Two years ago, I discovered previously undocumented scoliosis in a girl, aged 7 years. Her primary-care physician agreed with my recommendation to send her to an orthopedist.
The girl’s parent has told me that the orthopedist seemed unconcerned and merely told her to come back if there is a problem. Recently, the girl returned to my clinic complaining of ankle pain. On examination, it appeared that the scoliosis had worsened (4° to 6° increase on x-ray). I am sending her back to the orthopedist but am worried about the possibility of such other underlying problems as neurofibromatosis.
What should I be looking for if she is only advised to wear a brace? It is my understanding that there are usually other problems when scoliosis occurs at such an early age. — Kathleen Ambrose, MSN, CFNP, Allentown, Mich.
It is hard to determine the degree of curvature in this girl’s spine given the information provided. Therefore, I also cannot determine whether it needs any treatment. It would be ideal if you could communicate your concerns directly to the orthopedist and ask for an explanation of his or her opinion. Communication between consulting physicians and patients is not always optimal, and misunderstandings do occur.
Neurofibromatosis-1 (NF-1) occurs in approximately 10% of patients with early-onset scoliosis. Precocious puberty can also be associated with NF-1, so it is important to assess this variable as well, especially since it will be necessary to follow the patient’s curve progression closely during the pubertal growth spurt. Early-onset scoliosis is not the only sign required for diagnosis of NF-1, and such cutaneous manifestations as café au lait spots or axillary freckling are usually present as well.
Other rare genetic syndromes (e.g., Angelman) can also be associated with early scoliosis. If any suspicion of a syndrome exists, a genetic referral might be helpful. However, it is also possible that your patient has a slight congenital scoliosis that may or may not continue to progress and, depending on skeletal maturation, needs treatment only once it reaches a certain point. Discuss this with the referring orthopedist. If you get an unsatisfactory answer, send your patient for a second opinion. — Julee B. Waldrop, DNP (172-1)
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