Initial Work-up for Left-Sided Spine Curvature (Scoliosis)
The initial work-up for a patient with left-sided spine curvature should include a thorough clinical evaluation, radiographic assessment, and consideration for advanced imaging due to the atypical left-sided pattern which raises suspicion for underlying pathology. 1
Clinical Significance of Left-Sided Curvature
Left-sided scoliosis is particularly important to note because:
- Typical adolescent idiopathic scoliosis (AIS) presents with right-sided thoracic curves 1
- Left-sided curves are atypical and may suggest underlying neural axis abnormalities requiring additional imaging 1
- This pattern warrants more thorough investigation compared to the more common right-sided pattern
Initial Evaluation Components
1. Clinical Assessment
- Document patient age (critical for determining progression risk)
- Assess skeletal maturity (Risser sign)
- Evaluate for associated symptoms:
- Back pain (uncommon in idiopathic scoliosis, suggests secondary cause) 2
- Neurological symptoms (radiculopathy, weakness, sensory changes)
- Respiratory compromise
2. Physical Examination
- Forward bend test to assess rotation and rib hump
- Evaluation for leg length discrepancy (may cause secondary scoliosis) 3
- Neurological examination including:
- Motor strength
- Sensory testing
- Deep tendon reflexes
- Abdominal reflexes (asymmetry suggests intraspinal pathology)
- Assessment for cutaneous markers of underlying conditions:
- Café-au-lait spots (neurofibromatosis)
- Hairy patches or dimples (spinal dysraphism)
3. Radiographic Assessment
- Standing full-spine posteroanterior and lateral radiographs 4
- Measure Cobb angle (≥10° defines scoliosis) 4
- Assess vertebral rotation using Nash-Moe method 4
- Identify apex, end vertebrae, and neutral vertebrae 4
- Evaluate for congenital vertebral anomalies
4. Advanced Imaging Considerations
- MRI of the entire spine is indicated for left-sided curves due to higher association with underlying neural axis abnormalities 1
- MRI should be considered when any of these are present:
- Left-sided thoracic curve
- Early onset scoliosis (under age 10)
- Rapid progression
- Neurological abnormalities
- Back pain
- Atypical curve patterns
Screening for Associated Conditions
Assess for syndromic features associated with scoliosis:
- Marfan syndrome (arm span, arachnodactyly, joint hypermobility)
- Ehlers-Danlos syndrome (joint hypermobility, skin elasticity)
- Neurofibromatosis (café-au-lait spots, axillary freckling)
- Osteogenesis imperfecta (blue sclera, history of fractures) 1
Evaluate for cardiopulmonary issues:
- Cardiac assessment if syndromic features present
- Pulmonary function testing for severe curves
Referral Guidelines
A patient should be referred to a scoliosis specialist if:
- Curve is >10° in a patient younger than 10 years of age 2
- Curve is >20° in a patient 10 years or older 2
- Left-sided thoracic curve (atypical pattern)
- Presence of back pain or neurological abnormalities 2
- Rapid progression of curve
- Presence of congenital anomalies or syndromic features
Common Pitfalls to Avoid
- Assuming all scoliosis is idiopathic without investigating atypical patterns
- Failing to recognize that left-sided curves have higher association with underlying pathology
- Neglecting to order MRI for left-sided curves or when neurological symptoms are present
- Overlooking leg length discrepancy as a potential cause of secondary scoliosis 3
- Delaying referral for curves that meet specialist evaluation criteria
Left-sided scoliosis requires particular vigilance as it may represent a secondary curve due to underlying pathology. The presence of intraspinal abnormalities such as Chiari I malformation, syringomyelia, tethered cord, and intrinsic spinal cord tumors are found in 2-4% of seemingly "idiopathic" cases 1, with higher rates in atypical curve patterns like left-sided thoracic curves.