Radiological examination of scoliosis

Scoliosis is a multifactorial three-dimensional (3D) spinal

deformity with integral and directly related vertebral deviations in
the coronal, sagittal and horizontal planes(1).
1-Coronal plane: excessive kyphosis, excessive lordosis, flattening
of the spine.
2-Sagittal plane: lateral deviation of the spine.
3-Horizontal plane: rotational deformity of vertebrae.

The radiographic examination of scoliosis includes:

1-Static x-ray: A-P and lateral view of the entire spine and to
include the iliac crests in at least one of these radiographs for a
determination of skeletal maturity.
2-Dynamic x-ray: bending laterally to each side for evaluation of
the curve flexibility.

N.B) There is a clear recommendation for standing position to

make spinal radiographs. The posture should be neutral,
spontaneous which means not actively corrected(2).
 Projection/ Demostration
Technique

Anteroposterior -Lateral deviation

-Angle of scoliosis (by Risser-Ferguson and
Lippman-Cobb methods and scoliotic
index)
-Vertebral rotation (by Cobb and Moe
methods)

of vertebra Ossification of ring apophysis as

determinant of skeletal maturity

of pelvis Ossification of iliac crest apophysis as

determinant of skeletal maturity

lateral bending Flexibility of curve

Amount of reduction of curve

Lateral Associated kyphosis and lordosis

Standard Radiographic Projections and Radiologic Techniques for

Evaluating Scoliosis
Terminology used in describing the scoliotic curve:

For each curvature, there are terminal and apical vertebrae.

-The terminal vertebra is the most tilted superior or inferior vertebra
(upper end and lower end vertebra) included in a curve and are selected to
make the largest Cobb angle.
-The apical vertebra is the most laterally displaced and most profoundly
rotated vertebra and is generally found at the apex of the curve.
-primary curve, major curve and structural curve.
-secondary curve, minor curves and non-structural curves that develop
above and/or below the primary curve to maintain balance.
N.B) The compensatory curve is usually smaller, less rotated and more
flexible than the primary, it is considered a consequence of the primary
curve in an attempt of the body to restore balance (3)
 A-P View
-There are different methods to measure the lateral deviation of the spine
as:
1- Lippman-Cobb method is the standard method
2-Risser-Ferguson method
3-Scoliotic index

-lateral curvature of the spine more than 10° as measured by means of the
Cobb’s method on a standing X-ray considered scoliosis (4).
-Values differ in literature, but generally
10° - 30°, 30° - 40° and >40° are regarded as a ‘mild’, ‘moderate’ or
‘severe’ scoliosis (4)
1-Lippman-Cobb method:
In this method of measuring the degree of scoliotic curvature, two angles
are formed by the intersection of two lines.
The first set of lines, one drawn tangent to the superior surface of the
upper end vertebra and the other tangent to the inferior surface of the
lower end vertebra, intersects to form angle (a). The intersection of the
other set of lines, each drawn perpendicular to the tangential lines, forms
angle (b). These angles are equal, and either may serve as the
measurement of the degree of scoliosis.
2-Technique of measuring the Cobb angle by use of the Bunnell
scoliometer:
a – the scoliometer is adhered to the computer screen with its superior
edge parallel to the proximal end plate of the proximal end vertebra; the
scale displays 21◦ of inclination (arrow)
b – the scoliometer is adhered to the computer screen with its superior
edge parallel to the distal end plate of the distal end vertebra; the scale
displays 25◦ of inclination (arrow). The Cobb angle for the curve measured
is 46◦ (summation of both inclinations).
Risser-Ferguson method:
In this method, the degree of scoliotic curvature is determined by the
angle formed by the intersection of two lines at the center of the apical
vertebra: The first line originating at the center of the upper end vertebra,
and the other at the center of the lower end vertebra.
Scoliotic index:
In the measurement of scoliosis using the scoliotic index, each vertebra (a-
g) is considered an integral part of the curve. A vertical spinal line (xy) is
first determined whose endpoints are the centers of the vertebrae
immediately above and below the upper and lower end vertebrae of the
curve. Lines are then drawn from the center of each vertebral body
perpendicular to the vertical spinal line (aa′, bb′, … gg′). The values yielded
by these lines represent the linear deviation of each vertebra; their sum,
divided by the length of the vertical line (xy) to correct for radiographic
magnification, yields the scoliotic index. A value of zero denotes a straight
spine; the higher the scoliotic index, the more severe the scoliosis.
 Rotational deformity
-the vertebral body rotates towards the convexity of the curve and the
spinous process towards the concavity of the curve.
-There are different methods to measure vertebral rotation as(4):
1- Nash and Moe’s method which assesses how far the centre of the
convex pedicle has moved in relation to the overall width of the vertebral
body (commonly used method)
2- Mehta’s rib vertebra angle is another measurement option which is
particularly applicable to the infantile curve.
3- special protractor (Pedriolle’s torsiometer)
Figure: A summary of common radiographic methods of vertebral rotation measurement (5).
Nash and Moe’s method
The apical vertebral body is divided into six equal segments longitudinally.
When both pedicles are in view, there is no vertebral rotation. It is graded
as "0".
When the pedicle in the concave side (the right side) starts disappearing, it
is graded as "1".
When the pedicle disappears, it is graded as "2".
When the contralateral pedicle (pedicle in the convex side) is in the midline
of the vertebra, it is graded as "3".
When it crosses the midline of the vertebra, it is graded as "4".
 Lateral view
How to measure thoracic and lumber spine curves ?
Cobb’s angle, is the most commonly applied method to assess sagittal
spinal curves.
There is a wide range of normal values exist.

