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Curvature Disorders

Scoliosis and spinal curvature disorders: diagnostic Cobb angle thresholds, etiology-based classification, and indications for surgical intervention.

Overview

Spinal deformities represent a spectrum of conditions ranging from congenital anomalies to adolescent idiopathic scoliosis, which affects approximately 2% to 3% of children [14]. While congenital scoliosis is typically slowly but relentlessly progressive, other forms exhibit variable progression [5, 8]. The severity of the deformity, rather than its direction, primarily determines the impact on cardiac health in resting patients [1]. In specific syndromes like Noonan syndrome, deformities develop early and tend to be relatively severe [2]. Regardless of etiology, an unacceptable deformity results from congenital scoliosis if active treatment is not administered [5].

Treatment strategies are dictated by the specific diagnosis and patient factors. For congenital scoliosis, the majority of cases are managed non-surgically, while operative intervention relies on fusion, resection, or growth-friendly techniques based on patient age, curve characteristics, and anomaly type [8]. In adolescent idiopathic scoliosis, goals focus on minimizing deformity and maximizing functional outcomes [14]. Surgical correction has shifted from addressing isolated coronal deformity to restoring segmental and global sagittal alignment to achieve optimum long-term results [63]. Recent research provides updated criteria for selecting candidates for selective fusion, emphasizing that selection must be weighed against patient goals and specific factors to limit complications and maximize successful correction [52].

Surgical indications vary by pathology. For kyphotic deformity associated with myelomeningocele, operative intervention is indicated based on clinical manifestations rather than radiographic measurements [10]. In adult Scheuermann kyphosis, surgery is reserved for patients with persistent pain and unacceptable deformity caused by significant kyphosis [28]. Correction and stabilization are also considered beneficial for spinal deformity in familial dysautonomia [24]. Surgical treatment for scoliosis is effective, particularly when motion segments are preserved, and is valuable for limiting curve progression [12]. Successful surgery requires careful selection of the fusion area to include all vertebrae rotated toward the convexity of the major curve, preferably including a neutral unrotated vertebra at each end to prevent distal extension of the curve [6]. Ultimately, scoliosis exerts detrimental effects on patient-reported outcomes, underscoring the value of intervention [12].

Anatomy & Pathophysiology

Osseous and Growth Dynamics

Structural scoliosis arises from asymmetrical vertebral growth driven by pressure-induced epiphyseal growth arrest on the concave side, with rotation and wedging occurring as passive mechanical consequences of this disturbance during skeletal development [83]. In peri-pubertal girls with idiopathic scoliosis, variations in spinal growth velocity exert a more direct influence on angle velocity than height velocity when predicting curve progression [81]. For patients undergoing conservative treatment, Cobb angle, curve type, flexibility, and correction rate serve as strong and consistent predictors of curve progression [77]. While structural variations of the lumbosacral joint are generally not clinically important unless extreme [70], modifications in spinal curvatures during childhood are not large enough to impact surgical planning despite significant changes during skeletal maturity [74].

Cervical and Thoracolumbar Biomechanics

Three distinct morphotypes of the cervical spine have been identified based on C2-C7 alignment and T1 slope [16]. The C2-C3 and C6-C7 segments experience increased mechanical loads in straightened cervical alignment and kyphotic deformity, increasing their susceptibility to facet joint degeneration [73]. Understanding the biomechanical principles of spinal instrumentation and motion coupling is essential for optimizing three-dimensional correction of thoracolumbar deformities and achieving favorable mechanical environments for fusion [34]. In resting patients with severe scoliosis, the severity of the spinal deformity, rather than curvature direction, is the primary determinant of its impact on cardiac health [1].

Soft Tissue and Kinematics

Paraspinal muscle morphology and composition are associated with sagittal spinopelvic alignment [44], and the coronal Cobb angle along with the symmetry index (SI) of paraspinal muscle activity vary with posture changes in adolescent idiopathic scoliosis patients [80]. Altered gait kinetics exist in individuals with scoliosis, characterized by significant differences in ground reaction force and energy cost [68]. Different forms of scoliosis exhibit unique vibrational characteristics, with scoliotic vertebrae acting as weak links under whole-body vibration loading [78]. Forces in zone 3 applied by spinal orthoses neither significantly reduced thoracic kyphosis nor exacerbated the deviation of the scoliotic spine from the sagittal plane [75].

Diagnostic and Modeling Advances

Patient-specific spine digital twins enhance the understanding of scoliosis biomechanics, facilitate risk assessment for disc prolapse, and aid in treatment selection [44]. A deep learning model can accurately and automatically measure spinal alignment parameters with reliable results, significantly reducing diagnostic time for adolescent idiopathic scoliosis [50]. Early screening for incorrect postures and angle of trunk rotation is an effective and economical strategy to predict the severity of adolescent idiopathic scoliosis [54]. Additionally, a novel rabbit model of angular kyphosis provides a reliable platform for investigating the pathophysiology of spinal deformities and evaluating therapeutic interventions [61].

