Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of congenital thoracic scoliosis identified on [Imaging/Physical Exam]. Parents report [no/presence of] associated symptoms including back pain, respiratory distress, or neurological deficits. No history of rapid progression noted. Family history is [positive/negative] for congenital vertebral anomalies.
Clinical Examination Findings
General: Well-appearing, no dysmorphic features. Spine: Visible lateral curvature in the thoracic region. Adam’s forward bend test reveals a thoracic rib hump on the [right/left]. Neurological: Gait is [normal/abnormal], motor strength 5/5 in all extremities, reflexes 2+ and symmetric, no clonus or pathological reflexes. Skin: No café-au-lait spots or hairy patches noted over the spine.
Treatment Protocol
Plan: 1. Obtain standing AP/Lateral spine radiographs to assess Cobb angle and vertebral anomalies. 2. MRI of the total spine to rule out intraspinal anomalies (e.g., syrinx, tethered cord). 3. Serial clinical and radiographic follow-up every [3/6] months to monitor for curve progression. 4. Referral to pediatric orthopedics for potential bracing or surgical consultation if progression is documented.