CHAPTER
Frank Schwab
88
Adult Spinal Deformity Classification
INTRODUCTION
Spinal deformity in the adult is increasingly recognized as a
significant healthcare issue. With an aging population there are
also increasing functional expectations of an older population
in western societies. The cost of caring for the elderly who lose
autonomy risks growing substantially. Several studies have dem-
onstrated pain and disability associated with spinal deformity
and one prevalence study9 has shown a rate of more than 60%
deformity in a population older than 60 years.
The treatment of adult spinal deformity has received rather
sparse attention compared with deformity in the pediatric pop-
ulation. Despite the substantially greater number of deformi-
ties in the adult population and potential for marked loss of
function,1 adult deformity remains poorly understood. One
limitation relates to the diversity of pathologies associated with
spinal deformity in the adult and the lack of a coherent system
for categorizing patients.
The role classification systems in orthopedics are numerous;
ranging from a common language between specialists to treat-
ment algorithms for guiding optimal intervention. A classifica-
tion of adult spinal deformity requires an effort that can permit
an organized approach to the care of patients, offer guidelines
for therapies and permit prediction of outcome. The lack of
such a classification in adult spinal deformity to date can be
explained by the broad range in presentation and variable clin-
ical impact. In one patient coronal deformity may be minor
while rotatory subluxation may be pronounced. In another
case significant coronal Cobb angulation may be noted as well
as global sagittal deformity while no rotatory subluxations are
present.
This chapter sets out to summarize the efforts to date that
seek a universal classification of adult spinal deformity. The
current state of the art will be presented as well as ongoing
work that is certain to impact our management of the often
complex adult patients affected by a spinal deformity.
CLASSIFICATION CONSIDERATIONS
The advent of radiography in 1895 by Wilhelm Conrad Roent-
gen was a substantial contribution to the medical field. To this
date, plain X-ray films remain the basis for diagnostic approaches
to much orthopedic pathology. While newer imaging modali-
ties have emerged, substantial variation in interpretation of
information related to spinal pathologies exist. In terms of
LWBK836_Ch88_p921-928.indd 921
Sigurd Berven
Keith H. Bridwell
establishing a classification of adult deformity, it may be ideal
to base this principally on X-ray image information to remain
simple in form and reliable in application.
Adult spinal deformity has a wide range of etiology, but most
cases appear to relate to the degenerative process of aging (de
novo degenerative spinal deformity, DDS) or adolescent scolio-
sis in an adult (ASA).10 Other causes of deformity can relate to
osteoporosis, trauma, infection, and iatrogenic factors. For
DDS and ASA, the two largest categories, a common pathway
appears to lead to loss of function and pain. This will be out-
lined further. Given that treatment of adults with deformity is
driven by the patient who wishes to regain function without
pain, a classification of adults must take this as a basis upon
which to build categories. It is not reasonable to transpose clas-
sification efforts applied to adolescent idiopathic scoliosis (AIS)
because the treatment concerns are of a very different nature.
Pain and disability are rarely noted in AIS.
Realizing that adult spinal deformity is often treated due to
pain, clinical impact is a critical element in building a system to
categorize patients and arrive at a language of classification. In
an ideal system, clinical data should drive such an effort and
permit creation of treatment algorithms based upon out-
comes.
CLASSIFICATION EFFORTS TO DATE
Adult spinal deformity has historically been classified accord-
ing to categories applied to the pediatric population. Such an
approach appeared to be justified for it maintained a common
approach to deformation of the spine across all age groups and
was thus simple. Furthermore, scoliosis was perceived to be pre-
dominantly a pediatric pathology and an adult-specific approach
may not have been considered necessary.
Although Swank et al14 reported in 1981 that adult scoliosis
treatment was commonly driven by pain; her study still classi-
fied deformity by pure radiographic coronal curve location as
used in AIS. King et al6 in 1983 offered a unified approach to
the classification of AIS, which became a surgical guideline in
the use of Harrington instrumentation and was often applied
to young adults as well. Sponseller et al13 in 1987 offered a sum-
mary of results in the treatment of adults with AIS and again
applied a classification of curves purely in the coronal plane
and by location as well as minor and major modifier.
A significant advance in the classification of scoliotic defor-
mity is attributed to Lenke et al.7 In publication by 2001, this
classification offered an updated approach to AIS, which was
921
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 922 Section VIII Adult Spinal Deformity

