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TYPE
Original Research
PAGE NO.
38-44
10.37547/tajmspr/Volume07Issue01-05
OPEN ACCESS
SUBMITED
18 October 2024
ACCEPTED
20 December 2024
PUBLISHED
12 January 2025
VOLUME
Vol.07 Issue01 2025
CITATION
Bianca Gabriella de Oliveira, Lucas da Silva Lucena, Tiago Alves da Silva,
Fred Schinaider Cerqueira, & Marcella Rodrigues Costa Simões. (2025).
Surgical approach to idiopathic scoliosis: a systematic review with meta-
analysis. The American Journal of Medical Sciences and Pharmaceutical
Research, 7(01), 38
–
44.
https://doi.org/10.37547/tajmspr/Volume07Issue01-05
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Surgical approach to
idiopathic scoliosis: a
systematic review with
meta-analysis
Bianca Gabriella de Oliveira
Universidade Salvador-UNIFACS, Salvador, BA, Brasil
ORCID: https://orcid.org/0000-0003-0503-7999
Lucas da Silva Lucena
Médico residente de Ortopedia e Traumatologia pelo Hospital
Fornecedores de Cana, Piracicaba, São Paulo, Brasil
ORCID: https://orcid.org/0009-0000-8459-2450
Tiago Alves da Silva
Médico residente de Ortopedia e Traumatologia Hospital Fornecedores de
Cana, Piracicaba, São Paulo, Brasil
ORCID: https://orcid.org/0009-0004-2698-0702
Fred Schinaider Cerqueira
Médico residente de Ortopedia e Traumatologia pelo Hospital
Fornecedores de Cana, Piracicaba, São Paulo, Brasil
ORCID: https://orcid.org/0009-0006-5610-0344
Marcella Rodrigues Costa Simões
Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
ORCID: https://orcid.org/0000-0001-7334-5921
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The American Journal of Medical Sciences and Pharmaceutical Research
Abstract:
Objectives: to analyze surgical approaches
for the treatment of idiopathic scoliosis and the
prognosis achieved. Methodology: A systematic review
with meta-analysis was carried out using the electronic
databases PubMed/MEDLINE and Cochrane Library.
Results: The sample consisted of 217 patients with a
mean age of 15 years diagnosed with idiopathic
scoliosis. In all the studies included, the pathological
curvature was reduced by more than 49%. Conclusion:
The pathological curvature was reduced in all surgical
interventions, and the short- and long-term post-
operative results were satisfactory.
Keywords:
Scoliosis; Adolescent; Surgical procedures.
Introduction:
Adolescent idiopathic scoliosis is a spinal
deformity comprising a lateral curvature in the frontal
plane, thoracic lordosis in the sagittal plane and
transverse vertebral rotation, resulting in posterior
elevation of the rib cage on the convex side of the
curve and a depression on the concave side. The rate
of progression of this pathology is quite variable, while
mild curves can result only in aesthetic problems, more
severe curves can cause pain and more serious
problems such as spinal imbalance and camptocormia.
This deformity can be caused by problems in the
formation of the spine at the embryonic stage, or it can
be part of certain syndromes. However, most cases of
scoliosis are called “idiopathic” because the underlying
cause cannot be determined. Adolescent idiopathic
scoliosis is the most common form of spinal deformity
in children and adolescents, with a prevalence of 1-3%
in adolescents aged 10 to 16, a higher incidence in
females and with almost 10% of patients requiring
treatment, of which 0.1% require surgical treatment.
The diagnosis of adolescent idiopathic scoliosis is
traditionally based on the Cobb method for assessing
the curvature of the spine. This method measures the
angle of the spine, and the diagnosis is made when the
result of the Cobb angle is greater than or equal to 10
degrees. Depending on the age of the individual at
diagnosis, scoliosis evolves and can deteriorate rapidly
during periods of rapid growth spurt. Early diagnosis is
difficult, often because the external changes in the
early stages are minimal and most of the changes occur
at the back of the torso and are hidden by clothing.
