Management of Constipation in an Adolescent with Scoliosis
Myofascial release techniques to the thoracic spine are the most appropriate next step in managing this 16-year-old boy with constipation and scoliosis after instituting heel lift therapy.
Rationale for Management Approach
The patient presents with a complex clinical picture involving:
- 2-month history of occasional constipation
- Normal abdominal examination (bowel sounds present, no tenderness)
- Structural examination showing sacral base declination
- S-shaped scoliosis with apex of lower curve at T12 and upper curve at T6
- Already initiated heel lift therapy
Understanding the Biomechanical Connection
The relationship between spinal alignment and gastrointestinal function is important to consider in this case. The thoracic spine (particularly at T9-T12) contains sympathetic innervation to the intestines, which can affect bowel motility 1. The patient's scoliosis with an apex at T12 may be contributing to his constipation through altered neural pathways or mechanical effects on the abdominal cavity.
Appropriate Management Steps
Myofascial release techniques to the thoracic spine
- This approach addresses the musculoskeletal component that may be contributing to the constipation
- Particularly appropriate given the location of the lower curve apex at T12, which corresponds to sympathetic innervation of the intestines
- Complements the already initiated heel lift therapy which addresses the sacral base declination
Why other options are less appropriate:
- Barium enema or colonoscopy would be invasive and not indicated without red flag symptoms or failed conservative management
- Paravertebral stimulation at T9-T12 could be considered but is typically reserved after trying less invasive approaches
- Stool culture is unnecessary given the absence of infectious symptoms
Clinical Considerations
Scoliosis Assessment and Management
The American College of Radiology guidelines suggest that adolescents with scoliosis should be monitored with:
- Radiographs every 12 months for Risser stages 0-3
- Radiographs every 18 months for Risser stages 4-5 1
For this patient with S-shaped scoliosis, it's important to note:
- The heel lift therapy already initiated is addressing the sacral base declination
- The thoracic component (T6 and T12 apices) requires additional management
- Myofascial techniques can help address both the spinal alignment and potentially improve bowel function
Constipation Management in Adolescents with Scoliosis
Constipation is a common issue in adolescents with scoliosis, with studies reporting bowel morbidity as high as 78% following scoliosis surgery 2. While this patient has not undergone surgery, the biomechanical alterations from scoliosis may contribute to his constipation.
Implementation of Myofascial Release Techniques
The myofascial release should focus on:
- Thoracic paraspinal muscles
- Abdominal musculature
- Diaphragmatic release
- Special attention to the T12 region where the lower curve apex is located
These techniques can help:
- Improve spinal mobility
- Reduce muscle tension that may be affecting neural pathways
- Enhance abdominal function and potentially bowel motility
Follow-up Recommendations
After implementing myofascial release techniques:
- Reassess constipation symptoms in 2-4 weeks
- Continue monitoring scoliosis progression
- Consider additional conservative measures for constipation if symptoms persist:
- Dietary modifications (increased fiber and fluids)
- Regular physical activity
- Proper toileting habits
Cautions and Considerations
- If constipation worsens or if red flag symptoms develop (weight loss, blood in stool, severe pain), further gastrointestinal evaluation would be warranted
- The patient's scoliosis should be monitored according to standard protocols, with surgical consideration if progression occurs beyond established thresholds 3
- The effectiveness of heel lifts should be assessed regularly, as studies show they can affect lower limb biomechanics and potentially influence spinal alignment 4, 5