SPINE Volume 41, Number 5, pp E282–E288

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DEFORMITY

Clinical Relevance of the SRS-Schwab

Classification for Degenerative Lumbar Scoliosis
Kee-Yong Ha, MD, PhD, Won-Hee Jang, MD, Young-Hoon Kim, MD, PhD, and Dong-Chul Park, MD

CA, CI, CDD, and PI-LL to be correlated with clinical parameters.

Study Design. Retrospective cohort study.
On analysis for clinical outcomes (surgical rates and patient self-
Objective. The aim of this study was to evaluate the clinical
reported disability) along the grades of the SRS-Schwab sagittal
relevance of the SRS-Schwab classification for degenerative
modifiers, PT and SVA were not related to higher surgical rates or
lumbar scoliosis (DLS).
Summary of Background Data. The SRS-Schwab classifi- disability.
Conclusion. Even though some radiological parameters showed
cation has been presented and validated as a useful tool for
statistically significant results, correlation between radiological
adult spinal deformity (ASD). This classification includes various
and clinical parameters was weak. Not only deformity but also
types of ASD (degenerative de novo scoliosis or adult form of
other clinical factors should be considered when evaluating
idiopathic scoliosis). However, DLS has different clinical charac-
DLS.
teristics and pathophysiology compared with other forms of
Key words: adult spinal deformity, degenerative scoliosis,
ASD.
SRS-Schwab classification.
Methods. In this retrospective cohort study, 216 (146 conserva-
Level of Evidence: 4
tively treated and 70 surgically treated) DLS patients were Spine 2016;41:E282–E288
enrolled. The average patient age was 72.1  7.4 years. Clinical
parameters for disability were measured using Oswestry disabil-
ity index (ODI) and back and leg pain numerical rating scale.
Radiographic parameters included SRS-Schwab sagittal modifiers

(pelvic tilt [PT]; sagittal vertical axis [SVA];pelvic incidence-
lumbar lordosis [PI-LL]), T1 pelvic angle, and coronal parameters
(Cobb’s angle [CA]; coronal imbalance [CI]; coronal deviation
distance [CDD]; tilting angle [TA]). Correlations between clinical
parameters and radiographic parameters were assessed and
surgical rates along the SRS-Schwab sagittal modifiers were
evaluated.
Results. Only PI-LL as a sagittal radiographic parameter
showed a weak correlation with clinical parameters (r ¼ 0.137–
0.176) (P < 0.05). Coronal parameters such as CA, CI, CDD, and
TA also showed weak correlation with clinical parameters
(r ¼ 0.137–0.202) (P < 0.05). Multiple regression analysis identified
From the Department of Orthopedic Surgery, Seoul St. Mary’s Hospital,
College of Medicine, The Catholic University of Korea, Seoul, Korea.
Acknowledgment date: June 22, 2015. First revision date: July 18, 2015.
Second revision date: August 5, 2015. Third revision date: August 27, 2015.
Acceptance date: August 31, 2015.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work.
No relevant financial activities outside the submitted work.
Address correspondence and reprint requests to Young-Hoon Kim, MD,
PhD, Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, School
of Medicine, The Catholic University of Korea, Seoul, Korea, 222 Banpo-
dae-ro, Seocho-Gu, Seoul 137–701, Korea; E-mail: boscoa@catholic.ac.kr
DOI: 10.1097/BRS.0000000000001229
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A
s Aebi described,1 adult spinal deformity (ASD)
has received increased clinical attention because
of the increased number of the aged population
and advances in surgical technique. Considering surgical
morbidity in the aged population, however, determination
of proper treatment for this complex condition is not
easy task. The SRS-Schwab classification has presented
that several radiographic parameters, especially sagittal
spino-pelvic balance, were relevant to clinical results.2 – 5
Following studies regarding this classification system have
further validated this classification scheme.6,7 However,
this classification includes various conditions of ASD
(adult form of idiopathic scoliosis and degenerative sco-
liosis). Degenerative lumbar scoliosis (de novo scoliosis,
type I of Aebi’s classification) is a different condition from
the adult form of idiopathic scoliosis. Not only is the
deformity located in the thoracolumbar/lumbar spine,
but concurrent neurological compromises are also com-
mon. And both deformity correction for most mobile
segments of the spine and decompression for neurologic
compromise should be taken into consideration in clinical
and surgical decision-making. Therefore, the hypothesis of
this study is that radiographic parameters, especially those
in the SRS-Schwab classification, are not sufficient to
evaluate adult spinal deformities with degenerative lumbar
scoliosis (DLS).
March 2016
 DEFORMITY The SRS-Schwab Classification for Degenerative Lumbar Scoliosis  Ha et al

