Management Recommendation for Unremarkable Thoracic Spine MRI
No further imaging or intervention is indicated for this 41-year-old woman with an unremarkable thoracic spine MRI showing only minimal left thoracic curvature that does not meet criteria for scoliosis. 1
Clinical Context and Imaging Findings
This patient's MRI demonstrates:
- Minimal broad-based left convex curvature without significant scoliosis (implying Cobb angle <10 degrees) 2
- No fracture, disc herniation, spinal canal stenosis, or cord compression 1
- Overall unremarkable findings with no acute pathology 1
The minimal left thoracic curvature described does not meet the diagnostic threshold for scoliosis (Cobb angle ≥10 degrees) and represents a normal anatomical variant. 2 While left thoracic curves can be associated with neural axis abnormalities in true scoliosis cases (54% prevalence), 3 this patient's curve does not qualify as scoliosis and the MRI has already excluded neural axis pathology. 1, 3
Evidence-Based Management Algorithm
No Active Treatment Required
The patient requires reassurance only. 1 The ACR Appropriateness Criteria explicitly state there is no relevant literature supporting any imaging modality for evaluation of thoracic back pain without red flags or neurologic deficits when initial imaging is unremarkable. 1
Key Clinical Decision Points
- Asymptomatic or minimal symptoms without red flags: No further workup needed 1
- Skeletally mature adult (age 41): No risk of curve progression requiring monitoring 2
- Curve magnitude below scoliosis threshold: Does not warrant orthopedic referral 4, 5
- MRI already excludes compressive pathology: No indication for additional imaging 1
When to Reconsider Evaluation
Only pursue further evaluation if new symptoms develop: 1
- Myelopathy symptoms: Progressive weakness, gait instability, bowel/bladder dysfunction, hyperreflexia 1
- Radiculopathy: Dermatomal pain, numbness, or weakness in thoracic distribution 1
- Severe intractable pain: Pain unresponsive to conservative measures 1
- Red flag symptoms: Fever, weight loss, night pain, history of malignancy 1
Important Clinical Nuances
Normal Anatomical Variants
Minimal thoracic curvature is common in asymptomatic individuals. 6, 7 Research demonstrates that 73% of asymptomatic individuals have positive anatomical findings on thoracic spine MRI, including disc bulging (53%), annular tears (58%), and even cord deformation (29%). 6 Right thoracic curvature is actually the normal pattern in adolescents and adults, 7 making this patient's minimal left curvature even less clinically significant given its magnitude does not reach scoliosis criteria.
Scoliosis Management Thresholds (Not Applicable Here)
For context, true scoliosis management thresholds are: 4, 8, 5
- <20 degrees in skeletally mature patients: Observation only 8, 2
- 20-25 degrees with skeletal immaturity: Consider bracing 8, 5
- >50 degrees in skeletally mature patients: Surgical consideration due to 1 degree/year progression risk 4, 8
This patient's minimal curvature falls well below any treatment threshold and does not constitute scoliosis. 2
Common Pitfalls to Avoid
- Do not order repeat imaging without new clinical symptoms 1
- Do not refer to orthopedics for normal anatomical variants 5
- Do not misinterpret minimal curvature as requiring scoliosis monitoring protocols 4, 8, 2
- Do not pursue contrast-enhanced imaging, as the non-contrast study is already comprehensive and unremarkable 1
Documentation and Patient Communication
- The MRI shows no abnormalities requiring treatment
- Minimal spinal curvature is a normal finding in many adults
- No follow-up imaging is needed unless new symptoms develop
- She should return only if she develops progressive neurologic symptoms, severe pain, or other concerning features