Juvenile idiopathic scoliosis, the Cobb angle and surgery: An inevitable trio? – A case report

Abstract

Juvenile idiopathic scoliosis (JIS) refers to scoliosis occurring between the ages of 4–10 and represents 10–15% of all idiopathic scoliosis. The growth potential rises the risk of curve progression and subsequent surgery. Curves that reach 30° tend to worsen without treatment. The general indication for surgery is a curve size > 50°. This case report aims to alert the clinicians to the value of looking beyond the Cobb angle when approaching JIS. We present a case of JIS with a Cobb angle > 50° treated with bracing, evaluated in Physical and Rehabilitation Medicine outpatient. A 6-year-old girl with asymptomatic JIS and a structured 56° right thoracic curvature and Risser 0/5 was referenced to our department by the spinal surgeon to delay surgery. Clinically, she presented a 30 mm right thoracic hump in the Adams test and hypokyphosis. Brace treatment was started with a thoraco-lumbo-sacral-orthosis Boston, 23 hours per day. After 3 months and 1 year of treatment, the in-brace x-rays revealed a reduction of Cobb angle to 23° and to 20° respectively, and Risser 0/5. Currently, at 3-year follow-up, she has a 36° curve on out-of-brace x-ray and a 10 mm hump on physical examination. The orthotist technician care was crucial (she needed 3 braces and several adjustments). She maintains treatment with noteworthy compliance and continues asymptomatic. Growth restriction and complications associated with spinal fusion make conservative treatment a frequent first option. Reports on the success of bracing in JIS range between 13–81%. Clinical experience, multidisciplinary approach (physiatrist, physiotherapist, orthotist technician, spinal surgeon) and compliance to bracing play a significant role. This case highlights the enduring importance of questioning ourselves if we are properly managing scoliosis in early ages. JIS natural history is not always the same; besides the growth potential and Cobb angle, we should consider other factors.