Week 2 Case 2: CHIR13009 Reef Cook

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-menarchal 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.
She is 2 years post-menarchal. She is engaged in typical activities for an
adolescent female including netball and skateboarding. She is unhappy with
her physical appearance and believes she is ugly as her body is asymmetrical
causing her to be self-conscious about her looks. The degree of the idiopathic
scoliosis is measured as a 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. A Scoliometer of the thoracic curve is 15° and the
lumbar is 8° has been reported. Taking all this into consideration it is likely
that this patient is highly likely to require surgery as she has been
unresponsive to conservative therapy and exercise with physiotherapist for 3
months and would require an orthopedic consult for a surgical opinion.

2. What is the prognosis for this patient?

Taking all this into consideration, this patient is highly likely to require surgery
as she has been unresponsive to conservative therapy and exercise with
physiotherapist for 3 months and would probably require an orthopedic
consult for a surgical opinion.
Ongoing chiropractic care could be offered to this patient once surgery had
been performed to help manage MSK pain and improve mobility if patient
wished to do so.

3. Discuss how you would manage/treat this patient.

Referral to a GP to arrange an orthopedic consult would be recommended

And a trial of chiropractic care may help alleviate some of the MSK pain using
flexion/ distraction, soft tissue therapy and gentle manipulation

4. Is this patient a candidate for conservative care, bracing or surgical correction , if

so why?

The degree of the idiopathic scoliosis is measured as a 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. A Scoliometer of the
thoracic curve is 15° and the lumbar is 8° has been reported
The results of this case will be discussed in your tutorial by your tutors.
Selected Treatment
The patient underwent a Posterior Spinal Fusion T4-T12.

Post-treatment Images
Immediate Post-operative Images
2-year Post-operative Images
Outcome
At 2-year follow-up, the patient was participating in all desired athletic
activities without back pain or limitation. She was satisfied with her overall
body alignment and shoulder balance. The thoracic scoliometer measurement
was 5°; lumbar 2°

Based on the clinical presentation and clinical appearance, I would favour the
main thoracic curve to be the main deformity. However, there is significant
deformity in the lumbar region to consider including it in the construct. I feel
options 1, 2 and 3 to all be valid options in this case. If surgical treatment is
opted for by the patient, the discussion of a selective fusion of the thoracic
spine with the benefit of preserving lumbar motion should be countered with
the possibility of progression of the lumbar deformity and need for
subsequent surgery in the near or late future. This is usually an attractive
option for athletic patients wishing to continue to partake in sports. Treatment
of both curves with a fusion extending to L3 or L4 would have the benefit of
straightening both deformities with the sacrifice of significant lumbar motion,
and still may require further surgery of the remaining unfused lumbar levels
down the road.