Principal Director, Orthopaedics, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi
Part 4 of 8 in Adolescent Idiopathic Scoliosis
The Risser Sign: Predicting Whether a Scoliosis Curve Will Progress
August 4, 2024
Predicting whether a curve will progress matters as much as measuring it, and the Risser sign is the key tool for that. It's an indirect measure of skeletal maturity based on ossification of the iliac apophysis, divided into stages zero (not yet appeared) through five (fully fused).
Why skeletal maturity changes the plan
A child with a Risser sign of four or five is close to skeletal maturity, and a curve at that stage, even one that's cosmetically noticeable, is unlikely to progress much further, so more conservative management is reasonable. A child with a Risser sign of zero, one or two still has significant growth remaining, meaning the same curve magnitude carries a much higher risk of progression and needs closer monitoring. For girls specifically, whether menarche has already occurred matters too, since peak growth velocity typically happens about a year to a year and a half before menarche; once menarche has occurred, further curve progression is less likely.
How this sets the follow-up schedule
A young, skeletally immature patient, for example a 10-year-old with a 20-degree curve, needs X-ray follow-up as often as every 3 months given the high likelihood of progression. An older patient closer to maturity, for example a 13 or 14-year-old with the same 20-degree curve, can safely be followed up in 6 months to a year, since progression from that point is much less likely.
This article is based on a Jivo Masterclass session conducted by Dr. Manoj Miglani, Principal Director, Orthopaedics, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Manoj Miglani taught doctors across Africa on August 4, 2024.
FROM THE LIVE Q&A
Dr. Venuste Musoni
When treating AIS with bracing: how many hours per day should a brace be worn, what are the indications for considering the treatment a failure, and when should surgical options be considered after failure of bracing as non-operative management?
Dr. Manoj Miglani
A brace should be worn for 22 hours a day to be effective. Treatment is considered a failure if the deformity progresses both clinically and radiologically despite bracing. Surgery should be considered once the child has more than 40 degrees of deformity with growth still remaining.
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Frequently Asked Questions
What are the most common complications after surgical management of scoliosis, and how are they prevented?▼
Routine complications similar to other major surgeries: bleeding, infection, paralytic ileus, and malposition of hardware. Specific rates are neurological injury under 1%, respiratory complications 2-8%, infection under 1%, and mesenteric artery issues around 2.7%, kept low through routine intraoperative neuromonitoring and surgical volume/experience at the centre.
Is adolescent idiopathic scoliosis hereditary?▼
Around 30% of adolescent idiopathic scoliosis cases have a family member with scoliosis, suggesting some hereditary or familial component, though it's far from universal. Congenital scoliosis and some neuromuscular or syndromic forms of scoliosis have a much stronger chance of being hereditary, since they involve clearer genetic transmission.
For a patient being observed with a curve between 10 and 20 degrees, is it okay to start some physiotherapy or rehabilitation exercises, or does one have to wait?▼
At 10 to 20 degrees, the focus should just be on exercises to keep the back muscles healthy and avoiding extremes of posture, that is all that is needed. Follow-up frequency with X-rays, whether every 3 months, 6 months or a year, depends on the child's age and Risser sign, not on whether they are doing exercises.
You said between 3 to 6 months for the X-ray follow-up. Can you clarify how that's decided?▼
If the child is young, say 10 years old with a 20-degree deformity, X-rays should be done every 3 months since they are likely to progress more. If the child is 13-14 years old with the same 20-degree curve, X-rays every 6 months to a year are enough, just to confirm the deformity isn't progressing rapidly.
Is there any preventive treatment, such as exercises, bed positioning or diet, that can help avoid developing scoliosis or keep it from progressing?▼
No, there are no preventive measures for idiopathic scoliosis, because the actual cause isn't known. The only genuinely useful advice is for the child to stay physically active, which most children naturally are.
What is the Risser sign?▼
An indirect measure of skeletal maturity based on ossification of the iliac apophysis, staged zero (not appeared) through five (fully fused), used to predict how likely a scoliosis curve is to progress.
How often should a scoliosis patient be X-rayed based on the Risser sign?▼
A young patient with significant growth remaining (low Risser stage) may need X-rays every 3 months; an older patient closer to skeletal maturity (Risser 4-5) can typically wait 6 months to a year.
In This Series: Adolescent Idiopathic Scoliosis
- 1.Adolescent Idiopathic Scoliosis
- 2.What Is Adolescent Idiopathic Scoliosis? Epidemiology and the Unknown Cause
- 3.Diagnosing and Classifying Scoliosis: Cobb Angle, Curve Types and True vs Postural Deformity
- 4.The Risser Sign: Predicting Whether a Scoliosis Curve Will Progress
- 5.Treatment Thresholds: Observation, Bracing and Surgery by Curve Severity
- 6.Why Bracing Has Real Limits: Brace Types, Compliance and When It Fails
- 7.Surgical Correction: From the Harrington Rod to Modern Pedicle Screw Fixation
- 8.Scoliosis Complications: Untreated Progression, Surgical Risk and a Post-Traumatic Case