Classification

Severity-Based Impact: In severe scoliosis, the severity of spinal deformity, rather than curvature direction, is the main determinant of its impact on cardiac health [1]. Morphometric characteristics of vertebral bodies differ according to the pathogenesis of scoliosis [18], and the pathology of wedging in idiopathic scoliosis could not be a result only of asymmetric loading to the vertebral bodies [18]. The specific morphology of the scoliotic curvature may manifest by differences in the ATI/Cobb correlation depending on the location of the scoliosis [20], and this correlation changes with age [20].

Scheuermann's Kyphosis: Scheuermann's kyphosis is a rigid structural deformity with a generally benign natural history for mild cases [3]. Mild cases of Scheuermann's kyphosis are successfully treated nonsurgically [3].

Congenital Spinal Deformities: Congenital spinal deformities are caused by defects of formation or segmentation [4]. The natural history and treatment of congenital spinal deformities correspond to the three major patterns of lordosis, kyphosis, and scoliosis [4]. Congenital scoliosis is a spinal deformity with variable progression [8] but is usually slowly but relentlessly progressive [5]. An unacceptable deformity results from congenital scoliosis if active treatment is not given [5]. Treatment for congenital scoliosis is non-surgical in the majority of cases [8] and relies on fusion, resection, or growth-friendly techniques depending on patient age, curve characteristics, and anomaly type [8].

Adolescent Idiopathic Scoliosis (AIS): The current method of classification of adolescent idiopathic scoliosis does not appear to have sufficient intraobserver reliability among scoliosis surgeons to portray curve types accurately [33]. The current method of classification of adolescent idiopathic scoliosis does not appear to have sufficient interobserver reliability among scoliosis surgeons to portray curve types accurately [33]. A new 3D classification has the potential to identify the subtypes of Lenke 1 adolescent idiopathic scoliosis without a need for quantitative 3D image post-processing [46]. Surgical treatment for scoliosis requires careful selection of the fusion area to include all vertebrae rotated toward the convexity of the major curve [6]. Surgical treatment for scoliosis preferably includes a neutral unrotated vertebra at each end of the fusion area to prevent distal extension of the curve [6].

Early-Onset Scoliosis (EOS): A novel classification system for early-onset scoliosis (C-EOS) was developed utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis [38]. All core components of the C-EOS classification system demonstrated substantial to excellent interobserver reliability [38].

Other Considerations: Three morphotypes of the cervical spine have been identified based on C2-C7 alignment and T1 slope [16]. Differences between spinal muscular atrophy types II and IIIa should be taken into consideration when developing new treatments and in management of scoliosis in the childhood years of these patients [45]. Classification of coronal deformity based on preoperative global coronal malalignment for adult spinal deformity is questionable [48]. A chapter on pediatric spine disorders provides a comprehensive overview of idiopathic scoliosis, congenital anomalies, and tumors [9]. The chapter details epidemiology, pathoanatomy, evaluation, classification, and treatment recommendations for pediatric spine disorders based on natural history and existing literature [9].

Clinical Presentation

The clinical impact of spinal deformity is primarily determined by severity rather than curvature direction [1]. In pediatric populations, deformities often present early and with significant severity, particularly in Noonan syndrome [2]. Kyphosis is a common structural abnormality associated with developmental vertebral defects, while congenital deformities arise from formation or segmentation errors [4, 13]. Congenital scoliosis typically follows a slowly but relentlessly progressive course [5], whereas congenital kyphosis and kyphoscoliosis are uncommon but may progress rapidly to cause severe deformity and neurological deficits [7]. Conversely, mild cases of Scheuermann's kyphosis generally follow a benign natural history and respond well to nonsurgical management [3].

Adolescent idiopathic scoliosis is a three-dimensional deformity affecting 2% to 3% of children [14]. Pathologically, vertebral wedging is present in mild cases and increases as the curvature progresses [19], though this wedging cannot be attributed solely to asymmetric loading [18]. The correlation between the angle of trunk inclination (ATI) and Cobb angle varies by curvature location and changes with age [20]. In patients with disproportionate short stature secondary to dwarfing conditions, kyphosis is the most common spinal abnormality, and all such patients exhibit some manifestation of spinal disorder [35]. Similarly, cervical spine abnormalities are frequent in neurofibromatosis, especially in cases with severe scoliosis or kyphoscoliosis, though many remain asymptomatic [36].

