Scoliosis in Children
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Direct answer
Scoliosis in children is a lateral curvature of the spine with rotation, quantified on a standing radiograph by the Cobb angle, and idiopathic scoliosis of adolescence is the commonest form. The Adams forward bend test screens for it by revealing a rib hump or lumbar prominence. A Cobb angle above about 10 degrees defines scoliosis, and management depends on curve size and the child's remaining growth.
What you must remember
- Cobb angle: measured on a standing posteroanterior radiograph between the endplates of the most tilted vertebrae; above about 10 degrees defines scoliosis.
- Adams forward bend test: a screening test in which the child bends forward, showing a rib hump or lumbar prominence from rotation.
- Idiopathic scoliosis: the commonest type, usually presenting in adolescence with a right thoracic curve.
- Age-based types: infantile scoliosis presents before about 3 years, and juvenile scoliosis between about 3 and 10 years, with a higher progression risk.
- Red flags: a left thoracic curve, rapid progression, pain or neurological signs warrant MRI to exclude intraspinal pathology such as syringomyelia.
- Risser sign: grades iliac apophysis ossification to indicate skeletal maturity and the amount of growth remaining.
- Neuromuscular scoliosis: seen in cerebral palsy and muscular dystrophy, and tends to progress more rapidly than idiopathic curves.
Matching the curve to its management
Management is decided by the Cobb angle and how much growth remains, because bracing works only while the spine can still change. The table summarises the usual thresholds in a growing child.
| Cobb angle | Usual approach |
|---|---|
| Below about 20 degrees | Observation with serial clinical review and radiographs |
| About 20 to 40 degrees, growing child | Bracing, aiming to halt progression |
| Above about 45 to 50 degrees, or progressive despite bracing | Posterior spinal fusion with instrumentation |
Bracing is generally ineffective once skeletal maturity is reached, so the Risser stage guides timing. Surgery corrects and stabilises a curve that is large or still progressing.
Scoliosis is judged over time rather than on a single film. Serial standing radiographs matter as much as the first measurement, because an increase of several degrees between visits signals progression. A modest initial angle that keeps rising can justify earlier intervention than the table alone would suggest. Clinicians also record the rib hump, shoulder balance and pulmonary function in larger curves, since severe thoracic curvature can affect breathing.
Where the exam tries to catch you
Questions on this topic usually test measurement, red flags and the thresholds for treatment.
- Trap: using the Adams test to measure severity Correct: the test is only a screen, and the Cobb angle on a standing radiograph measures curve size.
- Trap: labelling a left thoracic curve as idiopathic without imaging Correct: left-sided curves are unusual for idiopathic disease and need MRI to exclude a spinal cord lesion.
- Trap: bracing a large curve in a skeletally mature adolescent Correct: bracing cannot correct an established curve, so surgery is considered for large or mature curves.
- Trap: confusing postural asymmetry with scoliosis Correct: postural asymmetry disappears on bending, whereas a structural curve with rotation does not.
Frequently asked questions
How is the Cobb angle measured in scoliosis?
The Cobb angle in scoliosis is measured on a standing posteroanterior spine radiograph by drawing lines along the endplates of the most tilted vertebrae at the top and bottom of the curve. The angle between perpendiculars to these lines gives the curve size, and a value above about 10 degrees defines scoliosis.
What does the Adams forward bend test show in scoliosis?
The Adams forward bend test in scoliosis shows a rib hump or lumbar prominence when the child bends forward with the knees straight. It is a screening tool that detects rotation of the spine, and any positive finding needs a standing radiograph for measurement.
Why is MRI needed for a left thoracic curve in scoliosis?
MRI is needed for a left thoracic curve in scoliosis because such curves are unusual in idiopathic disease and may be caused by an underlying spinal cord lesion such as syringomyelia. A neurological examination and spinal MRI are therefore performed before the curve is labelled idiopathic.
How is bracing for scoliosis decided?
Bracing for scoliosis is decided by the Cobb angle, the child's skeletal maturity and the likelihood of progression. Curves of about 20 to 40 degrees in a growing child are commonly braced, while bracing is generally not effective once skeletal maturity is reached.