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SPINE Volume 27, Number 4, pp 387–392

©2002, Lippincott Williams & Wilkins, Inc.

Adult Scoliosis
A Quantitative Radiographic and Clinical Analysis

Frank J. Schwab, MD,*† Vinson A. Smith, MD,* Michele Biserni, MD,‡ Lorenzo Gamez,§
Jean-Pierre C. Farcy, MD,*† and Murali Pagala, PhD储

Study Design. Prospective analysis of a consecutive mulas for self-reported pain levels were obtained. [Key
series of adult patients with adolescent idiopathic scolio- words: adult scoliosis, pain, radiographic analysis, lateral
sis of the adult and de novo degenerative scoliosis. olisthy] Spine 2002;27:387–392
Objectives. To clinically and radiographically study
two populations of adult patients with either adolescent
idiopathic scoliosis of the adult or de novo degenerative Significant work has been dedicated to the diagnosis,
scoliosis in a quantitative manner to identify reliable radio- classification, and treatment of scoliosis in the pediatric
graphic parameters that correlate with clinical symptoms. population. Based on radiographic parameters and nat-
Summary and Background. Although there are many
causes of spinal deformity in the adult, there are two main ural history studies, classification systems and clinical
categories of adult scoliosis: adolescent idiopathic scoli- treatment guidelines have been established for idio-
osis of the adult and de novo degenerative scoliosis. Un- pathic, congenital, neuromuscular, and metabolic scoli-
like pediatric scoliosis, in adults there are no established otic spinal deformities. By contrast, for adult scoliotic
radiographic parameters or classification systems that re- deformities there are no clear diagnostic criteria, useful
liably provide a clinical correlation or offer a useful lan-
guage for communication among specialists. This study classification systems, or accepted treatment guidelines.
gathered complete clinical and radiographic information A significant limitation in developing useful classifica-
on 95 patients with adult scoliosis and established several tions and treatment guidelines for adult scoliosis has
radiographic parameters that correlated with clinical been the limited understanding of relevant radiographic
symptoms. parameters in these deformities.
Methods. Each of the 95 patients completed a clinical
questionnaire that included a self-reported visual analog The prevalence of adult scoliosis in the general popu-
scale and underwent full-length standing anteroposterior lation has been reported as ranging from 1.4% to
and lateral radiography. Radiographic analysis was per- 12%.2,11,14 Aside from the esthetic considerations of this
formed by use of digital analysis and included measure- physical deformity, significant pain and disability can
ment of the Cobb angle, the number of vertebrae in each develop.1,3,4,12 With the demographic shift involving an
curve, plumbline offset from T1 to the midsacral line, the
upper endplate obliquities of L3 and L4, and maximal aging population in the United States and increased at-
lateral olisthy between two adjacent lumbar vertebrae. tention to quality of life issues, adult scoliosis is becom-
Sagittal plane measurements included lumbar lordosis, ing a significant health care concern. The progression of
thoracolumbar kyphosis, and the Sagittal Pelvic Tilt In- spinal deformities in the adult population, treatment ap-
dex. Statistical analysis of both radiographic and clinical proaches for adult scoliosis, and surgical techniques have
parameters of pain was performed to determine any sig-
nificant correlations between the two. been reported in the literature.5,7,13,15–18
Results. This study showed that lateral vertebral olis- Adult scoliosis can be defined as a spinal deformity in
thy, L3 and L4 endplate obliquity angles, lumbar lordosis, a skeletally mature patient with a Cobb angle greater
and thoracolumbar kyphosis were significantly correlated than 10°. Although there are many known causes of spi-
with pain. nal deformity in the adult, two categories include the
Conclusion. This quantitative analysis identified sev-
eral clinically relevant radiographic parameters in adult largest number of scolioses. The first category includes
scoliosis patients. Additionally, excellent predictive for- patients with scoliosis during childhood and adolescence
that may progress or become symptomatic as the patient
ages. This type of scoliosis is often idiopathic and can be
termed adolescent scoliosis of the adult (ASA). The sec-
ond category includes patients in whom a the spinal de-
From the *Department of Orthopaedics, Maimonides Medical Center,
Brooklyn, New York, the †New York University School of Medicine, formity developed after skeletal maturity.6 This type of
New York, New York, the ‡Istituto di Scienze Ortopedico Trumato- scoliosis most commonly involves some form of degen-
logiche e Riabilitative dell Universita di Siena, the §New York Medical erative disease and can be termed de novo degenerative
College, Valhalla, New York, and the 储Neuromuscular Research Lab,
Department of Surgery, Maimonides Medical Center, Brooklyn, New scoliosis (DDS). Although the causes of ASA and DDS
York. appear quite different, they may share a common path-
Supported by the Maimonides Medical Center Research and Develop- way in symptomatic patients: gradual loss of interseg-
ment Foundation.
Acknowledgment date: November 28, 2000. mental stability with aging and consequent progressive
First revision date: February 26, 2001. deformity and pain. Certainly, many adult deformities
Second revision date: April 5, 2001 may not fit clearly into the categories of ASA or DDS,
Acceptance date: April 24, 2001.
Device status category: 1. such as traumatic, metabolic, osteoporotic,16 or iatro-
Conflict of interest category: 12. genic deformities.