Assessment must prioritize neurologic status due to the risk of injury in children with kyphosis [13]. In patients with myelomeningocele, operative intervention is indicated by clinical manifestations rather than radiographic measurements [10]. For congenital thoracic lordosis, early recognition and fusion are recommended due to the severity and progression of the deformity [21]. In mucopolysaccharidoses, the initial severity of kyphosis may predict the progression of thoracolumbar deformity [11]. Therapeutic strategies for early-onset scoliosis must preserve the growing spine and thorax while correcting the deformity [30]. Treatment for congenital scoliosis is non-surgical in the majority of cases [8], but when active treatment is required, it relies on fusion, resection, or growth-friendly techniques based on patient age, curve characteristics, and anomaly type [8]. Pediatric spine disorders broadly include idiopathic scoliosis, congenital anomalies, and tumors [9].

Investigations

Plain radiography: The Cobb angle can be measured accurately and rapidly by summing the tilt angles of the upper and lower end vertebrae [79]. Standing chest radiographs are utilized to study thoracic side curvature in normal spines [69], though clinicians must exercise caution when applying thresholds across different modalities and positions for scoliosis diagnosis and assessment [55]. In preoperative adolescent idiopathic scoliosis (AIS), biplanar low-dose stereoradiography and computed tomography can largely represent scoliotic curvatures despite differences in body positioning [71]. Routine radiographs offer low utility in guiding treatment for asymptomatic pediatric patients following scoliosis surgery [57].

MRI: A routine MRI evaluation is warranted for infantile and juvenile patients with "presumed idiopathic" scoliosis if they are under 10 years of age, male, or present with a left thoracic or right lumbar curve [72]. Clinical indicators identify a high-risk adolescent scoliosis population requiring whole-spinal MRI preoperatively to rule out intramedullary abnormalities [66]. MRI measurements may predict cervical alignment, particularly for excluding kyphosis and a sagittal vertical axis (SVA) greater than 40 mm [65]. Additionally, MR images can distinguish histological structures of normal versus malformed spines, showing that malformed vertebrae in mice are accompanied by adjacent intervertebral structures corresponding to fully segmented structures seen in human congenital scoliosis [62].

Other Considerations: The severity of spinal deformity, rather than curvature direction, is the main determinant of its impact on cardiac health in resting patients with severe scoliosis [1]. Vertebral wedging is present in mild scoliosis and increases as the condition progresses [19]. Congenital spinal deformities arise from defects of formation or segmentation, with natural history and treatment patterns corresponding to lordosis, kyphosis, and scoliosis [4]. Congenital kyphosis and kyphoscoliosis are uncommon but may progress rapidly, causing severe deformity and neurological deficits [7]. Early recognition of congenital thoracic lordosis and early spine fusion are recommended for this severe, progressive deformity [21]. In patients with myelomeningocele, operative intervention for kyphotic deformity is indicated by clinical manifestations rather than radiographic measurements [10]. Severity of kyphosis at initial presentation may predict the progression of thoracolumbar deformity in mucopolysaccharidoses [11]. Clinical and radiographic assessment with careful follow-up is necessary for early detection and treatment of spinal deformities in Noonan syndrome due to their early development and relative severity [2]. Mild cases of Scheuermann's kyphosis generally follow a benign natural history and are successfully treated nonsurgically [3].

Treatment

Non-Operative

Mild cases of Scheuermann's kyphosis have a generally benign natural history and are successfully treated nonsurgically [3]. Nonsurgical treatment can be an effective early management strategy in delaying or even precluding the need for surgery, especially surgery with growing instrumentation, in early-onset scoliosis [56]. If a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely [41]. When a patient with scoliosis has back pain, a careful history, thorough physical examination, and good-quality plain radiographs should be performed; if initial evaluation reveals normal findings, a diagnosis of idiopathic scoliosis can be made and non-operative treatment initiated [53]. Surgical stabilization of the spine in infantile developmental thoracolumbar kyphosis with segmental subluxation can be reserved for severe progressive deformities unresponsive to conservative treatment [49].

Operative

Indications: The primary indications for operative intervention in kyphotic deformity associated with myelomeningocele are the clinical manifestations of the deformity rather than radiographic measurements [10]. Surgical intervention for adult Scheuermann kyphosis is indicated in patients with persistent pain and unacceptable deformity caused by significant kyphosis [28]. Surgical correction for Scheuermann's kyphosis is indicated for progressive deformity, refractory pain, or neurologic deficit, with strict adherence to fusion levels and correction limits to prevent junctional kyphosis [67]. Scoliosis has detrimental effects on patient-reported outcomes, and treatment is effective in limiting curve progression, particularly when motion segments are preserved [12]. Correction and stabilization of spinal deformity in patients with familial dysautonomia is considered beneficial despite results, supporting continued operative management [24].

