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SPINE Volume 26, Number 20, pp 2244–2250

©2001, Lippincott Williams & Wilkins, Inc.

Progression of Vertebral and Spinal Three-Dimensional


Deformities in Adolescent Idiopathic Scoliosis
A Longitudinal Study

I. Villemure, MASc,*† C-E. Aubin, PhD,*‡ G. Grimard, MD,*† J. Dansereau, PhD,*‡ and
H. Labelle, MD*†

of the rib cage.8,18,19 Local structural deformities de-


Study Design. The evolution of scoliotic descriptors velop concurrently in pedicles, spinous and transverse
was analyzed from three-dimensionally reconstructed processes,11,14,23,25,37 vertebral bodies, and interverte-
spines and assessed statistically in a group of adolescents
with progressive idiopathic scoliosis.
bral disks.1,9,11,17,23,24,38 In the anterior column, verte-
Objectives. To conduct an intrasubject longitudinal bral endplates, initially parallel in the frontal plane, yield
study quantifying evolution of two- and three-dimen- one relative to the other while the vertebrae are rotating.
sional geometrical descriptors characterizing the scoliotic This results in a 3D phenomenon of torsion and wedging
spine and vertebral deformities.
that develops both in vertebral bodies and intervertebral
Summary of Background Data. The data available on
geometric descriptors usually are based on cross-sec- disks.1,9,11,17,23,24,38
tional studies comparing scoliotic configurations of dif- Initiation of adolescent idiopathic scoliosis still is not
ferent individuals. The literature reports very few longitu- clearly understood in either the nature or the sequence of
dinal studies that evaluated different phases of scoliotic expression of its structural deformities.3 The initial de-
progression in the same patients.
Methods. The evolution of regional and local descrip- formity is associated with a primary rotation,17,21 an
tors between two scoliotic visits was analyzed in 28 ado- initial instability in the sagittal equilibrium,6,26 the pre-
lescents with scoliosis. Several statistical analyses were carious coronal balance,34 or a viscoelastic buckling in
performed to determine how spinal curvatures and ver- both the transverse and coronal planes.14 However, after
tebral deformities change during scoliosis progression.
onset of the initial deformity, it generally is accepted that
Results. At the thoracic level, vertebral wedging in-
creases with curve severity in a relatively consistent pat- adolescent idiopathic scoliosis progresses within a self-
tern for most patients with scoliosis. Axial rotation mainly sustaining biomechanical process involving asymmetri-
increases toward curve convexity with scoliosis severity, cal growth modulation (alteration) of vertebrae evolving
worsening the progression of vertebral body deformities. during the growth spurt.2,8,17,18,22,30
No consistent evolution is associated with the angular
orientation of the maximum wedging. Thoracic kyphosis The development of scoliosis has been investigated
varies considerably among subjects. Both increasing and through clinical characterization of its deformities using
decreasing kyphosis are observed in nonnegligible pro- geometrical descriptors to quantify curvatures (regional
portions. A decrease in kyphosis is associated with a shift scale) and intrinsic alterations of vertebral and interver-
in the plane of maximum deformity toward the frontal
tebral tissues (local scale). Two-dimensional (2D) scoli-
plane, which worsens the three-dimensional shape of the
spine. otic descriptors identified on standard posteroanterior
Conclusions. The results of this study challenge the and lateral radiographs include Cobb angles, angular in-
existence of a typical scoliotic evolution pattern and sug- clination of vertebral endplates, disks,17,24,38 and linear
gest that scoliotic evolution is quite variable and patient measurement of vertebral body heights.38 Most 3D stud-
specific. [Key words: curvature, idiopathic scoliosis, ky-
ies involve direct measurements of vertebral body heights
phosis, rotation, spine, vertebra, wedging] Spine 2001;26:
2244 –2250 or scoliotic curvatures on anatomic specimens.6,7,17
Other 3D studies are performed analytically on the basis
of imaging techniques combined with 3D geometrical
Adolescent idiopathic scoliosis is a complex three- reconstruction and measurement such as in vivo com-
dimensional (3D) anomaly of the spine involving devia- puted tomography (CT) scans,9,11 multiview radiogra-
tions in the frontal plane, modifications of the sagittal phy,1,5,29 or in vitro techniques using magnetic point-
profile, rotations in the transverse plane, and alterations ers.12,15 Several studies have emphasized that evaluation of
3D descriptors, as compared with 2D investigation alone,
From the *Research Center, Sainte-Justine Hospital, Montreal, the provides a more complete assessment of spinal curve pro-
†University of Montreal Biomedical Engineering Institute, and the
‡Ecole Polytechnique of Montreal Mechanical Engineering Depart- gression for full interpretation of the real 3D scoliotic cur-
ment, Quebec, Canada. vatures and intrinsic deformities.1,6,8,32,33
Funded by the Natural Sciences and Engineering Research Council of Evaluation of geometric descriptors usually is re-
Canada, the Canadian Institutes for Health Research, and the Founda-
tions of Sainte-Justine Hospital and Ecole Polytechnique. ported mainly in cross-sectional intersubject studies
Acknowledgment date: November 3, 2000. comparing scoliotic configurations of different individu-
First revision date: November 19, 2000. als. Some studies investigate 2D and 3D relations be-
Acceptance date: March 9, 2001.
Device status category: 1. tween regional and local scoliotic deformities, providing
Conflict of interest category: 14. additional information on scoliosis develop-

