Treatment. Treatment of infantile and juvenile sco- liosis remains a therapeutic challenge because of the adverse effects of multisegmental fusion in a growing spine. If conservative treatment (cast, braces) has failed to control the curve, spinal instru- mentation without fusion becomes necessary. Sur- gery for these curve types is very demanding and prone to complications often requiring revision sur- gery. The natural history of adolescent idiopathic scoli- osis is benign without significant differences to an asymptomatic control group regarding physical functioning and quality of life in adulthood. The treatment depends on the severity of the curve and the risk of progression. Conservative treatment is intended to control progression of smaller curves. It consists of observation and physiotherapy in curves less than 10°–25° in skeletally immature patients. Curves of 25° –40° are usually treated by bracing. Braces are only effective before skeletal maturity is reached. Surgery is indicated in curves larger than 40°– 50° or rapidly progressing curves despite conservative treatment. The objective of scoliosis surgery is to stop the progression and to correct the deformity. Posterior instrumentation and fusion remains the gold standard and allows for a correction of the coronal deformity with resto- ration of the coronal and sagittal balance and pro- file. Today, pedicle screws are frequently used as they allow a better correction and shorter fusion length than systems only using hooks and wires. In skeletally immature patients an anterior release and fusion is necessary to avoid further anterior growth after posterior fusion with a deterioration of the deformity (crankshaft phenomenon). The more demanding anterior scoliosis surgery often allows motion segments to be spared and vertebral rotation to be better addressed. In contrast to adolescent scoliosis, adult idiopathic scoliosis patients often present with symptoms (pain, neurological deficits) due to secondary degenerative changes. Surgical decision-making in adult idiopathic scoliosis strongly depends on the underlying causes of the pain or neurological defi- cits. The goal in adult scoliosis is to achieve a bal- anced spine without pain or neurological deficits. Decompression of a nerve root compression or sec- ondary central stenosis is possible in selected patients with a balanced spine. Fusion in situ (w/o short-segmental instrumentation) should be added when extensive decompression is needed to avoid curve deterioration. The treatment of an imbalanced spine with secondary degenerative changes often requires extensive posterior release and in some cases necessitates multiple spinal osteotomies. Key Articles Nachemson A (1968) A long term follow-up study of non-treated scoliosis. Acta Orthop Scand 39:466 – 476 This is one of the first long-term follow-up studies on the natural course of scoliosis. Dif- ferenttypes of scoliosis are included. For congenital, thoracogenic and neurogenic scolio- sis prognosis was found to be worse than for idiopathic, rachitogenic and poliomyelitic scoliosis. Weinstein SL, Z avala DC, Ponseti IV (1981) I diopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am 63:702 – 712 Thoracic curves of 50°–80° were found to be at a high risk of progressing even after skele- tal maturity was reached. Curves smaller than 30° did not progress regardless of the curve pattern. In thoracic curves, the Cobb angle and vertebral rotation were found to be important risk factors for curve progression. Lonstein JE, Carlson JM (1984) The prediction of curve progression in untreated idio- pathic scoliosis during growth. J Bone Joint Surg Am 66:1061 – 1071 In this study of patients with mild idiopathic scoliosis, pattern and magnitude of the curve, the patient’s age at first diagnosis, menarchal status and the Risser sign were found to be related to curve progression during growth. Harrington PR (1962) Treatment of scoliosis. Correction and internal fixation by spine instrumentation. J Bone Joint Surg 44A:591 – 610 Historical paper on spinal instrumentation for scoliosis describing the technique of scoli- osis correction by distraction. Idiopathic Scoliosis Chapter 23 653 Cotrel Y, Dubousset J (1984) A new technique for segmental spinal osteosynthesis using the posterior approach. Rev Chir Orthop Reparatrice Appar Mot 70:489 – 494 Cotrel and Dubousset describe their technique for the posterior segmental derotation technique of scoliosis correction. Dubousset J, Herring JA, Shufflebarger H (1989) The crankshaft phenomenon. 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