Surgical Approach / Technique: Surgical treatment for scoliosis requires careful selection of the fusion area to include all vertebrae rotated toward the convexity of the major curve and preferably to a neutral unrotated vertebra at each end to prevent distal extension of the curve [6]. Treatment for congenital scoliosis is non-surgical in the majority of cases and relies on fusion, resection, or growth-friendly techniques depending on patient age, curve characteristics, and anomaly type [8]. Surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe, and effective [32]. Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis [42]. The convex pedicle screw technique for posterior spinal fusion in adolescent idiopathic scoliosis carries low neurological and vascular risks and achieved satisfactory correction of scoliosis, improved thoracic kyphosis, and normal global sagittal balance with excellent patient satisfaction and functional outcomes [39]. Patients with quadriplegic cerebral palsy and severe lumbar hyperlordosis or lordoscoliosis can be successfully treated with posterior instrumented pedicle screw fusion, achieving satisfactory correction of the deformity with an acceptable rate of complications [40]. A multimodal approach to treating scoliosis in patients with osteogenesis imperfecta achieved a 53% major curve correction with minimal complications over 2-year follow-up [37].

Implant Selection: Sustained spinal correction and favorable patient-reported outcomes for at least 2 years postoperatively were obtained in skeletally mature patients with severe congenital spinal deformities [17]. Fragility of the dystrophic laminae and the risk of injury to a fragile dural ectasia in thoracic lordoscoliosis associated with neurofibromatosis do not exclude the possibility of correcting the deformity [76].

Alignment / Balancing Strategy: Adolescent idiopathic scoliosis is a three-dimensional deformity affecting approximately 2% to 3% of children, with treatment goals aimed at minimizing deformity and maximizing functional outcomes [14]. Successful management of idiopathic scoliosis requires understanding the etiology, natural history, evaluation, and available nonsurgical and surgical management options [15].

Other Considerations: Spinal deformities in Noonan syndrome tend to develop early and are relatively severe, necessitating clinical and radiographic assessment with careful follow-up for early detection and treatment [2]. Congenital scoliosis is usually slowly but relentlessly progressive, resulting in an unacceptable deformity if active treatment is not given [5]. Kyphosis is a common deformity in children associated with developmental structural abnormalities of the vertebral bodies, and assessment of neurologic status is critical due to the risk of injury [13]. The development of proximal junctional kyphosis following spinal fusion for adolescent idiopathic scoliosis or Scheuermann kyphosis has not been shown to lead to a negative clinical outcome [47].

Complications

Natural History and Progression: The severity of the spinal deformity, rather than the curvature direction, is the main determinant of its impact on cardiac health [1]. Severe spinal deformities in Noonan syndrome tend to develop early and are relatively severe [2]. Congenital scoliosis is usually slowly but relentlessly progressive, resulting in an unacceptable deformity if active treatment is not given [5]. In contrast, congenital kyphosis and kyphoscoliosis are uncommon deformities with the potential to progress rapidly; this rapid progression can result in severe deformity and possible neurological deficits [7]. Scheuermann's kyphosis is a rigid structural deformity with a generally benign natural history for mild cases [3].

Long-Term Outcomes and Quality of Life: Scoliosis is a life-long condition with potentially significant poor health-related quality of life scores many years after diagnosis [25]. The detrimental effects of scoliosis on patient-reported outcomes are confirmed by long-term studies [12]. Patients with scoliosis may need to be followed up in a timely and appropriate manner for decades rather than for just a few years [25]. Sustained spinal correction and favorable patient-reported outcomes for at least 2 years postoperatively were obtained in skeletally mature patients with severe congenital spinal deformities [17].

Neurological and Functional Complications: Rapid progression of congenital kyphosis and kyphoscoliosis can result in severe deformity and possible neurological deficits [7]. Thoracolumbar/lumbar convex coronal imbalance in dystrophic scoliosis is prone to persistent postoperative imbalance [58]. Correcting overall sagittal alignment is crucial to prevent compensatory hyperextension and long-term complications in ankylosing spondylitis [59]. Functional benefits of spinal fusion remain unclear in patients with globally involved cerebral palsy, and there are no randomized controlled trials comparing spinal fusion with the natural history of the disease in this population [29].

Other Considerations: The natural history and treatment of congenital spinal deformities correspond to the three major patterns of lordosis, kyphosis, and scoliosis [4]. Congenital spinal deformities are caused by defects of formation or segmentation [4]. Mild cases of Scheuermann's kyphosis are successfully treated nonsurgically [3]. Treatment is valuable for limiting curve progression in scoliosis [12]. Surgical treatment for scoliosis is effective, especially with preservation of motion segments [12]. Surgical treatment for scoliosis requires careful selection of the fusion area to include all vertebrae rotated toward the convexity of the major curve [6]. Surgical treatment for scoliosis preferably includes a neutral unrotated vertebra at each end of the fusion to prevent distal extension of the curve [6]. It is currently impossible to state that bracing effectively alters the natural history of scoliosis in immature patients who are at high risk for progression [82]. Schroth exercises exhibited long-term effects in improving both spinal deformity and quality of life in adolescent idiopathic scoliosis [23]. Correcting the spinal deformity permitted longer-term improvement in pulmonary function in patients with severe early-onset scoliosis [27]. Spinal fusion can arrest deformity progression and improve posture in patients with globally involved cerebral palsy [29].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or desk work in the provided literature. However, successful management of idiopathic scoliosis requires understanding available nonsurgical and surgical management options, which may include early mobilization protocols [15]. For congenital kyphosis and kyphoscoliosis, which can progress rapidly to cause neurological deficits, assessment of neurologic status is critical due to the risk of injury [7, 13].

