A 13-year-old girl is brought to the physician by her father for a routine physical examination for school. The father notes that her clothes seem to hang unevenly, and one of her shoulder blades appears more prominent than the other. The patient denies any back pain, weakness, or sensory changes. She reached menarche six months ago. Past medical history is otherwise negative. On physical examination, the Adam forward bend test reveals a right-sided thoracic prominence. Measurement with a scoliometer shows a trunk rotation angle of 7°. A subsequent standing posteroanterior radiograph of the spine demonstrates a right-sided thoracic curvature with a Cobb angle of 28°.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
E) Thoracolumbosacral orthosis (TLSO) bracing
The patient has adolescent idiopathic scoliosis (AIS), defined as a lateral curvature of the spine with a Cobb angle ≥10° in a patient older than 10 years. Management is dictated by two main factors: the severity of the curvature (Cobb angle) and the remaining skeletal growth potential. Skeletal maturity is often assessed using the Risser scale (ossification of the iliac apophysis) or by clinical milestones like menarche. In a skeletally immature patient (Risser 0-2 or pre-menarche/early post-menarche) with a Cobb angle between 25° and 40°, the risk of progression is high. The standard of care to prevent further progression and avoid future surgery is a thoracolumbosacral orthosis (TLSO), or brace. Bracing does not fix the existing curve but aims to maintain it until skeletal maturity is reached.
Answer choice A: Formal physical therapy, is incorrect. While core strengthening and specialized exercises may be used as adjuncts, they have not been proven to stop the progression of the Cobb angle in the same way that bracing has for curves >25° in growing children.
Answer choice B: Observation with repeat radiographs, is incorrect. Observation is typically reserved for patients with a Cobb angle <20° or for those who are already skeletally mature with a curve <40°. Because this patient is still growing and her curve is 28°, she is at high risk for worsening and requires active intervention.
Answer choice C: Posterior spinal fusion, is incorrect. Surgical intervention is generally reserved for patients with a Cobb angle >40° to 50°. Surgery is not indicated as an initial step for a 28°∘ curve unless conservative measures fail or the curve progresses rapidly.
Answer choice D: Surgical release of the filum terminale, is incorrect. This procedure is used to treat tethered cord syndrome. While a tethered cord can cause neuromuscular scoliosis, this patient's presentation is classic for idiopathic scoliosis, and there are no red flags such as neurologic deficits, foot deformities, or a left-sided thoracic curve, to suggest an underlying spinal cord pathology.
Key Learning Point
Adolescent idiopathic scoliosis management is based on the Cobb angle: 10°–19° requires observation; 20°–29° requires observation unless progression is noted (then bracing); and 30°–39° in a growing child requires immediate bracing. If the Cobb angle is ≥40°–50°, surgical evaluation for spinal fusion is necessary.