388 Spine • Volume 27 • Number 4 • 2002

Table 1. Correlation Between Radiographic Parameters

and Self-Reported Pain in Adult Scoliosis
Relevant Nonrelevant

Olisthy Cobb angle

L3 Endplate angle Age
L4 Endplate angle Level of olisthy
Lumbar lordosis SPTI
Thoracolumbar kyphosis Plumbline offset
SPTI ⫽ Sagittal Pelvic Tilt Index.

metabolic bone disease, or underlying pathologic state of the

bone such as metastatic disease.
A series of 95 patients met the above criteria. Each patient
completed a detailed questionnaire, which reviewed demo-
graphic data, medical history, and type, location, and duration
of pain. The self-reported Visual Analog Scale (VAS) was ap-
Figure 1. Illustration of radiographic measurements taken from plied to evaluate the severity of pain. In addition to the clinical
standing spine x-ray. questionnaire, each patient underwent a complete radiographic
series, including full-length standing anteroposterior and lat-
eral radiographs (scoliosis series).
The purpose of this study was to clinically and radio-
graphically study a population of adult patients with Radiographic Analysis. The full-length spine radiographs
ASA or DDS in a quantitative manner. The hypothesis were evaluated for several parameters. All measurements were
made by digital analysis, using the Xcalliper (Eisenlohr Corp.,
was that reliable radiographic parameters could be iden-
Davis, CA). From the frontal plane (anteroposterior radio-
tified that would correlate with clinical symptoms in a graphs), the following were recorded: Cobb angle of all scoli-
population of patients with adult scoliosis. otic curvatures (thoracic, thoracolumbar, lumbar), number of
Materials and Methods vertebrae in each curve, plumbline offset from T1 to midsacral
line, endplate obliquities (from the horizontal) of L3 and L4
The study included a consecutive series of adult patients with vertebrae, and maximal lateral olisthy (offset) between any two
ASA or DDS in the practice of the two lead authors. The inclu- adjacent lumbar vertebrae (Figure 1). From the sagittal plane
sion criteria were as follows: patient age over 18 years, scoliosis (lateral radiographs) the following were recorded: lumbar lor-
(thoracic, thoracolumbar, or lumbar) exceeding 15° by Cobb dosis (upper endplate L1 vertebra to upper endplate S1 verte-
angle, complete radiographic and clinical data. The exclusion bra, Cobb angle), thoracolumbar kyphosis (upper endplate
criteria were as follows: recent trauma, history of spinal sur- T11 vertebra to lower endplate L1 vertebra, Cobb angle), sag-
gery, evidence of compression fracture or severe osteoporosis, ittal pelvic tilt index (Figure 2).

Figure 2. Illustration of radiographic measurements taken from

standing lateral spine radiographs. Figure 3. Relation between Visual Analog Scale (VAS) and olisthy.
Quantitative Analysis of Adult Scoliosis • Schwab et al 389

Figure 4. Relation between Visual Analog Score (VAS) and L3 Figure 6. Relation between Visual Analog Score (VAS) and lumbar
endplate obliquity. lordosis.