Full activity (months): The literature does not provide a specific month range for the return to manual work or sport. While spinal fusion can arrest deformity progression and improve posture in patients with globally involved cerebral palsy, functional benefits remain unclear [29]. In contrast, correcting spinal deformity permitted longer-term improvement in pulmonary function in patients with severe early-onset scoliosis [27].

Complete recovery / outcome plateau (months): Sustained spinal correction and favorable patient-reported outcomes were obtained for at least 2 years postoperatively in skeletally mature patients with severe congenital spinal deformities [17]. Scoliosis is a life-long condition with potentially significant poor health-related quality of life scores many years after diagnosis, indicating that patients may need to be followed up in a timely and appropriate manner for decades rather than for just a few years [25]. Patients with idiopathic scoliosis had significantly decreased health-related quality of life and capacity to work 40 years after diagnosis [60].

Rehabilitation protocol: Schroth exercises exhibited long-term effects in improving both spinal deformity and quality of life [23]. Surgical treatment for scoliosis requires careful selection of the fusion area to include all vertebrae rotated toward the convexity of the major curve and preferably to a neutral unrotated vertebra at each end to prevent distal extension of the curve [6]. The sagittal spinal alignment should be considered when assessing the long-term prognosis of patients with reverse total shoulder arthroplasty [51].

Functional milestones: The chief prognostic feature at an early stage of juvenile idiopathic scoliosis was the level of the most rotated vertebra at the apex of the primary curve, and the final pattern of deformity was defined by the level of the caudad neutral vertebra [84]. Severity of kyphosis at initial presentation may predict progression of thoracolumbar deformity in patients with mucopolysaccharidoses [11]. The severity of spinal deformity, rather than curvature direction, is the main determinant of its impact on cardiac health [1].

Other Considerations: Spinal deformities in Noonan syndrome tend to develop early and are relatively severe, necessitating clinical and radiographic assessment with careful follow-up for early detection and treatment [2]. Mild cases of Scheuermann's kyphosis have a generally benign natural history and are successfully treated nonsurgically [3]. Congenital spinal deformities have a natural history and treatment corresponding to the three major patterns of lordosis, kyphosis, and scoliosis [4]. The natural history of idiopathic scoliosis may be becoming more benign spontaneously [22].

