Idiopathic Scoliosis Clinical Presentation

Updated: Jan 03, 2023
  • Author: Charles T Mehlman, DO, MPH; Chief Editor: Jeffrey A Goldstein, MD  more...
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The vast majority of patients with idiopathic scoliosis initially present because of a perceived deformity. This may be patient or family perception of asymmetry about the shoulders, waist, or rib cage. The asymmetry of the rib cage can cause patients to present with concerns for rib-cage deformity or breast asymmetry before they are aware of having scoliosis. A primary care physician or school-screening nurse may perceive some of these findings as well.

The Adams forward-bending test (in conjunction with the use of a scoliometer) has been found to be an effective screening tool. Traditionally, a value of 7º of angulation on the scoliometer has been used to determine whether the child or adolescent should undergo radiography or be referred to an orthopedic surgeon.

Highlights of the patient's history include obtaining information relative to other family members with spinal deformity, performing an assessment of physiologic maturity (eg, menarche), and ascertaining the presence or absence of pain.

Traditionally, scoliosis has been described as a nonpainful condition, and aggressive workup has been recommended for patients in whom this rule is violated. [64] Ramirez et al from the Texas Scottish Rite Hospital studied more than 2400 patients with scoliosis and found that a full 23% (560 of 2442 patients) had back pain at the time of presentation. [65] An underlying pathologic condition was identified in 9% (48 of 560) of the patients with back pain; in most cases, the underlying condition was spondylolysis or spondylolisthesis, but one instance of an intraspinal tumor was also noted. 


Physical Examination

Physical examination should include a baseline assessment of posture and body contour. Shoulder unleveling and protruding scapulae are common. In the most common curve pattern (right thoracic), the right shoulder is consistently rotated forward, and the medial border of the right scapula protrudes posteriorly. Truncal shift is present when the shoulders, neck, and head are translated laterally instead of centered over the pelvis.

A basic neurologic evaluation should be performed, including assessment of lower-extremity (and often upper-extremity) reflexes, abdominal reflex, Babinski sign, and clonus. The presence or absence of hamstring tightness should be investigated, and screening should be performed for ataxia and/or poor balance or proprioception (ie, Romberg test).

Recognizing a difference in limb lengths will prove valuable, in that a significant percentage of patients presenting with scoliosis have several centimeters of limb-length discrepancy; this creates an oblique takeoff of the spine, which, in turn, causes the compensatory curve back to the midline. This pattern of scoliosis is not truly idiopathic. This scoliosis is secondary to a limb-length discrepancy and, if still flexible, will be corrected if the radiographs are taken with a equalizing lift under the shorter limb.