prognosis in idiopathic scoliosis · the conservative attitude of this clinic in the treatment of...

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32:381-395, 1950. J. Bone Joint Surg. Am.IGNACIO V. PONSETI and BARRY FRIEDMAN

PROGNOSIS IN IDIOPATHIC SCOLIOSIS

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pi{( )( �NOSIS IN IDIOPATHIC SCOLIOSIS

liv IGNACI() V. PONSE’�t, M.D. , AND BARRY FRIEDMAN, M.D., IOWA CITY, IOWA

Iront the I)epart�nent O,f Orthopaedic &S’urgery, State University of Iowa, Iowa City

The conservative attitude of this Clinic in the treatment of scoliosis has made it

possible to accumulate a great number of cases of idiopathic scoliosis with prolonged

follow-up studies, ti’eated without sur’gery. These cases have been studied w’it.h the object

of establishing criteria for’ deter’tssining the prognosis in idiopathic scoliosis.

Befor’e an opei’ation is itnder’taken in a young patient with scoliosis, tise surgeon

should have a th(Irougli knowledge of the natural course of the curve he is going to tr-eat.

and the probal)Ie outcome. The pr’ohlens is so conssplex anti so many abstract theoretical

studies have been nsade that the orthopaetiic surgeon is prone to overrate the dangers

involved in scoliosis and to carry out surgical fusion of the spine which is often unneces-

sary. In Inany cases of idiopathic scoliosis, there is a natural tenden�y for the curve to

stop progressing after a certain growth has been reached. Furthermore, the body posture

is often ivehl maintained in spite of sizable spinal curvatures. On the other hand, extremely

defortssing tlsoracic cur’ves, requiring early and active tt’eatment, may develop over a

short period of time. It is tise purpose (If this paper to outline the course of the most (‘0155-

rnon patterns (If idiopathic curvature (If the spine, and to give sorsie basis for’ prognosis

w’ith any given cirr’ve.

Material

In a gr’oup of 444 y��ung patients with idiopathic scoliosis, spine fusion hsa(i been

perfortssed in fifty cases. This study is l)ased on an analysis of the 394 cases of itiiopathic

scohiosis which wete not tr’eated sitrgically. Of these, 335 cases were observed through

maturity. Roentgenogranss taken with the patient in the standing and supine positions,

photographs, and clinical examination wet-c employeti in the study. Cases with tninitssal

curves were not includeti. The average follow-up period was two years and ten months.

A great number of patients in this series received conservative treatnsent �, consistitig

of exercises designed to increase nsuscle strength and to correct postural imbalance.

Tightness of the abdonsinal nsuscles at the side of the overhang was corrected by passive

anti active stretching. The patients were taught to shift their thorax into proper aligntnent.

with tise pelvis. Bt’aces \Ver’(’ often given to help maintain body post.ure. It is n(It Olin’

intention to evaluate the results of conservative tm-eatnsent in this paper. Wisile consei’va-

t.ive them’apy may imssprove hO(iY posture, it has never been found-or clainsed-t.o deci’ease

the size of a spinal curvature . As this stutly is baseti upon the characteristics of the curves,

the fact. that. most patients received (‘onservat.ive treatment di(l not influence the n’esult.s

of our observations.

Measurement of C urves

The method used for tietermnining the angle of a curve is as follows : The top anti

bottom vertebrae of the cttrve are identified by the w’idth of the intervertebral space, the

tilting, and the degree of rotation of the vertebrae. The intervertebral spaces are widem’

on the side of the convexity and narrower on the concave side. At the top and bottom of

the curve, the intervertebral space is either of equal width or is wider toward the con-

cavity of the curve. The rotation of a vertebra is indicated on the roentgenograms by the

relationship of the spinous process to the body of the vertebra. The degree of rotatiots is

greatest at the apex of the cinrve an(i diminishes tow’at’d each end, where a neutral vet’t.e-

bra-that is, a non-rotatetl vertebi’a-is frequently found. The top and bottom vertebrae

VOL. 32-A, N(I. 2, APRIL 1950 381



382 I. �. PONSETI AND 13. PRIEtMA�

are usually the ones which rotate the least in the curve, but an exception should be madefor the cases with curves showing concave rotation. Lines are drawn parallel to the upper

surface of the top vertebra and to the undersurface of the bottom vertebra. The angle

fttrmed by these lines is the angle of the cur�re.

Cut’ve Pauerius

In idiopathic scohiosis, most of the characteristics of the curve or curves are present

from the onset of the deformity and tb not. change throughout its entire course. The size

of the curvature nsay increase considerably, and in some cases one or two more vertebrae

may be included in the curve in the late stages. However, the apex, the direction of rota-

tion, and the location of the curve do not change. Roentgenogranss taken shortly after

the onset, ��‘hen the curvature is still minimal, point almost unnsistakably to the pattern

of the scoliosis (Figs. 4-A to 4-C and 7-A to 7-D). Only in exceptional cases does a change

in pattern occur dttring the development of the scoliosis.

It was possible to group all the cases of idiopathic scoliosis studied into five main

patterns : nsain lunsbar, main thoracolumbar, consbined thoracic and lumbar, main

thoracic, and nsain’cervicothoracic. In Table I the 394 cases are classified according to the

curve patterns. These gr-oupings correspond quite closely to the ones described by

Schttlthess in 1905.

The course and prognosis in idiopathic scoliosis vary considerably frons pattern to

pattern. For this reason, each group will be considered in detail.

Age at Onset

The final angular value of a curve is usually correlated with the age at which the

scoliosis begins. However, it is often tiifficult to (letermine just when the curvatut’e starts.