Key Evidence

  • [L3] The severity of the spinal deformity, rather than the curvature direction, is the main determinant of its impact on cardiac health. (10.1186/s13018-025-06113-3)
  • [L4] Since the deformities tend to develop early and are relatively severe, a clinical and, if necessary, radiographic assessment of the spine with careful follow-up should be performed for early detection and treatment of spinal deformity. (10.2106/00004623-200110000-00006)
  • [L5] Scheuermann's kyphosis is a rigid structural deformity with a generally benign natural history for mild cases, which are successfully treated nonsurgically. (10.5435/jaaos-d-17-00748)
  • [L5] Congenital spinal deformities are caused by defects of formation or segmentation, with the natural history and treatment corresponding to the three major patterns of lordosis, kyphosis, and scoliosis. (10.2106/00004623-199602000-00020)
  • [L4] Congenital scoliosis is usually slowly but relentlessly progressive, and an unacceptable deformity results if active treatment is not given. (10.2106/00004623-196850010-00002)
  • [L5] Surgical treatment for scoliosis requires careful selection of the fusion area to include all vertebrae rotated toward the convexity of the major curve and preferably to a neutral unrotated vertebra at each end to prevent distal extension of the curve. (10.2106/00004623-196648010-00017)
  • [L3] Congenital kyphosis and kyphoscoliosis are uncommon deformities with the potential to progress rapidly, resulting in severe deformity and possible neurological deficits. (10.2106/00004623-199910000-00002)
  • [L5] Congenital scoliosis is a spinal deformity with variable progression; treatment is non-surgical in the majority of cases and relies on fusion, resection, or growth-friendly techniques depending on patient age, curve characteristics, and anomaly type. (10.1530/eor-21-0121)
  • [L4] The primary indications for operative intervention are the clinical manifestations of the deformity rather than the radiographic measurements. (10.2106/00004623-199409000-00004)
  • [L3] Severity of kyphosis at initial presentation may predict progression of thoracolumbar deformity. (10.1302/0301-620x.98b2.36144)
  • [L4] The study confirms the detrimental effects of scoliosis on patient-reported outcomes, the value of treatment to limit curve progression, and the effectiveness of surgical treatment, especially with preservation of motion segments. (10.2106/jbjs.18.00180)
  • [L5] Successful management of idiopathic scoliosis requires understanding the etiology, natural history, evaluation, and available nonsurgical and surgical management options for these patients. (10.5435/00124635-200602000-00005)
  • [L4] We have identified 3 morphotypes of the cervical spine based on C2-C7 alignment and T1 slope. (10.2106/jbjs.19.01384)
  • [L3] Sustained spinal correction and favorable patient-reported outcomes for at least 2 years postoperatively were obtained in skeletally mature patients with severe congenital spinal deformities. (10.1186/s13018-025-06421-8)
  • [L3] Morphometric characteristics of vertebral bodies differed according to the pathogenesis of scoliosis, and the pathology of the wedging of vertebral bodies in idiopathic scoliosis could not be a result only of asymmetric loading to the vertebral bodies. (10.1186/s12891-017-1801-0)
  • [L4] Vertebral wedging was present in mild scoliosis and increased as the scoliosis progressed. (10.1371/journal.pone.0071504)
  • [L3] The specific morphology of the scoliotic curvature may manifest by differences in the ATI/Cobb correlation depending on the location of the scoliosis and change with age. (10.1186/s12891-022-05878-6)
  • [L4] Early recognition of the diagnosis and early spine fusion are recommended treatment for this severe and progressive deformity. (10.2106/00004623-197860060-00014)
  • [L4] The results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously. (10.2106/00004623-199609000-00006)
  • [L1] Meanwhile, Schroth exhibited long-term effects in improving both spinal deformity and quality of life. (10.1186/s12891-024-08223-1)
  • [L4] Despite these results, the authors believe correction and stabilization of spinal deformity in these patients is beneficial and plan to continue operative management. (10.2106/00004623-199509000-00012)
  • [L5] Scoliosis is a life-long condition with potentially significant poor health-related quality of life scores many years after diagnosis, indicating that patients may need to be followed up in a timely and appropriate manner for decades rather than for just a few years. (10.1302/0301-620x.105b2.bjj-2022-1298)
  • [L4] Correcting the spinal deformity permitted longer-term improvement in pulmonary function in patients with sEOS. (10.2106/jbjs.22.01088)
  • [L5] Surgical intervention is indicated in patients with persistent pain and unacceptable deformity caused by significant kyphosis. (10.5435/00124635-201202000-00007)
  • [L5] It notes that while spinal fusion can arrest deformity progression and improve posture, there are no randomized controlled trials comparing fusion with the natural history of the disease, and functional benefits remain unclear. (10.2106/jbjs.n.00468)
  • [L4] This review elucidates early-onset scoliosis in terms of its aetiology, pathogenesis, pathology and treatment, highlighting that therapeutic strategies must preserve the growing spine and thorax while correcting deformity. (10.1186/s13018-023-03665-0)
  • [L3] Scoliosis developing in children with idiopathic short stature receiving growth hormone therapy predominantly manifests as mild curvature. (10.1186/s13018-025-06224-x)
  • [L4] Surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective. (10.1302/0301-620x.95b11.31376)
  • [L4] The current method of classification of adolescent idiopathic scoliosis does not appear to have sufficient intraobserver or interobserver reliability among scoliosis surgeons to portray curve types accurately. (10.2106/00004623-199808000-00002)
  • [L5] Understanding the biomechanical principles of spinal instrumentation and motion coupling is essential for optimizing three-dimensional correction of thoracolumbar spinal deformities and achieving favorable mechanical environments for fusion. (10.5435/jaaos-d-24-01156)
  • [L4] All patients with disproportionate short stature secondary to a dwarfing condition had some manifestation of a spinal disorder, with kyphosis being the most common abnormality. (10.2106/00004623-198163090-00007)
  • [L4] Cervical spine abnormalities are common in patients with neurofibromatosis, particularly those with severe scoliosis or kyphoscoliosis, and many are asymptomatic. (10.2106/00004623-197961050-00007)
  • [L4] This study demonstrated the effectiveness and safety of a multimodal approach to treating scoliosis in patients with OI, achieving a 53% major curve correction with minimal complications over 2-year follow-up. (10.5435/jaaos-d-23-00889)
  • [L4] Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. (10.2106/jbjs.m.00253)
  • [L4] The convex pedicle screw technique carries low neurological and vascular risks and achieved satisfactory correction of scoliosis, improved thoracic kyphosis, and normal global sagittal balance with excellent patient satisfaction and functional outcomes. (10.1302/0301-620x.99b8.bjj-2016-1351.r1)
  • [L4] Patients with CP and severe lumbar hyperlordosis or lordoscoliosis can be successfully treated with posterior instrumented pedicle screw fusion, achieving satisfactory correction of the deformity with an acceptable rate of complications. (10.1302/0301-620x.96b6.33020)
  • [L2] If a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely. (10.2106/jbjs.18.00483)
  • [L4] Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. (10.1302/0301-620x.103b7.bjj-2020-2162.r1)
  • [L5] This modeling approach enhances the understanding of scoliosis biomechanics, facilitating risk assessment for disc prolapse and aiding in treatment selection. (10.1186/s13018-024-05417-0)