Statistical Analysis. The clinical parameters of pain (leg or

back), intensity of pain by self-reported VAS, and radiographic years). Some degree of pain was reported in 78 patients
parameters were entered into a SigmaStat (SPSS Corp., Chi- (74%). The mean VAS score for the symptomatic pa-
cago, IL) worksheet. A statistician not involved with data ac- tients in the study group was 58 (range, 20 –100). The
quisition and blinded to patient identity evaluated the correla-
type of scoliotic deformity was DDS in 57 patients (54%)
tions between pain and radiographic parameters. Linear
and ADA in 38 patients (46%). Scoliotic curvatures of
regression analysis was applied to assess the relation between
the VAS score of pain and each of the relevant radiographic the lumbar or thoracolumbar spine averaged 36° (SD,
parameters to obtain predictive formulas. 18°; range, 15–72°), and curvatures of the thoracic spine
averaged 28° (SD, 22°; range, 10 –120°).
Results After statistical analysis of both radiographic and
The study population included 95 patients, 33 men and clinical data, significant correlations between radio-
62 women. The average age was 59 years (range, 18 – 88

Figure 5. Relation between Visual Analog Score (VAS) and L4 Figure 7. Relation between Visual Analog Score (VAS) and thora-
endplate obliquity. columbar kyophosis.
390 Spine • Volume 27 • Number 4 • 2002

Table 2. Predictive Formulas for Self-Reported Pain in L3 endplate obliquity angle was significant (r ⫽ 0.433,
Study Group of Adult Scoliosis Patients: Visual Analog P ⬍ 0.002). The predictive formula was VAS ⫽ 45.96 ⫹
Pain Score and Radiographic Parameters (0.833 ⫻ L3 angle) (Figure 4). The VAS and L4 endplate
angle showed a significant correlation (r ⫽ 0.375, P ⬍
Level of
Formula Significance (P) 0.006). The predictive formula was VAS ⫽ 42.95 ⫹
(0.934 ⫻ L4 angle) (Figure 5). In terms of sagittal plane
VAS ⫽ 42.947 ⫹ (0.934 ⫻ L4 angle) ⬍0.006 radiographic analysis, the correlation between VAS and
VAS ⫽ 45.96 ⫹ (0.833 ⫹ L3 angle) ⬍0.002
VAS ⫽ 41.52 ⫹ (3.152 ⫻ olisthy) ⬍0.001 lumbar lordosis was significant (r ⫽ 0.465, P ⬍ 0.001).
VAS ⫽ 86.353 ⫺ (0.695 ⫻ lordosis) ⬍0.001 The predictive formula was VAS ⫽ 86.353 ⫺ (0.695 ⫻
VAS ⫽ 39.612 ⫹ (1.720 ⫻ kyphosis) ⬍0.001 lordosis) (Figure 6). The correlation between VAS and
VAS ⫽ Visual Analog Scale. thoracolumbar kyphosis was significant (r ⫽ 0.508, P ⬍
0.001. The predictive formula was VAS ⫽ 39.612 ⫹
(1.720 ⫻ kyphosis) (Figure 7).
graphic and clinical parameters (pain) were identified. There was no statistically significant correlation be-
From standing anteroposterior radiographs it was deter- tween the VAS and the number of vertebrae involved in
mined that lateral vertebral olisthy, and L3 and L4 end- the scoliotic Cobb angle. Even more convincing was that
plate obliquity angles, were correlated with VAS pain the Cobb angle of the scoliotic deformity had no statis-
score. From standing lateral radiographs it was deter- tically significant correlation to the VAS. The sagittal
mined that lumbar lordosis and thoracolumbar kyphosis pelvic tilt index and plumbline offset showed no statisti-
were statistically significantly correlated with self- cally significant correlation with self-reported pain by
reported pain (Table 1). VAS (Table 2).
In terms of frontal plane radiographic analysis, the
correlation between VAS and lateral olisthy was statisti-
cally significant (r ⫽ 0.473, P ⬍ 0.001). The predictive
formula was VAS ⫽ 41.52 ⫹ (3.152 ⫻ olisthy) (Figure Adult scoliotic deformities have received little attention.
3). The level of lateral vertebral olisthy from L1 to L5 did In part this may result from the impression of limited
not bear a statistically significant correlation with the scoliotic progression in this group and the focus of treat-
VAS. In other words, although the amount of olisthy was ment on regional degenerative pathologic conditions
highly significant, the level of the olisthy had no impact (stenosis, spondylolisthesis, disc degeneration) rather
on patient pain scores. The correlation between VAS and than the deformity itself. An additional reason may lie in