more comprehensive than the King classification and offered

Radiographic Parameters
sagittal plane consideration. Furthermore, the new AIS classifi-
TABLE 88.1 Tied to Pain and Disability,
cation offered guidelines on surgical fusion levels using seg-
mental fixation. Preliminary Work
The classification of adult scoliosis is clearly more complex Parameters Linked to Pain/
than approaches to AIS. Adult deformity covers a broad range Disability Parameters not Linked to HRQOL
of segmental, regional, and global expression. The treatment is
driven by disability and pain and not simply by radiographic Obliquity L3 Cobb angle
appearance. The latter has thus made it difficult to arrive at a SVA offset AIS in adult versus de novo
degenerative scoliosis
clinically relevant X-ray classification. One of the first studies
Loss of lordosis Coronal plane offset of C7 versus
aimed at isolating the pain generator in adult scoliosis was pub-
midsacrum
lished in 2002.12 This work by Schwab et al launched an ongo- Thoracolumbar kyphosis Thoracic kyphosis
ing effort at reconciling health-related quality of life (HRQOL) Rotatory subluxation
measures and radiographic presentation of adult deformity Spondylolisthesis
(Table 88.1). The approach has lead to the Schwab-Spinal
Deformity Study Group (SDSG) classification that will be AIS, adolescent idiopathic scoliosis SVA, sagittal vertical axis; C7,
outlined. offset from sacrum.
An effort of adult classification that attempted to modify an
AIS approach to the adult was also recently proposed by Lowe
et al.8 The effort was aimed at defining a variety of curve pat- to the success of an adult spinal deformity classification is the
terns and adding modifiers but did not have clinical data to link between categories and clinical impact. Anther important
back the category definitions. Continued work by the Scoliosis consideration is simplicity of a classification so that it remains
Research Society (SRS) will help this effort to evolve to a clini- clinically useful. Finally, the classification must form a basis for
cally valid approach. treatment of patients.
The classification has been an ongoing effort over the last 5
years and will certainly continue to undergo refinement as
THE CLINICAL IMPACT treatment approaches and patient management evolves.
CLASSIFICATION (SCHWAB-SDSG) However, the basic structure of the classification has been firmly
established and hinges on the following principles:
Initial efforts at correlating radiographic parameters with
Basic coronal curve locations and basic patterns (single vs.
HRQOL in adults led to an expanded analysis through a multi-
multiple)
center effort. The SDSG consists of more than 10 centers that
A principally sagittal plane deformity category
enroll adult patients with deformity in a common database.
Regional and global modifiers with three grades tied to
This repository now contains more than 2000 adult cases and
HRQOL
thus permits validation and refinement of early efforts at clas-
sification. All aspects of the classification (Table 88.2) found a basis in
Adults with spinal deformity are most commonly treated for HRQOL analysis. The basic curve types are as follows, with cut-
some degree of compromised function and pain. Thus, critical offs in levels defined by clinical difference in outcomes

TABLE 88.2 Schwab-SDSG Adult Spinal Deformity Classification

Type: Location of the deformity (apical level of the major curve or sagittal pane only)
Type I Thoracic-only scoliosis (no thoracolumbar or lumbar component)
Type II Upper thoracic major, apex T4-8 (with thoracolumbar or lumbar curve)
Type III Lower thoracic major, apex T9-T10 (with thoracolumbar/lumbar curve)
Type IV Thoracolumbar major curve, apex T11-L1 (with any other minor curve)
Type V Lumbar major curve, apex L2-L4 (with any other minor curve)
Type K Deformity in the sagittal plane only
Lordosis modifier: Sagittal Cobb angle from T12-S1
A Marked lordosis 40
B Moderate lordosis 040
C No lordosis present Cobb 0
Subluxation modifier: Frontal or sagittal plane (anterior or posterior), max value
0 No subluxation
 Subluxation 16 mm
 Subluxation 7 mm
Global balance modifier: Sagittal plane C7 offset from posterior superior corner S1
N Normal: 0 to 4 cm
P Positive: 4 to 9.5 cm
VP Very Positive: 9.5 cm