Figure 1. Representative case of degenerative lumbar scoliosis with flexible sagittal imbalance. Ten years of follow-up AP/lateral radiographs
for 76-year-old woman (2013) who presented with a degenerative de novo scoliosis. Her last Oswestry disability index (ODI) score was 64
and back/leg pain numerical rating scale (NRS) was 8/6. She remains under conservative management.

The primary objective of this study was to evaluate the
clinical relevance of radiographic parameters suggested in
the SRS-Schwab classification and other established signifi-
cant radiographic parameters with clinical parameters and
treatment approach (surgical rates).
MATERIALS AND METHODS
This was a single-institute, retrospective study of 216
patients (mean age 72.1  7.4 years, M: F ¼ 186: 30) with
DLS deformity. The definition of DLS was coronal curva-
ture 108 measured by the Cobb method with the apex
located at the thoracolumbar or lumbar spine.1,8,9 Even
though discrimination between DLS and the adult form
of idiopathic scoliosis was difficult, several criteria were
used to exclude the adult form of idiopathic scoliosis.
Scoliosis with the apex of the main curve at the thoracic
spine, maintenance of lumbar lordosis, and a relative large
Cobb angle (CA) considering the intervertebral disc
degeneration were considered as characteristics of the adult
form of idiopathic scoliosis. Patients with these findings
were excluded. Patients with previous spine surgery, hip
pathology, or leg length discrepancy were also excluded.
Patients registered from 2009 to 2014 with the diagnosis of
degenerative lumbar scoliosis with sagittal imbalance were
enrolled. The mean CA of coronal curvature in this cohort
was 21.1  8.98. A total of 146 conservatively treated
patients (group I) and 70 surgically treated patients (group
II) were included (Fig. 1).
All radiological measurements were performed by two
independent senior orthopedic residents using the PACS
system (m-view, Marosis Inc, Seoul, Korea). Whole spine
antero-posterior/lateral radiographs were used. Measure-
ment reliability was assessed with interclass correlation
coefficient (ICC) analysis using a two-way random-
effects model. Sagittal parameters including spinopelvic
parameters were measured on whole spine lateral

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 DEFORMITY The SRS-Schwab Classification for Degenerative Lumbar Scoliosis  Ha et al

