SPINE Volume 30, Number 10, pp 1202–1205
©2005, Lippincott Williams & Wilkins, Inc.
Use of the Scoliosis Research Society Outcomes
Instrument to Evaluate Patient Outcome in Untreated
Idiopathic Scoliosis Patients in Japan
Part II: Relation Between Spinal Deformity and Patient Outcomes
Kei Watanabe, MD, Kazuhiro Hasegawa, MD, Toru Hirano, MD, Seiji Uchiyama, MD, and
Naoto Endo, MD
Study Design. This study clarifies the relation between
the results of the Scoliosis Research Society Outcomes
Instrument (SRS-24) and radiographic parameters of back
deformity in Japanese idiopathic scoliosis patients.
Objectives. To investigate the relation between mag-
nitude of back deformity and results of the SRS-24 in
untreated patients.
Summary of Background Data. In idiopathic scoliosis,
it is necessary to clarify the relation between patient-
perceived outcomes of the deformity and magnitude of
back deformity before considering treatment. The relation
between the magnitude of spinal deformity and out-
comes of untreated patients, however, has not been fully
investigated.
Methods. Patients (n ⫽ 166) under 30 years of age with
untreated scoliosis were evaluated. Radiologic examina-
tion included Cobb angle, rotation angle of apical verte-
brae, and translation of C7 vertebra from the central sa-
cral line (C7 translation) on the coronal plane. Patient
evaluation using section 1 (15 questions) of the SRS-24
was compared with radiologic findings using Spearman’s
correlation coefficient by rank (rs).
Results. The average pain domain score was 27.0 ⫾
2.2 points, general self-image 9.9 ⫾ 1.7 points, general
function 12.7 ⫾ 1.1 points, and overall level of activity
14.9 ⫾ 0.6 points. In radiologic deformity, the average
Cobb angle and rotation angle of the thoracic curve were
35.8° ⫾ 12.1° (range, 17°–73°) and 13.9° ⫾ 8.2° (range,
0°–38°), respectively. The average Cobb and rotation an-
gle of the lumbar curve were 31.4° ⫾ 9.3° (range, 13°–56°)
and 15.4° ⫾ 9.7° (range, 2°–36°), respectively. The mean
C7 translation was 12.4 ⫾ 9.7 mm (range, 0 – 48 mm).
Comparison between individual domains and radiologic
measurements revealed that the total pain (rs ⫽ ⫺0.33;
P ⬍ 0.0001) and general self-image (rs ⫽ ⫺0.25; P ⫽
0.0024) domain scores had a significant inverse correla-
tion with thoracic curve Cobb angle. Comparison be-
tween the scores of individual questions and radiologic
measurements revealed that the scores of question 3 (to-
tal pain domain) had a significant inverse correlation with
From the Niigata University Graduate School of Medical and Dental
Sciences, Niigata City, Japan.
Acknowledgment date: January 15, 2004. First revision date: June 22,
2004. Acceptance date: June 30, 2004.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Kei Watanabe, MD,
Division of Orthopaedic Surgery, Department of Regenerative and
Transplant Medicine, Niigata University Graduate School of Medical
and Dental Sciences, 757 Asahimachidori Ichibancho, Niigata City
951-8510; Japan; E-mail: watakei@med.niigata-u.ac.jp.
1202
thoracic curveCobb angle (rs ⫽ ⫺0.36; P ⬍ 0.0001). The
scores of question 5 (general self-image domain) had a
significant inverse correlation with thoracic curve Cobb
angle (rs ⫽ ⫺0.41; P ⬍ 0.0001) and rotation angle (rs ⫽
⫺0.30; P ⫽ 0.0006).
Conclusion. The patients did not have negative self-
image regarding back appearance when the thoracic
curve Cobb angle was less than 30° but had a negative
self-image when the thoracic curve Cobb angle was more
than 40°and the rotation angle was more than 20°. On the
other hand, the lumbar curve Cobb angle and the rotation
angle did not correlate with patient self-image. The re-
sults of the present study will help to define the parame-
ters for the initiation of active treatment and physicians
should maintain or reduce scoliotic deformity so that the
thoracic curve Cobb angle is less than 40° and the rotation
angle is less than 20° in idiopathic scoliosis.
