Can a 32 degree levoscoliosis cause referred pain to the thoracic spine?

Can a 32-Degree Levoscoliosis Cause Thoracic Spine Pain?

Yes, a 32-degree levoscoliosis can directly cause thoracic spine pain through mechanical stress at the curve apex, asymmetrical loading patterns, and associated degenerative changes, though the left-sided curve pattern warrants evaluation for underlying pathology before attributing pain solely to the scoliosis itself. 1

Understanding Pain Patterns in Scoliosis

Direct Mechanical Pain from Scoliosis

• Scoliotic curves cause asymmetrical pain localization, most commonly at the apex of the curve, where mechanical stress is greatest due to abnormal biomechanical loading 1
• The type and location of the curve significantly impacts pain presentation, with lumbar and thoracolumbar curves being more painful than isolated thoracic curves 1
• A 32-degree curve represents moderate scoliosis that creates sufficient biomechanical alterations to generate pain through facet joint overload, muscular imbalance, and paraspinous soft tissue strain 2

Specific Characteristics of Scoliosis-Related Pain

• Pain in adults with scoliosis presents with asymmetrical localization as the most specific distinguishing feature compared to non-scoliotic back pain 1
• When radicular symptoms occur in scoliosis patients, they typically manifest as cruralgia (anterior thigh pain) rather than sciatica, relating to rotational olisthesis at the curve 1
• The pain pattern differs from typical thoracic back pain in that it follows the curve's convexity and concavity with asymmetric paraspinous muscle tension 1

Critical Red Flag: Left-Sided Curve Pattern

Why Levoscoliosis Requires Additional Scrutiny

• Left thoracic or thoracolumbar curves are atypical and considered a "red flag" that should prompt investigation for underlying neural axis abnormalities 3
• The American College of Radiology identifies that 2-4% of patients diagnosed with apparent idiopathic scoliosis actually have neural axis abnormalities causing their scoliosis, including Chiari I malformation, cord syrinx, cord tethering, and intraspinal tumors 3
• Left-sided curves warrant MRI evaluation to rule out underlying pathology before attributing symptoms solely to the scoliotic deformity 3

Additional Risk Factors Requiring Investigation

• Short segment curves, rapid progression, functionally disruptive pain, focal neurologic findings, male sex, and pes cavus all increase suspicion for underlying pathology in left-sided curves 3
• Painful scoliosis with acute or subacute onset should raise suspicion for intraspinal lesions, including herniated discs, tumors (such as osteoblastoma), or infections 4, 5

Clinical Assessment Algorithm

Initial Evaluation Steps

• Determine the acuteness of pain onset: acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks) 2
• Screen systematically for red flags including fever, unexplained weight loss, history of cancer, recent infection, immunosuppression, constant pain unrelieved by rest, and neurologic deficits 6, 7
• Perform focused neurological examination looking for myelopathy (gait disturbance, hyperreflexia, Babinski sign) or radiculopathy (dermatomal sensory changes, motor weakness) 6

Imaging Decision Framework

• For left-sided curves with pain, MRI thoracic spine without contrast is appropriate initial imaging to exclude neural axis abnormalities, regardless of symptom duration 3
• If red flags are present (fever, weight loss, neurologic deficits), MRI with and without contrast is indicated to evaluate for malignancy or infection 6, 7
• For patients >65 years or with chronic steroid use presenting with acute pain, thoracic spine X-rays are appropriate initially to assess for compression fractures 2

Common Pitfalls to Avoid

• Do not assume all pain in a patient with known scoliosis is scoliosis-related—the left-sided pattern mandates exclusion of intraspinal pathology 3
• Avoid delaying imaging in atypical presentations: acute onset severe pain, rapidly progressive symptoms, or associated neurologic findings require prompt MRI evaluation 6, 5
• Do not overlook cervicothoracic scoliosis as a potential contributor to thoracic outlet syndrome, which can cause upper extremity pain and paresthesias that may be misattributed to thoracic spine pathology 8
• Weight-bearing imaging may reveal scoliosis not apparent on supine studies, with scoliosis rates being significantly higher (78.2% vs 18.2%) in weight-bearing versus supine MRI in symptomatic patients 9

Management Implications

• If MRI excludes intraspinal pathology and confirms the pain is mechanically related to the scoliotic curve, conservative management with physical therapy targeting asymmetric muscle imbalances and core strengthening is first-line 2
• Patients with progressive neurologic deficits require urgent neurosurgical evaluation regardless of curve severity 6
• For confirmed mechanical scoliosis pain without red flags, a trial of 4-6 weeks of conservative therapy is appropriate before considering advanced interventions 2