Paeds · rheumatology-musculoskeletal-and-sports
Scoliosis and spinal deformity
Also known as adolescent idiopathic scoliosis · AIS · Cobb angle · Risser sign · Sanders maturity · Lenke classification · early-onset scoliosis · congenital scoliosis · neuromuscular scoliosis · Adams forward bend test · scoliometer · BrAIST trial
A fellowship approach to scoliosis and spinal deformity in children and adolescents: scoliosis is a lateral spinal curvature of 10 degrees Cobb or more with vertebral rotation, the adolescent idiopathic curve is common and painless, and the clinical skill is to separate the idiopathic curve managed by the observe-brace-surgery ladder (under 25, 25 to 40, 45 to 50 degrees or more) from the non-idiopathic curve that hides a congenital anomaly, a neural-axis lesion, or a syndrome behind the red flags of age under 10, a left thoracic curve, pain, a neurological deficit, and rapid progression.
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Target exams
Red flags
- A scoliosis diagnosed before 10 years of age (early-onset) is non-idiopathic by default and threatens the developing thorax and lungs; it demands a workup for a congenital, neuromuscular, or syndromic cause and early referral
- A left-sided thoracic curve (levoscoliosis) is atypical for idiopathic scoliosis, which is usually right thoracic, and it raises concern for an underlying neural-axis lesion such as a syringomyelia or a Chiari malformation until the magnetic resonance imaging proves otherwise
- Back pain with a scoliosis is a red flag — the idiopathic curve is painless, and pain points to an osteoid osteoma, an infection, a tumour, a spondylolysis, or a neural-axis lesion that demands urgent imaging
- Any neurological deficit — an asymmetric abdominal reflex, focal weakness, a reflex asymmetry, or a gait change — signals a spinal cord or nerve-root lesion and warrants an urgent magnetic resonance imaging
- Skin stigmata over the spine — a hair tuft, a dimple, a sinus, or a birthmark — flag a spinal dysraphism such as a tethered cord that may underlie the curve
- Rapid progression of a curve, or a curve that progresses through bracing, warrants re-evaluation of the diagnosis and the imaging strategy, because the non-idiopathic and the high-risk curve accelerate
Life stages
Care settings
Clinical exam formats
Board mappings
- Musculoskeletal medicine - screen the child for scoliosis with the Adams forward bend test and refer appropriately
- Adolescent medicine - recognise the adolescent with a spinal deformity and the red flags that demand investigation
- Growth and Development - normal spinal posture and the adolescent growth spurt
- Musculoskeletal medicine - apply the observe-brace-surgery ladder of scoliosis by the Cobb angle and the skeletal maturity
- Orthopaedics and musculoskeletal medicine - recognise the non-idiopathic curve and the indications for the magnetic resonance imaging
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Musculoskeletal 10-12
- Adolescent health 10-12
- Clinical Applications
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- Long Cases
- 9. Musculoskeletal medicine - the child with a spinal deformity and the red-flag assessment
- 11. Child health and the school-age child and adolescent - scoliosis screening and the growth-spurt curve
- 4. Professional skills and knowledge: Patient management
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- Applied Knowledge in Practice (AKP)
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- General Pediatrics Content Outline - Musculoskeletal disorders
- General Pediatrics Content Outline - Adolescent medicine
- General Pediatrics Content Outline - Universal Task 3: Physical Examination
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 2: Conditions common in pediatric primary care
- Systems-Based Practice 2: Coordinated acute and chronic care
- Medical Expert
- Pediatrics: Foundations EPA #5 - Performing a focused physical examination
- Pediatrics: Rheumatology and musculoskeletal applied domain
A twelve-year-old girl is sent by her school nurse because her right shoulder sits higher than her left and a rib hump appears when she bends forward — the classic painless right thoracic adolescent idiopathic curve, found on screening and managed by the curve magnitude and the remaining growth. A four-year-old boy has a visible spinal curve and a left thoracic prominence with an asymmetric abdominal reflex — a non-idiopathic curve until the magnetic resonance imaging excludes a syrinx. A six-month-old with a hemivertebra on the spine film has a congenital scoliosis that is destined to progress and that carries a renal anomaly until the ultrasound proves otherwise. The task in each is to measure the Cobb angle, stage the maturity, run the red-flag screen, and place the child on the right rung of the management ladder. [2] [12]
