From the Guidelines
The best initial imaging for a 12-year-old with scoliosis and a 18-degree Cobb angle is a standing posteroanterior (PA) and lateral radiograph of the entire spine. This recommendation is based on the most recent and highest quality study, which suggests that radiographs of the complete spine are usually appropriate for the initial imaging of an adolescent with adolescent idiopathic scoliosis and no risk factors 1. The PA view is preferred over an anteroposterior (AP) view because it reduces radiation exposure to breast tissue, which is particularly important in adolescents.
Key Considerations
- The patient's age and scoliometer reading suggest a significant curve that may require intervention beyond observation 1.
- The Cobb angle, as determined on these radiographs, has been shown to play a key role in the surgical decision-making process 1.
- Early detection and accurate measurement are crucial as adolescent idiopathic scoliosis can progress rapidly during growth spurts, and appropriate management decisions depend on precise curve measurement.
Imaging Protocol
- The radiographic evaluation should be performed with the patient in a natural standing position, without shoes, and with arms at the sides or slightly forward to visualize the entire spine from the base of the skull to the pelvis on a single image.
- The PA and lateral radiographs will confirm the diagnosis, determine the Cobb angle, identify the curve pattern, assess skeletal maturity using the Risser sign, and evaluate for any underlying structural abnormalities.
Follow-up
- Serial PA spine radiographs are also an integral part of the follow-up of these patients, with the frequency of follow-up depending on the patient's skeletal maturity and curve severity 1.
From the Research
Initial Imaging for Scoliosis
The initial imaging for a 12-year-old with scoliosis and an 18-degree Cobb angle is typically radiography, as it is the primary imaging modality for diagnosing and monitoring scoliosis 2.
Imaging Modalities
- Radiography: Postero-anterior erect full spine radiograph is generally prescribed, and is supplemented by lateral full spine radiograph when indicated 2.
- EOS® stereoradiography: This modality is preferred when available, as it reduces radiation hazard, with a microdose protocol that is 45 times less than conventional radiography 2.
- Other imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) may be required for patients with atypical presentation to assess for underlying pathology 2.
Referral to a Specialist
According to the study by 3, a child should be referred to a specialist if the curve is greater than 20 degrees in a patient 10 years of age or older. Since the patient in question has an 18-degree Cobb angle, they may not require immediate referral to a specialist based on this criterion alone. However, the decision to refer should be based on a comprehensive evaluation of the patient's history, physical examination, and radiographs.
Treatment and Monitoring
The treatment for idiopathic scoliosis is based on age, curve magnitude, and risk of progression, and includes observation, orthotic management, and surgical correction with fusion 3, 4, 5. Patients with mild scoliosis are usually asymptomatic, but may require monitoring to limit progression 6.