Disability and Rehabilitation, 2008; 30(10): 742 – 751

Evaluation of scoliosis today: Examination, X-rays and beyond

TOMASZ KOTWICKI

Department of Paediatric Orthopaedics and Traumatology, University of Medical Sciences of Poznan, Poland
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

Abstract
Purpose. The purpose of this paper is to provide an overview of the techniques of evaluation of patients, suffering from
idiopathic scoliosis.
Methods. The presentation is provided, concerning the medical history, clinical examination, conventional radiography,
stereo-radiography, surface topography, ultrasounds, computer tomography, and magnetic resonance imaging, focusing on
the points specific for the pathology of idiopathic scoliosis.
Results. Use of the scoliometer became systematic in the clinical evaluation. Quality of life questionnaires, including those
endorsed by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), oriented towards scoliotic
patients, gain on popularity and are extremely helpful to objectively evaluate the disability related to scoliosis. Classical
radiography serves as the basic exam to determine the curve type and magnitude. Ultrasounds, computer tomography and
For personal use only.

magnetic resonance imaging are indicated in precisely defined clinical situations. Stereo-radiography and surface topography
seem to be the most promising techniques, however requiring standardisation.
Conclusions. Apart from sophisticated measurements, the experience of a physician cannot be underestimated. High
standard clinical evaluation will probably continue to serve as a reference for other methods of assessment of patients with
scoliosis. Stereo-radiography and surface topography deserve common use, after standardization is achieved.

Keywords: Idiopathic scoliosis, evaluation of deformity, clinical examination, radiological examination, stereo-radiography,
surface topography

vertebrae and the ribs, as well as by shortening

Definition
and contractures of the adjacent soft tissues.
Idiopathic scoliosis is a developmental deformity of Therefore, time is the fourth dimension of idiopathic
the spine and of the whole trunk. The etiology is scoliosis.
unknown. The nature is three-dimensional (3-D). Definition of the Scoliosis Research Society [3]:
There exists: (i) A lateral spinal curvature in the Scoliosis – lateral deviation of the normal vertical line
frontal plane, (ii) a disturbance of physiological of the spine which, when measured by X-ray, is
spinal curvatures in the sagittal plane, and (iii) an greater than ten degrees. Scoliosis consists of a lateral
axial rotation of vertebrae in the transverse plane. curvature of the spine with rotation of the vertebrae
The development of the deformity occurs in the within the curve.
three planes simultaneously. Idiopathic scoliosis
appears in the growing spine. In the initial stages
Aims of the examination
stability, regression or deterioration are possible.
Once a certain degree of curvature develops, a The principal aim of the examination of a child
mechanical vicious cycle imposes scoliosis progres- presented at the physician with the suspicion of
sion [1,2]. The periods of progression are strictly scoliosis is to get answers to the three questions [4]:
related to the periods of rapid spinal growth. The (i) Is it scoliosis? (meaning a structural 3-D
initial 3-D spatial displacements of vertebrae are deformity of the spine), (ii) is it idiopathic scoliosis?,
followed by the 3-D disturbances of the shape of the and (iii) what is the risk of progression?

Correspondence: Tomasz Kotwicki, Department of Paediatric Orthopaedics and Traumatology, University of Medical Sciences of Poznan, Poland.
E-mail: [email protected]
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2008 Informa UK Ltd.
DOI: 10.1080/09638280801889519
 Evaluation of scoliosis today 743

discrepancy compensated with a lift. For unclear

History
situation around the pelvis (torsional deformity of
The parents are asked when the scoliosis was first the iliac spines, hip joint contracture, sacroiliac
noted and by whom, and how it has been treated junction’s pathology) the exam may be performed
before. The child’s developmental history and family in the sitting position. General neurological exam-
history are asked. The date of menarche is noted in ination is recommended; a detailed exam is
girls. Back pain is not typical for idiopathic scoliosis mandatory if any neurological abnormalities are
and requires a detailed examination. Pathology of the suspected.
gait, limbs, hearing, vision, heart, or the urinary Facing the patient, the asymmetries are easily
system indicate that scoliosis may be a part of a observed: head, shoulders, waist position, lower
syndrome. limbs alignment. Searching for the possible cause
of scoliosis, the skin consistency and joint laxity are
tested, skin pigmentation, facial dysmorphy, dental
Questionnaires
and palatine abnormalities are observed. Thorax
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

Structured questionnaires investigating the health- mobility is assessed by observing chest expansion
related quality of life rightly become more and more during deep breathing. Certain characteristic pheno-
popular, as they place the patient as the subject and types are considered: Marfan syndrome (tall, thin
not the object in the centre of the therapeutic subjects with increased arm span, high arched palate
process. The questionnaires collect the data on and arachnodactyly), Ehlers-Danlos syndrome (im-
disability of patients with scoliosis [5]. General portant joint hyperlaxity, hyperextensible fragile skin
health instruments (SF-36) [6] or questionnaires tissue, facial dysmorphy).
related to the low back pain (Oswestry) [7] have been From the side, the physiological spinal curvatures
applied to patients with scoliosis after bracing or are examined. Sagittal distances from the plumb line
surgical treatment [8], however, the scoliosis specific to the back may be noted at the cervical, thoracic,
questionnaires (SRS-22) have been constructed [9], lumbar and sacral levels [17], or the curvatures may
For personal use only.

