Scoliosis in Children and Adolescents: When Observation Is Enough and When Surgery Is Needed—A Contemporary Evidence-Based Review

Abstract 

Scoliosis is among the most prevalent spinal deformities in childhood and adolescence, affecting approximately 2–4% of the global pediatric population. (Wang et al., 2025) Despite extensive clinical experience and research, significant controversy remains regarding optimal management strategies, particularly in determining the appropriate timing for transitioning from observation to active intervention or surgical correction. (R. et al., 2013) Although Cobb angle thresholds continue to inform treatment decisions, recent evidence indicates that curve magnitude alone is insufficient to predict progression risk and long-term outcomes. (Development and Validation of Transformer- and Convolutional Neural Network-Based Deep Learning Models to Predict Curve Progression in Adolescent Idiopathic Scoliosis, 2023) Scoliosis progression is now understood to result from a complex interplay of skeletal maturity, growth velocity, curve morphology, biomechanical factors, genetic susceptibility, and environmental influences. (Lenz et al., 2021) As a result, contemporary management emphasizes individualized risk stratification over rigid radiographic criteria. (Addai et al., 2020) Observation is suitable for most mild curves, while bracing may reduce progression in selected skeletally immature patients with moderate deformities. Surgical intervention is typically reserved for progressive curves that exceed established treatment thresholds or are associated with significant functional, cosmetic, or physiological consequences. This review critically evaluates current evidence on scoliosis progression, conservative management, surgical indications, emerging technologies, and ongoing controversies, highlighting the need to balance overtreatment with the risks of delayed intervention.

Keywords: Adolescent idiopathic scoliosis, Pediatric scoliosis, Spinal deformity, Cobb angle, Bracing, Spinal fusion, Vertebral body tethering, Curve progression.