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 Chapter 88 Adult Spinal Deformity Classification 923

measures: Oswestry Disability Index (ODI), SRS, Short Form-12
(SF-12) instruments2:
Type I: thoracic-only scoliosis (no thoracolumbar or lumbar
component)
Type II: upper thoracic major curve, apex T4-8 (with a thora-
columbar or lumbar curve)
Type III: lower thoracic major curve, apex T9-T10 (with thora-
columbar/lumbar curve)
Type IV: thoracolumbar major curve, apex T11-L1 (with any
other minor curve)
Type V: lumbar major curve, apex L2-L4 (with any other minor
curve)
Type K: deformity in the sagittal plane only
The type I in the SDSG database are the least symptomatic
while the type K are the most disabled.
Modifiers of the classification were established through pre-
liminary studies by Schwab et al and repeated database correla-
tions. A parallel analysis by Glassman et al3,4 underlined the
primary importance of global sagittal balance in the setting of
adult deformity. In order to condense key parameters into a
clinically useful approach, the modifiers integrated in the clas-
sification have been reduced to the following:
Global Balance Modifier: Sagittal plane offset; C7-posterosuperior
corner S1
N (Normal): 0 to 4 cm
P (Positive): 4 to 9.5 cm
VP (Very Positive): 9.5 cm
Lordosis Modifier: T12-S1 sagittal Cobb angle
A: Marked lordosis 40
B: Moderate lordosis 0 to 40
C: No lordosis present Cobb 0 (Kyphosis)
Subluxation Modifier: Frontal/sagittal plane; maximal value
0: No subluxation
: Subluxation 1 to 6 mm
: Subluxation 7 mm
The cutoffs between groups within each modifier were deter-
mined by the HRQOL measures, splitting the population
into discreet groups by clinical impact of each modifier
parameter.
CLASSIFICATION AND TREATMENT
In an effort to analyze treatment by classification group, a pro-
spective study including 784 adult patients (18 years) with
thoracolumbar (type IV) or lumbar deformity (type V) of the
spine was pursued.11 Subjects were drawn from the SDSG
database. The inclusion criteria included scoliotic curvature
with minimal Cobb angle of 30 and apex of the major curva-
ture in the thoracolumbar spine (type IV) or lumbar spine
(type V). Of the 784 patients, 339 were treated surgically
(43%). An analysis by gender revealed no significant differ-
ences. Further analysis (Fig. 88.1) by Lordosis Modifier
revealed greater surgical rates for patients with moderate (B,
rate  37%) or no lordosis (C, rate  46%) than for patients
with marked lordosis (A, rate  51%). Analysis by Sublux-
ation Modifier revealed greater surgical rates for patients with
large subluxation (, rate  52%) than for patients with
moderate (, rate  42%) or no subluxation (0, rate  36);
differences were significant between  and 0 patients
(p  .05). Finally, patients with greater Sagittal Malalignment
(VP, rate  58%) were more likely to receive surgical treat-
ment than did patients with moderate (P, rate  46%) or
neutral (N, rate  39%) sagittal alignment; differences were
significant (N vs. VP, p  .002).
The data furthermore revealed significant association between
modifiers and surgical technique/strategy (Table 88.3):
Role of curve Type (apex):
Thoracolumbar deformities (type IV) were more likely to
have circumferential procedure than lumbar deformities
(type V) (64% compared with 47%, p  .007).
Lordosis modifier:
In terms of operative intervention, loss of lumbar lordosis
(modifier B and C) lead to increased osteotomy rates (A 
26%, B  40%, C  57%, p  .005). Modifier B and C
patients also were treated more frequently by a posterior or
circumferential surgical approach than anterior.
Subluxation modifier:
Marked subluxation (modifier ) was associated with
more circumferential surgery (65% compared with 46% for
0 and  combined, p  .002)

Initial treatment analysis: surgical rates (%)

70

60

50

40

30

20

10

0
Lordosis Subluxation Global Balance

Figure 88.1. Surgical rates by classification modifier.