and then progressively refined [10]. New instru- be assessed with a plurimeter. Observing from the
ments oriented towards conservative management side the child’s back during forward flexion is a
were proposed by Vasiliadis and Grivas [11], as well sensitive way of detecting local thoracic hypokypho-
as by the Bad Sobernheim team [12], to be applied in sis, which can be present in a beginning thoracic
clinical situations [13,14]. The health-related ques- scoliosis (Figure 1B), and of eliminating the
tionnaires will probably gain in importance. Lenke Scheuermann’s juvenile kyphosis. Pectoralis major
et al. stressed: ‘Although most decisions for mana- shortening is detected by the range of the shoulder
ging idiopathic scoliosis are based on the coronal flexion in the upright position. In forward flexion, the
Cobb angle measurement of the curve, the patient is distance from the tip of the fingers to the floor may
often more concerned with his or her cosmetic be assessed, serving as approximate measure of
appearance, especially the degree of rib hump spinal flexibility and of hamstring muscles short-
deformity’ [15]. ening, the latter is precisely determined in supine
position by measuring the popliteal angle. Muscle
shortening in extremities is not the sign of idiopathic
Clinical examination
scoliosis but of common superposed postural
The child is to be examined, not the scoliosis. The defects; muscle shortening may also be found in
child should get undressed for clinical examination. non-idiopathic scoliosis.
On the one hand, the naked child, embarrassed by From behind the trunk, asymmetries usually
the situation, will not adapt a habitual posture. On become evident and are systematically noted:
the other hand, the covers prevent observing the gait Shoulders, scapulae, waists. The lumbo-sacral region
and dynamic posture when the cultural and social is checked to rule out any suspicion of spinal
contexts are respected. Examination of the pubertal dysraphism. Trunk balance is assessed with the
stage (pubic hair and breast development) according plumb line placed from the tip of the C7 spinous
to Tanner’s staging [16], which has to be done in process or from the external occipital tuberosity. Left
the pre-menarchial adolescent girls with progressive or right imbalance is measured in centimetres at the
scoliosis, is a test of the physician’s gentleness. The natal cleft level. Thorax imbalance is checked with
patient’s weight, height and sitting height should be left and right plumb lines falling from the posterior
noted. axillary fold; their distance from the great trochanter
Observing the child while walking is helpful in is measured at each side, and both distances are
assessing the global posture. Then standing upright compared. Structured charts and clinical indices are
normal posture is watched from the front, back and a way to systematize the results of the clinical
sides. The pelvis should be level, lower limbs examination and to study its reliability. Zaina et al.
 744 T. Kotwicki

proposed the TRACE index which converts the curves: proximal thoracic, main thoracic, thoraco-
quantitative observations into a numerical scale [18]. lumbar or lumbar (Figure 2).
Examination of the symmetry of the back in Grosso and Negrini found a good inter-observer
forward flexion (Adams’ test [19]) is essential repeatability (0.9) for the hump height clinical
(Figure 1A). The trunk flexion is being performed measurement and the angle of trunk rotation (0.86)
progressively; the observer can stop it at any degree in 116 patients [20]. The correlation between the
to measure the trunk inclination with a scoliometer. ATR and the Cobb seems better in the thoracic than
The term ‘rib hump’ is rejected by many clinicians in the lumbar spine [21], and better in aged scoliotics
and replaced with rib prominence or trunk inclina- than in younger children [22]. One should also
tion (rotation). The angle of trunk inclination (ATI), consider the variations of trunk asymmetry in normal
called also the angle of trunk rotation (ATR), is the population [23]. Most widely used scoliometers were
parameter of the high clinical value, comparable to constructed by Bunnell [24] and by Pruijs [25].
the value of the radiological angle of Cobb. It is Traditional assessment with a ruler is also possible,
recommended to measure the ATR at three levels of and sometimes advantageous in big curves. Exam-
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

the spine, corresponding to the location of structural ination in forward bending enables us to detect the
For personal use only.

Figure 1. Adams’ forward bending test is sensitive in detecting trunk rotation (A). Observation of the spinal alignment made from the side is
helpful in the assessment of the sagittal curvatures. In this patient, the beginning thoracic scoliosis was responsible for limitation of flexion of
the lower thoracic spine (B).

Figure 2. The use of the scoliometer enables quantification of the trunk deformity. The normal range of back asymmetry up to 3 degrees is
observed. The values of 4 to 6 degrees require repeated examination every 3 to 6 months during the phase of the rapid growth spurt. It is
necessary to assess the trunk deformity at least at three levels: proximal thoracic (A), main thoracic (B), thoracolumbar/lumbar (C).
 Evaluation of scoliosis today 745

number of curvatures, their location, the side of Th12 or L1 or the disc Th12/L1, a lumbar scoliosis
convexity. Adams’ test serves for scoliosis screening; from L2 to L4. The scoliosis is right or left,
it may be regularly practised by parents of adolescent depending on the side of the convexity. Identification
girls. Scoliosis flexibility assessment is another key of primary and secondary curvatures is essential; it
measure for both conservative and operative treat- may be largely facilitated by comparing the radio-
ment; it is clinically assessed by lateral bending or graph with the clinical exam.
shifting of the trunk, by gentle passive traction, or by The curve magnitude is assessed by measuring the
direct palpation. angle of scoliosis on the radiograph. The Cobb
method [29] is widely accepted, as the simplest;
actually it reflects only the tilt of the two limit
Radiological examination
vertebrae, without giving any information on the
Classical radiography is still the most important curve length, the vertebral rotation or lateral trans-
imaging of scoliosis. Frontal and lateral standing position of the apex. Variations in the Cobb angle
radiographs are taken in normal (non-corrected) measurements comprise mean difference of 2.4
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

posture. For the frontal plane radiograph, the degrees between the antero-posterior and the
postero-anterior projection is reported advantageous postero-anterior films [30]; the differences of about
comparing to the antero-posterior one, because of 2.0 – 3.0 degrees are reported for the intra-observer
the lower irradiation of the breasts and the thyroid and inter-observer rates [26,31]. There is a con-
[26]; the concomitant increase of bone marrow sensus that differences of less than + 5.0 degrees,
exposition is considered relatively unimportant. compared to the previous radiograph, do not have
Digital radiography offers good image resolution; clinical significance. Detecting curve progression
the exposition seems to be reduced. A long cassette needs at least 6 degrees of difference [32].
(90 cm) allows visualization of the cervical, thoracic The spine rotation is assessed on the frontal
and lumbar spine, the thorax and the pelvis. If the radiograph by measuring vertebral axial rotation,
hip joints are visible, the accurate lower limbs length usually at the apical level. The method of assessing
For personal use only.

