukee brace, is preferred. The brace usually provides adequate support for the head and chin by a neck ring. Conversely, as the apex below T8, an underarm-type thoraco-lumbo-sacral orthosis (TLSO), such as the Boston or Wilmington brace, is much preferred. These braces offer greater comfort and cosmetic acceptability, thereby improving patient compliance. For patients with curvature at the thoracolumbar junction or the lumbar spine, nighttime braces such as the Charleston brace should be taken into consideration. Nighttime braces are equipped only during sleep and are intended to overcorrect the curve, allowing shorter daily wearing [59]. In addition, a specially designed brace, named SpineCor brace (https://www.spinecor.com), is the only true dynamic brace specifically for patients with idiopathic scoliosis at a Cobb angle greater than 15 degrees [60]. The SpineCor brace permits normal body movement and daily activities while providing gradual correction of the curve. It is comfortable to wear and can be covered discreetly under clothing, making it more acceptable for patients. Although SpineCor brace is well-tolerated and cosmetically favorable, its clinical efficacy remains relatively limited compared to other traditional braces [61,62].
It is regarded as effective for a well-designed brace to reduce the Cobb angle by more than 20% while being worn. This threshold of in-brace correction is linked to better long-term outcomes [63,64]. In terms of an ideal wearing schedule, patients are required to use the brace for 23 hours each day, only removing it for bathing and exercising [65,66]. However, in real-life scenarios where full compliance is hard to reach. A minimum of 16 hours per day is generally advised instead. A meta-analysis by the SRS, along with a randomized controlled trial from The New England Journal of Medicine, indicates that the effectiveness of bracing in preventing the progression of spinal curvature is positively correlated with the overall time the brace is worn each day [65,67]. Furthermore, it is important to educate patients to follow a home exercise program while using braces. The program motivates them to participate in activities suitable for their age and improves the therapeutic benefits of bracing. Moreover, patients should be instructed to perform active self-correction exercises for better outcomes.
Successful bracing is defined as the spinal curve not progressing more than 5 degrees in the period of treatment [68,69]. A well-known study, conducted by SRS in 1995, involving 286 girls with AIS, reported a 74% success rate in the bracing group, 33% in the group using electrical stimulation, and 34% in the control group with only observation [70,71]. Moreover, patients who received a combination of bracing and therapeutic exercise had a lower rate of curve progression during the follow-up compared to those who underwent bracing alone [72].
BrAIST-Calc (https://braistcalc.com/calc.html) is a clinical prediction tool to estimate the risk of curve worsening to the threshold for surgical intervention, defined as a Cobb angle of 50° or greater, in cases of AIS without bracing. The model is based on a multicenter prospective study conducted across North America, known as the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST). The calculator quantifies the risk of curve progression with several key clinical variables, including age, sex, the maximum Cobb Angle, Risser stage, height, and weight. This tool aids in making well-discussed clinical decisions among the medical team, patients, and families, especially in determining the adoption of bracing [73-75].
Cobb angle over 40° to 45°
When the spinal curvature exceeds 40 to 45 degrees, surgical treatment is generally discussed [76]. There are two main surgical approaches: fusion methods and non-fusion methods. Spinal fusion methods typically include posterior spinal fusion, anterior spinal fusion, and combined posterior and anterior spinal fusion. These fusion approaches aim to stabilize the spine, halt further spinal growth, and prevent curve progression. The posterior spinal fusion surgery is the gold standard for treating AIS with large curves [77]. The standard protocol of a fusion surgery harnesses pedicle screws to fix the vertebrae with rods. The correction of the spinal curvature is ultimately achieved through intraoperative maneuvers of compression, distraction, and de-rotation.
A study including 84,320 patients with AIS extracted from the SRS database over a 13-year period from 2004 to 2016 reports an overall complication rate of 1.5% after spinal deformity surgery, along with a mortality rate of 0.014%. The three most frequent complications, listed in order, are surgical wound infections at 0.52%, new-onset neurological deficits at 0.35%, and implant-related complications at 0.20%. Encouragingly, the complication rate has fallen over the years. Between 2004 and 2007, the rate was 4.96% and then it lowered drastically to 0.98% from 2013 to 2016. The drop in complication rate may be attributed to advancements in surgical techniques, resulting in fewer implantation-related complications and a reduction in new neurological impairment [78].
