To whom should I refer an adult with dextroscoliosis?

Adult Dextroscoliosis Referral Guidelines

Adults with dextroscoliosis should be referred to an orthopedic specialist with expertise in spine deformities, as they can provide the most appropriate evaluation and management for this condition to reduce morbidity and mortality risks.

Understanding Dextroscoliosis

Dextroscoliosis is a type of scoliosis characterized by a right-sided lateral curvature of the spine. In adults, it typically falls into one of these categories:

• Primary degenerative scoliosis ("de novo")
• Progressive idiopathic adolescent scoliosis that continues into adulthood
• Secondary scoliosis due to other conditions (leg length discrepancy, osteoporosis, etc.)

Referral Decision Algorithm

Primary Referral: Orthopedic Specialist

Adults with dextroscoliosis should be referred to an orthopedic specialist with expertise in spine deformities 1. This is because:

• Orthopedic specialists can assess the severity and progression of the curve
• They can evaluate associated symptoms like pain, neurological issues, and functional limitations
• They can determine appropriate treatment options based on curve magnitude and symptoms

Secondary Referrals Based on Specific Findings

1. If significant bone density concerns exist:

   • Consider referral to an osteoporosis specialist, especially for:
     • Adults with osteoporosis and scoliosis progression
     • Patients with fragility fractures and scoliosis 1

2. If neurological symptoms are present:

   • Consider additional neurosurgical consultation for:
     • Progressive neurological deficits
     • Spinal cord compression
     • Radicular symptoms not responding to conservative management

3. If significant pain management issues exist:

   • Consider pain management specialist referral for:
     • Chronic pain not responding to first-line treatments
     • Need for specialized pain interventions

Clinical Considerations Affecting Referral Urgency

Higher Urgency Referral Indicators:

• Progressive curve (>5° increase in a year)
• Significant pain not responding to conservative measures
• Neurological symptoms (weakness, numbness, radicular pain)
• Functional limitations affecting daily activities
• Respiratory or cardiac symptoms in severe thoracic curves
• Significant sagittal imbalance causing postural problems

Important Assessment Factors:

• Curve magnitude (Cobb angle)
• Rate of progression
• Location of curve (thoracic, lumbar, thoracolumbar)
• Presence of rotational deformity
• Sagittal balance
• Associated symptoms (pain, neurological issues)
• Impact on quality of life

Treatment Considerations

The orthopedic specialist will typically consider:

1. Nonoperative management:

   • Physical therapy
   • Pain management
   • Bracing (in select cases)
   • Monitoring for progression

2. Surgical intervention when indicated for:

   • Progressive curves with significant symptoms
   • Neurological compromise
   • Significant sagittal imbalance
   • Failure of conservative management 2, 3

Potential Pitfalls to Avoid

• Delayed referral: Adult scoliosis can progress and lead to increased disability and reduced quality of life if not properly managed 2
• Overlooking osteoporosis: Bone density should be evaluated as osteoporosis can accelerate curve progression 1
• Focusing only on the curve: The entire clinical picture, including pain, function, and neurological status, should guide management decisions
• Ignoring sagittal balance: This is a critical factor in symptom development and treatment planning
• Underestimating impact: Adult scoliosis can significantly affect quality of life and may warrant intervention even in older adults 3

By referring to an orthopedic specialist with spine expertise, you ensure your patient receives comprehensive evaluation and appropriate management options for their dextroscoliosis, which can significantly improve their quality of life and prevent progression of the deformity.