Mega Doctor News
by Children’s Hospital Los Angeles
Newswise – Is surgery the right choice for a 14-year-old with a 50-degree curve who is nearing skeletal maturity? Should a 10-year-old with a 19-degree curve start bracing—or just be watched?
These are the kinds of questions that Children’s Hospital Los Angeles surgeons often encounter in patients with adolescent idiopathic scoliosis (AIS)—and the answers are rarely straightforward.
“Many cases fall into a clinical gray zone,” says Michael Heffernan, MD, a pediatric spine surgeon in the Jackie and Gene Autry Orthopedic Center at CHLA, one of the leading pediatric spine programs in the nation. “The by-the-book answer isn’t always the right answer. It’s much more nuanced.”
The lens of growth
With AIS, traditional algorithms focus on curve magnitude: brace at 25-40 degrees and operate at 50 degrees. But curve size is only part of the equation.
“You have to look at the curve through the lens of how much growth someone has left,” Dr. Heffernan explains. “A 30-degree curve in an 11-year-old with open growth plates behaves very differently from the same curve in a skeletally mature 16-year-old.”
To better assess remaining growth, CHLA surgeons use hand X-rays with Sanders scoring, a more precise measure of skeletal maturity than traditional methods such as Risser staging.
This approach—typically only offered at pediatric spine centers—is especially important in gray zone cases, when it’s unclear whether to brace, operate, or observe.
Borderline bracing decisions
Uncertainty in AIS management doesn’t start at 50 degrees. It often begins much earlier.
Although bracing is typically recommended for adolescent scoliosis curves between 25 and 40 degrees in growing children, CHLA’s team tailors those decisions to each patient and family.
“If a 15-degree curve is 22 degrees four months later, that spine is telling you something,” Dr. Heffernan says. “Even if it hasn’t hit 25 degrees yet, we’ll strongly consider bracing if it’s progressing quickly.”
Randomized trial data have shown that bracing can slow curve progression in AIS. But it can also carry a significant physical and psychosocial burden.
“Bracing is effective, but it’s not always benign,” he says. “Even if we know a child will eventually need a brace, if we can safely delay it, we will. Sparing kids a year or two of that experience can be meaningful.”
Letting the spine ‘declare itself’
For patients near skeletal maturity with curves around 50 degrees, the decision to operate is often treated as a foregone conclusion. In practice, it’s not.
“In what world does a 49-degree curve never get worse and a 51-degree curve always get worse?” Dr. Heffernan says. “Those X-rays look identical, and measurement error exists. It has to be more nuanced than that.”
For younger patients who are still growing, approaching that threshold is a different story. “Delaying surgery in those cases can turn a several-hour procedure into something much more complex,” he notes.
But for skeletally mature adolescents, the CHLA team often recommends observation first.
“We let the spine declare itself,” Dr. Heffernan says. “If the curve doesn’t change over several years, it may never progress.”
Navigating family decisions
Even with careful assessment of growth and progression, many scoliosis decisions do not have a single right answer. Often, patient and family preferences play a critical role.
“There are families who want to do everything possible to avoid surgery, and others who want a definitive solution,” he notes. “Sometimes the mom, dad, and child will all have a different opinion.”
Concerns about appearance, anxiety about progression, and tolerance for bracing or surgery all factor into the discussion. For CHLA’s surgeons, navigating these conversations is a central part of managing borderline cases.
“One of our strengths is our experience in guiding families toward a shared plan,” Dr. Heffernan says. “That’s not something you learn from a textbook. It comes from walking families through these decisions every day.”
Learn more about adolescent scoliosis care at CHLA.
