A 12-year-old girl is brought to the clinic for evaluation of poor posture. She is an avid gymnast, and for the past couple of months, her coach has noticed that her shoulders seem uneven when she stands. The patient has had no back pain or trauma. She has no chronic medical conditions and has not undergone menarche. Her mother had scoliosis during adolescence but did not require treatment. BMI is at the 25th percentile. Vital signs are normal. Examination shows a right-sided rib rise with mild scapular prominence on forward bending. There is no tenderness along the spine, and neurologic examination is normal. The legs are equal in length. The patient has Tanner stage 3 development. Plain radiograph of the spine reveals right thoracic scoliosis with a Cobb angle consistent with mild scoliosis. Which of this patient's current findings is the greatest risk factor for curve progression?

Question

A 12-year-old girl is brought to the clinic for evaluation of poor posture.  She is an avid gymnast, and for the past couple of months, her coach has noticed that her shoulders seem uneven when she stands.  The patient has had no back pain or trauma.  She has no chronic medical conditions and has not undergone menarche.  Her mother had scoliosis during adolescence but did not require treatment.  BMI is at the 25th percentile.  Vital signs are normal.  Examination shows a right-sided rib rise with mild scapular prominence on forward bending.  There is no tenderness along the spine, and neurologic examination is normal.  The legs are equal in length.  The patient has Tanner stage 3 development.  Plain radiograph of the spine reveals right thoracic scoliosis with a Cobb angle consistent with mild scoliosis.  Which of this patient's current findings is the greatest risk factor for curve progression?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d60e_e572_bc81_919eb401797f_MD0003_00 Adolescent idiopathic scoliosis, or lateral curvature of the spine, typically presents in asymptomatic children age ≥10. Manifestations may include a rib hump, asymmetric scapulae, or unilateral thoracic/lumbar prominence on forward bend test. Spine x-ray (anteroposterior and lateral) is used to assess skeletal maturity, measure the degree of curvature (ie, Cobb angle), and rule out other structural deformities. Cobb angle >10 degrees is consistent with scoliosis. forward bend test Cobb angle Management of scoliosis is based on the risk of curve progression. The greatest increase in curvature occurs during early adolescence at the time of the pubertal growth spurt, after which progression slows and subsequently stops once bone ossification is complete. Risk factors at diagnosis associated with curve progression include: Female sex Age <12 Early pubertal status (eg, premenarchal) Skeletal immaturity Severe curvature (ie, Cobb angle ≥25 degrees) Although this patient has mild scoliosis, her premenarchal status indicates that she still has significant remaining growth potential. Therefore, she should be clinically monitored for curve progression until 2 years after menarche, when skeletal maturity is typically complete. (Choice A) BMI at the ≥85th percentile is associated with increased severity of scoliosis at diagnosis (possibly due to delayed detection) but is not a risk factor for curve progression. In addition, this patient's BMI is normal. (Choice B) A positive family history increases the likelihood of developing scoliosis but does not predict the severity of disease or increase the risk for curve progression. (Choice C) Physical activity level is not associated with scoliosis curve progression. (Choice E) Left thoracic curves may be more commonly associated with underlying pathology (eg, tumor) in children age <10; however, direction of curvature in an asymptomatic adolescent does not affect risk of curve progression. In addition, this patient has a right-sided curve. Educational objective: Adolescent idiopathic scoliosis (ie, lateral curvature of the spine) typically progresses until growth and bone ossification are complete. Risk factors associated with curve progression include female sex, age <12, premenarchal status, skeletal immaturity, and initial severe curvature. References: Adolescent idiopathic scoliosis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24506121)

A 12-Year-Old Girl Is Brought to the Clinic for Evaluation