An 11-year-old boy is seen at the office for a routine health screening examination before
entering 6th grade. He has no complaints and is generally in very good health, the parents tell
you. He has had a recent growth spurt that eliminated the marginal obesity present on the prior
physical examination, and he is now in the 95th percentile for both height and weight. The
patient's vital signs are within normal limits and the only abnormality is a slight discrepancy in
the shoulder level-the right shoulder seems to be about half an inch higher than the left
shoulder when he stands up. Which of the following is the most appropriate way to screen this
patient for scoliosis?
A. Adams test
B. Myelogram of the spinal canal
C. Neurosurgical evaluation
D. Pulmonary function testing
E. Radiographs of the spine
E. Radiographs of the spine
a? screening for scoliosis is Adams
Ever since she was a toddler a girl was nagged by her mother to stand up straight. As she became older she had little interest in sports because of shortness of breath. She also constantly complained that the shorts and slacks her mother purchased for her were shorter in one leg than the other. In the sixth grade at the age of 12 years, a school nurse asked her to strip to the waist and bend forward at a 90º angle while she looked at her back. On the basis of this examination the nurse called in her parents to recommend that the girl see an orthopedic surgeon. Which of the following is the most likely diagnosis suspected by the nurse?
A: Ankylosing spondylitis
B: Pott's disease of the spine
C: Idiopathic scoliosis
D: Osteomyelitis
E: Neurofibromatosis
answer
The nurse suspects that the patient has idiopathic scoliosis (choice C). The school screening test for this disorder is called the Adam's forward-bending test. By assuming this near 90º bent position, abnormal lateral curvature (S or C shape) of the spine is easy to observe. Confirmation is generally made by an imaging study in which the degree of curvature is determined by a geometrical process called the Cobb method. A curvature greater than 25º is considered significant, greater than 45“50º is considered severe. In the United States, the prevalence of scoliosis greater than 25º is 1.5 cases per 1000; most states have mandatory screening by a school nurse by the 5th or 6th grade. Scoliosis is most commonly idiopathic and often is first diagnosed in adolescent girls from 10 to 16 years of age. Scoliosis refers to lateral displacement of the spine, while kyphosis refers to forward displacement (e.g., hunchback) of the spine. A third type of unusual spinal shape is called lordosis (aka sway back); this is not considered pathologic as long as the back remains flexible.
Pott's disease of the spine (choice B) refers to tuberculosis involving the vertebral column. Ankylosing spondylitis (choice A) is a human leukocyte antigen (HLA)-B27“positive arthropathy that is more common in men. Sacroiliitis and fusion of the spine (bamboo spine) are prominent features of this disease. Forward bending of the spinal column becomes increasingly more pronounced as the disease progresses. Osteomyelitis (choice D) does not typically produce spinal abnormalities. Neurofibromatosis (choice E) is associated with kyphoscoliosis; however, café au lait spots are likely to be present as well.