Figure 8. A, Standing anteropos-

terior radiograph of the spine in a
subject with minimal back dis-
comfort, showing a marked sco-
liotic deformity. The patient re-
ceived a diagnosis of idiopathic
scoliosis as an adolescent. B,
Standing lateral radiograph of
the spine in the same patient. A
well-preserved lumbar lordosis is
Quantitative Analysis of Adult Scoliosis • Schwab et al 391

Figure 9. A, Standing anteroposterior radiograph of the spine in a patient with significant back pain. Scoliosis was not diagnosed during
adolescence. B, Anteroposterior lumbar radiograph, showing significant lateral olisthy at L3–L4. C, Standing lateral radiograph of the
patient. A marked loss of lumbar lordosis is evident.

the limited surgical treatment in the elderly who have though its role in pediatric deformity is paramount. Pa-
deformities frequently associated with other medical tients with ASA had larger major scoliosis curvatures
conditions. For several reasons the perceptions of scoli- than patients with DDS (ASA mean, 40°; DDS mean,
osis in the adult may be changing. Notable demographic 25°; although the radiographic parameters correlating
shifts in Western societies and an increased life expect- with pain were identical for these groups). This appears
ancy are evident, and quality of life concerns are focusing to substantiate the belief that a common end pathway
attention on the degenerative pathologic conditions in (degenerative instability and unfavorable lumbar verte-
aging persons who wish not only to age but to do so with bral alignment) among both groups of patients is related
independence in daily living. to symptoms rather than the degree of curvature or the
Although the common degenerative conditions of the cause of the original scoliosis.
spine are frequently treated as focal pathologic states, it In this quantitative analysis, several clinically relevant
appears intuitive that deformity of the spinal column, by radiographic criteria in two adult scoliosis populations
altering the mechanical loading conditions, can acceler- were identified. Excellent predictive formulas for self-
ate the degenerative cascade. The question that arises, reported pain levels on the VAS were obtained. The most
therefore, is whether radiographic parameters can be significant radiographic parameters in the adult scoliotic
identified in an adult with scoliosis that will serve a pre- group were upper endplate obliquities of L3 and L4,
dictive purpose on a clinical level.8 –10 Furthermore, it lateral olisthy between adjacent lumbar vertebrae on the
appears that radiographic criteria should be developed frontal plane, lumbar lordosis, and thoracolumbar
for the adult scolioses to serve as a basis of analysis in kyphosis.
longitudinal studies and perhaps eventually for treat- The highly significant radiographic parameters iden-
ment guidelines. tified in this study population of adult scoliosis patients
The findings in this study clearly illustrate that tradi- appear to reflect the level of regional balance, instability,
tional parameters such as Cobb angle and age are not and pathologic mechanical loads of the spinal elements.
useful in the assessment of adult scoliosis ( Figures 8 and It is not clear to what degree the individual parameters
9). The Cobb angles of patients in this study covered a are interrelated and whether progression beyond a cer-
wide range, but this parameter itself was not a significant tain level of intervertebral alignment of one factor will
criterion in this group of adult scoliosis patients, al- inevitably lead to changes in other measured parameters.
392 Spine • Volume 27 • Number 4 • 2002

