A 12-year-old girl is brought to the office for a preventive health maintenance examination. The patient's mother has noticed that over the last few months, her daughter "seems to sit sideways" and does not sit up straight when asked. The patient occasionally takes acetaminophen in the morning due to mild "aches and pains." She fractured her left femur in a horse-riding accident at age 8. Height and weight are at the 75th and 50th percentiles, respectively. Physical examination shows a well-appearing, nondysmorphic girl. Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot. Flexion of the lumbar spine is normal and the patient is able to touch her toes. Lower extremity strength is normal. Patellar and Achilles deep tendon reflexes are 2+. Gait is normal. Posteroanterior and lateral x-rays of the spine are obtained, which reveal a Cobb angle of 5 degrees. Which of the following is the best next step in management of this patient's spinal problem?

Question

A 12-year-old girl is brought to the office for a preventive health maintenance examination.  The patient's mother has noticed that over the last few months, her daughter "seems to sit sideways" and does not sit up straight when asked.  The patient occasionally takes acetaminophen in the morning due to mild "aches and pains."  She fractured her left femur in a horse-riding accident at age 8.  Height and weight are at the 75th and 50th percentiles, respectively.  Physical examination shows a well-appearing, nondysmorphic girl.  Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot.  Flexion of the lumbar spine is normal and the patient is able to touch her toes.  Lower extremity strength is normal.  Patellar and Achilles deep tendon reflexes are 2+.  Gait is normal. Posteroanterior and lateral x-rays of the spine are obtained, which reveal a Cobb angle of 5 degrees.  Which of the following is the best next step in management of this patient's spinal problem?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0c4_6793_8f63_f1a99222ec26_MD0005_00 Although scoliometry helps to predict patients with clinically significant scoliosis, the results are user-dependent and nonspecific. Therefore, concerning scoliometer findings require further evaluation with posteroanterior and lateral x-rays. Cobb angle measures spine curvature on x-ray and is the gold standard for determining diagnosis and treatment of scoliosis. A Cobb angle <10 degrees, as seen in this patient, is considered a variant of normal. Therefore, no follow-up is needed unless new findings (eg, significant pain, neurologic symptoms) develop. Conversely, patients with a Cobb angle ≥10 degrees have scoliosis. Scoliosis management depends on the risk for curve progression, with a larger Cobb angle signifying higher risk. Although observation or the use of a back brace is typically sufficient for low/medium risk curves (Choice B), severe scoliosis (Cobb angle ≥40 degrees) requires surgical evaluation for possible spinal fusion given the high risk for progression and future complications (eg, chronic back pain, pulmonary compromise) (Choice E). However, once puberty and skeletal maturity are complete, progression is typically minimal and treatment is not required unless severe deformity is present. (Choice C) MRI of the spine can evaluate for congenital or neuromuscular causes of scoliosis if x-ray of the spine reveals concerning vertebral anomalies (eg, wedged or hemi-vertebrae, vertebral lucency), not seen in this case. (Choice D) Although idiopathic scoliosis may have a hereditary component, genetic testing is expensive and unnecessary as x-ray determines diagnosis and management. This patient does not have scoliosis based on her Cobb angle and does not need further testing. Educational objective: Abnormal scoliometry results must be confirmed on x-ray by measuring the Cobb angle. A Cobb angle <10 degrees is considered normal and requires no follow-up unless back pain or neurologic symptoms develop. References: Optimal management of idiopathic scoliosis in adolescence. (http://www.ncbi.nlm.nih.gov/pubmed/24600296)

A 12-Year-Old Girl Is Brought to the Office for a Preventive