may be determined. Lower limbs discrepancy should the relative position of the shadows of vertebral
be compensated with a shoe lift before the radio- pedicles versus the shadow of the vertebral body was
graph is taken. Lateral radiograph is technically proposed by Nash and Moe [33], then developed to
demanding because the upper limbs cover the the current measure by Perdriolle [34]. Drerup [35]
thoracic spine and have to be taken away; they and Raimondi [36] proposed other ways of quantify-
usually repose on a special support or against the ing the pedicle position.
homolateral clavicles [27]; the habitual posture Evaluating curve flexibility with radiography is as
should be maintained. important, as doing it with the clinical exam. Side,
The analysis of the frontal radiograph can begin bending radiographs can be made in a standing or in
with drawing a central vertical sacral line (CVSL), supine position. Traction X-ray is practised before
passing through the centre of the sacrum [28]. surgical treatment.
Structural spinal curvatures usually cross this line. After the analysis of the frontal radiograph, the
In idiopathic scoliosis the spinal curvature is harmo- findings may be summarized in a short formula, for
nious and gently goes through the adjacent curva- example: Idiopathic single right thoracic scoliosis
tures; sharp curvatures are typical for congenital from Th5 to Th12 of 34 degrees of Cobb angle and
anomalies. There may be one or two, or exception- 15 degrees of Perdriolle angle of vertebral axial
ally three, primary structural curvatures, and two rotation.
compensatory curvatures – one below and the other The analysis of the lateral radiograph is the object
above the structural ones. The upper and the lower of more controversy than the frontal one, because the
limit vertebrae are the last vertebrae inside the scoliotic deviation is superposed on the normal
curvature; they are situated close to the CVSL, are sagittal curvatures. The thoracic kyphosis and
most tilted, least deformed and usually present no lumbar lordosis are measured with angles similar to
axial rotation. The apical vertebra is most distant the Cobb method [37], Th4 or Th5 is often taken at
from the CVSL, most rotated and most deformed the proximal level of thoracic kyphosis, because they
but not tilted. If there are two apical vertebrae, the are usually the highest well visible vertebrae. The
curve apex is situated in the intervertebral disc in segmental sagittal analysis, seeking for local distur-
between. Defining the apical vertebra is the basis of bances of thoracic kyphosis, seems to be a promising
scoliosis nomenclature. For example, a cervicothor- procedure [38]. Particular attention is paid to the
acic scoliosis has the apex at the level of the junctional zones, especially to the thoracolumbar
cervicothoracic junction (C7 or Th1 or the disc junction [39,40]. A harmonious sagittal profile is of
C7/Th1), a thoracic scoliosis has the apex at the level great value as a result of therapy. The pelvic
from Th2 to Th11, a thoracolumbar scoliosis at incidence is a somewhat sophisticated but important
 746 T. Kotwicki

parameter, which can be measured on the lateral

radiograph, as proposed by Duval-Beaupere [41]. It
is the angle between the line perpendicular to the
upper plate of the first sacral vertebra, drawn from its
centre, and the line joining this point with the centre
of the bi-coxo-femoral axis. Grivas et al. pay
attention to the double contour of the posterior ribs,
which is an additional variable to quantify thorax
asymmetry [42].
Estimation of the residual spinal growth is crucial
to establish prognosis, it is based on radiography.
Bone age is assessed from the hand and wrist
radiograph [43]. Pelvic tri-radiate cartilage closes at
the age of 11 years in girls, while all cartilages of the
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

elbow joint close at the age of 13, shortly before

menarche [44]. Observation of the appearance of the Figure 3. Three-dimensional radiological analysis of scoliosis may
secondary ossification centres of bones is a good be facilitated with computed reconstruction of digitized images of
the frontal and the lateral spinal radiograph (stereoradiography).
indicator of skeletal maturation. Development of the Direct visualization of the transverse plane deformity (top view) is
iliac bone apophysis, quantified by Risser [45], provided and the vertebral rotation can be accurately assessed.
became a universally accepted sign. There exist six Scoliosis conservative or surgical treatment outcome can be
stages, from zero to five, denoting the course of the analyzed for the quality of the 3D correction of the spinal
apophysis from the anterior to the posterior iliac deformity.
spine, and then the fusion with the iliac bone,
however, the stages 3 and 4 are differently described
in some European publications [46]. In infantile film is a simple technique, advocated by Graf and
For personal use only.

