Levoscoliosis

Case Discussion

Adolescent idiopathic scoliosis is the most common type of scoliosis. During puberty, a period of rapid growth, the spine may grow asymmetrically, resulting in a lateral curvature of the spine. Patients may present with poor posture; however, scoliosis is often otherwise asymptomatic and identified incidentally on routine examination. Levoscoliosis describes the spine when it curves to the left side of the body. Dextroscoliosis describes the spine when it curves to the right side of the body.

A thoracic or lumbar prominence on forward bend test is the most sensitive examination finding for scoliosis. To estimate the severity of curvature, a scoliometer is placed sequentially along the spine, measuring the angle of trunk rotation. Spinal rotation >7 degrees (or >5 degrees in overweight children) may suggest clinically significant scoliosis. Abnormal scoliometry or obvious deformity on examination necessitates posteroanterior and lateral x-rays of the spine to confirm the diagnosis. 

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 the diagnosis and treatment of scoliosis. A Cobb angle <10 degrees 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. Patients with a Cobb angle 10°-19° are managed with radiography every 6 months and no referral. Observation is sufficient. If the Cobb angle is > 20° there is a high risk that the curve will progress and that the patient may need treatment. In this case, radiography every 6 months and referral are indicated. A brace is indicated if the Cobb angle is >25 degrees. 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). However, once puberty and skeletal maturity are complete, progression is typically minimal and treatment is not required unless severe deformity is present.