In children who are well cared for, the scoliosis nsay be detected shortly after its onset;

TABLE I

SUMMARY 0. 394 CASEs OF IDItIPATHIC SCoLIosms TREATED WITHOUT SURGERY

Average Age Average Degrees

\\‘lsen

Curve At At Conivex- At At

Curve Pattern No. (If First First Stabil- itv First Stabil-Cases Sex Noticed Visit izationi to Visit ization

_____________ ________ M. F. Vrs. Mo. Yrs. Mo. Yrs. Mo. Rt. Lt. St. Sup. St. Sup.

Lumbar 93 13 80 13 4 14 1 14 10 28 65 33.9 27.7 36.8 29.1

(23.6%)

Thoracolumbar 63 14 49 13 11 14 15 11 51 12 36.3 31.6 42.7 35.0

(15.9%)

Combined

S Thoracic 146 . 136 10 44.0 39.8 51.9 41.4

� Lumbar (37. 1 %) � � 13a 12 4 13 1 lo i �o 136 35 . 1 30 . 1 41 . 4 37.7

Thoracic 87 25 62 11 1 12 10 16 1 79 8 60.2 53.7 81.4 73.8

(22.1%)Cervicothoracic 5 1 4 15 2 16 16 1 4 32.6 30.0 34.6 32.2

_______________ (1.3%) ________ _______ _______ _______

Totals 394 (14 330 295 99

I ________ _______ ________ ________ ____________ ___________Rt.=right. Lt. =left.

St. = standing. Sup. = supinic.

THE JOURNAL OF BONI: AND JoINT SURGERY



Age of PatientWhen Curve

First Noted

(Years)

No. of

Patients

12

14

9 4 4 0 1

12 6 4 1 1

34 22 10 2 0

33 20 11 2 0

88 52 (59%) 29 (33(( ) 5 (6%) 2 (2��)

Under 10From 10 to 12

From 12 to 14

Over 14

3

3

22

26

54 27 (50%) 12 (22%) 12 (22%) 3 (6%)

14 T.0 3 4 7

L. 1 4 3 6

28 T. 3 10 14 1

L.10 16 2 0

T.12 23 6 4

L.21 18 (; 0

T.13 17 0 0

14.26 4 0 0

T. 28 (24%)

L. 58(50%)

Over 14 � 30

Total � � 117

Main Thoracic � �

Apex: 8th or 9th thoracic Under 10 18

l’xtenit of curve: 5th or 6th From 10 to 12 16

thlora(’ic to 1 ith or 12th Fm’om 12 to 14 21

thoracic � Over I 4 16

Total � � 71

Cervicothsom’acic �

Apex : 3rd thom’acic � Unidem’ I 0 0

1’�xtenit of curve: 7th cervical Frons 10 to 12 0

or I st thoracic to 4th or From I 2 to I 4 1

5th thoracic ()ver 14 4

Total

0

0

0

3

T. = ‘Flnon’acic. I.�. = Lunsham’.

5

�(IL. 32-A, N(I. 2, APRIn. 1(150

PROGNOSIS IX IDIOPATIIIC SCOLIOSIS

TABLE II

COURSE OP IDIOPATHIC ScoLlosls IN 335 CASES, CORRELATED WITH PATTERN

AND AGE OF PATIENT AT ONSET OF CURVE

383

Curve Pattern

Mains Lumllar

Apex: 1st or 2nd lumbar

Extent of curve: 11th tho-

ra(’ic to 3m’d lunshar

Under 10

From 10 to

Fm’ons 12 to

Over 14

Total

Thoracolunshar

Apex: 11th or 12th thioracic

Extent of curve: 6th or 7ththoracic to 1st or 2ndlumbar

Total .

Combined

Thoracic

Apex: 7th or 8th thoracic

Extent of curve: 6th to lOths

thoracic

Lumbar

Apex: 2nsd lumbarExtent: 11th thoracic to 4th

lumbar

Under 10

Frons 10 to 12

From 12 to 14 45

Angle of Curve at Maturity

No. of Patients with Curves Measuring

(Degrees):

Under 40 40 to 60 60 to 80 Over 80

0 0 2

0 1 1

8 7 0

18 4 4 0

53 (45%) 24 (21%) 12 (10%)

42 (36%) 11 (9i’�) 6 (5%)

0 1 4 13

0 1 4 11

1 8 5 7

4 3 5 4

5 (7�) 13 (18�) 18 (25%) 35 (50�)

0 0 0

0 0 0

1 0 0

1 0 0

3 2 0 0



381 I. v. PONSETI AND 13. FRIEDMAN

THE JOURNAL (IF BONE ANI) JOINT SURGERY

Fig. 1-A : 1�Iem1tgen1ogm:nmii � s1no�ving lumiil ian’ (‘um’ve in a t hirteenn-veam’-old girl . Scoliosis lund firstIIUCI1 rnOti(’e(.I at the age (If t W(lVe. Apex is at first lumbar vertebra. Curve exteni(ls frons (‘levenit Ist h(Ira(’ic to t.hil’(l lunisbar.

Fig. 1-13 : �\.t the age of seventeeni years, t here has Ileeni (lIlly niiinnirnal inl(’rease of tine cun’ve.

Lunslsar (‘urves usually inn(’rease omrlv slight lv.Fig. 1-C : Photogra�sh of 1)atienrt at severrteeni years (If age. Bod� P(Isture was good.

ins other cisiltiren, the (‘tit”i’e is ofteni ivell a(lvansceti h)efore it is noticed. Tise age of the

patient at the tirsse the curve was first noticed is useti. In Table II, the cases observed

until nsatirritv ��‘ere groupe(1 a(’(’ording to the age of the patient when the scoliosis was

first noticeti. In each of the five patterns, four groups were made, according to whether

the scoliosis was first notice(l: (a) before the age of ten years; (h) between ten and twelve

years; (c) betw’een twelve and four’teen years; anti (d) after fourteen years of age.