scoliosis the prognosis may be supported by measur- Hecquet, who applied it firstly to the assessment of
ing the rib-vertebra angle of Mehta [47]: the line infantile scoliosis [53]; this technique has been used
joining the head and the neck of the apical rib makes by the author for studying the pathomechanism of
an angle with the vertical axis of the apical vertebra; scoliosis [38], the effect of brace [54] or of the
difference of the concave minus the convex angle, surgical treatment results [55]. The Montreal team
which is superior to 20 degrees, was reported to proposed a more sophisticated technique, compris-
indicate a progressive infantile scoliosis. The rib- ing simultaneous frontal and lateral digital radio-
vertebra angles can be studied at any thoracic level in graph capturing. The image acquisition is effectuated
order to get a better description the thorax in a specially designed frame for controlling the
shape [48]. position of the patient, and includes an additional 20
degrees inclined projection, to recapture the rib cage.
This technique could be successfully applied for
Stereoradiography
various clinical issues [56,57]. Stereoradiography
Traditional plane radiography currently is and provides a novel top view of the spine, shows the
probably will remain the basic examination of plane of the maximum deformity, the real (3-D)
children with spinal deformities, because it provides angle of scoliosis, as well as the spinal balance in the
information on both the displacement and the three planes. It should certainly be learned by
deformation of the vertebral column; moreover the medical professionals of scoliosis care.
X-ray film is a practical and durable data carrier,
the exam is easily available, not expensive, and
both the medical professionals and the patients
Surface topography
maintain that they know to read a radiograph.
Stereoradiography or computer-aided reconstruction Surface trunk asymmetry measurements are very differ-
of the 3-D, based on a frontal and a lateral ent than radiographic measurements.
radiographs, has been developed for last 30 years, M.A. Asher & B.J. Manna, 1999 [58]
being an important step from the one-plane to the
three-planes assessment [49 – 51]. The frontal and Surface topography is a general term to denote
the lateral views are digitized from classical X-ray techniques, which nowadays consist in capturing an
films or may be produced as originally digitized optical image of the surface of the trunk of the
images. Due to the direct linear transformation [52] patient, and in automatic processing it, in order to
or other non-linear algorithms, the transverse plane produce parameters objectively describing the ex-
is visualized (Figure 3). Digitizing the standard x-ray ternal body shape. Cosmetic appearance is the first
 Evaluation of scoliosis today 747

preoccupation of every adolescent consulted for (ii) the videocamera recording and (iii) the automatic
scoliosis, moreover the technique is non-invasive, image analysis are developed. The commercialized
precise, sensitive, and has been systematically devel- equipments differ in the technique of image acquisi-
oped for more than 30 years. However, its clinical tion, the degree of resolution, the scanning time, the
significance stays far behind theoretical capabilities. degree of automation and the parameters proposed
The lack of standardization, the hypersensitivity with by the software. Irrespective the type of the hard-
deficient specificity, charges of the hardware, which ware, the detailed configuration of the body surface
needs a specialized staff and occupies a separate is reproduced, with the precision sufficient for
room, cannot completely explain nor justify the clinical usefulness. The aim of the surface topogra-
deficiency in utilization of this technique, potentially phy is to quantify the severity of trunk deformity.
capable to improve the care of patients. Petit, Aubin Usually, only the posterior aspect of the trunk is
and Labelle suppose: ‘Because surgeons are so analyzed, and only the standing upright relaxed
familiar with Cobb angle measurements on radio- position is used.
graphs, the introduction of new surface shape In fact, excessive number of parameters provided
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

measures whose meaning may not be readily by the software is a difficulty. All the distances and
apparent to clinicians has been difficult’ [59]. the angles can be unnecessarily measured. Reducing
When debating on the role of the surface the information noise seems to be the challenge for
topography in the evaluation of the body morphol- further clinical research. The parameters useful in
ogy in children with idiopathic scoliosis, one should the author’s experience are: the POTSI index and
begin with rejecting the dogma of the radiological the Hump Sum. The POTSI is an indicator
Cobb angle, as the only gold standard for scoliosis proposed by Suzuki et al. [66,67] for a compre-
evaluation. The dissociation between the radio- hensive quantification of the frontal plane asymme-
graphic versus the surface measures has been tries of the back. It is a sum of six indices,
demonstrated. Thulbourne and Gillespie showed describing the asymmetry of the shoulders, waists,
that the rib hump does not always follow the Cobb axillas and C7 position (Figure 4). The ideal back
For personal use only.

angle [60]. Asher and Manna stated that surgical symmetry (POTSI ¼ 0) is uncommon, the values of
reduction of the Cobb angle does not always result POTSI below 27.5 were reported to be within
in reduction of trunk asymmetry [58]. Hackenberg normal limits; the intra-observer error of 5.5 and
reported that operative correction of radiological the inter-observer error of 6.4 were reported [66].
vertebral rotation of 40%, stable in a 1.5-year The POTSI, as well as parallelly proposed Trunk
follow-up was combined with the loss of the surface Distortion [68], are not affected by growth, because
rotation correction (measured with raster-stereogra- they are based on angles or ratios of lengths; they
phy) from the initial 36 – 28% [61]. The initial can be calculated even after a simple photo of
hopes for surface topography aimed to substitute the back of the patient. The Hump Sum is a
the Cobb angle, and describe the spinal deformity surface topography parameter quantifying the trans-
without exposing the patient to ionizing radiation. verse plane asymmetry of the back. It is a sum of
However, as stated by Goldberg et al., the surface three hump indices, corresponding to the three
and the X-rays ‘are not measuring the same aspect levels of the spine: the proximal thoracic, the main
of the deformity’ [62]. Knowledge of the fact that thoracic and the thoracolumbar or lumbar. Thus,
various patients, each having a 50 degrees Cobb the Hump Sum may be compared to the measures
angle right single thoracic scoliosis, may present a made at three levels of the spine with a scoliometer
various sagittal profile, a various rib hump seize, [69]. Publications of Asher et al., concerning the
and a various trunk balance – is a part of a common issues of the durability of clinical improvement after
experience of clinicians. One cannot find a ratio- surgical correction [70], and the influence of
nale, why the Cobb angle – a radiological measure, surface parameters on the quality of life question-
which describes exclusively the tilt of two vertebrae naire responses [71], are the examples of utilization
(reduced to the frontal plane shadow), should be of the POTSI and the Hump Sum. Surface
taken as a reference for other non-radiological topography is helpful in assessing the changes of
parameters. the back shape after brace treatment [72].
The physical basis of image capturing has been New interesting measures are being proposed,
described [63,64]. The raster-stereography techni- however, more experience is necessary to formulate
que seems to be commonly used. It originates from any opinion. Goldberg et al. proposed quantifying
Moire images [65], which have a form of fringes and the left-right asymmetry of the back by a calculation
which can be constructed, due to light waves made at the three levels, each in between the two
diffraction and interference, by simple projection of points, corresponding in relation to the median
a lighted grid on the body surface. Currently, (i) the sagittal plane; the X, Y and Z vectors are created in
projection of an optic raster (a pattern of lines), order to fully describe the back asymmetry [73].
 748 T. Kotwicki
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

