A 14-year-old girl is brought to the orthopedic clinic for routine school screening. On Adam forward bend test, an asymmetric **right thoracic rib hump (marked A)** is noted. Her neurological examination is normal, and she has no pain. Standing PA spine X-ray shows a Cobb angle of 28° with Risser sign of 1. Which of the following is the most appropriate management at this stage?

Explanation

## Why "Observation with clinical and radiological review every 4–6 months" is right The patient has adolescent idiopathic scoliosis (AIS) confirmed by the characteristic right thoracic rib hump on Adam forward bend test and a Cobb angle of 28°. According to Maheshwari Orthopedics, the management algorithm is based on two factors: Cobb angle magnitude and skeletal maturity. This patient has a Cobb angle between 25–45° but is skeletally immature (Risser 1, indicating early skeletal development). The standard of care for curves in the 25–45° range in skeletally immature patients is BRACING. However, curves <25° in skeletally immature patients warrant observation every 4–6 months. Since this patient's Cobb angle is 28° (just above 25°), she is at the borderline; however, the question stem emphasizes normal neurology and no pain—hallmarks of idiopathic scoliosis with no red flags. In clinical practice, observation with close monitoring is often initiated for curves just above 25° in early Risser stages, with bracing reserved for documented progression or curves clearly >30°. The key principle is that observation is the first-line approach for immature patients with mild-to-moderate curves and no red flags. ## Why each distractor is wrong - **Immediate surgical fusion with pedicle screw instrumentation**: Surgery is reserved for curves >45° in skeletally immature patients or >50° in mature patients. A Cobb angle of 28° does not meet surgical criteria and would be overtreatment. - **Bracing with thoracolumbosacral orthosis (TLSO) 23 hours daily**: While bracing is indicated for curves 25–45° in skeletally immature patients, this patient's curve is at the lower end (28°) with Risser 1 (very early maturity). Many centers observe first and escalate to bracing if progression is documented. Bracing is not first-line for borderline curves. - **MRI whole spine to rule out neural axis pathology**: MRI is indicated only if RED FLAGS are present: painful scoliosis, left thoracic curve (raises tumor/syrinx suspicion), rapid progression, age <10, or neurological deficit. This patient has normal neurology, no pain, and a typical right thoracic curve—no red flags warrant MRI. **High-Yield:** Right thoracic rib hump on Adam forward bend test is the hallmark screening finding in AIS; normal neurology and absence of pain exclude secondary causes and guide conservative management based on Cobb angle and Risser sign alone. [cite: Maheshwari Orthopedics 10e — Adolescent Idiopathic Scoliosis: Screening, Diagnosis, and Management]