What is the appropriate assessment and follow‑up plan for an adult patient with incidental mild thoracic scoliosis (upper levoconvex Cobb angle 7.5°, lower dextro‑convex Cobb angle 9°), normal vertebral height and alignment, no fracture or subluxation, and mild multilevel degenerative disc disease with facet arthropathy?

Assessment and Follow-Up for Incidental Mild Thoracic Scoliosis in Adults

No imaging follow-up or treatment is indicated for these mild curves (7.5° and 9° Cobb angles), as they fall well below the 10-degree diagnostic threshold for scoliosis and pose no risk of progression or clinical significance. 1

Diagnostic Context

• These curves do not meet diagnostic criteria for scoliosis. The American College of Radiology defines scoliosis as a Cobb angle exceeding 10 degrees on standing PA radiographs, and both your upper thoracic (7.5°) and lower thoracic (9°) curves fall below this threshold 1

• The mild degenerative changes are age-appropriate findings and do not require specific intervention in the absence of symptomatic thoracic back pain, myelopathy, or radiculopathy 2

Clinical Management Algorithm

No Routine Imaging Follow-Up Required

• Serial radiographic monitoring is not indicated because these curves are below the diagnostic threshold and the patient is skeletally mature 1

• Even if these curves technically met the 10-degree threshold, skeletally mature patients with curves under 20 degrees have less than 30% risk of progression and typically require only observation 1

• Imaging is only warranted if new symptoms develop, specifically thoracic back pain with red flags, myelopathy, or radiculopathy 2

Symptom-Based Approach

If the patient remains asymptomatic:

• No further imaging or specialist referral is needed 2
• Reassure the patient that these findings are incidental and clinically insignificant 1

If thoracic back pain develops without red flags:

• Conservative management without imaging is appropriate initially 2
• Imaging is not typically indicated for acute or chronic thoracic back pain without myelopathy, radiculopathy, or red flags 2

If red flags emerge, obtain MRI thoracic spine without contrast to evaluate for:

• Compressive etiologies (myelopathy or radiculopathy) 2
• Infection or neoplasm 2
• Neural axis abnormalities 3

Red Flags Requiring Urgent Evaluation

Watch for these specific findings that would change management:

• Functionally disruptive pain 4
• Focal neurological deficits, abnormal reflexes, or muscle weakness 4
• Rapid curve progression (>1° per month if serial imaging obtained for other reasons) 4
• New left thoracic curve pattern (atypical) 4

Key Clinical Pitfalls to Avoid

• Do not order routine follow-up radiographs for curves this small in skeletally mature adults, as this exposes patients to unnecessary radiation without clinical benefit 1

• Do not refer to orthopedic surgery for curves below 10 degrees, as surgical intervention is only considered when Cobb angles exceed 50 degrees in skeletally mature patients 3

• Do not attribute future back pain automatically to these minor curves, as degenerative lumbar scoliosis and facet arthropathy are more common pain generators in adults 5

• Recognize that mild degenerative disc disease and facet arthropathy are normal aging findings that do not require treatment unless symptomatic 2, 6

Documentation Recommendations

Document in the patient's chart:

• Curves are below diagnostic threshold for scoliosis (7.5° and 9° vs. required 10°) 1
• No clinical intervention or imaging follow-up indicated 2, 1
• Patient counseled that findings are incidental and not clinically significant 1
• Instructed to return only if new thoracic pain, neurological symptoms, or functional limitations develop 2