Therefore, in the diagnosis, during the evaluation of
the progression of the curve, all factors are taken into
account in order to decide the best type of treatment
for the patient.
Treatment strategies for adolescent idiopathic
scoliosis can be conservative or surgical, the type of
treatment being determined by the deformity itself.
Conservative treatments are applied to patients with
small curves and surgical treatment is recommended for
those with severe curves.2, 4 That said, the aim of this
study is to analyze surgical approaches to the treatment
of idiopathic scoliosis and the prognosis achieved.
METHODOLOGY
This systematic review is registered on the PRÓSPERO
platform under ID CRD42024572386. It is a systematic
review with meta-analysis in which a bibliographic
search was carried out using the electronic databases:
PubMed/MEDLINE and Cochrane Library without
language restriction of publications up to February
2024, using a search strategy combining keywords and
MeSH terms and the Boolean operator AND/OR. The
search terms “Scoliosis” AND “Adolescent” AND
“Surgical Procedures” were used.
As this was a meta-analysis of published works, there
was no need for approval by the ethics committee or
institutional scientific review board. The reference lists
of the included and previously published articles were
searched for more relevant studies that met the
eligibility criteria.
This systematic review and meta-analysis followed the
Preferred Reporting Items for Systematic Reviews and
Meta-analyses (PRISMA) guidelines: 5
1. Population: Patients diagnosed with adolescent
idiopathic scoliosis.
2. Intervention: Surgical treatment
3. Comparator: Comparison between the pre- and post-
operative results of the established surgical
interventions.
4. Results: Surgical intervention provides satisfactory
results in the short and long term.
5. Study design: Randomized controlled designs,
counterbalanced crossovers or repeated measures
designs that investigated the effects of the recovery
interval.
Inclusion and exclusion criteria
(01) studies evaluating the surgical treatment of
idiopathic scoliosis in adolescents (2) patients aged
between 12 and 18 (3) original retrospective studies and
randomized clinical trials.
Studies with the following criteria were excluded: (1)
experimental studies using animal models (2) non-
original studies - literature reviews (3) opinion studies
(4) studies which reported on the treatment of
idiopathic scoliosis in other age groups (5) studies
published more than ten years ago (6) studies which did
not meet the other inclusion criteria mentioned above.
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The search and selection of studies was carried out by
two reviewers who analyzed the studies. Initially,
studies published in the last five years (2020-2024)
were selected using the aforementioned DECS and
Boolean operators, followed by an analysis of titles and
abstracts. At this stage, studies using animal models,
opinion articles and literature reviews were excluded.
Once this stage had been completed, the full texts of
the articles were retrieved for analysis of the other
inclusion and exclusion criteria. Duplicate citations and
studies not corresponding to the proposed review
parameters
were
also
excluded.
Possible
disagreements were resolved by discussion with a third
reviewer, and inclusion was decided after consensus
with the two main reviewers.
To prioritize methodological quality, studies classified
as “Good” after the NIH quality assessment were
included, with studies with more than nine items
ticked being considered suitable for inclusion.
Epidemiological and demographic data was extracted
using a Microsoft Excel spreadsheet, including
parameters such as number of patients, surgical
approach, risk factors described, infection prevention
strategies.
RESULTS
The five studies selected were obtained by excluding
articles that did not meet the inclusion criteria. Current
studies analyzing surgical treatment for the correction
of idiopathic scoliosis in adolescents were selected
(Figure 1). A total of 217 patients aged 12-18 years
were included.
The analysis of the variation in the greatest Cobb angle
is shown in Table 1 and Figure 2.