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 924 Section VIII Adult Spinal Deformity

TABLE 88.3 Surgical Strategies by Classification Category

Type

Thoracolumbar (IV ) Lumbar (V )

Circumferential procedure 64% Circumferential procedure 47%
Posterior-only procedure 27% Posterior-only procedure 48%
Osteotomy rate 34% Osteotomy rate 35%
Fixation to sacrum (66%) Fixation to sacrum (75%)
Lordosis Modifier

Marked (A) Moderate (B ) None (C )

All approaches No anterior approach No anterior approach
Osteotomy rate 26% Osteotomy rate 40% Osteotomy rate 57%
Fusion to sacrum 64% Fusion to sacrum 78% Fusion to sacrum 81%
Subluxation Modifier

None (0 ) Moderate () Marked ()

Anterior approach 10% Anterior approach 5% Anterior approach 5%
Circumferential approach 46%* Circumferential approach 46%* Circumferential approach 65%
Posterior only 46%* Posterior only 46%* Posterior only 31%
Sagittal Balance Modifier

Normal (N ) Positive (P ) Very Positive (VP )

Posterior only 30% Posterior only 44% Posterior only 55%
Osteotomy rate 25% Osteotomy rate 41% Osteotomy rate 55%
Fixation to sacrum 61% Fixation to sacrum 78% Fixation to sacrum 89%
*
Combined rates for none (0) and moderate () subluxation modifier.

Combined rates for moderate () and marked () subluxation modifier.

Sagittal balance modifier:
Greater sagittal imbalance (modifiers P and VP) was associ-
ated with a higher rate of posterior-only surgery. Rates of
osteotomies also increased with increasingly positive sagittal
alignment (N  25%, P  41%, VP  55%, p  .001). Fixa-
tion to the sacrum was more likely to occur as sagittal align-
ment became increasingly positive (N  61%, P  78%,
VP  89%, p  .001).
SURGICAL OUTCOME AND THE
CLASSIFICATION
The classification was designed initially to categorize nonopera-
tively treated patients as well as preoperative patients. It is
important, however, that postoperative patients can also be cat-
egorized into clinical groups based upon classification. Thus a
set of patients with 1- and 2-year postoperative follow-up were
analyzed. The clinical follow-up included 111 patients at 1 year
and 45 patients who had reached a minimum 2-year postopera-
tive follow-up and had complete radiographic and outcomes
questionnaires at the 1- and 2-year milestones. Analysis revealed
that the classification modifiers were correlated with HRQOL
in the follow-up population.
In the outcomes analysis of the 1- and 2-year follow-up no
significant difference was noted in outcome between the 1- and
2-year mark. However, outcome was linked to surgical strategy,
and there was variation in improvement by classification
category:
Patients with no lordosis (modifier C) had the greatest dis-
ability before surgery and the least disability 1 year following
surgery. In contrast, patients with marked lordosis (modifier
A) had the least disability before surgery and the greatest
disability 1 year following surgery.
Greater subluxation was associated with greater baseline dis-
ability and greater improvement in ODI score at 1 year.
Patients without subluxation (modifier 0) had higher base-
line scores and less improvement in score than patients with
marked subluxation (modifier ). These differences were
significant (p  .003).
Greater imbalance (P, VP vs. N) was associated with greater
baseline disability, and there was a trend toward greater
improvement in ODI score at 1 year (p  .09). This differ-
ence was significant in terms of improved SF-12 Physical
Component Score (PCS) (p  02).
Patients who had osteotomies had significantly lower scores
prior to surgery, but higher scores at 1 and 2 years. The inter-
action between SF-12v2 PCS scores and osteotomy status was
also significant, with patients who had osteotomies showing
worse health status before surgery, but better health status at
1 and 2 years following surgery (p  .035).
Patients with sagittal balance of less than 40 mm (modifier N)
without fixation to the sacrum showed less disability preop-
eratively and continued to have the lowest ranking disability
postoperatively. Patients with sagittal balance greater than
95 mm (modifier VP) whose fixation stopped above the
sacrum showed the greatest disability before surgery, and
had worse postoperative versus preoperative scores.