Figure 2. Coronal radiographic parameters measured in the study.
(A) Coronal imbalance (CI) was measured as the distance between
C7 plumb line and center sacral vertical line (CSVL); (B) tilting angle
of the apex (TA) was measured as the angle between the horizontal
line and lower endplate line of the apex vertebra; (C) coronal devi-
ation distance (CDD) was measured as the distance between the
lateral margin of the apex vertebra and the center sacral line; rotation
of the apex vertebra was measured using Nash-Moe methods.
radiographs, including the location of apex, coronal CA,
spinopelvic parameters, lumbar lordosis, and sagittal ver-
tical axis. In addition, coronal imbalance (CI), tilting angle
of the apex vertebra (TA), coronal deviation distance
(CDD), and rotation of the apex vertebra (Nash-Moe
grade) were measured for coronal radiograph parameters
(Fig. 2). T1-pelvic angle (TPA) suggested by the Inter-
national Spine Study Group was also measured.10 For
clinical parameters, numerical rating scale (NRS) for back
and leg pain, and Oswestry disability index (ODI) were used
as a patient self-reported outcome. Clinical data from the
same period as radiograph examination were used
for analysis.
Pearson correlation analysis was performed between
clinical and radiographic parameters. A stepwise linear
regression analysis was performed on all patients between
clinical parameters (ODI, back, and leg NRS) as the depend-
ent variables and radiographic parameters as the independ-
ent variables. Multiple regression analysis was also
performed to investigate the relationships between the
clinical and radiographic parameters. Surgical rates and
patient-reported outcomes along the SRS-Schwab sagittal
modifiers were assessed using analysis of variance analysis.
All statistical analyses were performed using SPSS software
(SPSS Corp, Chicago, IL) with statistical significance noted
at P > 0.05.
RESULTS
Clinical and radiographic data in this study were collected in
a cross-sectional manner. Preoperative data were used for
surgically treated patients, and while final follow-up data
were used for conservatively treated patients. Reliability of
radiologic measurement showed moderate-to-excellent
agreement (ICC ¼ 0.63–0.97). According to the SRS-
Schwab classification, 36 patients (17%) had TL/lumbar
curve type, and 180 (83%) had N type with <308 coronal
curves. Group II demonstrated worse clinical parameters
(high ODI and NRS) than group I (P < 0.01). Group I had
significantly higher pelvic tilt angle (27.8  10.98) than
group II (24.2  9.38) (P < 0.05). However, other radiologi-
cal parameters did not show any significant differences
(Table 1). On sagittal modifiers of the SRS-Schwab classi-
fication, 174 patients (80.6%) presented with þþ grade
pelvic incidence-lumbar lordosis (PI-LL), 32 patients had þ

TABLE 1. Clinical and Radiologic Parameters of the Study Subjects

Non-op (group I, n ¼ 146) Op (group II, n ¼ 70) P
Age (y) 72.2  7.9 72  6.1 NS
Sex (M: F) 16: 130 14: 56
ODI 34.6  12.5 49.6  17.7 <0.01
Back pain NRS 4.2  2.1 7.3  2.1 <0.01
Leg pain NRS 4.1  2.2 8.1  2.1 <0.01
Curve type (SRS-Schwab) N119; L27 N61; L9
Cobb angle (8) 20.3  8.7 19.1  9.2 NS
CI (mm) 15.3  13.8 19.1  17.1 NS
CDD (mm) 42.6  14.1 40.8  17.2 NS
Tilting angle (8) 10.6  5.6 9.7  3.5 NS
Nash-Moe grade 1.81  0.75 1.53  0.61 NS
PI-LL (8) 32.5  15.5 35.1  14.2 NS
PT (8) 27.8  10.9 24.2  9.3 <0.05
SVA (mm) 67.1  81.8 62.1  42.4 NS
TPA (8) 26.1  13.7 24.3  8.3 NS
All values are mean  SD.
CDD indicates coronal deviation distance; CI, coronal imbalance; NRS, Numerical rating scale; NS, not significant; ODI, Oswestry disability index; PI-LL, pelvic
incidence-lumbar lordosis; PT, pelvic tilt; SVA, sagittal vertical axis; TPA, T1 pelvic angle.

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 DEFORMITY The SRS-Schwab Classification for Degenerative Lumbar Scoliosis  Ha et al

grade PI-LL. For global sagittal imbalance, 35 patients
(16.2%) with þþ grade sagittal vertical axis (SVA
>9.5 cm) deviation, 94 (43.5%) with þ grade SVA, and
87 (40.3%) with non-pathologic (SVA <4 cm) sagittal
imbalance were included. For the degree of pelvic tilt
(PT), 79 patients (36.6%) with þþ grade PT (>308), 81
(37.5%) with þgrade PT, and 56 (29.5%) with normal PT
(<208) were included in the cohort.
method) including all radiographic parameters, CI
and PI-LL were significantly related to ODI (ODI ¼
34.97 þ 0.146  CI þ 0.266  P-LL with an adjusted
r2 ¼ 0.047), CA and CI were significantly related to back
NRS (back NRS ¼ 3.9 þ 0.041  CA þ 0.031  CI with an
adjusted r2 ¼ 0.054), and PI-LL was significantly related to
leg NRS (leg NRS ¼ 4.3 þ 0.033  PI-LL with an adjusted
r2 ¼ 0.026).

