Benefits and complications: A systematic review and meta-analysis of serial casting in early onset scoliosis.

PURPOSE: Early-onset scoliosis (EOS) presents a unique therapeutic challenge, requiring interventions that achieve deformity correction while preserving spinal and thoracic growth. This systematic review and meta-analysis aimed to synthesise current evidence on serial casting outcomes in EOS, with a primary focus on treatment-related complications and secondary evaluation of radiographic, pulmonary, and quality-of-life outcomes. METHODS: Comprehensive searches were performed in MEDLINE, Embase, Cochrane Library and CINAHL without date restrictions to identify eligible studies. The primary outcome was treatment-related complications; secondary outcomes included Cobb angle correction, thoracic height progression, pulmonary function, and patient-reported quality of life. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tools. Meta-analyses were conducted using random-effects models, and narrative synthesis was applied where quantitative pooling was not feasible. RESULTS: From 578 records, 23 studies met inclusion criteria. Sixteen studies were rated as low risk of bias, six moderate, and one high. The pooled complication rate from the single-arm meta-analysis was 17% (95% CI 9-24%), with moderate heterogeneity. Dermatological complications predominated (skin irritation, ulceration), while gastrointestinal and transient respiratory symptoms were infrequent. Comparative studies demonstrated lower complication rates with casting compared to growth rods (1/27 vs 12/27), with outcomes comparable or superior to bracing. Mean annual thoracic growth ranged from 0.8 to 3.8 cm. Cobb angle correction was generally greater in non-congenital compared to congenital scoliosis. Pulmonary function may transiently decline during casting but improves following cast removal, while long-term outcomes remained acceptable when early surgery was avoided. Quality-of-life analysis demonstrated inverse associations between residual curvature and domains including daily living, pain, and emotional wellbeing. CONCLUSION: Serial casting remains an effective, low-risk, and growth-preserving intervention for managing early-onset scoliosis. The predominance of minor, reversible complications underscores its safety, while radiographic and functional outcomes affirm its therapeutic value. Future research should prioritise prospective evaluation of pulmonary and psychosocial outcomes to optimise patient selection and refine treatment protocols.