Non-fusion methods, such as growing rod, vertebral body tethering (VBT), and ApiFix, are more appropriate for patients who still have several years until skeletal maturity but have already reached the threshold for surgery. The growing rod system is introduced to provide spinal stabilization while permitting continued axial growth at the same time by regularly adjusting the rod. The growing rod is typically lengthened by approximately 1 cm every 4 to 6 months [79].
VBT is an emerging non-fusion surgical technique, approved by the U.S. Food and Drug Administration (FDA) in 2019, for the treatment of idiopathic scoliosis. The procedure harnesses a flexible polyethylene tether with screws along the convex surface of the vertebral bodies in skeletally immature patients. VBT is founded on the principle of the Hueter-Volkmann Law, which states that differential growth can be modified by applying mechanical loads. The tether and screws exert compression on the convex side of the spinal curve and guide the spine into a proper upright alignment as the child grows. VBT preserves spinal mobility and allows for ongoing spinal growth while preventing excessive curvature progression [80-83].
ApiFix is another innovative, non-fusional, motion-preserving surgical technique for AIS patients. It also received approval from the U.S. FDA in 2019. The surgical method involves unilateral posterior implantation of a self-adjusting rod anchored to the concave side of the curve using about three pedicle screws. It permits gradual postoperative curve correction through spinal motion and physical therapy, without further need for spinal fusion or bone grafting. Early studies on the efficacy of ApiFix have reported promising short-term outcomes. These include a significant reduction in spinal curvature, decreased surgical time, minimal blood loss during surgery, and preserved spinal mobility [84]. However, the long-term evaluation of implant safety, durability, and possible complications, such as the need for revision due to implant failure, is still ongoing [85].
Though non-fusion surgery preserves the potential for continued growth, some patients with AIS may still need final fusion surgery to permanently stabilize the spine once they reach skeletal maturity and the magnitude of spinal curvatures remains significant.
To enhance the precision of screw placement in AIS surgery, robot-assisted techniques have increasingly been adopted. Compared to conventional fluoroscopy-guided methods (typically using a C-arm), robotic navigation has been shown to improve the accuracy of pedicle screw implantation, while reducing operative time, radiation burden, and intraoperative complications [86,87]. These advances in surgery for AIS reflect a trend toward non-fusion, motion-preserving, and robotic-assisted techniques aimed at optimizing both functional and structural outcomes.
Spinal deformity surgery carries a high risk to the spinal cord and nerve roots. During the operation, there is a possibility of direct nerve injury or spinal cord ischemia, which can lead to catastrophic complications, including paralysis of the lower limbs. Therefore, intraoperative neurophysiological monitoring (IONM) is invaluable for protecting the integrity of neural structures throughout the surgery [88]. Combined multimodal IONM in the corrective surgery for AIS has demonstrated its remarkable diagnostic value, achieving an overall sensitivity of 100%, specificity of 98.5%, and positive predictive value of 85% [89]. In the practice at Taipei Veterans General Hospital, IONM using both motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) is recommended in brain and spinal surgeries to assess the integrity of both ascending and descending neural pathways [90-94]. The surgical team is immediately alerted if there is a significant deterioration in either MEP or SSEP signals. This alarm allows them to take prompt action to address the signal drops by adjusting the degree of correction, repositioning pedicle screws at specific levels, or, if necessary, removing all instrumentation to relieve any possible neural compression.