Figure 4. POTSI index summarizes trunk asymmetries expressed on the surface of the back in the frontal plane. It should be mentioned that
this index can be calculated from an ordinary photography, as well. However, surface topography equipment is needed for capturing and
calculation of the 3D parameters describing surface deformity.

Minguez et al. proposed the deformity in the axial

plane index (DAPI) which consists of comparing
left-right asymmetry of the back in the transverse
For personal use only.

plane, at the level of the most protruding points of

the scapulae and at the deepest lumbar lordosis; the
line joining the tip of the spinous process of the C7
vertebra with the top of the intergluteal furrow,
serves as the reference line for left-right asymmetry
calculations; the value of DAPI inferior than 3.9%
was reported as normal [74]. The assessment of the
surface deformity in the sagittal plane seems to be the
most difficult and needs further research. This
difficulty is rather not a defect of the surface
topography technique, but signifies general insuffi-
cient capability to perform a comprehensive assess- Figure 5. Computer tomography enables a direct view inside the
ment of the sagittal plane of the scoliotic deformity, transverse plane deformity of patients with scoliosis. Both
regardless the method applied: clinical, radiological, vertebra displacement (rotation) and the intra-vertebral
or surface topography. Complete trunk visualization deformation (distortion) are studied. The rib cage deformity
can be assessed.
(anterior and posterior aspect) was found to be
useful for brace manufacturing [75]. Combined
technique for simultaneous surface and radiological
evaluation was proposed by Poncet et al., including used ultrasounds to measure rotation of the vertebrae
four laser cameras on a mounting ring to scan the and ribs [77]. The advantages of the sonographic
entire torso, combined with a stereo-radiographical exam comprise: Voluntary patient’s positioning and
imaging device and supplied with special software real time monitoring. However, the scoliometer,
[76]. Certainly, more input from the clinicians which is attached to the ultrasound head, imposes
would be beneficial to standardize the surface the measures in the prone position, as advocated by
topography. Burwell et al. [78]. More research is needed to
evaluate the usefulness of sonographic exam in
idiopathic scoliosis.
Ultrasounds
Ultrasounds penetrate soft tissues, but are halted by
Computer tomography
the osseous structures, therefore the acoustic shadow
of the posterior elements of the spine (the spinous It enables direct visualization of the transverse
processes and the laminae) is observed. Kirby et al. plane of both the spine and the thorax which is
 Evaluation of scoliosis today 749
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

Figure 6. Magnetic resonance imaging detects abnormalities of the central nervous system in scoliotic patients which are apparently healthy.
In this patient, clinical examination supported idiopathic aetiology of scoliosis (A). Spinal radiography showed non fused laminae at Th12
level (B, C). MRI revealed a tethered spinal cord at the lumbar level (D).

essential to study the phenomena of rotation and

Conclusion
distortion [79]. 3-D reconstructions are helpful in
the evaluation of congenital vertebrae malformations After a short panorama of the techniques of evalua-
For personal use only.

before surgical treatment. In idiopathic scoliosis the tion of the patient referred for scoliosis, one should go
scanning or the whole trunk imposes excessive back to the three questions initially asked. Apart from
irradiation; the selected slices visualize the apical sophisticated measurements, the experience of a
zone, the transient zones and the pelvis (Figure 5). physician cannot be underestimated. Dubousset
The basic parameters are: the angle of rotation of the discussed the findings revealed during the ‘first exam
vertebra to the sagittal plane and to the midline, of a child with scoliosis’ [4], comprising a history, a
introduced by Aaro and Dahlborn [80]. In surgical careful clinical evaluation and a standard X-ray.
management of idiopathic scoliosis, the computer Dubousset maintained that at this first visit: in 90% of
tomography is used to reveal the placement of cases the future curve progression can be confirmed
spinal implants, and to assess the quality of spinal or excluded; in 10% only the regular checking is
arthrodesis. needed to establish prognosis. Such a proportion
seems to be difficult to obtain with any of the above
presented imaging techniques. Unfortunately, the
Magnetic resonance imaging
experience is not directly transmittable to other
Detecting abnormalities in the vertebral canal, professionals. A high standard clinical evaluation will
namely in the nervous system, is the primary probably continue to serve as a reference for other
application. Abnormal neurological examination or methods of assessment of patients with scoliosis.
unusual curve pattern (left thoracic) oblige to
perform an MRI. The Chiari malformation, the
syringomyelia and the tethered spinal cord are References
sought; important spinal cord pathologies, such a 1. Stokes IAF, Burwell RG, Dangerfield PH. Biomechanical
diastematomyelia may be suspected already after spinal growth modulation and progressive adolescent
clinical and radiological exams, they are assessed scoliosis – a test of a ‘vicious cycle’ pathogenetic hypothesis:
with the MRI (Figure 6). Summary of an electronic focus group debate of the IBSE.
Scoliosis 2006;1:16.
The main inconvenience of the computer tomo- 2. Hawes MC, O’Brien JO. The transformation of spinal
graphy and of the magnetic resonance imaging in the curvature into spinal deformity: Pathological processes and
study of scoliosis is the horizontal position of the implications for treatment. Scoliosis 2006;1:3.
patient, which eliminates both the gravity force and 3. Scoliosis Research Society: Definitions of Scoliosis Terms.
the proprioception dependent postural reflexes. Accessed 15 September 2007 from the website: http://www.
srs.org
Axially loaded MRI partially solves this issue [81] 4. Dubousset J. Premier examen d’un enfant scoliotic. In:
however, the trunk balance cannot be studied, unless Duparc J, editor. Ortho-pediatrie 1. Paris: Expansion
the standing MRI is applied. Scientifique Francaise 1991:1 – 11.
 750 T. Kotwicki

