Week 2 Case: CHIR13009

14-year-old Female with Adolescent Idiopathic Scoliosis and Back Pain

History
The patient is a 14-year-old female with complaints of scoliosis and back pain. She is
greater than 2 years post-menarche and has no medical problems. She is engaged
in typical activities for an adolescent female including netball and skateboarding.

The back pain is primarily located in the mid-thoracic region. The pain is increased
by her sporting activities and absent at rest. The pain has been present for 1 year.
She is unhappy with her body alignment and appearance as her shoulder appear
imbalanced with (rib cage and breast asymmetry). She reports that she feels “ugly”

Examination
Patient is a healthy-appearing adolescent with near ideal body weight. The right
shoulder is slightly higher with minimal waist- line asymmetry. Scoliometer of the
thoracic curve is 15° and the lumbar is 8°. There is no clinical leg-length discrepancy.
The skin has no abnormalities, and the neurological assessment is normal.

Radiographic Examination

Cobb angle 54 degrees in the thoracic spine and lumbar spine 48 degrees with a
Risser 5. Side bending curve 15 degrees and lumbar curve 24 degrees.

Previous Treatment
The pain has not responded to prescribed exercises from physiotherapist. This
involved strengthening exercises for the core low back muscles for 3 months.

Diagnosis
Adolescent Idiopathic Scoliosis

Questions

1. Using the information in the case history and physical examination, give a
clinical impression.
Patient is a 14 yr old female, 2 yr post menarche presenting with AIS measuring
a Cobb angle 54 degrees in thoracic and 48 in lumbar, risser sign 5. Mid thoracic
pain increased with movement, absent at rest – present for 1 year now. Pain
management not responding to physiotherapy excises. It is to be noted there is
also presence of psychological involvement as patient is unhappy with
appearance caused by AIS.
2. What is the prognosis for this patient?
AIS cause is unknown
3. Discuss how you would manage/treat this patient.
I would refer the patient so a spinal surgery specialist as the curve has surpassed
45 degrees. Also ensure that the psycho related involvement is managed through
counselling etc
4. Is this patient a candidate for conservative care, bracing or surgical
correction, if so why?
Surgical correction due to size of curve

The questions for this week will focus on the assessment and treatment
of scoliosis.

Case Study Question1:

Tammy is a 23-year-old woman who has a structural scoliosis with
a single C curve having an apex at T7. Describe your assessment
plan before beginning treatment. How would you measure the
curve which is 28 degrees and the amount of rotation?
A scoliometer can be used as well as cobb angle measurement – I
would also do X-rays. Ortho test Allys and Adams forward bending
would also be used for assessment.

True/ False Questions

Q1. Functional scoliosis involves rotation and malformation of
vertebra?
False
Q2. The majority of idiopathic scoliosis’s will be progressive?
True
Q3. When assessing for scoliosis it is important to view the patient
doing a forward bending movement in all three planes?
True
Q4. A scoliometer is an instrument used to measure trunk inclination?
Trunk asymmetry
Q5. There is a correlation between nursing posture of an infant and
the development of a scoliosis curve?
True
Q6. Patients with idiopathic scoliosis may initially report fatigue in the
lumbar region after prolonged sitting or standing
True
Q7. Most idiopathic scoliosis curves are convex to the right in the
thoracic spine and to the left in the lumbar spine, so that the right
shoulder is higher than the left.?
True
Q8. A subtle scoliosis (less than 10-15 degrees) in the lower thoracic
and lumbar spine are easily missed on postural exam due to coupled
motion?
 True
Q9. Adolescent scoliosis rarely improves spontaneously and typically
halt only one skeletal maturity has been reached (17- 19 years)
True
Q10. Name 4 predictors of progression for idiopathic scoliosis

• Risser’s sign (0-5)

• gender (female > male)
• age at diagnosis
• menarche – increased progression pre- menarche (usually 12-
14 yrs)

Q11. Complete the table below

Infantile Juvenile Adolesc

ent
Ages Birth-3yrs 3yrs- Pubert
puberty y-
adultho
od
Sex males Females Equal
Progressi 90% remit Likely to Beyon
ve spontaneo progress d 20
usly 1 degree
degree/m s
nth,
brace if
icreases
over 25
degress -
brace
Radiogra Severe If over 25 Halt
phic progressio radiograp only
follow up n presents h if 20 once
needed wait reache
when 6mnth d
skeleta
l
maturit
y

Q12. Name (3) three orthopedic tests that would be considered when
assessing a patient with a scoliosis?
Alli’s, adams bending,
Q13. When measuring the severity of a scoliosis which (3) three
radiographic evaluations would be undertaken or referred for to be taken?
Cobb’s/Risser’s (Skeletal maturity), fusing of the vertebral ring epiphysis.
Q14. Do primary or double curves form more deformity?
Double
Q15. According to the literature what (3) three factors exist that may lead
to a greater chance of progression?
Primary     Double curve patterns progress more often than single curves
(single curves cause more deformity).    
The greater the curve at detection the greater the risk of progression.     
There is a greater chance of progression if the onset is before menarche in
females.     
The lower the Risser sign at the time of diagnosis, the greater the chance of
progression.     

Q16. What should the clinician be asking when considering the correct
management approach to an idiopathic scoliosis?
Risk of progression
Effectiveness of care
Risk of using chiropractic
Criteria for referral
Risks of surgery
Outcome desired

Q17. Would girls who are at pre-menarche or menarche with curves in the 20° to
40° range have the greatest chance of success with bracing. Yes/No
Yes

Q18. According to the literature how long should bracing be required for during the
day to have the best outcome and what factors may contribute to this success.
23 hrs a day for best results. However, it is more commonly prescribed 16-18 hrs.
More successful with compliance.

Q19. What management approaches have been shown to be effective in the

management of compensatory scoliosis
• Correct aberrant pelvic biomechanics
• Chiropractic literature on pelvic unleveling and physiological
short leg assumes that adjustments correct the distortion and
thereby the scoliotic compensation. There appears to be no
evidence to support this.
• Soft tissue techniques
• Exercises: stretching
 • Flexion distraction
• Gonstead states that a heel lift should only be used when the patient does not
hold the adjustment.
• Discrepency less than 6 mm – well tolerated.

Q20. When should a patient be referred for orthopedic surgery with an idiopathic
scoliosis?

Degrees 45 or above