Additionally, in corrective surgery for scoliosis, the common monitoring technique known as triggered electromyography (t-EMG) is employed following the implantation of pedicle screws. During this test, the screws are stimulated by electrical currents to evoke compound muscle action potential (CMAP) responses, which are electrical signals from the corresponding myotome. t-EMG helps the surgical team confirm whether the screws are properly placed intra-osseously and ensure that the neural structures remain unharmed. Several articles propose varied alarm thresholds for pedicle screw stimulation to detect early signs of neural impairment. Overall, stimulation levels above 5 to 11 mA that elicit the CMAP responses are considered safe [95-97]. For instance, if a CMAP response is triggered by a current stimulation below 5 mA when applied to the tip of a pedicle screw at a specific level, it indicates a high likelihood of a medial breach and a potential risk of compression on the corresponding spinal root. On the other hand, if a CMAP response can only be obtained by a current stimulation above 11 mA, this suggests that the screw is safely placed within the pedicle, with minimal concerns about a medial breach. Therefore, a stimulation reading from t-EMG below the threshold of 5 mA should prompt further evaluation of screw location, which can be conducted using C-arm fluoroscopy or by manually palpating the medial wall of the pedicle.
IONM is a pivotal role in spinal deformity surgery for scoliosis, as it greatly reduces the risk of major neurological complications and improves the likelihood of favorable outcomes. Fig. 3 illustrates the IONM signals commonly captured during spinal deformity correction surgery in a 13-year-old girl diagnosed with AIS.
The long-term prognosis of AIS is largely determined by the degree of curvature at skeletal maturity. If a patient’s curve can be managed below 30 degrees at the timing of skeletal maturity, the likelihood of significant progression in the future is minimal. In contrast, patients with curves that exceed 40 degrees can progress at a rate of 1 degree per year during middle age and beyond [98]. Consequently, the primary goal in treating AIS patients is to prevent curve progression that may ultimately compromise patients’ cardiopulmonary function over time. The overall clinical approach to AIS patients by physiatrists is illustrated in Fig. 4.
CONCLUSION
AIS is a progressive spinal deformity that can greatly impact a young patient’s appearance, self-esteem, psychological well-being, and overall quality of life. Cardiopulmonary function would also be compromised in severe cases with gigantic spinal curves. It requires an extensive understanding of spinal anatomy, physiology, and biomechanics for effective assessment and management. The curvature degree and remaining growth potential are key factors in predicting the risk of progression. Therefore, early detection through screening programs and timely intervention by a multidisciplinary team are the principles in AIS management. Rehabilitation specialists play indispensable roles in a team-based strategy for AIS patients by providing thorough clinical evaluations, continuous surveillance, and tailored therapeutic plans. The management includes scoliosis-specific exercise, bracing, proper referrals to pediatric orthopedics, and even IONM to optimize neurologic outcomes for patients with AIS.
With a comprehensive approach, the prognosis for AIS patients is generally favorable, as most achieve good function into adulthood. However, further research is needed to elucidate current knowledge gaps in the etiopathogenesis of AIS, more accurate models of progression prediction, and the optimization of both non-surgical and surgical treatment strategies. Sustained commitment to integrated team-based, patient-centered care and high-quality collaborative research is crucial to advancing the management and improving long-term outcomes for patients with AIS.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
None.
AUTHOR CONTRIBUTION
Conceptualization: Su YC, Feng CK, Yang TF. Project administration: Yang TF. Software: Su YC. Supervision: Yang TF, Feng CK. Validation: Su YC, Feng CK, Yang TF. Visualization: Su YC. Writing – original draft: Su YC, Yang TF. Writing – review and editing: Su YC, Feng CK, Yang TF. Approval of final manuscript: all authors.
ACKNOWLEDGMENTS
The authors would like to express their sincere appreciation to the entire scoliosis team at Taipei Veterans General Hospital for their great dedication and exceptional expertise in caring for scoliosis patients over several decades. Their collective contributions are pivotal in advancing the clinical management of scoliosis.
Fig. 1.
Radiographic series of a 13-year-old girl diagnosed with AIS in the pattern of double major curves, Risser 4. The complete imaging series for scoliosis includes full-length standing posteroanterior, lateral, and bilateral side-bending radiographs. (A) The full-length standing posteroanterior radiograph demonstrates a double major curve pattern. The apical vertebra at L2 is forward to the left. The Cobb angles are 49° from T4 to T10 (pink markings) and 65.6° from T10 to L4 (yellow markings). (B) The lateral radiograph shows the absence of hyper-kyphosis with a kyphotic Cobb angle of 14.6° (less than 40°) between T4 and T12 (pink markings). (C, D) The side-bending radiographs reveal that both curves remain greater than 25° in the left (yellow markings) and right (pink markings) bending positions, confirming that they are structural curves. (E, F) The post-operative full-length standing posteroanterior and lateral radiographs indicate significant improvement in spinal curvature following the spinal fusion from T4 to L4 level. AIS, adolescent idiopathic scoliosis.