Run the scoliosis pathway as five moves. Screen with the Adams forward bend test and the scoliometer at every opportunity, because a trunk-rotation angle of 7 degrees or more is the trigger for the standing radiograph. Measure the Cobb angle on the standing posteroanterior film, because the magnitude is the first number that drives the management. Stage the skeletal maturity with the Risser sign or the Sanders scale, because the remaining growth is the second number that decides whether the curve is still at risk. Decide on the rung of the ladder — observe, brace, or consider surgery — from the two numbers together, and Refer the non-idiopathic curve, the early-onset curve, and the one that needs surgery to the spinal team. [2] [9]
Overview & Definition
Scoliosis is a structural lateral curvature of the spine, and the paediatric clinician holds two ideas at once: most scoliosis in adolescence is idiopathic, common, and painless, and yet every curve is treated as non-idiopathic until the red-flag screen proves otherwise. The formal definition is a lateral curvature measured on a standing radiograph of 10 degrees Cobb or more, with a rotational component — a spinal curvature under 10 degrees is spinal asymmetry, not scoliosis, and it is observed rather than treated. The 10-degree threshold matters because it is the magnitude at which the curve becomes a structural deformity with a measurable rotation, and it is the cut-off that frames every prevalence and progression figure in the literature. [2] [8]
The rotational component is what makes scoliosis a three-dimensional deformity rather than a simple side-bend, and it is the rotation that produces the rib hump the examiner sees on the forward bend. The vertebrae rotate toward the convexity of the curve, the ribs on the convex side bulge posteriorly into a prominence, and the chest wall asymmetry is the visible sign that brings most adolescents to attention. A curve is therefore never fully described by the Cobb angle alone, and the forward-bend examination is as much a part of the assessment as the radiograph. [8] [2]
The clinical weight of scoliosis comes from what an untreated severe curve does to a child over a lifetime, and from what an unnecessary early fusion does to a developing lung. A large thoracic curve restricts the chest and, in the severe curve, the vital capacity. A curve fused in early childhood before the lungs and the thorax have grown leaves the child with a small chest and a restricted lung that no later operation can fully restore. The fellowship task is to identify the curve, measure and stage it, separate the idiopathic from the non-idiopathic, and place the child on the management rung that preserves growth and lung while preventing the deformity from progressing. [3] [7]
References12ShowHide
- [1]Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med, 2013.PMID 24047455
- [2]Weinstein SL, Dolan LA, Cheng JCY, Danielsson A, Morcuende JA. Adolescent idiopathic scoliosis. Lancet, 2008.PMID 18456103
- [3]Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history. JAMA, 2003.PMID 12578488
- [4]Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am, 2001.PMID 11507125
- [5]Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am, 1984.PMID 6480635
- [6]Sanders JO, Browne RH, McConnell SJ, Margraf SA, Cooney TE, Finegold DN. Maturity assessment and curve progression in girls with idiopathic scoliosis. J Bone Joint Surg Am, 2007.PMID 17200312
- [7]Karol LA, Johnston C, Mladenov K, Schochet P, Walters P, Browne RH. Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis. J Bone Joint Surg Am, 2008.PMID 18519321
- [8]Parent S, Newton PO, Wenger DR. Adolescent idiopathic scoliosis: etiology, anatomy, natural history, and bracing. Instr Course Lect, 2005.PMID 15948477
- [9]Negrini S, Donzelli S, Aulisa AG, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord, 2018.PMID 29435499
- [10]Grossman DC, Curry SJ, Owens DK, et al. Screening for adolescent idiopathic scolatitis: US Preventive Services Task Force recommendation statement. JAMA, 2018.PMID 29318284
- [11]Williams BA, Matsumoto H, McCalla DJ, et al. Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS). J Bone Joint Surg Am, 2014.PMID 25143496
- [12]McMaster MJ. Prognosis for congenital scoliosis due to a unilateral failure of vertebral segmentation. J Bone Joint Surg Am, 2013.PMID 23780534