Key words: idiopathic scoliosis, spinal deformity, un-
treated Japanese patients, Scoliosis Research Society
Outcomes Instrument. Spine 2005;30:1202–1205
The relation between the magnitude of spinal deformity
and patient outcome in untreated patients must be clar-
ified before considering surgical treatment. Only a few
outcome studies have been reported, however, with re-
gard to the relation between spinal deformity and patient
outcomes in untreated patients with idiopathic scoliosis.
Edgar and Mehta reported that 40% of unfused patients
were distressed by curves under 90°, and the percentages
rose to 77% for curves greater than 90°.1 In a cohort
study of 1,476 study participants with scoliosis, the
study participants had a poor perception of body image
and reported pain that was more intense, continuous,
and generalized throughout the back. Those outcomes
did not, however, significantly correlate with scoliosis
severity.2 Haher et al developed the Scoliosis Research
Society Outcomes Instrument (SRS-24) as a simple, prac-
tical, disease-specific questionnaire for idiopathic scolio-
sis in 1999.3 After the SRS-24 was established as a dis-
ease-specific questionnaire, postsurgical evaluation for
idiopathic scoliosis gradually became popular.
A relation between spinal deformity and patient out-
comes such as back pain, self-image, and functional ac-
tivity is not clearly understood in idiopathic scoliosis
patients. The purpose of the present study was to inves-
tigate the association between patient evaluation using
the SRS-24 and the magnitude of spinal deformity in
untreated Japanese patients.
 Spinal Deformity/Patient Outcomes and SRS • Watanabe et al 1203

Materials and Methods

The SRS-24 was developed by Haher et al to evaluate patient
satisfaction and performance among postsurgical patients with
idiopathic scoliosis.3 The instrument consists of 24 questions
divided into seven equally weighted domains that were deter-
mined by factor analysis: total pain, general self-image, post-
operative self-image, general function, activity, postoperative
function, and satisfaction. The authors independently trans-
lated the SRS-24 into Japanese and investigated the relation
between results of the SRS-24 and magnitude of spinal defor-
mity in untreated Japanese patients. Validation of the transla-
tion into Japanese of an original SRS-24 was certified by World
Support Inc. (Tokyo, Japan). There were no major discrepan-
cies between the independent translation from English to Jap-
anese and also Japanese to English by World Support Inc. and
those by our institution. Figure 1. Correlation between pain domain and thoracic Cobb
angle (rs ⫽ ⫺0.33; P ⬍ 0.0001)
The scoliosis group comprised 166 untreated patients under
30 years of age who had not had brace or surgical treatment
and had a Cobb angle of greater than 20°. There were 22 males
Results
and 144 females, ranging in age from 7 to 29 years (mean age,
14.7 years). Preoperative curve patterns were classified using Results of outcome evaluation using the SRS-24 and ra-
the King-Moe classification for thoracic curves4 and the SRS diologic evaluation of the scoliosis group are summa-
classification for thoracolumbar and lumbar curves (TL). There rized in Table 1. There was no statistically significant
were 25 cases of King type I, 38 type II, 58 type III, 1 type IV, difference in the scores for each SRS-24 domain between
21 type V, and 23 TL curves. All patients in this study were individual curve types. We did not find any significant
evaluated by the SRS-24 at the first visit to our clinic. In Japan, correlation between age of the patients and SRS-24
a nationwide school screening program has not yet established.
score.
Therefore, some patients with large curve can be missed from
The scores of the general function and activity do-
specialist on scoliosis, and the appropriate treatment delayed.