  • [L4] The differences between the two SMA types II and IIIa described in this study should be taken into consideration when developing new treatments and in management of scoliosis in the childhood years of these patients. (10.1186/1471-2474-14-283)
  • [L4] The new 3D classification has the potential to identify the subtypes of the Lenke 1 AIS without a need for quantitative 3D image post-processing. (10.1186/s12891-020-03798-x)
  • [L4] To date, the development of proximal junctional kyphosis has not been shown to lead to a negative clinical outcome following spinal fusion for adolescent idiopathic scoliosis or Scheuermann kyphosis. (10.5435/jaaos-d-14-00143)
  • [L3] Classification of coronal deformity based on preoperative GCM is questionable. (10.1186/s12891-022-05246-4)
  • [L4] Surgical stabilisation of the spine can be reserved for severe progressive deformities unresponsive to conservative treatment. (10.1302/0301-620x.97b7.35665)
  • [L4] This deep learning model can accurately and automatically measure spinal alignment parameters with reliable results, significantly reducing diagnostic time, and might provide the potential to assist clinicians. (10.1186/s13018-025-05620-7)
  • [L3] The sagittal spinal alignment should be considered when assessing the long-term prognosis of patients with rTSA. (10.1016/j.jse.2024.10.017)
  • [L5] Recent research provides updated criteria to determine optimal candidates for selective fusion, which must be weighed against patient goals and patient-specific factors to limit complications and maximize chances of successful deformity correction. (10.5435/jaaos-d-21-01175)
  • [L3] When a patient with scoliosis has back pain, a careful history, thorough physical examination, and good-quality plain radiographs should be performed; if initial evaluation reveals normal findings, a diagnosis of idiopathic scoliosis can be made and non-operative treatment initiated. (10.2106/00004623-199703000-00007)
  • [L3] Early screening for incorrect postures and angle of trunk rotation could be an effective and economical strategy to predict the severity of the condition. (10.1186/s13018-024-04767-z)
  • [L1] Clinicians should be careful when utilizing the thresholds for standing radiographs across other modalities and positions for diagnosis and assessment of scoliosis. (10.1530/eor-23-0032)
  • [L4] Nonsurgical treatment can be an effective early management strategy in delaying or even precluding the need for surgery, especially surgery with growing instrumentation. (10.5435/jaaos-d-14-00019)
  • [L4] Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. (10.2106/jbjs.l.01357)
  • [L4] Thoracolumbar/lumbar convex coronal imbalance in dystrophic scoliosis is prone to persistent postoperative imbalance. (10.1186/s12891-022-05321-w)
  • [L4] The authors suggest that correcting overall sagittal alignment is crucial to prevent compensatory hyperextension and long-term complications. (10.1302/0301-620x.95b2.29554)
  • [L3] In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis. (10.1302/0301-620x.105b2.bjj-2022-0897.r1)
  • [L5] It provides a reliable platform for investigating the pathophysiology of spinal deformities and evaluating therapeutic interventions. (10.1186/s13018-025-06220-1)
  • [L5] MR images could be used to distinguish the histological structures of normal and malformed mouse spines, and malformed vertebrae were accompanied by adjacent intervertebral structures that corresponded to the fully segmented structures observed in human congenital scoliosis, but the intervertebral conditions varied. (10.1186/s12891-024-07460-8)
  • [L5] The focus of surgical correction has shifted from isolated coronal deformity to include restoration of segmental and global sagittal alignment to achieve optimum long-term results. (10.1302/0301-620x.100b4.bjj-2017-0846.r2)
  • [L3] MRI measurements may be predictive of cervical alignment, especially for the exclusion of kyphosis and SVA > 40 mm. (10.3390/ijerph182413033)
  • [L3] These clinical indicators suggest that there is a high-risk adolescent scoliosis population who should undergo whole-spinal MRI preoperatively to rule out intramedullary abnormalities. (10.1186/s12891-020-3182-z)
  • [L5] Surgical correction is indicated for progressive deformity, refractory pain, or neurologic deficit, with strict adherence to fusion levels and correction limits to prevent junctional kyphosis. (10.5435/00124635-199801000-00004)
  • [L1] This systematic review and meta-analysis provide evidence of altered gait kinetics in individuals with scoliosis, highlighting significant differences in GRF and energy cost. (10.1186/s12891-025-08941-0)
  • [L4] Measurements of standing chest radiographs were used to study the thoracic side curvature in normal spines. (10.1186/1749-799x-6-4)
  • [L4] The findings eliminate structural variations of the lumbosacral joint as being of clinical importance except when extreme, contradicting commonly accepted opinions regarding posterior displacement and facet inclination. (10.2106/00004623-195941050-00012)
  • [L3] Findings suggested that scoliotic curvatures in preoperative AIS patients can be largely represented by both imaging modalities despite the difference in body positioning. (10.1186/s12891-020-03561-2)
  • [L3] Thus, a routine MRI evaluation appears warranted for those patients if aged less than 10 years, being male or having left thoracic or right lumbar curve. (10.1186/s12891-016-1026-7)
  • [Paper] The C2-C3 and C6-C7 segments are subjected to increased mechanical loads in straightened cervical alignment and kyphotic deformity, thereby increasing their susceptibility to facet joint degeneration. (10.1186/s12891-025-09285-5)
  • [L4] Despite significant changes during skeletal maturity, the modifications in spinal curvatures are not large enough to be considered in clinical practice and to impact surgical planning. (10.2106/jbjs.22.00977)
  • [L4] Notably, only forces in zone 3 neither significantly reduced thoracic kyphosis nor exacerbated the deviation of the scoliotic spine from the sagittal plane. (10.1186/s12891-024-08014-8)
  • [L4] Fragility of the dystrophic laminae and the risk of injury to a fragile dural ectasia are reasons for concern, but they do not exclude the possibility of correcting the thoracic lordosis associated with this disease. (10.2106/00004623-198567050-00025)
  • [L2] Strong and consistent evidence supports Cobb angle, curve type, flexibility, and correction rate as predictors of curve progression. (10.1302/0301-620x.104b4.bjj-2021-1677.r1)
  • [L5] Different forms of scoliosis exhibit different vibrational characteristics, with scoliotic vertebrae acting as weak links under whole body vibration loading. (10.1186/s12891-019-2728-4)
  • [L4] The scoliosis Cobb angle can be measured accurately and rapidly using the principle of the Cobb angle being equal to the sum of tilt angles of the upper and lower end vertebra, where in the film data of imaging will not be easily contaminated. (10.1186/s13018-018-0928-5)
  • [L3] The coronal Cobb angle and the SI of paraspinal muscle activity in AIS patients vary with posture changes. (10.1186/s12891-024-07329-w)
  • [L3] Variations of spinal growth velocity exerted more direct influence over changes in angle velocity as compared with height velocity. (10.1186/s12891-016-1221-6)
  • [L4] It is currently impossible to state that bracing effectively alters the natural history of scoliosis in immature patients who are at high risk for progression. (10.2106/00004623-199604000-00009)
  • [L5] Structural scoliosis is caused by asymmetrical vertebral growth resulting from pressure-induced epiphyseal growth arrest on the concave side of the curve, with rotation and wedging occurring as passive mechanical consequences of this growth disturbance during the period of skeletal development. (10.2106/00004623-194931030-00007)
  • [L4] The chief prognostic feature at an early stage was the level of the most rotated vertebra at the apex of the primary curve, and the final pattern of deformity was defined by the level of the caudad neutral vertebra. (10.2106/00004623-199608000-00003)

