From the Guidelines
The most appropriate next step for this 13-year-old girl with a positive Adams forward bend test is thoracic imaging to assess curvature of the spine, specifically to evaluate the degree of spinal curvature and measure the Cobb angle to determine severity of adolescent idiopathic scoliosis. The positive screening test suggests adolescent idiopathic scoliosis, which requires radiographic confirmation and measurement of the Cobb angle to determine severity 1. Typically, a standing posteroanterior and lateral radiograph of the spine would be ordered to evaluate the degree of spinal curvature, which is essential for treatment planning 2. The Cobb angle measurement helps categorize scoliosis as mild (less than 25 degrees), moderate (25-40 degrees), or severe (greater than 40 degrees), with treatment options ranging from observation for mild cases to bracing for moderate cases and surgical intervention for severe or progressive curves. Some key points to consider in the assessment and management of adolescent idiopathic scoliosis include:
- The importance of early detection and appropriate management to prevent physical deformity, pain, or cardiopulmonary complications if severe and left untreated 1
- The use of radiographic techniques, such as side bending, push prone, fulcrum bending, and traction radiographs, to assess curve flexibility and guide surgical decision-making 2
- The recommendation to limit spine radiographs to once every 12 months for those adolescent patients at Risser stages 0 to 3 and every 18 months for patients at Risser stages 4 to 5, unless there are objective clinical changes in the appearance of the scoliosis 2 It is also important to note that while MRI may be useful in certain cases, such as those with neurologic abnormalities or suspected spinal trauma, it is not typically the first-line imaging modality for evaluating adolescent idiopathic scoliosis 3.
From the Research
Osseous Abnormalities to Assess
In a 13-year-old girl with a positive Adams Forward Bend Test result, thoracic imaging should assess for the following osseous abnormalities:
- Curvature of the spine, specifically scoliosis, as it is a common condition in adolescents that can be diagnosed using various methods, including the Cobb method 4, 5 and ultrasound-based motion analysis systems 6.
- Vertebral rotation and thoracic torsion, which are important aspects of scoliosis that can be assessed using radiographic measures such as the Perdriolle and Nash-Moe techniques, as well as alternate measures like the rib-vertebral angle difference, apical rib hump prominence, apical vertebral body-rib ratio, and apical rib spread difference 7.
Imaging Modalities
Various imaging modalities can be used to assess these osseous abnormalities, including:
- Biplanar X-ray images, which are considered the gold standard for diagnosing and monitoring scoliosis 4, 5.
- Ultrasound-based motion analysis systems, such as the ZEBRIS spine examination method, which can provide accurate measurements of spinal curvature angles in the sagittal and frontal planes 4.
- Magnetic Resonance Imaging (MRI), which can provide detailed images of the spine in the sagittal and coronal planes, allowing for accurate measurement of sagittal Cobb angles and assessment of vertebral rotation and thoracic torsion 8.
- 3-D ultrasound volume projection imaging, which can provide automatic assessment of ultrasound curvature angle for scoliosis detection and has been shown to have good correlation with manually measured angles 6.