Adolescent Idiopathic Scoliosis: Can You Evaluate and Manage It?

During my 33 years of chiropractic practice in New Mexico, I experienced anxious mothers with adolescent daughters presenting with a similar question: “I have been told my daughter needs spinal surgery for scoliosis. Can chiropractic help her without surgery?” My response was, “I don’t know if I can help her, but I suggest we examine her and find out.”

So, when this mother shows up in your office, how do you determine if you can help her daughter and answer the question regarding surgical necessity? I will share my approach with a case report and provide the evidence to support the process.

"Adolescent idiopathic scoliosis is present in 2 to 4 percent of children between 10 and 16 years of age. It is defined as a lateral curvature of the spine greater than 10 degrees accompanied by vertebral rotation. It is thought to be a multigene dominant condition with variable phenotypic expression. Scoliosis can be identified by the Adam’s forward bend test during physical examination. Severe pain, a left thoracic curve or an abnormal neurologic examination are red flags that point to a secondary cause for spinal deformity."¹

The Case Report

Subjective Findings: A 14-year-old female, accompanied by her mother, presents with a chief concern of “My back hurts and it’s crooked.” The mother has been advised that her daughter will need spine surgery because of her scoliosis. She brought the radiographic report, but not the actual images. The imaging report, dated six months prior to this visit, states that the adolescent girl has a 15-degree scoliosis (Cobb method) with Risser grade of 3, and a levorotatory thoracic curve and dextrorotatory lumbar curve.

She has been experiencing lower back pain for the past year, which increases when she runs or jumps. Sitting and hot baths reduce the pain, which she describes as a deep ache on the left side of her lower back and hip. She points to the area of L5-S1 left and the left inguinal region.

She denies any trauma, but the pain is worst when playing volleyball. The pain level is rated at 5/10 when playing volleyball. In the morning, she wakes with some stiffness in the back. On the days that she plays volleyball, she has difficulty falling asleep because of the deep ache in the lower back. She has never seen a chiropractor. Her primary care physician referred her to a spine surgeon because of the pain and scoliosis. The surgeon advised her and her mother that she might need spinal surgery if the curvature in the spine worsens.

Objective Findings

Observation: A mesomorphic, healthy, Caucasian female demonstrates a normal gait without antalgia. She is a good historian with a pleasant demeanor. She is physically well-developed, well-nourished, and appears to be at Tanner stage 3.

Vital signs: Height 66”, weight 125, BP 110/64, respiration 12/minute, and oral temperature of 98.4 F.

Postural evaluation (standing) reveals a mild “S” type scoliosis with a right thoracic curve, a pelvic obliquity with a posterior inferior, left iliac crest and an anterior superior right iliac crest.

Palpation produces pain at the level of L5-S1 in the left multifidi and over the supraspinous ligament.

Kemp’s maneuver to the left is restricted and produces left L5-S1 pain, but without leg pain. Kemp’s maneuver to the right demonstrates a full range of motion without pain.

Long-sit test in the supine position demonstrates the appearance of a short left leg and a long right leg. Seated, the left leg appears to be long and the right leg appears to be short.

Myofascial trigger points revealed in the left iliopsoas and L4-5-S1 multifidi muscles with taut bands, painful nodules, and localized pain.

Posterior joint dysfunction at L5/S1 with pain, reduced range of motion, and hypertonicity of the left multifidi muscles.

Assessment

1. Functional adolescent idiopathic scoliosis due to the functional leg-length inequality.
2. Chronic low back pain syndrome
3. Lumbar facet syndrome with active myofascial trigger points

Treatment Plan

• After explaining the diagnoses, recommended treatment, and anticipated response to care, both the mother and the daughter agreed to proceed with treatment.
• Trigger-point pressure release to reduce the active trigger points in the left multifidi and iliopsoas was well-tolerated with reduction of the functional leg-length inequality and the pelvic obliquity.
• Spinal manipulation to reduce pain and improve joint function was well-tolerated with excellent response to care. She was able to perform Kemp’s maneuver without pain or restriction of motion.
• I advised the mother and daughter that we could manage the condition with spinal exercises, stretching exercises, and conservative chiropractic care.
• They were advised to follow-up with the PCP and the spinal surgeon. I was given permission to remit a report to both the PCP and the surgeon.

Although there is no ideal screening test, the Adam’s forward bend test requires no additional equipment (such as a scoliometer or humpometer) and can help to identify scoliosis. The child bends forward at the waist until the spine becomes parallel to the horizontal plane, while holding palms together with arms extended. The examiner looks along the horizontal plane of the spine from the back and side to detect an asymmetry in the contour of the back known as a “rib hump.”²

Discussion

This case report demonstrates the value of early chiropractic evaluation and management of a young female with chronic low back pain and functional scoliosis, rather than a structural scoliosis. There is the potential for this patient’s scoliosis to progress and become a structural scoliosis without correction of the functional leg-length inequality and the pelvic obliquity.

Quiz Time

1. A spinal curvature measuring more than 5 degrees indicates a scoliosis.

1. True
2. False

2. Pelvic obliquity due to a functional leg-length inequality and caused by an active trigger point in the iliopsoas may be corrected with reduction of the active trigger point.

1. True
2. False

Answers: 1. False. The Scoliosis Research Society has defined scoliosis as a lateral curvature of the spine greater than 10 degrees as measured using the Cobb method on a standing radiograph. 2. True. Active trigger points in the ipsilateral iliopsoas may cause pelvic obliquity.

References

1. Reamy BR, et al. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Pract, July 1, 2001;64(1).
2. Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am, 1999;30:353-65.