Correlation Between Radiographic Parameters
Four sagittal radiographic parameters (PT, SVA, PI-LL, and
TPA) showed a significant correlation with one another. For
example, PT correlated with SVA (r ¼ 0.252), PI-LL
(r ¼ 0.698), and TPA (r ¼ 0.71) (P < 0.05). Four coronal
radiographic parameters (CA, CI, CDD, TA and rotation
of the apex vertebra) also showed significant correlation
with one another. TA correlated with CA (r ¼ 0.858), CI
(r ¼ 0.534), CDD (r ¼ 0.647), and rotation of the apex
vertebra (r ¼ 0.422) (P < 0.05). However, the correlation
significance between sagittal and coronal parameters was
very weak (r ¼ 0.121–0.336).
Correlation of Radiographic Parameters With
Clinical Parameters
ODI as a dependent variable was tested for linear relation-
ships with eight radiographic parameters. Of these, CA
(r ¼ 0.17), CI (r ¼ 0.17), CDD (r ¼ 0.167), TA
(r ¼ 0.137), PI-LL (r ¼ 0.137), and TPA (r ¼ 0.137) showed
weak correlation with ODI (P < 0.05). Using back NRS
as a dependent variable, CA (r ¼ 0.174), CI (r ¼ 0.202), TA
(r ¼ 0.167), and PI-LL (r ¼ 0.17) were found to have weak
relationships. However, leg NRS only showed a linear
relationship with PI-LL (r ¼ 0.176) (P < 0.01). On the
multivariate regression analysis (backward elimination
Clinical Parameters Along the Sagittal Modifiers of
the SRS-Schwab Classification
On assessing ODI as a clinical parameter, statistically sig-
nificant differences between the grades of the SRS-Schwab
sagittal modifiers were noted in SVA and PI-LL (P < 0.05).
In post-hoc analysis, þþ grade SVA showed a significant
higher ODI compared with that of 0 grade, and þþ grade
PI-LL showed a significant higher ODI compared with that
of þ grade. Back NRS showed significant differences among
the grade of SVA (P < 0.05). In post-hoc analysis, þþ grade
of SVA showed a significant higher back NRS compared to
that of 0 grade. However, leg NRS did not show any
significant difference among the grades of the sagittal modi-
fiers (Table 2).
Surgical Rates Along the Sagittal Modifiers of the
SRS-Schwab Classification
On a stratified analysis of operative and conservative treat-
ment, higher grades of PI-LL were related to operative
treatment; however, PT and SVA did not show any signifi-
cant relation to higher operation rates (Table 3). Patients
with þþ grade of PI-LL showed significantly higher oper-
ation rates compared with that of 0 grade (P < 0.05). How-
ever, increased operation rate was not associated with
higher grade PT or SVA (Fig. 3).

TABLE 2. Clinical Parameters According to the Grade of the SRS-Schwab Sagittal Modifiers
ODI Back NRS Leg NRS
PT
0 39.7  13.7 5.1  2.5 5.6  2.9
þ 39.1  16.4 5.1  2.5 5.2  2.8
þþ 39.7  17.2 5.3  2.5 5.4  2.7
P 0.96 0.85 0.72
SVA
0 36.9  14.1 4.6  2.3 5.0  2.8
þ 39.1  16.5 5.5  2.7 5.6  2.7
þþ 44.8  17.4 5.7  2.3 5.6  2.9
P 0.03 0.03 0.33
PI-LL
0 37.2  11.5 3.6  2.1 3.5  2.9
þ 31.7  9.1 5.2  2.1 5.2  2.4
þþ 40.8  16.7 5.3  2.6 5.5  2.8
P 0.02y 0.15 0.12

Statistical significance in post hoc analysis (between group 0 and þþ).
y
Statistical significance in post hoc analysis (between group þ and þþ).
NRS indicates numerical rating scale; ODI, Oswestry disability index; PI-LL, pelvic incidence-lumbar lordosis; PT, pelvic tilt; SVA, sagittal vertical axis.