5. Negrini S, Grivas TB, Kotwicki T, Maruyama T, Rigo M, 26. DeSmet AA. Radiology of spinal curvature. St Louis: Mosby;
Weiss HR. Why do we treat adolescent idiopathic scoliosis? 1985.
What we want to obtain and to avoid for our patients. 27. Horton WC, Brown CW, Bridwell KH, Glassman SD,
SOSORT 2005 Consensus Paper. Scoliosis 2006;1:4. Suk Se-Il, Cha CW. Is there an optimal patient stance for
6. Ware JE, Sherbourne CD. The MOS 36-item short-form obtaining a lateral 3600 radiograph? A critical comparison of
health survey (SF-36). I. Conceptual framework and item three techniques. Spine 2005;30:427 – 433.
selection. Med Care 1992;30:473 – 483. 28. Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH,
7. Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry Lowe TG, Blanke K. Adolescent idiopathic scoliosis: A new
low back pain disability questionnaire. Physiotherapy 1980; classification to determine extent of spinal arthrodesis. J Bone
66:271 – 273. Joint Surg 2001;83-A:1169 – 1181.
8. Danielsson AJ, Wiklund I, Pehrsson K, Nachemson AL. 29. Cobb JR. Outline for the study of scoliosis. AAOS Instr
Health-related quality of life in patients with adolescent Course Lect 1948;5:261 – 275.
idiopathic scoliosis: A matched follow-up at least 20 years after 30. DeSmet AA, Goin JE, Asher MA, Scheuch HG. Clinical
treatment with brace or surgery. Eur Spine J 2001;10:278 – 288. study of the differences between the scoliotic angles measured
9. Haher TR, Gorup JM, Shin TM, Homel P, Merola AA, on posteroanterior and anteroposterior radiographs. J Bone
Grogan DP, Pugh L, Lowe TG, Murray M. Results of the Joint Surg 1982;64-A:489 – 493.
Scoliosis Research Society instrument for evaluation of 31. Pruijs JEH, Hageman MAPE, Keessen W, Meer R van der,
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

surgical outcome in adolescent idiopathic scoliosis. A multi- Wieringen JC van. Variation in Cobb angle measurements in
center study of 244 patients. Spine 1999;24:1435 – 1440. scoliosis. Skel Radiol 1994;23:517 – 520.
10. Asher MA, Min Lai S, Burton DC. Further development and 32. Richards BS, Bernstein RM, D’Amato CR, Thompson GH.
validation of the Scoliosis Research Society (SRS) outcomes Standardization of criteria for adolescent idiopathic scoliosis
instrument. Spine 2000;25:2381 – 2386. brace studies. Spine 2005;30:2068 – 2075.
11. Vasiliadis E, Grivas TB, Gkoltsiou K. Development and 33. Nash C, Moe J. A study of vertebral rotation. J Bone Joint
preliminary validation of Brace Questionnaire (BrQ): A new Surg 1969;51-A:223 – 229.
instrument for measuring quality of life of brace treated 34. Perdriolle R. La scoliose. Paris: Maloine SA; 1979.
scoliotics. Scoliosis 2006;1:7. 35. Drerup B. Principles of measurement vertebral rotation from
12. Botens-Helmus C, Klein R, Stephan C. The reliability of the frontal projections of the pedicles. J Biomech 1984;17:
Bad Sobernheim Stress Questionnaire (BSSQbrace) in adoles- 923 – 935.
cents with scoliosis during brace treatment. Scoliosis 2006; 36. Weiss HR. Measurement of vertebral rotation: Perdriolle
1:22. versus Raimondi. Eur Spine J 1995;4:34 – 38.
For personal use only.

