Clinical Manifestations of Scoliosis
Scoliosis presents with distinct clinical manifestations including trunk asymmetry, uneven shoulders, prominent scapula, rib hump during forward bending, and potential pain or respiratory compromise in severe cases. 1
Definition and Classification
Scoliosis is defined as a lateral curvature of the spine with a Cobb angle of 10 degrees or more in the coronal plane. It is often accompanied by vertebral rotation, creating a three-dimensional deformity. Scoliosis can be classified into several types:
Idiopathic (75-80% of cases, especially in adolescents)
- More common in females (10:1 ratio for developing larger curves)
- Often asymptomatic in mild cases
Congenital (due to vertebral anomalies)
Neuromuscular (associated with neurological or muscular disorders)
Syndromic (associated with Marfan syndrome, Ehlers-Danlos syndrome, etc.)
Degenerative (adult-onset, often due to asymmetric disc/facet degeneration) 1, 2
Physical Manifestations
Observable External Signs
- Uneven shoulder heights
- Asymmetric waistline
- Trunk shift (body appears off-center)
- Prominent scapula or rib hump (most visible during forward bend test)
- Uneven hip heights
- Head not centered over pelvis
- Clothes that hang unevenly 1
Functional Manifestations
Mild scoliosis (Cobb angle <20°): Usually asymptomatic
Moderate scoliosis (20-40°): May present with:
- Back pain (more common in adults)
- Muscle fatigue
- Postural changes
Severe scoliosis (>40°): May present with:
Associated Conditions
In approximately 2-4% of "idiopathic" scoliosis cases, intraspinal abnormalities may be present, including:
- Chiari I malformation
- Syringomyelia
- Tethered cord
- Intrinsic spinal cord tumors 1
These conditions may present with additional neurological symptoms that should prompt further investigation with MRI.
Progression and Complications
The risk of progression depends on:
- Patient's skeletal maturity (Risser sign)
- Magnitude of the curve
- Location of the curve (thoracic curves progress more than lumbar)
- Sex (females have higher risk of progression)
Long-term complications of untreated severe scoliosis may include:
- Chronic back pain
- Reduced pulmonary function
- Psychosocial distress related to appearance
- Disability in severe cases 1, 3
Special Considerations
Neuromuscular Scoliosis
Patients with neuromuscular scoliosis often present with:
- Pelvic obliquity making sitting difficult
- More rapid progression than idiopathic scoliosis
- Earlier onset
- Higher risk of respiratory complications
- Difficulty with positioning and mobility 4
Adult Scoliosis
Adult patients with scoliosis commonly present with:
- Back pain (predominant symptom)
- Leg pain and claudication symptoms due to spinal stenosis
- Progressive deformity, especially with osteoporosis
- Rarely neurological deficits
- Functional limitations rather than cosmetic concerns 2
Common Pitfalls in Assessment
- Delayed referral for specialist evaluation
- Overlooking non-idiopathic causes of scoliosis
- Neglecting psychological impact, especially in adolescents
- Failing to recognize associated conditions requiring further investigation
- Inadequate monitoring during growth spurts when progression risk is highest 1
When evaluating a patient with suspected scoliosis, a forward bend test with scoliometer measurement should be performed to confirm the diagnosis, followed by appropriate radiographic evaluation with standing full-spine posteroanterior and lateral views to assess curve severity and pattern 1, 5.