In the present study, the first section of the SRS-24 was
mains did not correlate with any radiographic parame-
investigated among the scoliosis group and the magnitude of ters of spinal deformity. On the other hand, the pain
back deformity was evaluated using Cobb angle, rotation angle (rs ⫽ ⫺0.33; P ⬍ 0.0001) and general self-image (rs ⫽
of the apical vertebra, and translation of the C7 vertebra from ⫺0.25; P ⫽ 0.0024) domain scores had a significant in-
the central sacral vertical line (C7 translation) in coronal plane verse correlation with thoracic curve Cobb angle (Fig-
radiographs. Rotation angle was measured using the Perdriolle ures 1 and 2). Comparison between the scores of indi-
method.5 Cobb angle and rotation angle were measured in the vidual questions and radiographic parameters revealed
thoracic and lumbar curve in patients with a double curve. that the scores of question 3 (pain domain) had a signif-
Correlations between the scores of the individual domains icant inverse correlation with thoracic curve Cobb angle
using the SRS-24 and radiographic parameters were calculated (rs ⫽ ⫺0.36; P ⬍ 0.0001) and tended to have an inverse
using Spearman’s correlation coefficient by rank (rs). Scores of correlation with thoracic curve rotation angle (rs ⫽
the SRS-24 were statistically compared using the Mann Whit- ⫺0.24; P ⫽ 0.0052). The scores of question 5 (general
ney U test. A correlation coefficient with an absolute value of at
self-image domain) had a significant inverse correlation
least 0.25 and a P value less than 0.01 were considered statis-
tically significant. StatView-J 5.0 (Abacus Concepts, Berkeley,
CA) was used for all statistical analysis.

Table 1. SRS-24 Outcome and Radiologic Value of the

Scoliosis Group
Value 关mean ⫾ SD (range)兴

Total pain domain 27.0 ⫾ 2.2

General self-image domain 9.9 ⫾ 1.7
General function domain 12.7 ⫾ 1.1
Activity domain 14.9 ⫾ 0.6
Cobb angle (°)
Thoracic curve (n ⫽ 147) 35.8 ⫾ 12.1(17–73)
Lumbar curve (n ⫽ 87) 31.4 ⫾ 9.3 (13–56)
Rotation angle (°)
Thoracic curve (n ⫽ 147) 13.6 ⫾ 8.2 (0–38)
Lumbar curve (n ⫽ 87) 15.4 ⫾ 9.7 (2–36)
Translation of C7 vertebra (mm) (n ⫽ 166) 12.4 ⫾ 9.7 (0–48) Figure 2. Correlation between general self-image domain and
thoracic Cobb angle (rs ⫽ ⫺0.25; P ⫽ 0.0024)
1204 Spine • Volume 30 • Number 10 • 2005
Figure 3. Correlation between scores of question 3 (rs ⫽ ⫺0.36;
P ⬍ 0.0001) or 5 (rs ⫽ ⫺0.41; P ⬍ 0.0001) and thoracic Cobb angle
(mean ⫾ SE) in a graphic form.
with thoracic curve Cobb angle (rs ⫽ ⫺0.41; P ⬍
0.0001) and rotation angle (rs ⫽ ⫺0.30; P ⫽ 0.0006)
(Figures 3 and 4). The scores of other questions did not
have any correlation with radiographic parameters. Pa-
tients with a thoracic curve Cobb angle of more than 40°
had a significantly lower outcome score than those with
a thoracic curve Cobb angle of less than 40° (Figure 5).
Furthermore, patients tended to have a lower outcome
score when the thoracic curve rotation angle was more
than 20° (Figure 6).
Discussion
In idiopathic scoliosis, a progressive curve of 30° to 40°
is an indication for orthotic treatment. Curves over 50°
to 60° in adolescents are considered an indication for
surgical treatment.6 Because these concepts were estab-
lished by radiologic studies7–9 of idiopathic scoliosis, pa-
tient outcomes were not considered in these studies. It is
necessary to clarify the relation between patient-
perceived evaluation of back deformity and radiographic
deformity before considering treatment. Few studies
have evaluated the relation between the magnitude of
spinal deformity and outcomes of untreated patients
with idiopathic scoliosis. Edger et al examined 77 un-
fused and 91 fused patients who were followed up for at
least 10 years after reaching skeletal maturity. The inci-
dence of complaints of self-consciousness or distress
Figure 4. Correlation between scores of question 3 (rs ⫽ ⫺0.24;
P ⫽ 0.0052) or 5 (rs ⫽ ⫺0.30; P ⫽ 0.0006) and thoracic rotation
angle (mean ⫾ SE) in a graphic form.