13. Kotwicki T, Kinel E, Stryla W, Szulc A. Estimation of the 37. Fon GT, Pitt MJ, Thies AC. Thoracic kyphosis: Range in
stress related to conservative scoliosis therapy: An analysis normal subjects. Am J Roentgenol 1980;134:979 – 983.
based on BSSQ questionnaires. Scoliosis 2007;2:1. 38. Kotwicki T. Sagittal and transversal plane deformity in
14. Weiss HR, Werkmann M, Stephan C. Brace related stress in thoracic scoliosis. Stud Health Technol Inform 2002;91:
scoliosis patients – comparison of different concepts of 251 – 256.
bracing. Scoliosis 2007;2:10. 39. Bridwell KH, Betz R, Capelli AM, Huss G, Harvey C. Sagittal
15. Lenke LG, Bridwell KH, Blanke K, Baldus C. Analysis of plane analysis in idiopathic scoliosis patients treated
pulmonary function and chest cage dimension changes with Cotrel-Dubousset instrumentation. Spine 1990;15:
after thoracoplasty in idiopathic scoliosis. Spine 1995;20: 921 – 926.
1343 – 1350. 40. Kiel AW, Burwell RG, Moulton A, Purdue M, Webb JK,
16. Tanner JM. Growth and endocrinology of the adolescent. In: Wojcik AS. Segmental patterns of sagittal spinal curvatures in
Gardner L, editor. Endocrine and genetic diseases of child- children screened for scoliosis: Kyphotic angulation at the
hood. Philadelphia: WB Saunders; 1975. thoracolumbar region and the mortice joint. Clin Anat
17. Stagnara P. Spinal deformity. London: Butterworths; 1988. 1992;5:353 – 371.
18. Zaina F, Atanasio S, Negrini S. Clinical evaluation of scoliosis 41. Boulay C, Tardieu C, Hecquet J, Benaim C, Mitulescu A,
during growth: description and reliability. In: Grivas TB, Marty C, Prat-Pradal D, Legaye J, Duval-Beaupere G,
editor. The conservative scoliosis treatment. SOSORT ICL Pelissier J. Anatomical reliability of two fundamental
book. Amsterdam: IOS Press; 2008. pp 125 – 138. radiological and clinical pelvic parameters: Incidence
19. Adams W. Lectures on the pathology and treatment of lateral and thickness. Eur J Orthop Surg Traumatol 2005;15:197 –
and other forms of curvature of the spine. London: Churchill; 204.
1882. 42. Grivas TB, Dangas S, Polyzois BD, Samelis P. The double rib
20. Grosso C, Negrini S, Boniolo A, Negrini A. The validity of contour sign (drcs) in lateral spinal radiographs. Aetiological
clinical examination in adolescent spinal deformities. Stud implications for scoliosis. Stud Health Technol Inform 2002;
Health Technol Inform 2002;91:123 – 125. 88:38 – 43.
21. Krawczynski A, Kotwicki T, Szulc A, Samborski W. Clinical 43. Greulich WW, Pyle SI. Radiographic atlas of skeletal
and radiological assessment of vertebral rotation in idiopathic development of the hand and wrist. 2nd ed. Palo Alto, CA:
scoliosis. Ortop Traumatol Rehabil 2006;8:602 – 607. Stanford University Press; 1959.
22. Grivas TB, Vasiliadis ES, Mihas K. The effect of growth on the 44. Dimeglio A. La puberte: Un tournant decisive. In:
correlation between the spinal and rib cage deformity. Implica- Dimeglio A, Herisson C, Simon L, editors. La scoliose
tions on idiopathic scoliosis pathogenesis. Scoliosis 2007;2:11. idiopathic. Paris: Masson; 1996. pp 155 – 162.
23. Grivas TB, Vasiliadis ES, Koufopoulos G, Segos D, 45. Risser JC. The iliac apophysis: An invaluable sign in the
Triantafilopoulos G, Mouzakis V. Study of trunk asymmetry management of scoliosis. Clin Orthop 1958;11:111 – 120.
in normal children and adolescents. Scoliosis 2006;1:19. 46. Bitan FD, Veliskakis KP, Campbell BC. Differences in the
24. Bunnell WP. An objective criterion for scoliosis screening. Risser grading systems in the United States and France. Clin
J Bone Joint Surg 1984;66-A:1381 – 1387. Orthop 2005;436:190 – 195.
25. Pruijs JEH, Hageman MAPE, Keessen W, Meer R van der, 47. Mehta MH. The rib-vertebral angle in the early diagnosis
Wieringen JC. Spinal rotation meter; development and com- between resolving and progressive infantile scoliosis. J Bone
parison of a new device. Acta Orthop Belg 1995;61:107 – 112. Joint Surg 1972;54-B:230 – 243.
 Evaluation of scoliosis today 751

48. Grivas TB, Burwell GR, Vasiliadis ES, Webb JK. A segmental 68. Hill DL, Mahood JK, Moreau MJ, Raso VJ, Durdle NG. The
radiological study of the spine and rib cage in children with scoring of trunk distortion in scoliosis. Stud Health Technol
progressive infantile idiopathic scoliosis. Scoliosis 2006;1:17. Inform 1997;37:289 – 292.
49. Suh CH. The fundamentals of computer aided X-rays analysis 69. Kotwicki T, Chowanska J, Kinel E, Lorkowska M, Stryla W,
of the spine. J Biomechanics 1974;7:161 – 169. Szulc A. Sitting forward bending position versus standing
50. Brown RH, Burstein AH, Nash CL, Schock CC. Spinal position for studying the back shape in scoliotic children.
analysis using a three-dimensional radiographic technique. Presented at the 4th International Conference on Conserva-
J Biomechanics 1976;9:355 – 365. tive Management of Spinal Deformities, Boston, 13 – 16 May
51. Hindmarsh J, Larsson J, Mattsson P. Analysis of changes in 2007. Published in Scoliosis. Accessed 15 October 2007 from
the scoliotic spine using a three-dimensional radiographic the website: http://www.scoliosisjournal.com
technique. J Biomechanics 1980;13:279 – 290. 70. Asher M, Lai SM, Burton D, Manna B. Maintenance of trunk
52. Abdel-Aziz YI, Karara HM. Direct linear transformation from deformity correction following posterior instrumentation
comparator coordinates into object space coordinates in close- and arthrodesis for idiopathic scoliosis. Spine 2004;29:
range photogrammetry. Symposium of American Society of 1782 – 1788.
Photogrammetry, Falls Church 1971. 71. Asher M, Lai SM, Burton D, Manna B. The influence of
53. Graf H, Hecquet J, Dubousset J. Aproche tridimensionelle des spine and trunk deformity on preoperative idiopathic scoliosis
deformations rachidiennes. Aplication a l’etude du pronostic patients’ health related quality of life questionnaire responses.
Disabil Rehabil Downloaded from informahealthcare.com by University of California Irvine on 10/29/14