That is, we cannot yet conclude that a certain degree of 3. Bradford D, Tay B, Hu S. Adult scoliosis: surgical indications, operative
management, complications, and outcomes. Spine 1999;24:2617–29.
endplate obliquity in the frontal plane will lead to inev- 4. Bradford D. Adult scoliosis: current concepts of treatment. Clin Orthop
itable vertebral olisthy over time and thence to changes 1988;229:70 – 87.
in sagittal plane contour and to pain. Such a theory 5. Duval-Beaupere G, Lamireau TH. Scoliosis at less than 30 degrees: Proper-
ties of the evolutivity (risk of progression). Spine 1985;10:421– 4.
would be appealing, and clearly longitudinal studies are 6. Grubb S, Libscomb H, Coonrad R. Degenerative adult-onset scoliosis. Spine
important in this area. Once such a link can be con- 1988;13:241–5.
firmed, treatment guidelines may be strongly affected, 7. Grubb S, Lipscomb H, Suh P. Results of surgical treatment of painful adult
scoliosis. Spine 1994;19:1619 –27.
and early intervention in a middle-aged adult with scoli- 8. Kopec JA. Measuring functional outcomes in persons with back pain: A
osis may, in some cases, be preferable to treating ad- review of back-specific questionnaires. Spine 2000;25:3110 – 4.
vanced deformity in that same person once he or she has 9. Jackson R, Peterson M, McManus A, et al. Compensatory spinopelvic bal-
ance over the hip axis and better reliability in measuring lordosis to the pelvic
become elderly. radius on standing lateral radiographs of adult volunteers and patients. Spine
Statistically highly significant radiographic parame- 1998;16:1750 – 67.
ters in the setting of clinical symptoms and adult scoliosis 10. Jackson R, Simmons E, Stripinis D. Coronal and sagittal plane spinal defor-
mities correlating with back pain and pulmonary function in adult idiopathic
have been identified. These data are encouraging, and the scoliosis. Spine 1989;14:1391–7.
establishment of a multicenter database is anticipated. 11. Korovessis P, Piperos G, Sidiropoulos P, et al. Adult idiopathic lumbar sco-
Further investigation will permit increased statistical liosis: A formula for prediction of progression and review of the literature.
Spine 1994;19:1926 –32.
power of these findings and may lay the groundwork for 12. Kostuik JP, Bentivoglio J. The incidence of low-back pain in adult scoliosis.
a classification system of the adult scolioses. Spine 1981;6:268 –73.
13. Kostuik JP. Adult scoliosis: The lumbar spine. Chapter 47 in The Textbook
of Spinal Surgery, 2nd ed. Philadelphia: Lippincott-Raven, 1977:733–75.
14. Perdriolle R, Vidal J. Thoracic idiopathic scoliosis curve evolution and prog-
Key Points nosis. Spine 1985;10:785–91.
15. Perennou D, Marcelli C, Herisson C. Adult lumbar scoliosis: Epidemiologic
● There is a correlation between radiographic pa- aspects in a low-back pain population. Spine 1994;19:123– 8.
rameters and pain in adult scoliosis. 16. Thevenon A, Pollez B, Cantegrit F, et al. Relationship between kyphosis,
● Highly significant radiographic parameters in- scoliosis, and osteoporosis in the elderly population. Spine 1987;12:744 –5.
17. Velis KP, Healey JH, Schneider R. Osteoporosis in unstable adult scoliosis.
clude endplate obliquities of L3 and L4, lateral olis- Clin Orthop 1988;237:132– 41.
thy between the lumbar vertebrae, lumbar lordosis, 18. Yasuo Y, Yamaguchi T, Asaka Y. Prediction of curve progression in idio-
and thoracolumbar kyphosis. pathic scoliosis based on initial roentgenograms: A proposal of an equation.
Spine 1988;13:1258 – 61.

The authors thank Sobhan Pagala for statistical support. Address reprint requests to
References Frank J. Schwab, MD
1. Balderston RA. Adult scoliosis: The thoracic spine. Chapter 46 in The 927 49th Street
Textbook of Spinal Surgery, 2nd ed. Philadelphia: Lippincott-Raven, Brooklyn, NY 11219
1977:715–32. E-mail:
2. Biot B, Pendrix D. Frequence de la scoliose lombaire a l’age adulte. Ann Med
Phys 1982;25:251– 4.