Indications for surgical treatment are based on curve magnitude, clinical deformity, risk of curve progression, skeletal maturity, and curve pattern. Curves greater than 50° should undergo surgical treatment because of the risk for continued curve progression in adulthood. Curves in the 40° to 50° range are analyzed on an individual basis. Curves greater than 40° with documented progression are indicated for surgery. Curves greater than 40° in skeletally immature patients (e.g. premenarchal female) should be treated surgically because of the natural history of continued curve progression with growth. Clinical deformity plays a role in decision making for select lumbar curves (35-40°). Some curves cause marked waistline asymmetry and may be considered for surgery on this basis. Sagittal plane alignment is also an important consideration. In a small subgroup of patients with severe thoracic hypokyphosis or actual thoracic lordosis, surgical treatment should be considered even if the coronal plane curve is less than 40°.
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