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
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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
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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
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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.
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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
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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
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%‘(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
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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.
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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.
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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
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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.
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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
PROGNOSIS IN IDIOPATHIC SCOLIOSIS 393
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.
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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
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PROGNOSIS IN IDIOPATHIC SCOLIOSIS 395
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
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