Isolated painless scoliosis in lumbar disc herniation

To the Editor,

Painful scoliosis and lumbar disc herniations (LDHs) are well documented in the pediatric, adolescent, and young adult populations.[1-3] However, isolated painless scoliosis and LDH rarely occur together and are often misdiagnosed as idiopathic scoliosis for long periods of time.

CASE REPORT

A 24-year-old male presented with a 12-month history of progressive scoliosis and difficulty walking without spinal or radicular pain. For the past several months, he had been misdiagnosed as having idiopathic scoliosis and was being treated with bracing and physical therapy without any improvement. On examination, he had a significant scoliotic deformity (i.e., tilt to the left) with a reduced range of lumbar motion and/muscle spasm restricting right lateral flexion [Figure 1]. He had no other focal neurological deficits. Plain radiographs showed a primary right lumbar curve (Cobb angle 30° and 70 mm deviation) without a rotational spinal deformity [Figure 2a]. The spinal CT scan and MR studies showed a right paramedian LDH at the L4–L5 level [Figure 2b-d]. Following a conventional right L4–L5 open discectomy, the “deformity” resolved, and the patient was neurologically intact demonstrating no recurrent symptoms 2 years later [Figure 3].

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Figure 1:: Appearance of the patient’s back before surgery without (a) and with bracing (b).

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Figure 2:: Anteroposterior plain radiograph of the thoracolumbar spine showing a primary right lumbar curve (Cobb angle 30° and 70 mm deviation) without rotational spinal deformity (a), axial lumbar spinal computed tomography scan (b), axial (c), and sagittal T2- weighted images (d) demonstrating a right paramedian lumbar disc herniation at L4–L5 level.

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Figure 3:: Appearance of the patient’s back the day after surgery. Note the spontaneous correction of scoliosis.

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CONCLUSION

In the pediatric, adolescent, and young adult populations, and acute LDH should be ruled out with MR studies as potential causes of and/or contributing to “deformity” before assigning a diagnosis of thoracolumbar scoliosis.