In each age group, the cur’ves were classified a(’cording to their final angular values

at mnaturitv : (a) curves over’ 80 tlegr-ees at misaturity (very severe) ; (b) curves between 60

5115(1 80 (iegrees (severe) ; (c) cur’\’es between 40 and 60 degrees (moderate) ; an(i (d) curves

trn(ler- 40 degrees (sniall).

CURVE PATTERNS

]fa in. L t� 10 1)151’( ‘ urves

Single i(ii(Ipathic lurssbar curves occurred in ninety-three of the 394 cases studied

(23.6 per’ (‘(‘1st.). Th�’ pr’oved to he the most benign of all types of idiopathic curves.

Eights’ of the patients were females, thirteen ii’ere nnales. The a\’erage age at w’hich the

curvatutre was first noticeti s�’as thirteen veals and four months. Lutlishar curves became

stabilized earlier than other pattem’ns, at an average of foutrteets years and ten months.

Since vertebral growth in this group of cases was not corssplete until an average of sixteen

�‘ears and eleven motsths, as evidenced by the completion of ossification excttrsion of the

iliac apophysest, it nsay he assurssed that it is not necessary for the growth of the spine

t(I lIe terminat.etl I)efom-e the lumbar type of s(’ohosis is ari’estetl.

* All the r000tgenn(Igranis show the left side (If the patient at the left side of the page. All were takemi with pa-

tnt’nit in stan(linng IIoSitD)ml 1115(1 arC anteroposterior VieWS.



PROGNOSIS IN IDIOPATHIC SCOLIOSIS 385

VOL. 32-A, NO. 2, APRiL 1950

FIG. 2-A FIG. 2-B FIG. 2-C

Fig. 2-A : Thoracolunsilan’ curve wit hi apex at t be t welft hs thor:u’ic vertebra mi a teni-year-()l(l girl.Scoliosis wits first mlOtice(i at six vean’s (If age. (‘urve extends frorss the ninith thoracic to seconndlumbar vertebra.

Fig. 2-B: In spite of its early onset, curve Intel imscr’ease(l only slightly by the tinsse the girl �seventeen �‘ears of age.

Fig. 2-C: Photographs of patient at seveniteemn years of age. Posture was good.

‘The lumbar’ t’urves generally its(’lu(ieti fk’e ver’teilrae arsd extemstied fi’orn the eleventh

thora(’i(’ to the tiurti lirtisham’ (Figs. 1-A, 1-B, anti 1-C). The apex of the cutrve was at the

first or second lumbar vertebra. They o(’cumred pretionsinantly to the left; sixty-five (70

per cent.) i�’ere conveX to the left and twenty-eight (30 per cent.) w’ere convex to the right..

Counter cttrves above anti below the nsain lunsbar cum’ve were snsall, but constant.

The two or three thoracic vertebrae above the curve were usually tilted opposite to the

vertebrae in the Iulflsi)aI’ cimrve, to forni the tipper (‘ounter curve and r’eahgn the hotly.

These vertebrae often rotated in the sanse direction as the �‘ertebi’ae in the lumisl)ar curve.

Thus, a concave rotation in the sissall thorat’i(’ counter t’tir’ve was pt’esent.

The lower counter’ cur’ve was for’nsied lIv tise foul’th anti fifth luimisbar ver’telII’ae.

These two vertel)rae \VeIe also tilted in the opposite (lire(’tioni to the lunsban’ curve, so that

the undersurface of the fifth lurssbam’ ver’tehr’a was h(Irizontal and the sacr’ursi was then

neutral, or ourt (If the curve. This was foutid in all bitt three of the ninety-thn’ee lumbar

curves. In these three (‘uses, the ltmrlsl)ar cur\’e was lowet’, extending fn’ons tise twelfth

thoracic to the fifth lUlisl)ar, with the apex at the tllir(i itirsibar vertel)r-a. Here, the sacrunss

formed the coutster curve.

Single lumbar curves �ver’e the least tlefor’issirig of all the patter’nss. �FIie gait, with the

alternatitsg rotation anti oscillatiots of the I)elvis, kept the lurssbar’ spine linslwn’, anti

extremne degrees (If defor’rssity w’ei’e not seen. i�he average angular’ value after’ the curve

ha(1 heconse stationary was 36.8 tiegrees with the patient standing, anti 29. 1 degr’ees

supine. In only seven cases (8 i�er cent.. ) � the angulat’ value of the curve over 60 tIe-

grees; but even in the nsore sever’e degrees of angulatitln, the curve ��‘as not very defornsing.

Eighty-eight patients with lumbar scoliosis wem’e observed until after they had reached



4

F1G. 3-A Fm�. 3-B �

Fig. 3-A. : Thoraolunssl Ian (‘UIV(’ ��it In apex at elevt-nit In t Inonacic v(rt(.’IIra inn a foumt (‘(‘ni-y(’ar-oldgirl . (�ur’vatum’e \Vas first m((It i(’e(l at (‘lev(’nI year’s. Ext emit (If (‘un-Ye IS frons eight Is t hon’acic to seconidlurssbar vertebra.

Fig. 3-B : I{oemltg(’n)(Ign’amil (If same Ilat ienrt at sevennteemi years (If age. TIre �‘ours�’ is typical for

curves (If this pattermi.F’ig. 3-C : Photograph (If l)at iennt at sevemiteemn \(‘aI’s (If age. I nn slate of sizable (‘urvatun’e, t he

general II(I(l\’ aligmin�nienit is riot great ly disturlled.

