Cobb Angle for Scoliosis

Cobb angle is the “universal standard” of measurement used to quan�fy a scoliosis for the purpose of measuring curve
progression over �me. Cobb angle is measured on a T-spine and/or L-spine PA radiograph as follows: A line is drawn at
the top of the vertebral body with the greatest lateral �lt above the curve apex and another line is drawn at the botom
of the vertebral body with the greatest lateral �lt beneath the curve apex. The lines should be extended into the margin
of the film. Next, lines are drawn perpendicular to the lateral �lt lines. The Cobb angle is calculated where these two
lines intersect.

Evalua�ng scolioses via Cobb angle is important since this angle is o�en the first objec�ve indicator. A lateral spinal curve
with a Cobb angle ≥10° is considered to be scoliosis. Due to intrinsic measurement variability, increases in curvature
between subsequent radiographs that are ≥10° are considered to be noteworthy (although some sources consider
increases that are ≥5° to be noteworthy). Scoliosis is considered mild at 10°-24°, moderate at 25°-50°, and severe at >50°.

To determine the extent of spinal rigidity, radiographs may be taken in both standing and supine on the same day and
�me. For example, if the standing Cobb angle is 40° and the supine Cobb angle is 20° this indicates some degree of spinal
flexibility. On the other hand, if there is no change in Cobb angle degree when radiographs are taken in a standing and
supine posi�on on the same day, the spine is considered rigid. In this case, it is less likely significant correc�on will be
able to be achieved with exercise or bracing. Conversely, if the Cobb angle measurement indicates that there is flexibility,
some degree of correc�on may be expected in a correc�ve brace, or from scoliosis exercises.

Spinal surgeons frequently reference a 45°-50° Cobb angle as the degree where surgical interven�on for scoliosis is
recommended. This threshold is a point of conten�on between advocates of conserva�ve care and spinal surgeons.

Pa�ents should try to ensure that as many factors as possible are constant with each set of radiographs. Radiographs
should be obtained at the same �me of day due to reported varia�ons in intraday measurements, which may be as high
as 20° (Beauchamp et al 1993). Furthermore, the pa�ent should assume the same posi�on in each radiographic series. If
the ini�al radiographs were taken in standing, then subsequent radiographs should also be taken in standing. Posture
also affects Cobb angle measurement. The pa�ent should avoid slouching and try to assume the same standing posture
for subsequent radiographs.

One shortcoming is that the Cobb angle is a two-dimensional view of a three-dimensional condi�on. So, Cobb angle
alone does not fully capture the complexity of a scolio�c curve.