Scoliosis Surgery — Procedure Guide, Recovery & Risks | MyMedicPlus

Scoliosis surgery is a major spinal deformity correction procedure that uses pedicle screw fixation, rods, and bone grafting to straighten an abnormal lateral curvature of the spine (scoliosis) and fuse the vertebrae in a corrected position. The procedure is indicated when the scoliotic curve, measured as the Cobb angle on a full-length standing radiograph, exceeds 40–50 degrees — the threshold at which curves are at significant risk of progressive worsening even after skeletal maturity and beyond which cardiopulmonary function may be compromised.

Scoliosis can be classified as idiopathic (most common, cause unknown), neuromuscular (cerebral palsy, muscular dystrophy, spina bifida), congenital (vertebral segmentation anomalies), or syndromic (Marfan syndrome, Ehlers-Danlos syndrome, neurofibromatosis). Adolescent idiopathic scoliosis (AIS) — affecting girls 7 times more commonly than boys during pubertal growth — is the most frequently operated form.

The goal of surgery is not necessarily to achieve a perfectly straight spine, but to halt curve progression, achieve a balanced, structurally sound spinal column in the coronal and sagittal planes, and prevent long-term cardiopulmonary complications from restrictive thoracic deformity. Surgery is typically performed at specialist paediatric or adult spinal deformity centres with dedicated multidisciplinary teams.

Surgery is recommended for adolescents with idiopathic scoliosis when the Cobb angle exceeds 40–50 degrees on a standing radiograph, particularly if the patient is still skeletally immature (Risser grade 0–2) as curves of this magnitude in a growing spine will predictably progress. Even in skeletally mature adolescents, curves greater than 50 degrees carry a lifetime risk of progression at approximately 1 degree per year, potentially reaching 80–100 degrees in adult life with significant cosmetic and functional consequences.

For adults, surgery is considered for progressive curves causing cosmetically unacceptable deformity, back pain unresponsive to conservative management, or curves exceeding 60–70 degrees causing dyspnoea from thoracic restriction. Neuromuscular scoliosis surgery, often involving longer fusion from the upper thoracic spine to the pelvis (sacropelvic fixation with iliac screws), is indicated for curves causing difficulty with seating, hygiene, pressure sores, or respiratory compromise in non-ambulatory patients with cerebral palsy or muscular dystrophy.

Growing-rod techniques (non-fusion constructs that are periodically lengthened) are used for young children (under age 8–10) with severe progressive curves, delaying definitive fusion until adequate chest wall and lung development has occurred.

Scoliosis surgery is performed under general anaesthesia with continuous multimodal spinal cord monitoring throughout the procedure — including somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and electromyography (EMG) — providing real-time feedback to prevent neurological injury.

The patient is positioned prone on a Jackson spine table or Wilson frame, carefully padded to protect pressure points and the eyes. A midline posterior incision is made from the highest to lowest instrumented vertebra. The paraspinal muscles are elevated from the spinous processes and laminae by subperiosteal dissection to expose the posterior elements and pedicle entry points.

Pedicle screws are placed bilaterally at each instrumented level using fluoroscopic or CT navigation guidance. Pedicle screws — inserted through the pedicle into the vertebral body — provide the strongest and most versatile fixation points and have replaced hooks and wires in modern deformity surgery. Titanium rods are then contoured to the desired corrected spinal profile and sequentially inserted into the screw heads. Correction manoeuvres including rod derotation, cantilever reduction, in-situ bending, and compression/distraction are used to achieve coronal and sagittal alignment goals.

Autologous bone graft (from the iliac crest or the spinous processes and laminae removed during the procedure) is placed along the decorticated fusion bed. Recombinant bone morphogenetic protein (rhBMP-2, Infuse) may augment fusion in adult deformity cases. Surgical time ranges from 3–6 hours for straightforward AIS cases to 8–12 hours for complex adult deformity revision cases. Intra-operative blood salvage (cell saver) reduces transfusion requirements.

Patients are mobilised to sit upright and walk with physiotherapy support as early as the first or second post-operative day, using log-roll technique for bed transfers to protect the spine. Hospital stay is typically 4–7 days for adolescent idiopathic scoliosis cases and longer (7–14 days) for complex adult cases.

Post-operative pain management uses a multimodal approach: regular paracetamol and NSAIDs, opioids in the first 48–72 hours, and patient-controlled analgesia (PCA) or epidural analgesia for selected patients. Bracing is generally not required after modern rigid instrumentation, as the screw-rod construct provides immediate stability while bone fusion matures.

Return to school or light activity occurs at 4–8 weeks post-surgery. Swimming is usually permitted at 3 months once wounds are fully healed. Non-contact sports are resumed at 6 months, and contact sports and heavy activity at 12 months when fusion is solid on imaging. Full bone fusion typically takes 9–18 months, though the instrumentation provides structural support during this period. Annual radiographic follow-up monitors fusion progression and curve maintenance through adolescence.

Neurological deficit from spinal cord or nerve root injury is the most feared complication, with an overall rate of less than 1% in experienced centres using intraoperative neuromonitoring. Neurophysiology monitoring allows prompt identification and correction of any signal changes before permanent injury occurs — a 'wake-up test' may be performed if monitoring changes occur. Permanent neurological deficit is extremely rare (0.1–0.3%) in modern series.

Infection rates are 1–3% for posterior instrumented fusions; deep infection requires irrigation, debridement, and prolonged antibiotic therapy (6–12 weeks). Implant-related complications include rod fracture or screw pull-out (2–5%), requiring revision, and prominence of instrumentation causing skin pain.

Pseudarthrosis (failure of bone fusion) occurs in 2–5% and may require revision surgery with bone grafting. Adjacent segment disease (accelerated degeneration above or below the fused segment) is a long-term consideration. Significant blood loss requiring transfusion occurs in up to 40% of major deformity cases despite cell salvage techniques. Flat back syndrome (loss of lumbar lordosis) causes chronic low back pain if lumbar fusion extends too distally.

Scoliosis surgery typically achieves a Cobb angle correction of 60–70%, transforming a 60-degree curve to approximately 18–25 degrees. Thoracic curves of 50–90 degrees are corrected to 10–30 degrees in the hands of experienced deformity surgeons. This correction is durable: at 10-year follow-up, less than 5% of corrected curves show more than 5 degrees of progression.

For adolescents, the improvement in body image and cosmesis — rib hump reduction, waist symmetry, shoulder balance — has profound psychological benefits. Health-related quality of life (SRS-22 questionnaire) shows significant improvement in the function, pain, self-image, and mental health domains at 2-year follow-up. Patients with severe thoracic curves (greater than 70–80 degrees) experience improvement in respiratory function after surgery, with vital capacity increasing by 10–20% in some series.

Preventing curve progression — and the associated cosmetic, functional, and cardiopulmonary consequences of a progressive 100-degree curve in adult life — is an equally important benefit that is difficult to quantify but clinically significant. Neuromuscular scoliosis correction improves sitting balance, nursing care, and quality of life for carers.