15-year-old Female with Adolescent Idiopathic Scoliosis and Back Pain

History

The patient is a 15-year-old female with complaints of scoliosis and back pain. She is greater than 2 years postmenarchal and has no medical problems. She is engaged in typical activities for an adolescent female including basketball and soccer.

The back pain is localized to the mid-thoracic region, is absent at rest and is exacerbated by her sporting activities. The pain has been present for 1 year. She is unhappy with her body alignment and complaints of shoulder imbalance and truncal rotation (rib cage and breast asymmetry).

Examination

Patient is a healthy-appearing adolescent with near ideal body weight. The right shoulder is slightly higher with minimal waist line asymmetry. Scoliometer of the thoracic curve is 16° and the lumbar is 7°. There is no clinical leg-length discrepancy. The skin has no abnormalities, and the neurological assessment is normal.

Prior Treatment

The pain has not responded to non-surgical management (ie, exercises and physical therapy).

Pre-treatment Images

Figure 1: Standing anteroposterior radiographs: The main thoracic curve Cobb measure is 54°; lumbar, 48°. Risser 5. There is a slight left trunk shift of 2.8 cm.

Figure 2: Supine anteroposterior radiographs: main thoracic Cobb measure is 37°; lumbar, 35°.

Figure 3: Side-bending radiographs demonstrate the main thoracic curve bends out to 15° and the lumbar to 24°.

Figure 4A: Clinical photos demonstrating deformity

Figure 4B: More clinical photos demonstrating deformity

Diagnosis

Adolescent Idiopathic Scoliosis, Lenke 1CN

Selected Treatment

The patient underwent a PSF T4-T12.

Post-treatment Images

Immediate Post-operative Images

Figure 5: Pre-op is on the left. The thoracic curve was reduced to 16° immediately post-op. The lumbar curve was reduced to 23°.

Figure 6: Pre-op is on the left.

2-year Post-operative Images

Figure 7: Pre-op is on the left. The thoracic curve is 15°; the lumbar curve is 24°.

Figure 8: Pre-op is on the left.

Figure 9: Pre-op is on the left.

Outcome

At 2-year follow-up, the patient was participating in all desired athletic activities without back pain or limitation. She was satisfied with her overall body alignment and shoulder balance. The thoracic scoliometer measurement was 5°; lumbar 2°

Case Discussion

Stephen Lewis, MD

Orthopaedic Spine Surgeon

Toronto Western Hospital and Hospital for Sick Children

Dr. Luhmann's case of adolescent idiopathic scoliosis illustrates the controversies that a surgeon faces when presented with a symptomatic moderate sized curve in the surgical range in a skeletally mature adolescent. Based on the standing radiographs, it is difficult to determine whether this is a case of a Lenke 3 curve as opposed to a Lenke 6. Looking at the radiographs, the curves seem almost equal with similar apical vertebral rotation and translation and Cobb measurements. The main thoracic curve is more flexible on bending favoring this to be a Lenke 6. However, the left shoulder is lower and clinically the main thoracic rib hump is more prominent favoring a Lenke 3.

With this curve in the surgical range and the patient concerned over the appearance of her back, surgical treatment is a reasonable undertaking. The presenting symptom of back pain should not be considered a primary reason to undergo scoliosis correction surgery. Her back pain may or may not resolve with surgical treatment, and in most cases of AIS with pain, the patient’s primary concern is deformity with the pain being used as a way of appeasing the parents to allow for surgical treatment. Long-term back pain may occur in a certain percentage of patients regardless of treatment.

Based on the clinical presentation and clinical appearance, I would favor the main thoracic curve to be the main deformity. However, there is significant deformity in the lumbar region to consider including it in the construct. I feel options 1, 2 and 3 to all be valid options in this case. If surgical treatment is opted for by the patient, the discussion of a selective fusion of the thoracic spine with the benefit of preserving lumbar motion should be countered with the possibility of progression of the lumbar deformity and need for subsequent surgery in the near or late future. This is usually an attractive option for athletic patients wishing to continue to partake in sports. Treatment of both curves with a fusion extending to L3 or L4 would have the benefit of straightening both deformities with the sacrifice of significant lumbar motion, and still may require further surgery of the remaining unfused lumbar levels down the road.

Dr. Luhmann opted for a selective thoracic fusion with a very nice clinical outcome. The patient’s shoulders and balance is nicely restored with very minimal truncal deformity. Radiographically, there is persistent coronal tilt on the lower instrumented vertebra which is required to maintain the balance of the two curves. There has been significant improvement in the apical vertebral translation of both curves and leveling of the rib cage and shoulders. The residual lumbar deformity will likely require treatment later in life, however, given the excellent clinical result, this is a fair trade-off for preserving the lumbar mobility at this stage.