386 I. V. Po)NSE’I’I AND ii. FRIEDMAN

.rnnE J(IU1INAL OF IIONE AND J(IINI’ sunt(;m:rt’v

nssatutr’it.y (Table II). Its tiilse cases (10.2 pet’ cent.), the curve was first. notice(l h)efore the

age of tets. In sl)ite of the early onset, in only one case did tise curve irscr’ease beyon(l 60

tiegrees. Its twelve cases, the scohiosis was first notice(l l)et\veens the ages of ten and twelve

Year’s ; it�1 two of these c�t5eS, the cum’ve progressed beyond 60 tlegrees. Of the sixty-seven

(�ti5(’5 iD which the scoliosis was first. noticetl after the age of twelve, (IIil\’ four- had

curves gr’eater tlsan 60 (legrees, the higlsest value heitsg 67 degrees. In no (‘use, regardless

of the age at. which the cun’ve was first niotit’ed, was clinit’alIy severe defol’rssity (Il)seI’Ve(l.

\Iinilssal lurssbar (‘loves are tiuite (‘(ItSSIiStIti tinUl wer’e not includetl in these statist i(’s.

Fisey ttr’e oft en ns ot. tiisc(I\’eI’e(l until m’)entgenogramsss are t a ken to ii vest igate t he �‘tiiise tlf

low-inick pain ins adult lift’.

Th.o,’acol U 10 bai ( ‘ ii 1-yes

Thtlr’acolulsshar patten’iss occur’n’ed in sixty-three cases, or 16 l)er’ (‘emit . of the total

numssber (If ithiopathic cut’ves studied. Of these, forty-nine were fensales, fout’t.een were

rssales. Tlie th(Iracolumsshai’ curve 1551(1 a great tendency to he convex toward the right, as

thiti thor’acic curves. Fifty-one or’ 80.9 i)er cent. were convex to the right, susd twelve or’

19.1 per cent. were consvex ttl the left.

Six to eight. vertebt’ae \\‘(‘I’e imiclittled in the tlloracolutlssban’ curve, whicis extentled

froris the sixth or seventh thoracic vertebra to the first or second Iirnsbar’, The apex was

at the eleventh on’ twelfth thorsu’ic ; it was at the twelfth t.hor’acic Ven’tel)I’tl. in foi-t.y cases

anti at the eleventh tht)racic its twentv-thr-ee cases (Figs. 2-A to 3-C).

Although tlsem’e pr(I\’(’(i to be no ruajon’ (liffel’eflces ill their e�’enitual outcome, notable

tlifferences in the char’acterist.ics of these cum’ves were foumnd, tiepending upon the location



%‘(II�. 32-A, NO. 2, APRIL 1950

FIG. 4-A FIG. 4-B FIG. 4-C

Fig. 4-.� : ( ‘orssllinle(I t h1(Ina(’i(’ amid lumobam’ scohosis in a nninie-year-old girl . 1�)en1tgenogran1 wastaken onnlv a few weeks after curvature was first Iioti(’ed, Ilut j)atternl was already well defined,

Fig. 4-B : ltoerntgensogranss of sanse Patient at sixteeni year’s of age, sIi(Iwimng great increase of thet’urves. Inncrease (If (‘:1(11 (‘urVe was proporti(Inlate.

Fig. 4-C: Photograph of Patiemit :tt sixteemi years of age. mi spite of size (If the ctrrvature, bods’rensainie(l �veIl ahgmne(l.

of the apex. Tise curves with an apex at the elevetsth thoracic vertebra had a tendency

to grow’ larger anti to penetrate into the thorax nssore than did the cimrves with an apex at

the tw’elfth thoracic vertebra. When the apex was at the eleventh thoracic, the counter

curves ai)ove and below’ the muain curve were usually well tieveloped anti the vertebrae

rotated toward the convexity of each cutve (Figs. 3-A, 3-B, anti 3-C). The sum of the

angimlar values of the counter’ curves imsually equaled the value of the mssain curve. The

countem’ curves in the t.horacolunsbar scoliosis with an apex at the twelfth thoracic ��‘ere

very smssahl or (‘�‘(‘I3 non-existent. IJsumally the erstire spine rotated toward the convexity

(If the nsain (‘uII’\’e, and, if the cotintet’ curves existetl, they showed a slight degmee of

concave m’otation (Figs. 2-A, 2-B, amsd 2-C).

The thoracolunibar scoliosis starteti late. �Fiie average age at which the curve was

first noticei \VII5 four-teen year’s. Fifty-four’ patienits with thoracolurnbar scoliosis �s’ere

observed until they reachetl tssatur’ity. Spontaneous stabilizati(In of the (‘urve occurred

at an average age of sixteen years, whereas the ossifrt’atn)n ex(’lmrsion (If the iliac apophysis

of the patients in this group was not coisspleted until an average age of seventeen years

ant! four nsont.hs. The average angulan’ �‘alue after the (‘urve Isad become stationary was

42.7 degrees w’ith the patient stan(hing, an(l 35.0 tiegrees when stipine.

In six cases, the scohiosis was fir’st noticed before the age of twelve years (Table II).

In three cases of this group, the angle of the curve progresse(i beyond 80 degrees ; in one

case it was 67 degrees. The curve was srisall in the othem’ two cases. In none of forty-eight

cases in w’hich the sc(Ihosis was first noticed after thse age of twelve years, did the curve

reach 80 tlegm’eeS eleven had curves of from 60 to 80 (iegm’ees, an(i in twenty-five the curve

did not. increase beyond 40 degrees.

