Casting, bracing and surgery: A comparative review of treatment approaches for early onset scoliosis

Early-onset scoliosis (EOS) comprises a heterogeneous group of spinal deformities diagnosed before the age of ten years, including idiopathic, congenital, neuromuscular, and syndromic etiologies. Management remains particularly demanding because treatment must simultaneously address deformity progression while preserving spinal growth, thoracic development, and pulmonary function. Despite major advances over the past two decades, treatment strategies continue to vary considerably and no universally accepted algorithm has been established. This review examines the current role of conservative and surgical treatment modalities for EOS and discusses their respective indications, benefits, and limitations. Nonoperative management remains the preferred initial approach for most progressive deformities. Bracing may delay curve progression, particularly in idiopathic EOS, although outcomes are influenced by curve magnitude, patient age, brace compliance, and family support. In congenital, neuromuscular, and syndromic scoliosis, its effectiveness is generally more limited. Serial casting represents a valuable option for younger children and for more severe deformities, especially in idiopathic EOS, where substantial correction may occasionally be achieved. However, repeated cast applications may be associated with local complications and, when performed under general anesthesia, expose patients to cumulative anesthetic risks. When conservative treatment fails or when progressive deformity threatens thoracic growth and respiratory function, surgical intervention becomes necessary. Contemporary management favors growth-preserving techniques rather than early definitive fusion, which has been shown to compromise spinal and thoracic development. Magnetically controlled growing rods currently represent the most widely adopted growth-friendly strategy, although complication and reoperation rates remain substantial. Emerging technologies, including modern Luque trolley constructs, one-way self-expanding rods, and spring-based distraction systems, may further reduce the burden of repeated surgical procedures. Successful management of EOS requires individualized decision-making based on etiology, deformity severity, growth potential, and overall patient condition. Regardless of the selected treatment pathway, families should be counselled regarding the prolonged nature of care and the persistent risk of complications throughout childhood.