Fig. 2.
Demonstration of Adam’s forward test and the application of the scoliometer on a 13-year-old girl with AIS. (A, B) Adam’s Forward is a widely used screening tool for scoliosis in schools and clinic offices. To perform the test, the examinee stands shoulder-width apart and bends forward with arms hanging naturally or together. The examiner observes the examinee from behind to assess for signs of spinal asymmetry, such as a visible curve (dotted line), a hump (arrows), or uneven shoulders and hips, which may indicate scoliosis. (C, D) Scoliometer is used to measure ATR. The patient is positioned as they would be during Adam’s forward bend test. The examiner places the notch of the scoliometer on the patient’s spine to identify the largest angle, usually at the curve’s apex. If the reading exceeds 5 degrees, it implies a potential scoliosis condition and prompts further radiographic evaluation. To use the patient's photos, a consensus was reached with the girl and her parents to minimize identifiable body characteristics. AIS, adolescent idiopathic scoliosis; ATR: angle of trunk rotation.
Fig. 3.
Representative of IONM signals commonly captured during spinal deformity correction surgery. All recordings were obtained from the same AIS patient who underwent posterior spinal fusion from T4 to L4, as illustrated in Figs. 1 and 2. The IONM system used in this case was the Cascade IOMAX (Cadwell Industries, Inc.). (A) Baseline MEPs recorded immediately after the induction of general anesthesia. MEP responses were bilaterally monitored from the abductor pollicis brevis, vastus medialis, abductor hallucis, and anal sphincter muscles. (B) Baseline SSEPs recorded through stimulation of the ulnar and tibial nerves. (C) Safe t-EMG responses following pedicle screw placement. Stimulation of the right T9 screw (13.0 mA) elicited EMG responses of the rectus abdominis muscle (indicated by pink arrows). (D) Another example of safe t-EMG responses following pedicle screw implantation. Stimulation of the screw at the left T7 level (>25.0 mA) evoked EMG responses of the rectus abdominis muscle (indicated by the pink arrow). IONM, intraoperative neurophysiological monitoring; AIS, adolescent idiopathic scoliosis; MEPs, motor evoked potentials; SSEPs, somatosensory evoked potentials; t-EMG, triggered electromyography.
Fig. 4.
Schematic diagram for physiatrists to approach patients with suspected AIS. AIS, adolescent idiopathic scoliosis; PA,posteroanterior; AP, anteroposterior; MRI, magnetic resonance imaging; CT, computed tomography.
Table 1.
Classification of scoliosis with corresponding descriptions and associated conditions
Category of scoliosis
Description
Common example
Congenital scoliosis
Scoliosis caused by vertebral malformations present at birth
Vertebral malformation due to
- Failure of formation
- Failure of segmentation, or mixed
Neuromuscular scoliosis
Scoliosis associated with neurological or muscular disorders
Cerebral palsy
Spinal muscular atrophy
Charcot-Marie-Tooth disease
Chiari malformation, type 1
Duchenne muscular dystrophy
Friedreich ataxia
Spina Bifida
Myelomeningocele
Poliomyelitis
Idiopathic scoliosis
Scoliosis of unknown cause, which can be further classified based on the age of onset
Infantile scoliosis: onset from birth to 3 years old
Juvenile scoliosis: onset between 4 and 10 years old
Adolescent scoliosis: onset after 10 years of age
Syndromic scoliosis
Scoliosis associated with certain syndromes or association
A non-structural curvature often due to temporary or external factors
Leg length discrepancies
Imbalance of the paraspinal muscles
Miscellaneous
Other etiologies that may lead to scoliosis
Previous trauma to the spine or spinal cord
Tumor at the spine or spinal cord
Vertebral infection
Rickets
Table 2.
Terminology in adolescent idiopathic scoliosis [13,14]
Term
Description
Direction
The direction refers to the orientation of the curve’s convexity, indicating whether it points to the right or left.