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 Chapter 88 Adult Spinal Deformity Classification 925

The patient group most likely to improve from surgery had

Strength of Predictive
the following characteristics: TABLE 88.4
Models
Low baseline HRQOL scores (greater disability)
High baseline classification modifier scores (C, , or VP) % Correct
An improvement in classification lordosis and global balance Classification by Area Under ROC
modifiers through surgery Outcome Score* Model Curve
Use of osteotomies
SRS pain 81.10% 0.864
Fusion to sacrum for significant sagittal imbalance
SRS appearance 75.40% 0.838
Based upon data indicating that change in classification SRS pain and 78.10% 0.845
modifier is linked to improvement in outcome and that base- appearance
line health status plays a significant role, preliminary predictive SF-12v2 PCS 77.90% 0.862
modeling was pursued. *
Meeting the minimal clinically important difference (MCID)
threshold.

0.80 and above is considered good discrimination.
PREDICTIVE MODELS FOR OUTCOME
In building predictive models of outcome from surgery it is key
to identify what combination of patient characteristics (includ-
ing Schwab classification modifiers) and treatment options can
be used to predict which patients will meet an outcome thresh- binary and logistic regression, predictor variables included all
old for success. Previous work by the SDSG on minimal clini- classification types, all treatment options within surgery, patient
cally important difference (MCID) has identified improvement age, gender, body mass index (BMI), previous surgery, and
thresholds for discriminating between patients who report baseline health status. Backwards and stepwise techniques were
being satisfied with surgical results and those who report being used to eliminate redundant predictor variables.
less than satisfied (Table 88.4). Based upon those identified An analysis of most and least likely patients to reach an
thresholds, binary logistic regression was used to examine how MCID can be drawn from the predictive models (Table 88.5). It
adult classification types and surgical strategy combine and was found that in addition to the classification modifiers, base-
interact to predict successful surgical outcomes. A second line HRQOL was associated with higher chance of a poor out-
approach was to employ multiple linear regressions. For both come.

Summary of Groups Likely to Reach MCID (Success) or Unlikely

TABLE 88.5
to do so (Poor Outcome)
Groups Less Likely to Reach Threshold Groups with Higher Chance of Reaching
Improvement Threshold Improvement
SF-12v2 PCS MCID summary Apical level III Apical level IV
Marked lordosis Subluxation  or 
No subluxation Positive sagittal balance
Negative sagittal balance Surgery involved osteotomy
Baseline PCS of 35 or greater Surgery involved fixation to sacrum
Baseline PCS 35
SRS combined pain/appearance MCID Apical level III No lordosis
summary Marked lordosis Subluxation 
No subluxation Circumferential surgery
Negative sagittal balance Surgery involved osteotomy
SRS pain MCID summary Apical level III Apical level IV
Marked lordosis Subluxation 
No subluxation Circumferential surgery
Negative sagittal balance Surgery involved osteotomy
Posterior-only surgical approach Baseline PCS 35
No fixation to the sacrum
SRS appearance MCID summary Apical level V No previous surgery
Surgery involved fixation to sacrum Apical level IV
Baseline PCS of 35 or greater

MCID, minimal clinically important difference; SRS, Scoliosis Research Society.

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 926 Section VIII Adult Spinal Deformity

A B

Figure 88.2. Case 1. (A) A 54-year-old woman with iatrogenic adult spinal deformity [K, B, 0, VP] (curve
type K: sagittal plane deformity, lordosis  B, subluxation  0, sagittal alignment  VP). SVA  159 mm,
L1-S  37, no sacropelvic fixation. (B) Improvement in classification modifiers; lordosis B A, sagittal
alignment VP N via L3 pedicle subtraction osteotomy. SVA  45 mm, L1-S  61, with pelvic fixation.