Byun et al presented a study of 35 patients with a mean
age of 14.9 years undergoing correction of idiopathic
scoliosis by posterior spinal fusion, in which pulmonary
function and correction in degrees of deviation were
analyzed as outcomes. Forced vital capacity (FVC) and
forced expiratory volume in 1 second (FEV1) were part
of the pulmonary assessment. Of the study
participants, 20 had impaired lung function as a result
of the pathology. In this sample, the pre- and post-
operative FVC values showed differences in the mean
percentages of 66.1 ± 15.6% versus 70.7 ± 13.2%
(p=0.29), and for FEV1 the variation was 79.2 ± 37.7%
versus 81.1 ± 9.1% (p=0.60). It was observed that those
who had no previous pulmonary impairment did not
show significant variations in these parameters
(p=0.63). The correction of the thoracolumbar
curvature recorded was 45.7 ± 14.4º versus 20.0º ±
10.2º (p=0.06).
Zhang et al presented a study evaluating the correction
of juvenile idiopathic scoliosis in 11 patients (4 males
and 7 females) with a mean age of 13 years, using
posterior surgical correction with halo-femoral traction.
The follow-up period for these participants was 32
months. The preoperative Cobb angle was 139.01°±
5.83° and was reduced to 82.98°± 6.91° after surgery, a
correction rate of 40.39%. The mean thoracic kyphosis
angle (TK) varied from 65.02° ± 7.21° to 23.85° ± 5.14°,
and lumbar lordosis (LL) from 39.05° ± 4.08° to 44.95° ±
2.26°. Pulmonary function was also assessed; the
preoperative percentage of FVC% and FEV1% were
50.08% ± 6.07% and 53.46% ± 5.96%, respectively, while
the postoperative values were increased to 65.45% ±
5.29% and 69.08% ± 5.32%. The average duration of the
surgical procedure was 335.91 ± 48.31 minutes and
blood loss was 1590 ± 520.1 ml.
Sapriza et al reported on the use of pedicle screws to
correct adolescent idiopathic scoliosis in a longitudinal
observational study, which included 19 patients. The
follow-up period was nine years. The mean
preoperative Cobb angle reported was 58°±3.0° to
23°±4.1° postoperatively, an improvement of 60%. With
regard to patient satisfaction, only one patient reported
feeling severe pain and 18% felt no pain at all. 90%
reported being very satisfied with the surgical result,
95% had no limitations for sports or daily activities and
90% said they were satisfied with the aesthetic result.
Santos et al's study of 43 patients showed a mean Cobb
angle of the greatest curvature preoperatively of 51.5°
± 13.7°, corrected to 16.5° ± 7.5° after surgery. Another
relevant point was the difference in the measurement
of the T1 profile inclination from 1.5 ± 0.6 to 0.60 ± 0.2
and the variation in neck inclination from 38.4 ± 11.4 to
36.8 ± 12.3. Some parameters did not show significant
changes pre- and post-operatively, such as cervical
lordosis.
Benli et al. presented a study of 109 patients, with an
average age of 14, over a 136-month follow-up. As a
primary outcome, the Turkish SRS-22 questionnaire
showed values for general self-image 3.8±0.7, function
4.0±0.8, mental state 3.6±0.7, pain 3.6±0.8 and
satisfaction 4.6±0.3. The mean Cobb angle of the main
curves in the frontal plane was 60.8°±7.5°. The
correction rate of the main curves was 38.7±22.1% post-
operatively, with a mean overall loss of correction of
5.3°±5.8°. The largest curves showed correction of
38.7+/-22.1%, the average post-operative kyphosis
angles in these cases was 37.7º +/-7.4 and for lumbar
lordosis 36.3º±8.5 º. The complications reported were
superficial infection in 2.8% of patients, and 3.7% of
patients had neurological deficits, including one case of
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late distal paraplegia.
DISCUSSION
Idiopathic scoliosis is the most common spinal
deformity in children and adolescents, and its
treatment differs according to the degree of severity of
the pathology. In severe idiopathic scoliosis, for
example, the aim of treatment is to achieve an
acceptable balance of the spine and save fusion levels.
There are currently numerous surgical techniques for
treating this deformity, including hybrid treatment and
posterior spinal fusion. That said, in recent years the
surgical method for scoliosis has progressed
extensively and recently, the various imaging,
navigation and robotic technologies available for spinal
fusion surgery have increased significantly, facilitating
through modern assistive technologies high precision
in the placement of pedicle screws.