Location
The location refers to the vertebra at the apex of the curve, defined as the vertebral level most laterally deviated from the midline. It is classified according to whether the apical vertebra is situated in the cervical, thoracic, or lumbosacral level.
Major curve
A major curve is a curve with the greatest angular degree of scoliosis.
Double major curves
Patients with double major curves have the thoracic and lumbar curves both in significant severity. It is generally characterized by a lumbar curve exceeding 40° and a thoracic curve greater than 30°.
Compensatory curve/Minor curve
A compensatory curve or a minor curve is smaller than the major curve and develops as a compensatory mechanism in response to the major curve.
Structural curve
A structural curve refers to either the major or minor curve that remains greater than 25 degrees on side-bending radiographs, indicating a rigid and fixed deformity.
Non-structural curve
A non-structural curve is a curve decreased to less than 25 degrees or disappears on side-bending radiographs, suggesting it is flexible and not a definite structural deformity.
Cobb angle
The angle between the extension lines of the most tilted upper endplate and the most tilted lower endplate.
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Evaluating the Effectiveness of sEMG Biofeedback for Posture Training and Scoliosis Management Yiu-Hong Wong, Mei-chun Cheung, Qi-Wen Emma Lei, Joanne Yip, Yoel A. Klug BioMed Research International.2026;[Epub] CrossRef
Interrelationships among 3D spinal alignment variables during active self-correction in adolescents with idiopathic scoliosis Arkadiusz Żurawski, Sun-Young Ha European Spine Journal.2026;[Epub] CrossRef
Three-Dimensional Surface Topography for the Assessment of Spinal Alignment: A Cross-Sectional Study of Biomechanical Correlates Brigitte Osser, Csongor Toth, Gyongyi Osser, Laura Ioana Bondar, Liliana-Oana Pobirci, Florin Mihai Marcu, Ramona Nicoleta Suciu, Nicoleta Anamaria Pascalau, Adina Mincic, Corina Dalia Toderescu Diagnostics.2026; 16(10): 1445. CrossRef
Assessment and Management of Adolescent Idiopathic Scoliosis: From the Perspective of a Physiatrist
Fig. 1. Radiographic series of a 13-year-old girl diagnosed with AIS in the pattern of double major curves, Risser 4. The complete imaging series for scoliosis includes full-length standing posteroanterior, lateral, and bilateral side-bending radiographs. (A) The full-length standing posteroanterior radiograph demonstrates a double major curve pattern. The apical vertebra at L2 is forward to the left. The Cobb angles are 49° from T4 to T10 (pink markings) and 65.6° from T10 to L4 (yellow markings). (B) The lateral radiograph shows the absence of hyper-kyphosis with a kyphotic Cobb angle of 14.6° (less than 40°) between T4 and T12 (pink markings). (C, D) The side-bending radiographs reveal that both curves remain greater than 25° in the left (yellow markings) and right (pink markings) bending positions, confirming that they are structural curves. (E, F) The post-operative full-length standing posteroanterior and lateral radiographs indicate significant improvement in spinal curvature following the spinal fusion from T4 to L4 level. AIS, adolescent idiopathic scoliosis.
Fig. 2. Demonstration of Adam’s forward test and the application of the scoliometer on a 13-year-old girl with AIS. (A, B) Adam’s Forward is a widely used screening tool for scoliosis in schools and clinic offices. To perform the test, the examinee stands shoulder-width apart and bends forward with arms hanging naturally or together. The examiner observes the examinee from behind to assess for signs of spinal asymmetry, such as a visible curve (dotted line), a hump (arrows), or uneven shoulders and hips, which may indicate scoliosis. (C, D) Scoliometer is used to measure ATR. The patient is positioned as they would be during Adam’s forward bend test. The examiner places the notch of the scoliometer on the patient’s spine to identify the largest angle, usually at the curve’s apex. If the reading exceeds 5 degrees, it implies a potential scoliosis condition and prompts further radiographic evaluation. To use the patient's photos, a consensus was reached with the girl and her parents to minimize identifiable body characteristics. AIS, adolescent idiopathic scoliosis; ATR: angle of trunk rotation.
