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. 2019;39(1):85–88.

Acute Onset Atypical Severe Scoliosis: A Case Report

Luca Labianca 1,2,3, Cosma Calderaro 1,2,✉, Stuart L Weinstein 1
PMCID: PMC6604548  PMID: 31413680

Abstract

Background:

Although most cases of scoliosis are idiopathic, scoliosis may also be congenital or associated with other diseases. Herniated Nucleus Pulposus (HNP) has been reported as a potential cause of non-structural scoliosis. HNP is unusual in adolescents and the clinical features are typically different from those in adults.

Case Presentation

An 18-year-old Caucasian male was referred to our ambulatory service for evaluation of scoliosis after orthopedic evaluation at another center. He had noticed left-sided low back pain in the previous 6 months, which had worsened over the last two months with the development of limp and left lower extremity (LLE) paresthesias. After an accurate clinical evaluation, the acute onset of the curvature with mild back pain and associated neurological findings were suggestive of an intraspinal lesion. The MRI examination showed an L4-L5 HNP compressing L4 nerve root and displacing the distal L5 nerve root. An L4-L5 laminectomy and discectomy were performed. His left leg pain was completely relieved the day after surgery. At 3 months follow-up complete resolution of scoliosis deformity and return to full activity was achieved.

Conclusions:

Every child who presents with atypical scoliosis should have a complete physical examination and appropriate imaging studies seeking an underlying cause.

Level of Evidence: V

Keywords: herniated nucleus pulposus, scoliosis, atypical scoliosis, acute onset scoliosis, MRI, laminectomy, discectomy

Introduction

Adolescent idiopathic scoliosis (AIS) is a musculoskeletal disorder of unknown etiology.1-3 Idiopathic scoliosis has standard recognizable patterns.3 Although most cases of scoliosis are idiopathic, scoliosis may also be congenital or associated with neuromuscular diseases, spondylolysis/ spondylolisthesis, infections, syringomyelia, syndromes, and tumors.4-14

Herniated Nucleus Pulposus (HNP) has been reported as a potential cause of postural, non-structural scoliosis.15-18 HNP is unusual in adolescents and the clinical features are typically different from those in adults and there are only a few studies in the literature about scoliosis secondary to HNP.19-21

The rapid development of a severe curve in the presence of back pain and neurological features, suggests non-idiopathic scoliosis.22-25 We report a rare case of an otherwise healthy 18-year-old male presenting with the acute onset of atypical severe scoliosis due to HNP.

Case Presentation

An 18-year-old Caucasian male was referred to our ambulatory service for evaluation of scoliosis after orthopedic evaluation at another center. He had noticed left-sided low back pain in the previous 6 months, which had worsened over the last two months with the development of limp and left lower extremity (LLE) paresthesias. He had also noticed a truncal shift, which had not been present previously. His discomfort was never severe enough to require medication, and he had never undergone physical therapy.

The clinical examination showed a left-sided thoracic rib prominence with a significant truncal shift to the right. He had level shoulders and pelvis, normal strength in all muscle groups, intact sensation and symmetric abdominal and deep tendon reflexes; Babinski’s manuever resulted in plantarflexion of the toes. Supine straight leg raise (SLR) however was positive on the left side, with radicular symptoms at 20 degrees of hip flexion.

Standing scoliosis films showed 37° right long atypical thoracic curve, and 33° left thoracolumbar curve, with loss of lumbar lordosis. There was a significant right truncal shift. He was a Risser stage 5 (Fig. 1).

Figure 1.

Figure 1

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Standing x-rays demonstrating an atypical right thoracic curve measuring 37°, and a left thoracolumbar curve measuring 33°, with a significant truncal shift to the right, The patient also has loss of normal sagittal contours. The patient is Risser 5.

Clinical and radiological findings suggested a secondary cause of scoliosis. Therefore, an MRI was performed. The MRI showed an L4-L5 left paracentral HNP compressing L4 nerve root and displacing the distal L5 nerve root (Fig. 2).

Figure 2.

Figure 2

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MRI T2-weighted shows herniated nucleus pulposus (HNP) with superimposed central/left paracentral disc protrusion at the L4-L5 level which likely contacts the exiting left L4 nerve root and posteriorly displaces the distal descending left L5 nerve root.

Due to his neurological symptoms and the severity of the curve, an L4-L5 laminectomy and discectomy were performed. His left leg pain was completely relieved the day after surgery. At 3 months follow-up complete resolution of scoliosis deformity and return to full activity was achieved (Fig. 3).

Figure 3.

Figure 3

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Standing scoliosis films obtained at the three months follow-up show almost a complete resolution of scoliosis.

Discussion

This case report represents the most severe atypical scoliosis case secondary to an HNP reported in the literature.21 The acute onset of the curvature in association with mild back pain and neurological findings were suggestive of an intraspinal lesion causing scoliosis.

Our patient was referred to us by another orthopedic surgeon with an AIS diagnosis and asking us to provide for treatment.

Pain may be a warning sign in patients presenting with a scoliosis curve, as most patients complain of little or no discomfort. 22-25 Ramirez reported mild back pain in 23% out of 2442 patients diagnosed for AIS and 9% of them resulted in a different etiologic condition.22 Likewise, progression rate, onset age, neurological symptoms, and signs should raise the index of suspicion for a non-idiopathic etiology.4-14 In these cases, MRI is the most useful adjunctive diagnostic tool.4,26-28

The diagnosis in this patient was problematic for the initial evaluator because of the patient’s lack of significant pain and failure to check the SLR in the face of severe scoliosis as well as the uncommon occurrence of HNP in adolescents.21,25,29

The etiology, pathophysiology, and patterns of the scoliotic posture in cases secondary to HNP remain debated. Zhu hypothesized that the trunk shift on the opposite side of the HNP reduces the weight-bearing on the involved leg, improving the symptoms of the nerve root irritation.21 Finneson speculated that the opposite trunk shift allows decreasing the nerve root compression. Conversely, Suk hypothesized that the trunk shift side is opposite to the HNP side and not related to the inflammation.30-31

HNP in children and adolescents are less responsive to non-operative management with pharmacologic and physical therapy18,32-35 and are more likely to undergo surgery with reported good to excellent results.15,32,36

Conclusion

We present here a case of an HNP in an adolescent with a secondary severe atypical scoliosis misdiagnosed as AIS. This case exemplifies that every child who presents with atypical scoliosis should have a complete physical examination and appropriate imaging studies seeking an underlying cause.

List of Abbreviations

AIS: A Adolescent idiopathic scoliosis

HNP: Herniated Nucleus Pulposus

LLE: Left lower extremity

SLR: Straight Leg Raising Test

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