Pediatric Scoliosis with Restrictive Respiratory Physiology: Perioperative Assessment, Optimization, and Surgical Decision-Making

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Background: Pediatric scoliosis with restrictive respiratory physiology represents a high-risk clinical setting in which pulmonary impairment functions both as a marker of perioperative risk and a target for optimization. The respiratory burden varies by phenotype, particularly in early-onset scoliosis/thoracic insufficiency syndrome (EOS/TIS), neuromuscular scoliosis, and scoliosis associated with intrinsic parenchymal lung disease, and these differences have important implications for perioperative planning and surgical strategy. Objectives: To synthesize current evidence on phenotype-driven perioperative respiratory assessment, preoperative optimization, surgical decision-making, and expected outcomes in children and adolescents with scoliosis and restrictive respiratory physiology. Methods: This narrative review was structured according to the SANRA framework. PubMed/MEDLINE and Google Scholar were searched through February 2026 using terms related to scoliosis, restrictive lung disease, thoracic insufficiency syndrome, early-onset scoliosis, neuromuscular scoliosis, pulmonary function testing, noninvasive ventilation, perioperative management, and postoperative pulmonary complications. English-language and English-translated publications from 2010 to 2026 were considered, with older landmark studies retained when essential for foundational concepts. Evidence was synthesized thematically, with emphasis on respiratory risk stratification, predictors of adverse outcomes, phenotype-specific operative strategies, prehabilitation, postoperative respiratory care, and outcome patterns. Results: Across phenotypes, baseline physiologic reserve appeared more informative than curve magnitude alone when estimating perioperative risk. Forced vital capacity, cough effectiveness, nocturnal ventilatory failure, nutritional status, and comorbidity burden were the most clinically relevant markers for identifying children at increased risk of postoperative ventilation, intensive care needs, and pulmonary complications. In EOS/TIS, growth-friendly constructs aim to preserve thoracic and spinal growth while delaying definitive fusion when feasible. In neuromuscular scoliosis, surgical goals are more closely linked to function, sitting balance, caregiver ease, and quality of life, whereas respiratory outcomes are often better understood as stabilization rather than normalization. Evidence for intrinsic parenchymal lung disease remains limited and supports cautious, individualized planning within a multidisciplinary framework. Conclusion: Management of pediatric scoliosis with restrictive respiratory physiology should be phenotype-driven and multidisciplinary. Structured assessment of respiratory reserve, ventilatory failure, cough effectiveness, and comorbidity can guide perioperative optimization, align surgical strategy with physiologic risk, and support safer postoperative respiratory care.