One of the surgical procedures used to correct
adolescent idiopathic scoliosis is the posterior spinal
fusion technique. This technique consists of posterior
instrumental fusion after meticulous exposure of the
posterior elements of the spine to the tips of the
transverse processes on both sides. For the placement
of the thoracic screw, a technique was used that allows
inspection with a spatula inside the canal of the upper,
medial and lower edges of the pedicle. In addition to
the spatula inside the canal, the well-known
anatomical landmarks are used to determine the entry
point of the pedicle. The pedicle is placed using a small
curette, applying gentle pressure for 30 mm in the
proximal thoracic pedicles, 35 mm in the mid-thoracic
region and 40 mm for the lower thoracic pedicles,
directed along the axis of the pedicle in the frontal and
sagittal planes. Metal pins are inserted into the
thoracic holes and the screws are inserted with slow
force using a screw diameter corresponding to 80% of
the pedicle diameter.The direction of the screw is
more convergent medially in the upper thoracic spine,
convergent in the middle thoracic spine and straight at
the levels of T11 and T12. Finally, screw placement is
confirmed by fluoroscopy, using AP, lateral and oblique
views.
Posterior spinal fusion surgery and the placement of
screws can present additional difficulties, such as
excessive
screw
penetration.
However,
the
biomechanical advantages associated with their use
make screws the ideal construction for better
correction of scoliosis and restoration of thoracic
kyphosis. In addition, research has shown that this
technique has long-lasting and reliable results,
preventing the progression of deformity and the
decline of lung function. Regarding the postoperative
period of this surgery, two points are important to
note: changes in height after correction of the deformity
and changes in activity level. Thus, it is known that after
the procedure the patient's clinical and spinal height
increases, in addition, the patient's activity decreases
and the return to athletic activity is correlated with the
distal level of fusion.
As previously mentioned, new treatment techniques for
idiopathic scoliosis have emerged with advances in
technology. Recently, a technique has emerged that is
an advance on the “medial margin segmentation
method” performed using the O
-arm navigation system
(Medtronic O-arm II). This technique consists of
posterior exposure of the lumbar vertebra with
transverse process (TP) through appropriate soft tissue
dissection, thus a C-arm fluoroscope is gradually rotated
until a true posterior-anterior view is obtained, allowing
symmetrical visualization of both pedicles. For
extremely small lobar pedicles (ESLPs), the pedicle
shadows appeared as ellipses or long, thin lines, so an
imaginary pedicle contour was assumed based on the
elliptical or linear shadow. The entry point of a screw is
established at a 2 o'clock position on the presumed
pedicle contour. Then, after adjusting the appropriate
convergence of the gear, both cortices of the transverse
process were penetrated and the tip was advanced
towards the lateral wall of the vertebral div. After
creating an internal entry point from the div of the
lateral cortex, all the bony edges are checked by
palpation before and after tapping with a probe.
Subsequently, an extrapendicular screw is placed in the
vertebral div using tricortical fixation.
Some disadvantages and complications are to be
expected with this new surgical technique, which
include the possibility of irritation of the psoas muscle
along the trajectory of the screw, resulting in symptoms
such as a decrease in the degree of hip flexor muscle,
pain or irritation of the lumbar plexus in the post-
operative period. There is also the possibility of
segmental artery injury and the risk of screw removal
due to limited bone purchases. That said, there was no
case of screw pull-out in this procedure, which was
justified by the high bone density present in the group
of young patients. Therefore, fixation strength for the
correction and maintenance of scoliosis correction can
be achieved using fixation involving only the PT and the
vertebral div.
CONCLUSION
The pulmonary function analyzed by some studies
showed a significant improvement in FEV1 and FVC in
cases of severe AIS. Pathological curvature was reduced
in all the studies that used posterior spinal fusion and
showed good short- and long-term operative results.
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Figure 1- Studies selected according to the PRISMA methodology.
Table 1- Pre- and post-operative Cobb angles.
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Figure 2- Forest graph of Cobb angle variations.
