What is the recommended management for an otherwise asymptomatic adult with mild right‑sided thoracic dextroscoliosis and increased thoracic kyphosis, without significant disc disease, central canal narrowing, or neural foraminal stenosis?

Management of Asymptomatic Mild Dextroscoliosis with Increased Thoracic Kyphosis in Adults

For an asymptomatic adult with mild right-sided thoracic dextroscoliosis and increased thoracic kyphosis, without disc herniation, canal stenosis, or foraminal narrowing, observation with clinical monitoring is the appropriate management—no active treatment, bracing, or surgery is indicated. 1

Clinical Context and Rationale

Your imaging findings confirm no structural compromise requiring intervention—specifically, the absence of disc herniation, central canal stenosis, and neural foraminal stenosis means there is no compressive spinal pathology that would necessitate surgical consultation or advanced imaging at this time. 1

Key Management Principles

Observation is appropriate because:

• Mild curves in skeletally mature adults do not meet surgical thresholds. Surgical intervention is typically reserved for curves exceeding 50 degrees due to progression risk of approximately 1 degree per year even after skeletal maturity. 1, 2

• Absence of symptoms eliminates the primary indication for intervention. Without pain, neurologic deficits, myelopathy, or radiculopathy, there is no functional impairment requiring treatment. 3

• No compressive pathology on imaging. The explicit absence of disc herniation, canal stenosis, and foraminal narrowing rules out structural causes that would warrant surgical consideration. 1

Monitoring Strategy

For skeletally mature adults with mild curves:

• Radiographic surveillance is not routinely indicated unless symptoms develop or there is documented progression. 1 The guidelines for serial imaging (every 12-18 months) apply primarily to skeletally immature patients at risk for progression. 1

• Clinical follow-up should focus on symptom development, particularly new-onset pain, neurologic changes, or functional limitations. 3

When to Escalate Care

Obtain MRI thoracic spine without IV contrast if any of these red flags develop:

• New or progressive myelopathic symptoms (gait instability, hyperreflexia, positive Babinski sign, bladder dysfunction). 3
• Radicular symptoms (dermatomal pain, weakness, sensory changes). 3
• Functionally disruptive pain not responding to conservative measures. 1
• Documented curve progression despite skeletal maturity. 2

Increased Thoracic Kyphosis Considerations

The increased thoracic kyphosis noted on your imaging warrants attention to quality of life:

• Thoracic hyperkyphosis (>45 degrees) correlates with increased pain, lower self-image, and decreased function more strongly than scoliosis magnitude alone (correlation coefficients 0.40-0.66 versus 0.16-0.26 for scoliosis). 4

• However, increased kyphosis alone in asymptomatic patients does not indicate neural axis abnormalities. A study of 210 consecutive AIS patients found no significant association between thoracic kyphosis magnitude and neural axis abnormalities (17.9% in hypokyphosis, 9.8% in normal kyphosis, 13.6% in hyperkyphosis, p=0.60). 5

• Monitor for symptoms such as back pain, postural fatigue, or cosmetic concerns that may affect quality of life, as these would prompt consideration of physical therapy or postural interventions. 4

Common Pitfalls to Avoid

Do not assume progression will occur simply because kyphosis is increased. In skeletally mature adults without symptoms, curves typically stabilize, and the increased kyphosis does not independently predict neural axis abnormalities or require MRI evaluation. 5

Do not order routine MRI in asymptomatic patients with right thoracic curves and no red flags. Even in adolescents with right thoracic curves, neural axis abnormalities occur in only 6.8%, and the primary risk factors are increased rotation and kyphosis in the context of symptomatic presentation. 6 In asymptomatic adults with confirmed absence of compressive pathology, MRI adds no value. 3

Do not initiate bracing in skeletally mature adults. Bracing is indicated only for skeletally immature patients with progressive curves, not for adults with stable deformities. 1

Practical Algorithm

1. Confirm skeletal maturity (which is established in adults).
2. Document absence of symptoms (pain, neurologic deficits, functional limitations).
3. Review imaging for compressive pathology—your imaging shows none. 1
4. Reassure the patient that observation is appropriate and intervention is not needed.
5. Advise return for evaluation if new symptoms develop (pain, weakness, numbness, gait changes, bowel/bladder dysfunction).
6. No routine radiographic follow-up is required unless symptoms emerge or clinical examination suggests progression. 1