An 11-year-old girl is brought to the clinic due to concerns about her posture. She does not fully extend her back and has difficulty with some of the positions in her ballet class. The patient is active in multiple sports as well as dance and typically practices 2 hours a day with various activities. She also has mid-thoracic back pain that feels like a "dull ache," and she occasionally wakes up at night to adjust her position due to discomfort. The patient takes no medications and has no allergies. She has not undergone menarche. There is no family history of scoliosis. The patient is at the 50th percentile for height and weight. Examination shows a talkative girl with no dysmorphic features. Cardiopulmonary examination reveals normal heart tones and good air entry in all fields. The breasts and pubic hair are sexual maturity rating stage 3. Forward bend test reveals moderate scoliosis with a right rib hump that does not correct by placing a block under the left leg. Gait is normal. Two café-au-lait spots, each measuring 2 cm, are noted on the right flank. Which of the following features of this patient's presentation is concerning for a pathologic cause of scoliosis?

Question

An 11-year-old girl is brought to the clinic due to concerns about her posture.  She does not fully extend her back and has difficulty with some of the positions in her ballet class.  The patient is active in multiple sports as well as dance and typically practices 2 hours a day with various activities.  She also has mid-thoracic back pain that feels like a "dull ache," and she occasionally wakes up at night to adjust her position due to discomfort.  The patient takes no medications and has no allergies.  She has not undergone menarche.  There is no family history of scoliosis.  The patient is at the 50th percentile for height and weight.  Examination shows a talkative girl with no dysmorphic features.  Cardiopulmonary examination reveals normal heart tones and good air entry in all fields.  The breasts and pubic hair are sexual maturity rating stage 3.  Forward bend test reveals moderate scoliosis with a right rib hump that does not correct by placing a block under the left leg.  Gait is normal.  Two café-au-lait spots, each measuring 2 cm, are noted on the right flank.  Which of the following features of this patient's presentation is concerning for a pathologic cause of scoliosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0c4_dcc4_8f63_a3444009ee2f_MD0005_00 Scoliosis, lateral curvature of the spine, is most commonly idiopathic in asymptomatic adolescents. Rarely, scoliosis is a complication of spinal pathology and may be life-threatening. Further evaluation is required if the following red flags for a pathologic etiology are present: Back pain Neurologic symptoms Rapidly progressing curvature (>10 degrees each year) Vertebral anomalies on x-ray This patient's back pain that causes nocturnal awakening is concerning for an underlying spinal cord tumor. A spinal cord tumor can extend and disturb surrounding nerves, causing constant pain that is described as "dull" or "gnawing." In addition, impingement of spinal cord pathways can cause dysesthesias, weakness, and neurogenic bladder/bowel. Other pathologic causes of scoliosis include infection and trauma, which are less likely in this patient due to lack of fever or history of injury. Diagnostic workup often begins with x-ray of the spine, which may show abnormalities such as vertebral lucencies, pedicle erosion, or widened canal. However, MRI of the spine is the gold standard to delineate spinal anatomy. (Choice A) The degree of curvature on x-ray determines the severity of scoliosis but does not correlate with idiopathic versus pathologic etiology. (Choice B) Although adolescent idiopathic scoliosis is believed to have a hereditary component, a negative family history, as seen in this patient, does not make pathologic scoliosis more likely. (Choice C) Certain genetic disorders involving tissue formation, such as neurofibromatosis, Marfan syndrome, and osteogenesis imperfecta, can cause syndromic scoliosis. However, neurofibromatosis is characterized by multiple large café-au-lait macules, but this patient has only 2 and they are small, which is considered normal. (Choice E) Sexual maturity rating helps to predict remaining growth potential and risk for curvature progression in patients with idiopathic scoliosis. Patients who develop scoliosis before menarche are at risk for further curvature progression. However, this patient's risk for pathologic scoliosis is unaffected by sexual maturity. Educational objective: Although scoliosis is most commonly idiopathic, patients with associated back pain (nocturnal awakening), neurologic findings, rapidly progressing curvature, or abnormal vertebrae should undergo further evaluation for underlying spinal pathology (eg, spinal tumor). References: Back pain during growth. (http://www.ncbi.nlm.nih.gov/pubmed/23299906)

An 11-Year-Old Girl Is Brought to the Clinic Due to Concerns