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 DEFORMITY
TABLE 3. SRS-Schwab Sagittal Modifier Grades of 216 Patients With Degenerative Lumbar Scoliosis
Stratified by Treatment Modalities
All (n ¼ 216)
PT, N (%)
0 56 (25.9%)
þ 81 (37.5%)
þþ 79 (36.6%)
SVA
0 87 (40.3%)
þ 94 (43.5%)
þþ 35 (16.2%)
PI-LL
0 10 (4.6%)
þ 32 (14.8%)
þþ 174 (80.6%)

Indicates statistical significance between 0 and þþ grade.
PI-LL indicates pelvic incidence-lumbar lordosis; PT; pelvic tilt, SVA, sagittal vertical axis.
DISCUSSION
ASD including sagittal and coronal imbalance has been
receiving increased attention especially in the setting of
an aging society. DLS accompanied by flexible sagittal
imbalance is one of the types of ASD and is frequently
accompanied by neurologic compromise. In addition,
deformity involving the lumbar spine, the more mobile
segment of the spine, is another important factor for deter-
mination of proper management. Even though discrimi-
nation of DLS from the adult form of idiopathic scoliosis
is not simple, several distinguishing characteristics of DLS
have been suggested.1,11,12 Especially, de novo coronal and
sagittal deformities of the spine occur in the adult period.
Rapid asymmetric degeneration of the intervertebral disc
over autostabilization has been suggested as a pathogenesis
mechanism.13 Rotation of the involved segment and facet
joint subluxation are usually observed. In addition to the
Figure 3. Sagittal modifier grades (0, þ, þþ) of the SRS-Schwab
classification for surgically treated patients with degenerative lumbar
scoliosis. Patients with þþ grade of PI-LL showed higher operation
rates compared with that of 0 grade. Indicates statistically signifi-
cant differences. PT, pelvic tilt; SVA, sagittal vertical axis; PI-LL,
pelvic incidence-lumbar lordosis.
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The SRS-Schwab Classification for Degenerative Lumbar Scoliosis  Ha et al
Non-op Operative group P
32 (57.1%) 24 (42.9%) 0.13
56 (69.1%) 25 (30.9%)
58 (73.4%) 21 (26.6%)
64 (73.6%) 23 (26.4%) 0.23
58 (61.7%) 36 (38.3%)
24 (68.6%) 11 (31.4%)
8 (80%) 2 (20%) 0.04
24 (75%) 8 (25%)
114 (65.5%) 60 (34.5%)
coronal deformity, sagittal imbalance such as flat back is
frequently observed. Most of the curve apex is located in the
lumbar or thoracolumbar area and Cobb angle is rarely
>308. Although the precise prevalence of DLS is difficult to
define, several recent epidemiologic studies have reported a
17% to 29.4% cumulative incidence over 10 years.14,15
Even though the majority of these patients can be managed
using conservative measures, unremitting pain and disability
may warrant consideration of surgical intervention.
Although advances in surgical technique and perioperative
care may provide successful surgical outcomes for various
spine diseases, a lack of understanding of this complex
disease limits proper management. Fortunately, a recent
SRS-Schwab classification for ASD may present useful
guidelines for clinical decision making and surgical plan-
ning.5 Additionally, reliability and clinical relevance have
also been reported with this classification.6,7 As the global
sagittal balance was adopted as meaningful radiographic
parameters representing clinical parameters (health-related
quality of life), the importance of these global sagittal
factors was emphasized.3,4 However, this classification
includes heterogeneous types of adult spinal deformity.
As previously mentioned, clinical and radiographic charac-
teristics of DLS are different from those of other forms of
ASD. Therefore, the purpose of this study was to investigate
the clinical relevance of the sagittal modifier suggested by
the SRS-Schwab classification by limiting ASD to DLS.
Unlike previous reports, the present study showed that
PI-LL was only a statistically significant sagittal parameter
related to clinical parameters. PI-LL presented a weak
correlation (r ¼ 0.137–0.176) with clinical parameters such
as ODI and back and leg NRS in linear and multiple
regression analyses. However, other sagittal modifiers, PT
and SVA, did not show any significant correlation with
clinical parameters. For coronal radiographic parameters,
CA, CI, CDD, and TA presented statistically significant
correlation with clinical parameters. However, as the
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 DEFORMITY
overall value of r2 in linear regression analysis was low, high