The t.horacolunsbar curves wem’e, as a whole, not very defoi’nssing. The lower tiioracic

ttII(i thse lumbar segissents rcniainetl hinsbcr, anti a good body posture was mssaintained in



FIG. 5-B

Fig. 5-A : (�InsIIinit’d thoracic amid lunsl)ar scoliosis inn an eight-vean’-old gim’l . Curvature had heennni(It i(’(.�(1 for’ four nsonrt his. Apex is at eighth thon’acic vertebra inn upper curve, annd at second lunssbar

inn lowen’ (‘urVe.Figs. 5-B aIl(1 5-C : R(Ienltgenograniis takemi at niinie amid eleven years sIa)\\ gra(lual in(’rease (If

lIothi curves. The curves reached great size at maturity, as is set-mi frequemrtly in the conisilimned

patterni �vhneni it starts at ani early age.

,__......) --.-..--� �

Figs. 5-D anal 5-l.� : llo(-mntg(’malgraniis takeni at twelve an(l fifteen v(’ars of age show further’ innereaseof tine curves.

Fig. 5-F : Photograph of Patient at fifteens years of age, showmng (letormntv.

THE ,JOUItNAL O)� BO�j /NII J(IIN’l’ SURGERY

388 I. V. PONSETI AND 13. FRIEDMAN

all (‘X(’(’1It eight �‘ttses. In onily tw(I of these w’as a mssa�or’ loss of hotly alignment. obsenve(i.

�i’hse scoliosis appeared at a very early age in both cases.



PROGNOSIS IN IDIOPATHIC SCOLIO5IS 389

VOL. 32-A, NO. 2, APRIL 1950

Combined Th oi’acic a iid L a mba i’ Cu rr’es

Combined scoliosis was tise most frequent fot’m in this set’ies, witis ats itscidetice

of 37 per’ (‘ent. Of the 146 cases, 135 were girls and eleven were boys.

Thse cases of this group

had t \\‘tI maims recogtsizable

(‘lmr’ves l’r-ons thse �‘er’�’ (Ilsset.

One t’ur’ve was t.hom’acic, itsit-

ally extentletl over’ a tiistant’e

of five vei’tehn’ae from tise

sixth� to the tenth tlsOm’a(’ic

\‘em’teh)I’a, anti bath an apex at

t he sevent Is 01’ eight is t lsom’aci c

level. ‘[he other cur’ve of up-

pt e dim’ect ion was I u mi)a n’,�vith an apex at the seconstl

lumbar, anti inclurtled five �‘er’-

tehrae fm’om the eleventh tho-

racic to the fourth luml)ar’. A

few cases witis six or’ seven

vertel)t’ae in eacis (‘lirve were

seen. A neutral or’ non-r’tltated

vertel)ra was often pn’esent

betw’een the t\V(I cutm’ves. ‘Vise

convexity of t he t horacic curve

was predominantly to thse righst

antI that (If the lumbar’ cut-vt’FIG. 6-A FIG. 6-B

was Illost commomsly to tist’

left In t he 1 46 ca’-es -ill Ililt Fig. (h-.\ : (‘onisllinied thom’a(’ic ani(l lunnilar’ s(’oli(I-iis inn a t �velve-yea m-,. . ‘ , ‘ . . (11(1 gim’l. S(’(IhiOsis 11:1(1 Ileenn lInt-sent fon’ Ii:tlf a y(’am’.ten w’em’e rmgiit -t hor’acmc , let t- vig. ti-It : Sarsse 1)atiennt at seventeen �ear.s (If age. Curves had inn-

lunshar cornh)inat i(II55 ( Figs. (‘m(’ts(’d ver’� li!�tle. Cun’ves of the (‘�ni5lIin1ed llattem’mI which start often(‘lev(-mi \CD1’S of age usually do not mni(’re:tse greatly.

4-A to 6-B).

LTsuallv both the thl(Ir’a(’it’ and lursshar cttt’ves hatl the sarise numsshen’ of vertebn’ae,

and the rotation in cads WflS toward tise convexity of the n’espect.ive (-uI-ye. The tlegi-ee of

rotation of the ver-tebr-ae of one of the curves nssatcheti that of the (It.hsel curve from the

very beginning of the st-oli(Isis. Th(’ thom’acic curve usutally msseasum’eti several degiees

tssore than the lumbar curve. The vem’tebm’al rotation anti the angular value of 1)0th curves

increased at about the s�tti5e rate, so that the basic patter-n changed vemy little. In this

sei’ies, only rare instances ��‘cm’e seen whem’e one t-utm�’e gmew’ mssome tlsan tise other.

In fomty ca.ses (27 per’ cent . ) , the apex of tise thoracic curve was l(Iwer’ thans tise seventh

or eighth t.hom’acic vet’t.ebr’a,--- that is, at tise ninth or’ tenth t.hom’acic. The hutmssbar cun’ve

was, of necessity, short. \Vhseis this scoliosis increased, an oven’hang of the botly to the sitie

of the convexity of the tlsol’a(’ic cum’ve occurr’eti anti there was an upper cervicothoracic

counter curve, opposite to the thoracic cum�’e, which helped n’eahign the body posture.