See Also

References

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[2] Spinal Deformities in Noonan Syndrome. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200110000-00006

[3] Scheuermann's Kyphosis: Diagnosis, Management, and Selecting Fusion Levels. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00748

[4] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Congenital Spinal Deformity†. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199602000-00020

[5] Congenital Scoliosis A Study of 234 Patients Treated and Untreated. The Journal of Bone & Joint Surgery. 1968. DOI: 10.2106/00004623-196850010-00002

[6] Surgical Management of Scoliosis. The Journal of Bone & Joint Surgery. 1966. DOI: 10.2106/00004623-196648010-00017

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[13] Chapter 34 Kyphosis. 2020.

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[36] Cervical spine abnormalities in neurofibromatosis.. The Journal of Bone & Joint Surgery. 1979. DOI: 10.2106/00004623-197961050-00007

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[40] The surgical treatment of lordoscoliosis and hyperlordosis in patients with quadriplegic cerebral palsy. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b6.33020

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[46] Three-dimensional classification of the Lenke 1 adolescent idiopathic scoliosis using coronal and lateral spinal radiographs. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03798-x

[47] Proximal Junctional Kyphosis Following Spinal Deformity Surgery in the Pediatric Patient. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00143

[48] The classification of coronal deformity based on preoperative global coronal malalignment for adult spinal deformity is questionable. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05246-4

[49] Infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b7.35665

[50] A deep learning model for radiological measurement of adolescent idiopathic scoliosis using biplanar radiographs. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05620-7

[51] Global kyphosis of the spine influences the range of motion and deterioration of internal rotation after reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.10.017

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b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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