correlation between clinical and radiographic parameters
could not be explained through this study. These results are
different from those of other reports. A recent study also
showed TPA has a significant correlation with clinical
parameter (ODI)10; however, the coefficient of determi-
nation in the present study (r ¼ 0.137, adjusted
r2 ¼ 0.014) was lower than that in Protopsaltis et al’ study
(r2 ¼ 0.19). Furthermore, some coronal radiographic
parameters (CA, CI, CDD, and TA) showed some corre-
lation with patient self-reported disability even with the low
r value (0.137–0.202). In 2006, Schwab et al3 initially
presented the importance of coronal and sagittal subluxa-
tion of the vertebra. Following studies on ASD, however, did
not include coronal parameters with the exception of the
coronal angle and location of the apex. However, degener-
ative de novo scoliosis is usually accompanied by neurologic
compromises, which is another important factor when
determining proper management. Therefore, coronal abnor-
malities including lateral subluxation, rotation, and tilting
of the apex vertebra could significantly affect disability. On
analysis for clinical outcomes (surgical rates and patient self-
reported disability) among the grades of the SRS-Schwab
sagittal modifiers, the effect of these sagittal modifiers (PT
and SVA) was not significantly high compared with the
previous reports, which support the clinical relevance of this
classification.6,7
This study does not present a new classification or treat-
ment strategy for DLS. Even though reports on surgical
results of various treatments for DLS have been pre-
sented.16 – 18 Further studies on the extent of surgical cor-
rection and prevention of complications such as adjacent
segment pathology are necessary. Recently, a new classifi-
cation for DLS that focuses on the extent of the degenerative
segment and global deformity has been suggested.19 How-
ever, it is not easy to determine the proper fusion extent
when taking into account the adjacent segmental pathology
after limited fusion. PI-LL, one of the spinopelvic
parameters, has been considered to be an useful indicator
in intraoperative planning of lumbar deformity
surgery.20,21 In addition, the significance of the correlation
with clinical parameters was noted in the present study.
Therefore, PI-LL could be used not only for treatment
planning of deformity but as a considering factor of surgery
in DLS patients.
Although this study focused on the limited type of ASD
with data from a single center, the primary limitation is
the retrospective cross-sectional study design. Moreover,
the majority of data are corrected by radiographic
measurements, and clinical parameters such as SRS-22 were
not included in this study. Therefore, a general assessment
of health-related quality of life, as in this study, may
be insufficient. In addition, the individual surgical
indications for each surgeon may have affected treatment
since this study is based on data from a single institute.
Decision of surgery for all patients in this study is basically
based on the clinical aspects rather than radiographic
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The SRS-Schwab Classification for Degenerative Lumbar Scoliosis  Ha et al
findings. A sufficient number of patients from a multicenter
study are needed to support this study and refine these
results.
In conclusion, the SRS-Schwab classification showed
weak clinical relevance for DLS. Even though some radio-
logical parameters (PI-LL, TPA, CA, CI, CDD, and TA)
showed statistically significant results, correlation between
radiological and clinical parameters was weak. Addition-
ally, increased surgical rates along the sagittal modifier
(SVA or PT) grades were not noted in these DLS patients.
Therefore, other clinical factors should be also considered
for the proper management of DLS.
Key Points
Clinical relevance of the SRS-Schwab classification
for degenerative lumbar scoliosis was evaluated.
Radiological parameters showed weak correlation
with clinical parameters.
Surgical rate was not correlated with PT or SVA of
the SRS-Schwab sagittal modifiers.
Clinical factors such as neurological compromise
should be considered instead of radiological
parameters for proper management of
degenerative lumbar scoliosis.
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