The aven’age age tlf the Patient wisers the scoliosis was first noticetl was twelve years

and fout- nsontiss. The average age at ivisich the t’urve because stabilized was uiftt-en years

and five msionsths. FhI(’ (Issification (‘X(’UI’Sioti of the iliac ap(I�)hvsis in this group of cases

��‘as consplete �tt art :tvem’age (If sixt(’eIs V(’tti’S ans(i four’ miiomiths. ( )rle iitirs(ir’t’(l 015(1 seventeen

cases of the combined patter-ri w(’i’e followed t hir’ough rout um’ity (Table I I )

The ��rogiiosis in cases of t-omssbinetl seoliosis, in g(-nser-al, was good. ‘I’lie thor-acic auth

lumbar curves were similar in lengths, rotation, anti angular’ values. Consetjuently, the

body was well aligned even when both curves meached t-onsitlen’able size. In nisany cases,

curves of 60 on’ 70 degn’ees (Figs. 4-A, 4-B, anti 4-C) were not detectable ��‘hen the patient

was dressed.



m,n�,. 7-A

Fig. 7-.� : \Iainn t hnomacic cUn’V(’ ill a thnirteenl-y(’ar-old girl, shiortly after onset.

Figs. 7-B annd 7-(’: l{oenntgemnogranns taken at foum’teemi arid seventeeni years. In Sllite of its late oniset,

(-urve inncrea.sed great lv. Cases of this lI:Lttt’rni usually follow a similar course.Fig. 7-I ) : Ph(Itogna�)h I If pat i(’mlt at scvenite(’ni �t-ars of age, showing the (lefornhitv.

Fig. 8-A : )dairn thior:u’ic clmnv(- ml a sevenn-year’-(Il(l girl. S(-ohosis � fin’st noticed ��hienn patienit ��as six.A1)ex was at eighth thnora(’i(’, :01(1 (‘urV(’ extende(1 froni fourth to elevemith thoracic vertebra.

Fig. 8-B: Sanse curve whemn patienit � (-l(’v(’ms \‘ears (If age, showinig some ini(’rease.Fig. S-(’ : lioenntgenalgranii taken whcnn patient was fifteeni years of age shows great increase of the

eun’ve. ‘Fhie s(’(IliOsis jlm’(Igm’(-sse(l irregularly ; it inicreased misore rapi(lly during the p(-riod betweens elevemi011(1 fifteen years.

390 I. V. r’oNsE’rI AND Ii. FRIEDM.�X

THE JOURNAI� OF BONE AND JoiNT SURGERY



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m)ma)t;xo�Is IN ID1()PA’I’IIIC S(’OLIt)SlS 391

Vol.. 32-A, NO. 2, A1’RlL nasa



392 l. V. PONSETI AND 13. FRIEDMAN

TilE JOURNAL (IF BONE AND JOINT SURGERY

‘I’Iie most inspoi’tatit �Im’ognostic feature in this scoliosis pattern was the age of the

j)atient when the sctlliosis began (Table II). In seven of the fourteen cases in which the

scoliosis i�’as first notice(l Ilefor’e the age of ten years, the cuirves increaseti to angular

valumes t)f more thats 80 hegi’ees (Figs. 5-A to 5-F). This tendency of progression to exten-

sive tleformitv tir’opped off shar’ply when the s(’oliosis began after the age of ten years

(Figs. 6-A and (i-B).

Several inspor’tanst pm’(Igniosti(- signs wer’e observed in the r’oentgenograms (Figs.

9-A and 9-B). The tlitlm’a(’i(’ \‘er’t(’i)r’ae a(lja(’t’nit to the apex of the thoracic curve were

Oste(Ipor’(Iti(’ �ttstl hazily (lilt hued . ‘Fhse instem’vertehr’al spaces wer’e irregulam’ly outlined and

tSRi’i’O\V. A tr’anslator’v sisift was often seen, more pr’onount-ed at the ti’ansition vertebrae

lIe) \VeeI5 t hit’ tiiOi’a(’i(’ �tIi(i lIiIfll)Iti’ curves. ‘Fins is a sign of n’elaxation of the ligamentous

appar’attis (If tise 51)11i(’. lh(’se r’(Iemltgenogm’apisic signs wem’e pm’esent (lum’nsg the progression

(If t he �‘iii’�’e ; thsev were n(It seeni irs the scoliosis whicis remaine(l stationary.

\Vhers all tlsese features \i’ei’e taken imito t’onsitieration, a fair’lv act’ut’ate prognosis

of’ nssost (�If t lie (‘tlmilined (‘um-v(’s c(Iul(l lIe nnatie.

7’ho,’aeic ( ‘U1’P(�.�

)(htin tisoracic (‘lli’\’t’S a(’(’ounste(I for’ eighty-seven cases or’ 22 pen’ (‘ent. of the total.

Sixty-two were in females, twent�’-five in males. This cuirve was first noticetl at an aver-

age age of eleven year’s :05(1 (11W month-earlier than in an�’ of the other patterns. The

tiiOr’tt(’i(’ cur’ves he(’ame stabilizeti at an average age of sixteen years afl(i one montis,

Fig. 9-A : Roenitgemiogrann slalwinng l(-siumns of the vertebra(- inn a milaimi thon’acie curve. I)efects of thevertebral bodies oni the (‘omn(’av(- sid(’ ( If t he curve may lie set-mi.

Fig. 9-B : Roenitgenogrann of t ire tlnom’acit’ component of a corssbinied thoracic arid lunsbar st’oliosis. TheVertebral bodies adjacent to the apeX of thse curve are osteoporotic, wedge-shaped, and poorly outlined.



FIG. 10-A II �..

l)atnelit \Vas fourteenand one-half �‘ears old. There is a lonig, low thoracic counster curve.

Fig. 10-B : Photograph of patient, shs(Iwing elevationi of left shoulder.

VOL. 32-A, No. 2, APRIL 1950


thus allowing five years during

which this curve increased.