Fig. 3. Representative of IONM signals commonly captured during spinal deformity correction surgery. All recordings were obtained from the same AIS patient who underwent posterior spinal fusion from T4 to L4, as illustrated in Figs. 1 and 2. The IONM system used in this case was the Cascade IOMAX (Cadwell Industries, Inc.). (A) Baseline MEPs recorded immediately after the induction of general anesthesia. MEP responses were bilaterally monitored from the abductor pollicis brevis, vastus medialis, abductor hallucis, and anal sphincter muscles. (B) Baseline SSEPs recorded through stimulation of the ulnar and tibial nerves. (C) Safe t-EMG responses following pedicle screw placement. Stimulation of the right T9 screw (13.0 mA) elicited EMG responses of the rectus abdominis muscle (indicated by pink arrows). (D) Another example of safe t-EMG responses following pedicle screw implantation. Stimulation of the screw at the left T7 level (>25.0 mA) evoked EMG responses of the rectus abdominis muscle (indicated by the pink arrow). IONM, intraoperative neurophysiological monitoring; AIS, adolescent idiopathic scoliosis; MEPs, motor evoked potentials; SSEPs, somatosensory evoked potentials; t-EMG, triggered electromyography.
Fig. 4. Schematic diagram for physiatrists to approach patients with suspected AIS. AIS, adolescent idiopathic scoliosis; PA,posteroanterior; AP, anteroposterior; MRI, magnetic resonance imaging; CT, computed tomography.
Graphical abstract
Fig. 1.
Fig. 2.
Fig. 3.
Fig. 4.
Graphical abstract
Assessment and Management of Adolescent Idiopathic Scoliosis: From the Perspective of a Physiatrist
Category of scoliosis
Description
Common example
Congenital scoliosis
Scoliosis caused by vertebral malformations present at birth
Vertebral malformation due to
- Failure of formation
- Failure of segmentation, or mixed
Neuromuscular scoliosis
Scoliosis associated with neurological or muscular disorders
Cerebral palsy
Spinal muscular atrophy
Charcot-Marie-Tooth disease
Chiari malformation, type 1
Duchenne muscular dystrophy
Friedreich ataxia
Spina Bifida
Myelomeningocele
Poliomyelitis
Idiopathic scoliosis
Scoliosis of unknown cause, which can be further classified based on the age of onset
Infantile scoliosis: onset from birth to 3 years old
Juvenile scoliosis: onset between 4 and 10 years old
Adolescent scoliosis: onset after 10 years of age
Syndromic scoliosis
Scoliosis associated with certain syndromes or association
A non-structural curvature often due to temporary or external factors
Leg length discrepancies
Imbalance of the paraspinal muscles
Miscellaneous
Other etiologies that may lead to scoliosis
Previous trauma to the spine or spinal cord
Tumor at the spine or spinal cord
Vertebral infection
Rickets
Term
Description
Direction
The direction refers to the orientation of the curve’s convexity, indicating whether it points to the right or left.
Location
The location refers to the vertebra at the apex of the curve, defined as the vertebral level most laterally deviated from the midline. It is classified according to whether the apical vertebra is situated in the cervical, thoracic, or lumbosacral level.
Major curve
A major curve is a curve with the greatest angular degree of scoliosis.
Double major curves
Patients with double major curves have the thoracic and lumbar curves both in significant severity. It is generally characterized by a lumbar curve exceeding 40° and a thoracic curve greater than 30°.
Compensatory curve/Minor curve
A compensatory curve or a minor curve is smaller than the major curve and develops as a compensatory mechanism in response to the major curve.
Structural curve
A structural curve refers to either the major or minor curve that remains greater than 25 degrees on side-bending radiographs, indicating a rigid and fixed deformity.
Non-structural curve
A non-structural curve is a curve decreased to less than 25 degrees or disappears on side-bending radiographs, suggesting it is flexible and not a definite structural deformity.
Cobb angle
The angle between the extension lines of the most tilted upper endplate and the most tilted lower endplate.
Table 1. Classification of scoliosis with corresponding descriptions and associated conditions
Table 2. Terminology in adolescent idiopathic scoliosis [13,14]
