What assessment and treatment should be undertaken for a 23‑year‑old female with dextro‑convex thoracic and levoconvex lumbar scoliosis and worsening chronic back pain after a fall from a horse three years ago?

Assessment and Treatment for Post-Traumatic Scoliosis with Chronic Pain

This 23-year-old female requires comprehensive imaging with standing PA and lateral spine radiographs to measure Cobb angles and assess curve severity, followed by MRI of the complete spine given her atypical presentation of new-onset scoliosis after trauma with worsening pain, as this raises concern for underlying spinal pathology that must be excluded before initiating conservative management. 1

Initial Imaging Assessment

Standing radiographs of the complete spine (PA and lateral views) are the essential first step to quantify the degree of deformity and exclude congenital vertebral anomalies. 1 The Cobb angle measurement from these films will determine curve severity and guide all subsequent management decisions. 1

Critical Red Flags Requiring MRI

This patient has multiple concerning features that mandate MRI evaluation:

• New-onset scoliosis in a young adult following trauma is atypical and requires exclusion of intraspinal pathology 1
• Functionally disruptive pain is a recognized risk factor for neural axis abnormalities, with 2-4% of adolescents with scoliosis harboring intrinsic spinal cord anomalies (Chiari I malformation, syrinx, cord tethering, or tumor) 1
• Post-traumatic presentation raises concern for occult fracture, ligamentous injury, or secondary structural changes 2

The history and physical examination demonstrate only 62% accuracy for diagnosing intraspinal anomalies, and a negative neurologic examination does not predict a normal MRI. 1 Therefore, MRI of the complete spine is strongly indicated before proceeding with any treatment plan. 1

Treatment Algorithm Based on Curve Severity

If Cobb Angle <20-25 degrees:

Conservative management is the primary approach:

• Nonpharmacologic interventions are first-line treatment including exercise therapy, physical therapy, spinal manipulation, and heat therapy 2
• NSAIDs are the initial pharmacologic choice if nonpharmacologic measures are insufficient 2, 3
• Activity modification and patient education about avoiding bed rest 2
• Serial radiographs are not typically needed in skeletally mature patients unless clinical progression occurs 1

If Cobb Angle 25-40 degrees:

• Continue aggressive conservative management as above 4, 5
• Consider orthoses for pain control, though evidence in adults is limited 3
• Avoid epidural steroid injections, facet injections, and radiofrequency ablation as recent high-quality guidelines issued strong recommendations against these interventions for chronic axial spine pain 1
• Monitor for progression with repeat radiographs only if symptoms worsen 1

If Cobb Angle >40-50 degrees:

• Skeletally mature patients with thoracic curves exceeding 50 degrees may progress approximately 1 degree per year 1
• Surgical evaluation should be considered only if there is persistent functional disability despite conservative management, progressive deformity, or neurologic compromise 4, 5
• Flexibility assessment with side-bending or supine radiographs may be obtained for surgical planning if intervention is being considered 1

Critical Management Pitfalls to Avoid

Do not pursue interventional procedures such as epidural injections, facet blocks, or radiofrequency ablation, as the 2025 BMJ clinical practice guideline issued strong recommendations against these for chronic axial and radicular spine pain based on lack of effectiveness. 1

Do not delay MRI imaging in this patient given the atypical presentation of new-onset adult scoliosis following trauma with progressive pain—this is not typical idiopathic scoliosis and requires exclusion of secondary causes. 1, 4

Do not prescribe long-term opioids, as evidence is inconclusive for their benefit in chronic low back pain, and they carry significant risks. 2

Pain Management Specifics

For this patient's chronic pain component:

• NSAIDs are first-line pharmacologic therapy 2, 3
• Duloxetine may provide additional benefit for chronic low back pain 2
• Evidence does not support routine use of muscle relaxants, benzodiazepines, or long-term corticosteroids 2
• Focus on active therapies (exercise, physical therapy) rather than passive modalities 2

Follow-Up Strategy

Once imaging is complete and secondary causes are excluded, treatment intensity should be guided by the Cobb angle measurements, functional disability level, and pain severity. The goal is to optimize function and quality of life through conservative measures, reserving surgical consultation only for those with severe curves (>50 degrees) and persistent disability despite comprehensive conservative management. 4, 5