Thie tlssifi(’ati(Inl ex(-ur’sion of

the iliac apophyses i�’as corn-

plet;e at an average of seven-

teen years anti one month.

Of the eighty-seven cases

in this group, all butt eight had

curvatures convex to the right.

Six of the eight patients with

left convex thoracic scoli osis

were boys.

The apex of the t.hOm’a(’iC

curve usually was at the

eighth ot- ninth thoracic ver’-

tebra. Six vertebrae were gen-

erally included in the main

curve, w’isich extended from

the sixth to the eleventh

thoracic ; extreme degrees of

rotation were observed in the

vertebrae. Smaller counter

cuirves w’ere present above

and below the main curve.

The rotation of the vertel)rae

in the counter cuirves was i’d-

ativeiy mild (Figs. 7-A to 8-C).

The roentgenograms

showed significant changes in

the three or four vertebrae

located in the center of the

main thoracic cuirves (Figs. 9-A

and 9-B). The bodies of these vertebrae appeared osteop(Ir’otic, tiseir’ tlutlines were hazy,

and early in the evolution of the curve they sisoweti mar’keti \Vedging. use inten’vertebral

spaces were irregularly oimtlined and very nar’n’ow at thse site of the (‘OIscaVit.y. Often

disc herniations into the vertebral both’ �vem’e seen. Transslatom’y shift. between the vem’-

tebral bodies was often evident. These changes wer’e seens l)efor’e anti thimt’ing the pro-

gression of the curve. There was a direct i’elationslsip 1)etween the intensity of these lesions

and the increase of the curve. Tisese changes were mu(’h mote l)ronounceti than, but

similar to, the ones seen in the thoracic component. of the coml)ined type of scoliosis.

Thoracic curves progressed more rapitily, gr’ew to a gm’eater size, and pr’o(luced a

greater deformity than any other type of scoliosis. The cur’ve penetm-ate(i tieeply into the

thorax early in its course, producing an imr’evemsii)le defom-mity.

When main thoracic curves started befone the age of twelve year’s, the outlook was

poor (Table II). Of thirty-four cases in which thom-acic scoliosis was noticed pn’ion’ to this

age, in twenty-four or 70.6 per cent. the curve progressed to a final angular value greater

than 80 degrees. In half of these cases, the deformity was extreme, with ctmn’ves of angular

values well over 100 degrees. The thoracic curve often Isad a tendency to progress to

extensive deformity, even s�’hen it started late. About one-thirti of the patients whose

scoliosis was detected after twelve yeai-s of age had curves measuring mot-e than 80

degrees at maturity. However, in slightly less than half of the patients in this age gr-oup,

the curves did not increase beyond 60 degrees and were not very defom’ming.



394 I. V. PONSETI AND B. FRIEDMAN

Cervicothoracic Curves

In the present series there were only five cases with this type of curve. The scoliosis

�s’as first noticed when the patient was about fifteen years of age, and never became pro-

nounced. The angular value of the curve at maturity varied from 20 to 58 degrees. The

curve was convex to the left in all the cases hut one. Four of the patients w’ere girls and

one was a hot’.

The apex (If the cervicothoracic curves was at the third thoracic vertebra. From fotir

to six vertel)rae w’ete included in the curve, which extended from the seventh cervical or

first thon’acic ttl the fourth or fifth thoracic. The curve penetrated somewhat into the tipper

thtlrax, anti its verteb)r’ae wet’e wedge-shaped anti markedly i’otated. A long, low thoracic

cotrtstem t-urve was usually present (Figs. 10-A anti 10-B).

The s(’apula was elevated anti the shoultier i�’as higher at the side of the convexity

(If the cut’ve. In spite of these \‘isii)le tleformities, the bO(iy alignment was well preserved

iI.1 all thse (‘ases seen by irs.

DI5Ct’SsION

‘i’he study of the course of idiopathic scoliosis in a sizable number of cases has given

valuable tiata upon which to base the pm-ognosis. Four main factom’s were founti significant.

I . The patter-n of the curve;

2. Age of the patient at onset of the scoliosis;

3. Alterations in the density of the vertebrae and abnormalities of the disc spaces,

as seen in the roentgenograms;

4, Rapitlity of in(’r’ease in the size of the curve.

Pattei’n of the (‘ui’rc

‘Vise classification of itliopathic sctlliosis into five main cum’ve patterns s�’as found to

be fundamental in the determination of pr’ognosis. These calve pattet-ns weie well estab-

lisheti slstln’tlV aften’ the onset (If the sct)lit)sis and, w’ith a few exceptions, tiid not change

t Is n-thigh (Iii t i t s ctlurse.

The pattem’n si’as easy to itientify in the majority of cases. How’even, about 5 per cent.

of the t-um’ves represented transition forms between two patterns, and had characteristics

of eacis. Car’e w.as taken to classify these cases according to the pattern to which they

1)ore closest resemblance. I�or example, nine cases hati a main lumbar curve with a pro-

nounced low-thoracic counter’ t-um’ve. These cases resembled the coml)rned thoracolumbar

patterns. However, they were (‘lassiureti with the lumbar’ curves for three reasons: First,

the thot’acic t�ll1’Vd \\‘tLS a good tieal smaller than the lumbat- curve, whereas in the corn-

h)ine(i pattem-n, the ltmmbai’ curve is usually smaller. Second, the vertebrae of the thoracic

cut-ye ii’er’e only slightly r’otated, in contrast to the ativanced degree of rotation usually

noted in thse t.hsom’acic cut’ve of the combined pattet’n. Third, in the combined pattern there

is a small, high thotacic or cer’vicothorat’ic counter curve, not present in these nine cases.