Figure 88.4. Case 3: A 63-year-old M patient [V, B, , N] (curve

Figure 88.3. Case 2: A 72-year-old female patient [V, A, 0, N]
(curve type V: L apex curve, lordosis  A, subluxation  0, sagittal
alignment  N). Patient is without significant pain/disability and
managed with nonoperative care; back strengthening and occasional
nonsteroidal anti-inflammatory drug use.
type V: lumbar deformity, lordosis  B, subluxation  , sagittal
alignment  N). Patient has significant episodes of back and leg pain,
with marked loss of ambulatory endurance. Operative planning would
include decompression, stabilization of subluxation/deformity, and
realignment to increase lordosis from B A.

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 Chapter 88 Adult Spinal Deformity Classification 927

CONCLUSION In the analysis of outcomes by classification, it has emerged

Adult spinal deformity is emerging as an important health-
care issue of the 21st century. This is due in part to increased
awareness of its clinical impact, as well as the aging popula-
tion in western societies combined with functional expecta-
tions. Imperative to our improved understanding of adult
deformity is a common language in categorizing patients
that present across a broad range both clinically and radio-
graphically. Only through a valid classification will centers
be able to compare data and promote evidence-based
approaches to clinical management of patients suffering from
spinal deformity.
The classification of adult spinal deformity, as outlined in
this text, is the culmination of several years of data collection
and repeated analyses. With a foundation in clinical impact of
adult spinal deformity, the classification is a valuable tool for
grouping patients by the degree of disability and pain.
In addition to the descriptive aspect by curve type, the clas-
sification through a set of modifiers offers graduations of dis-
ability, which also ties to variation in surgical rates as the grade
of the modifier increases (i.e., lordosis A to C, subluxation 0
to , sagittal balance N to VP). This indicates that the
parameters defining the deformity by the classification system
are also the parameters influencing the decision to proceed
with surgical treatment.5 The classification thus offers a useful
clinical basis for categorizing patients by most likely treatment
required. Most effective approaches by category are also
emerging.
those patients most likely to obtain significant improvement
through surgical treatment had higher grades of classification
modifiers (lost lumbar lordosis, intervertebral subluxation, pos-
itive sagittal balance). Importantly a change in modifier grade
to a lower grade (increased lordosis, decreased sagittal global
imbalance) was highly linked to likelihood of reaching signifi-
cant improvement through surgery.
As the classification is applied to predict outcome from sur-
gery, the role of baseline disability has emerged as an important
parameter (ODI, SRS, SF-12 scores). By entering baseline classi-
fication modifiers and HRQOL measures, predicted change at
follow-up can be estimated. Further refinement work on out-
comes prediction may impact a decision to operate. Other moti-
vators of surgical treatment may then come to the forefront in
decision making (curve progression, cosmetic concerns, etc.).
While the classification already finds immediate application
in the clinical arena, further work continues. Notably, work is
under way to define transition zone modifiers to more precisely
guide end levels of fusion. Other predictive factors of outcome
are being investigated such as medical comorbidities. The
result of this additional research will lead to refined models for
outcome by classification type, patient factors, and surgical
parameters (approach and surgical plan). Thus, while the chal-
lenge of adult spinal deformity is substantial, effective multi-
center work and outcomes-based analyses have offered a criti-
cally necessary classification from which we can draw effective
treatment algorithms.
Case presentations appear in Figures 88.288.5.

A B

Figure 88.5. Case 4: (A) A 54-year-old female patient [IV, C, 0, VP] (curve type IV: TL curve,
lordosis  C, subluxation  , sagittal alignment  VP). SVA  245 mm, L1-S1  2, pelvic tilt  48.
(B) Improvement in classification modifiers; lordosis C A, sagittal alignment VP P via L4 pedicle
subtraction osteotomy. SVA  51 mm, L1-S  37, pelvic tilt  31, long fusion with pelvic fixation.

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 928 Section VIII Adult Spinal Deformity

8. Lowe T, Berven S, Schwab F, Bridwell K. The SRS classification for adult spinal deformity:
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