Figure 5. Comparison between the scores of question 3 or 5
(mean ⫾ SE) for thoracic Cobb angles under 40° and those for
thoracic Cobb angles greater than 40° using the Mann Whitney U
test.
about their body shape was 43 of 77 (56%) in unfused
patients and 41 of 91 in fused patients (54%). For curves
under 90°, 40% of unfused and 49% of fused patients
were distressed by their shape. For curves greater than
90°, the percentages rose to 77% and 68%, respective-
ly.1 Goldberg et al examined 1,476 surgically treated
study participants with adolescent idiopathic scoliosis in
a comparative retrospective cohort study. Scoliosis study
participants perceived themselves to be less healthy and
had a poor perception of body image, particularly
among woman. Although those outcomes were exam-
ined according to the severity of scoliosis, not all of the
results were statistically significant.2 Danielsson et al ex-
amined 127 patients with brace treatment who were fol-
lowed up for at least 20 years. Of 127 patients, 34%
were limited in their social activity due to their back,
mostly due to difficulties with physical participation in
activities or self-consciousness about appearance. Pain
was a minor reason for limited social activity.10
In Part 1 of this study, the authors reported that the
answers to questions 3 and 5 depended on self-image
regarding back appearance. The results of the second
part of this study clearly indicated that most of the pa-
tients did not have negative self-image regarding back
appearance when the thoracic curve Cobb angle was less
Figure 6. Comparison between the scores of question 3 or 5
(mean ⫾ SE) for thoracic rotation angles under 20° and those for
thoracic rotation angles greater than 20° using the Mann Whitney
U test.
 Spinal Deformity/Patient Outcomes and SRS • Watanabe et al 1205
than 30° but had a negative self-image when the thoracic
curve Cobb was more than 40° and a rotation angle of
more than 20°. We consider that the patient do not note
their back deformity due to rib hump when the curve
magnitude was mild, less than 30°. On the other hand,
once the curve becomes over 40°, the patients realize
waistline deformity, and complain of being self-
conscious or distressed regarding their trunk appear-
ance. The lumbar curve Cobb angle and the rotation
angle, however, did not correlate with patient self-image.
The reason for these results was that back deformity in
lumbar scoliosis was, in general, not more prominent
than thoracic scoliosis with rib hump. C7 translation, in
the present study, also did not influence self-image in
patients with idiopathic scoliosis. Trunk imbalance usu-
ally does not influence self-image as waistline or hump
does if C7 translation is around 20 to 30 mm. In the
present study, the imbalance was minimal (average,
12.4 ⫾ 9.7 mm) and did not affect self-image.
Further studies compared between visual appearance
of spinal deformity and radiographic parameters for
measuring scoliosis are necessary and our next assign-
ment. The scoliometer is an accepted method for detec-
tion and evaluation of visual spinal deformity. With re-
gard to the relation between back appearance and
radiologic examination, Korovessis and Stamatakis re-
ported a relation between gibbosity measured using a
scoliometer and the Cobb angle in thoracic curves (r ⫽
0.60) and thoracolumbar curves (r ⫽ 0.47).11 Griffet et
al12 and Pearsall et al13 also reported a liner correlation
of 0.59 between gibbosity and the Cobb angle in thoracic
curves. The results of Griffet et al, however, demon-
strated that gibbosity was not correlated with the Cobb
angle in lumbar curves12 Sanders et al reported a corre-
lation between the Walter Reed Visual Assessment Scale
scores, which was the only instrument designed specifi-
cally to assess patients’ perception of their visual spinal
deformity, and curve magnitude. Interestingly, the
Walter Reed Visual Assessment Scale scores clearly dif-
ferentiated curves of 30° or more from lesser curves.14
We think that back appearance strongly correlates with
radiographic parameters, and radiographic parameters
can be one of the objective indexes for visual spinal de-
formity.
The goal of surgical treatment for adolescent idio-
pathic scoliosis is to establish natural cosmesis and elim-
inate negative self-image without any sequelae. The re-
sults of the present study will help to define the
parameters for the initiation of active treatment, such as
orthotic or surgical treatment, in idiopathic scoliosis.
Physicians should maintain or reduce scoliotic deformity
so that the thoracic curve Cobb angle is less than 40° and
the rotation angle is less than 20°.
Key Point
● Untreated Japanese idiopathic scoliosis patients
with thoracic curve Cobb angle of more than 40° or
rotation angle of more than 20° had negative self-
image due to their back deformity.
Acknowledgments
The authors acknowledge Associate Professor N.
Tanabe of Division of Health Promotion, Department of
Community Preventive Medicine at the Niigata Univer-
sity Graduate School of Medical and Dental Sciences for
his special advice of statistical analysis.
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