Transition for-ms iven’e also seen between the lumbar and thoracolumbar patten’ns,

the thom’at-olumbar anti (-ornbine(i, and the combineti and main thoracic. A careful study

of eat-h of these cases was necessary for their proper classification.

As a whole, the main thoracic curves increased to greater deformities than the other

patterns. The pm-ognosis in the main lumbar, thoracolimmbar, and cervicothoracic curves

was usually favor-able. The prognosis with the combined thoracolumbar curves s�’as

usually good if tisey tleveloped aftet- ten yeat-s of age, anti poor if they st.arteti earlier.

.1�je (it Onset �kf the Scoliosis

Thse prognosis in cases of scoliosis (iepentieti in great measui-e upon the age of the pa-

tient si’lsens the cimm’vatur’e appeared. The m(Ist deforming curves originated at an early age.

Conversely, the (‘Ot’ves w’hich were tletecteti when the matut’ity of the patient was ivell

ativance(i increased only slightly or not at all. The age of the patient when the scoliosis

THi� J(It’RNAn OF BONE AND JOINT SURGERY




became apparent varied within each pattern. The main thoracic curves usually appearedat an earlier age than the other curves. The curves in the lumbar, thoracolumbar, and thecervicothoracic patterns appeared late,-often after the age of thirteen years. It is pos-

sible that these curves may have i)een present fom’ many months without becoming

clinically apparent, because they were usually not �‘ery tlefor’ming.

It would he desirable to evaluate thse skeletal age of thse patients anti to correlate it

with the growth of the scoliosis. The itiiopatliic cur-\’es almost alw’ays increase dum-ing

growth of the skeleton, and they cease to progress about one year l)efore the t’ompletion

of ossification excursion of the iliac apophyses. Unfortunately, we were not able to deter-

mine accurately the skeletal age of most of our’ patients, anti thims the clironoltlgical age

was useti instead.

Idiopathic 5(’(IliOsis is much mor’e frequent in gir’ls than in boys. In the group of cases

with main thoracic (‘urves, however, tlsen’e were many males. The scoliosis often progressed

in boys al)out t��’o years longer than in girls. This was probably (lute to tise fat-t that the

skeleton teaches maturity later in males than in females. ti�therwise, there wer’e no major’

thiffei’ences in the course of scoliosis in boys anti girls, and the tlata were compileti together’

in the ttti)les.

:1 lt(’l’atioflS in the I)ensity of the � el’t(’brae and A bnornialities of the J)isc S’paces

Changes in the vertebrae and in the inten-vertebral spaces were often seen in the

roentgenograms of the scoliotic patients. The vertebrae adjacent to the apex of the

thoracic curves were most frequently affected (Figs. 9-A and 9-B).

Most of these changes were apparent in the thoracic curves when the first I’OentgeflO-

grams were taken, shortly after the onset of the so-ohiosis. They were seen during the entire

progress of the curve. The intensity of these vertebral alter’ations is’as usually directly

related to the rapidity of increase of the curve. Thus, these spinal changes were of major

prognostic significance. The textute of the bone of the lumbar vertebr’ae appeam’eti to be

fairly nor’mal, even in the most extetssive lumbar’ (‘urves. Fr’anslat(Ir’y shift, however, was

often seen between the hmmbam’ vertel)rae.

Rapidity of Increase in the Size of the (‘ui-pc

When the scoliosis starteti after ten yean’s of age, the inct’ease was gr-adual in most

of the patients. The pr’ognosis, then, coulti often be best evaluateti after two or’ thr’ee su�’-

cessive examinations, taken at intem’vals of three months. If the roentgenogn’ams slsow’etl

marked increase of the curve, the pr’ognosis was usually poor’. On tise other hand, if there

was only a minor progression of the curve dur’ing this per’io(l of obsen’vation, the pr’ognosis

was much bettem’.

\Vhen the scoliosis started in chiltiren untier ten �‘ears of age, it often tlid not increase

much for a few’ years and then incm’eased suddenly. This scoliosis of early onset usually

carried a poor’ prognosis, in spite of its slow increase tiuring the first years.

For- practical usage, a graph ��‘as constructetl for each o’unve patten’n, to show tlse

size of the curvatumre which might i)e expected at maturity, as related to the age of the

patient. at the onset of the st’ohiosis (Chart I). The centr’al line m’epresents thse average

angular value; the secondary lines, the extm-eme cut-yes. I)ata for tisis char-t were obtained

from the study of the 330 cases of idiopathic scoliosis followed throtmgls matur’ity. Angular’

values of the curves in the standing position were recom’detl. ‘Vise ages r’eferr’ed to in tlse

graphi are thse chi-onological ages of gin-is.

R E FERENC ES

I . HISsER, J. C. : Importanit Practical Facts inn the Treatnsemnt of S(-(Iliosis. Instr’u(’tionial (oun’se L(’(’tur(-s,

Ani. Acad. Orthop. Surg., Vol. 5, 11!). 248-260. Anni Arbor’, Michiigani, .1. ‘tV. I�1w:tn’ds, 1948.

2. S(’IIULTHESs, WILHELM: Die Pathologic und Therapie den’ Rtickgm’atsverkrunsnsumngemi. In .Joachinsssthal:

Hanndlluch der Orthopiidischen Ciiirurgie, Bd. 1, AlIt. 2. Jemia, Gustav Fisciser, 1905-1907.

3. STErNDLER, ARTHUR: Diseases anti I)efom’nsities of the Spine atid Thorax. St. Louis, C. \‘. Mostly Co., 1929.

V(IL. 32-A, NO. 2, APRmI. 1950



prognosis in idiopathic scoliosis · the conservative attitude of this clinic in the treatment of...

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