des scolioses infantiles. Rev Chir Orthop 1983;69:407 – 416. Spine 2004;29:861 – 868.
54. Kotwicki T, Pietrzak S, Szulc A. Three-dimensional action of 72. Rigo M. Three-dimensional correction of trunk deformity in
Cheneau brace on thoracolumbar scoliosis. Stud Health patients with idiopathic scoliosis using Che˛neau brace. Stud
Technol Inform 2002;88:226 – 229. Health Technol Inform 1999;59:362 – 365.
55. Kotwicki T, Dubousset J, Padovani JP. Correction of flexible 73. Goldberg CJ, Groves D, Moore DP, Fogarty EE,
thoracic scoliosis below 65 degrees – a radiological compar- Dowling FE. Surface topography and vectors: A new measure
ison of anterior versus posterior segmental instrumentation for the three dimensional quantification of scoliotic deformity.
applied to similar curves. Eur Spine J 2006;15:972 – 981. Stud Health Technol Inform 2006;123:449 – 455.
56. Labelle H, Dansereau J, Bellefleur C, Poitras B, Rivard CH, 74. Minguez MF, Buendia M, Cibrian RM, Salvador R,
Stokes IA, De Guise J. Comparison between preoperative and Laguia M, Martin A, Gomar F. Quantifier variables of the
postoperative three-dimensional reconstructions of idiopathic back surface deformity obtained with a noninvasive structured
scoliosis with the Cotrel-Dubousset procedure. Spine 1995; light method: Evaluation of their usefulness in idiopathic
20:2487 – 2492. scoliosis diagnosis. Eur Spine J 2007;16:73 – 82.
For personal use only.

57. Labelle H, Dansereau J, Bellefleur C, Poitras B. Three- 75. Kohler R, Cottalorda J, Garin C, Lecante P, Rolet G. Analyse
dimensional effect of the Boston brace on the thoracic spine de la forme externe du tronc par prise d’empreinte optique:
and the rib cage. Spine 1996;21:59 – 64. Ses applications a la confection des corsets et a la surveillance
58. Asher MA, Manna BJ. Optimizing surgical improvement of clinique des scoliosis. In: Dimeglio A, Herrison C, Simon L,
trunk asymmetry from idiopathic scoliosis: A preliminary editors. La scoliose idiopathique. Paris: Masson; 1996.
report. Stud Health Technol Inform 1999;59:250 – 253. pp 238 – 244.
59. Petit Y, Aubin C-E, Labelle H. Three-dimensional imaging 76. Poncet P, Delorme S, Dudley R, Ronsky JL, Dansereau J,
for the surgical treatment of idiopathic scoliosis in adoles- Harder J, Dewar RD, Labelle H, Gu PH, Zernicke RF. 3D
cents. Can J Surg 2002;45:453 – 458. reconstructions of the external and internal geometries of the
60. Thulborne T, Gillespie R. The rib hump in idiopathic trunk using laser and stereo-radiographic imaging techniques.
scoliosis. Measurements, analysis and response to treatment. Stud Health Technol Inform 1999;59:21 – 24.
J Bone Joint Surg 1976;58-B:64 – 71. 77. Kirby AS, Burwell RG, Cole AA, Pratt RK, Webb JK,
61. Hackenberg L. Evaluation of three-dimensional correction of Moulton A. Evaluation of a new real time ultrasound
idiopathic scoliosis by Zielke instrumentation surface mea- method for measuring segmental rotation of vertebrae and
surement using videorasterstereography. Stud Health Technol ribs in scoliosis. Stud Health Technol Inform 1999;
Inform 1999;59:258 – 261. 59:316 – 320.
62. Goldberg CJ, Kaliszer M, Moore DP, Fogarty EE, 78. Burwell RG, Aujla RK, Kirby AS, Moulton A, Webb JK. The
Dowling FE. Surface topography, Cobb angles, and cosmetic early detection of adolescent idiopathic scoliosis in three
change in scoliosis. Spine 2001;26:E55 – 63. positions using the scoliometer and real time ultrasound:
63. Frobin W, Hierholzer E. Analysis of human back shape using Should the prone position also be used? Stud Health Technol
surface curvatures. J Biomech 1982;15:379 – 390. Inform 2002;88:74 – 80.
64. Frobin W, Hierholzer E. Video rasterstereography: A method 79. Kotwicki T, Napiontek M. Intra-vertebral deformation in
for on-line measurement of body surfaces. Photogr Eng Rem idiopathic scoliosis. A transverse plane CT study. J Pediatr
Sens 1991;57:1341 – 1345. Orthop 2008; (in press).
65. Takasaki J. Moire topography. Appl Optics 1970;9: 80. Aaro S, Dahlborn M. Estimation of vertebral rotation
1457 – 1472. and spinal rib cage deformity in scoliosis by computer
66. Suzuki N, Inami K, Ono T, Kohno K, Asher M. Analysis of tomography. Spine 1981;6:460 – 467.
Posterior Trunk Symmetry Index (POTSI) in scoliosis. Part 1. 81. Wessberg P, Danielson BI, Willen J. Comparison of Cobb
Stud Health Technol Inform 1999;59:81 – 84. angles in idiopathic scoliosis on standing radiograph and
67. Inami K, Suzuki N, Ono T, Yamashita Y, Kohno K, supine axially loaded MRI. Spine 2006;31:3039 – 3044.
Morisue H. Analysis of Posterior Trunk Symmetry Index
(POTSI) in scoliosis. Part 2. Stud Health Technol Inform
1999;59:85 – 88.