Thoracic curve:
-the curve is determined from the cephalad end plate of T2 (or T3 if T2 is
not visible) to the caudal end plate of T12.
-the most commonly accepted normal range values for kyphosis is 20° -
50°. Angles of more than 50° are regarded as hyperkyphosis, while thoracic
curves of 80⁰ or thoracolumbar curves of 60° - 70° are considered severe.
Angles of less than 20° are regarded as hypokyphosis or flat curve.

Lumber curve:
-the Cobb’s angle between the superior end plate of the first lumbar
vertebra and the superior end plate of the sacrum.
- the most commonly accepted normal range values for lordosis are 20°-
60°, angles more than 60° are regarded as hyperlordosis. Angles of less
than 20° are regarded as hypolordosis or flat curve.
Figure: Measurement of thoracic kyphosis and lumbar lordosis angle(4).
 Skeletal maturity
Risser sign (US classification)
Used to measure ossification of the iliac apophysis to
estimate the risk of progression
Fig: Grades on x-ray

-Progression factor formula= Cobb angle – (3 X Risser Sign) /

Chronological age
-SOSORT decision guidelines to manage scoliosis are
assisted by the following graph which is based on Lonstein
and Carlson's progression estimation formula.
For Example:
Cobb angle= 25 age=10 years risser sign= 1
Progression risk= 25-(3X1) /10=2.2
Incidence of progression =85%
Reference
1- Illés, T., Tunyogi-Csapó, M., & Somoskeöy, S. (2011). Breakthrough in three-
dimensional scoliosis diagnosis: significance of horizontal plane view and
vertebra vectors. European spine journal : official publication of the European
Spine Society, the European Spinal Deformity Society, and the European
Section of the Cervical Spine Research Society, 20(1), 135–143.

2- Kotwicki, T., Negrini, S., Grivas, T. B., Rigo, M., Maruyama, T., Durmala, J., Zaina,
F., & Members of the international Society on Scoliosis Orthopaedic and
Rehabilitation Treatment (SOSORT) (2009). Methodology of evaluation of
morphology of the spine and the trunk in idiopathic scoliosis and other spinal
deformities - 6th SOSORT consensus paper. Scoliosis, 4, 26.
https://doi.org/10.1186/1748-7161-4-26

3- Schlösser, T. P., van Stralen, M., Chu, W. C., Lam, T. P., Ng, B. K., Vincken, K. L.,
Cheng, J. C., & Castelein, R. M. (2016). Anterior Overgrowth in Primary Curves,
Compensatory Curves and Junctional Segments in Adolescent Idiopathic
Scoliosis. PloS one, 11(7), e0160267. https://doi.org/10.1371/journa

4- Britz, E., Langerak, N. G., & Lamberts, R. P. (2020). A narrative review on spinal
deformities in people with cerebral palsy: Measurement, norm values,
incidence, risk factors and treatment. South African medical journal = Suid-
Afrikaanse tydskrif vir geneeskunde, 110(8), 767–776.
https://doi.org/10.7196/SAMJ.2020.v110i8.14472

5- Lam, G. C., Hill, D. L., Le, L. H., Raso, J. V., & Lou, E. H. (2008). Vertebral rotation
measurement: a summary and comparison of common radiographic and CT
methods. Scoliosis, 3, 16. https://doi.org/10.1186/1748-7161-3-16