2244
Progression of Scoliotic Deformities • Villemure et al 2245

ment.6,17,24,32,33,38 As reported in the literature, thoracic


scoliosis severity, as measured by Cobb angles, is associ-
ated with a “coronalization” of the plane of maximum
deformity.32,33 Concomitantly, vertebral wedging in-
creases with curve severity,17,33,38 with the maximum
vertebral body height shifting toward the frontal plane of
the vertebra with curve severity.17,33 With progressing sco-
liosis, Perdriolle16 reported an increasing proportion of
disc, as compared with vertebral wedging, whereas
Ronchetti et al24 found an inverse relation. The vertebral
axial rotation also increases with scoliotic curvature.6,32,33
Notwithstanding the potential individuality involved
in scoliotic progression, the literature includes very few
longitudinal studies that evaluate different phases of sco-
liotic progression for the same individual. Perdriolle and
Vidal18 described the changes in regional and local sco- Figure 1. Thoracic kyphosis, Cobb angles in both the global pos-
liotic morphologies with scoliotic curvature, but their teroanterior view and the plane of maximum deformity, and angu-
analyses and supporting results are not clearly defined, lar orientation of the plane of maximum deformity.
nor are the patient groups. The objective of this study
was to conduct an intrasubject longitudinal study quan- The third regional descriptor consisted of the angular ori-
tifying the evolution of 2D and 3D geometrical descrip- entation of the plane of maximum deformity with respect to the
tors to provide complementary information on the devel- global sagittal plane of the subject (␪max) (Figure 1). Finally, the
opment of adolescent idiopathic scoliosis. thoracic kyphosis (Kt) was measured using the Cobb method to
describe the sagittal profile (Figure 1).
Methods
Four regional and five local descriptors were used to character- Evaluation of Local Scoliotic Descriptors. Five local de-
ize scoliotic deformities. The global (spine), regional (scoliotic scriptors were used to investigate the deformation patterns at
segment), and local (vertebra) anatomic reference systems used the vertebral level. Vertebral wedging was calculated as the
in this study were defined according to axis systems proposed angle between adjacent ellipses representing the vertebral end-
by the Scoliosis Research Society, with X, Y, and Z axes refer- plates. Projection of the wedging angle in three different planes
ring, respectively, to anterior, left lateral, and cephalic direc- provided relative inclinations (wedging angles) in different an-
tions.29 The descriptors were evaluated analytically from 3D atomic reference systems:
reconstructed spines of scoliotic subjects. Geometrical data of
1. The global posteroanterior (PA) wedging angle (␻PA)
vertebrae were reconstructed in 3D using two calibrated radio-
was evaluated from the projection of vertebral endplates in
graphs (posteroanterior and lateral) taken with an apparatus
the global frontal plane (Figure 2).
that normalized the position of the subject and incorporated a
2. The global lateral (LAT) wedging angle (␻LAT) was eval-
calibration object.5
uated from the projection of vertebral endplates in the
For each vertebra, six anatomic landmarks (the vertebral
global sagittal plane.
endplate centers and the superior and inferior tips of both
3. The maximum 3D wedging angle (␻3D) corresponded to
pedicles) were digitized on both radiographs and reconstructed
the real 3D inclination magnitude (i.e., maximum) between
in 3D using the direct linear transform algorithm.13 Eight ad-
two adjacent ellipses (Figure 2).
ditional noncorresponding points defining the vertebral body
extremities were digitized on the radiographs and used in an The fourth local descriptor referred to the angular orienta-
iterative procedure fitting 3D-oriented ellipses of adequate di- tion of the line joining the maximum and the minimum heights
ameters on both endplates of the vertebra.1 of the vertebral body with respect to the local sagittal plane of
the vertebra (␪␻3D) (Figure 2). The fifth local descriptor, the
Evaluation of Regional Scoliotic Descriptors. Four re- vertebral axial rotation (␪z), was calculated using an analytical
gional descriptors were used to characterize the spinal curva- method adapted from Stokes et al.31 It was defined as the angle
tures. The magnitude of curves was evaluated mathematically between the vertebral and global frontal planes when projected
from the reconstructed spines using computerized Cobb angles. in an auxiliary plane perpendicular to the vertebral body axis
These angles were evaluated in specified projections of the 3D (Figure 2). As viewed from above, clockwise axial rotation was
spinal curve by calculating the angle between the intersection of measured as negative and counterclockwise rotation as
two lines perpendicular to the curve at its inflection points. positive.
Cobb angles were calculated on two different projections of the
spine10: the frontal Cobb angle in the global posteroanterior Patients. This longitudinal study involved adolescent idio-
plane of the subject (Cobb) (Figure 1) and the Cobb angle, pathic scoliosis thoracic curves developed in right thoracic (n ⫽
confined by the same end vertebrae of the curve, projected in 12) and right thoracic left lumbar (n ⫽ 16) curve types. The 28
the plane of maximum deformity (i.e., in the plane rotated adolescents (27 girls and 1 boy) were recruited from the data-
around the vertical axis where it reaches its maximum value) bank of the scoliosis clinic at Sainte-Justine’s Hospital. The
(Cobbmax). This angle is an analog to Stagnara and Quene- selection of participants was based on a criterion of scoliosis
au’s28 plan d’élection (Figure 1). progression defined as a minimum frontal Cobb angle increase
2246 Spine • Volume 26 • Number 20 • 2001

Figure 2. Vertebral axial rotation


and global posteroanterior
wedging angle, as well as the
three-dimensional maximum
wedging angle and its angular
orientation.

of 5° in the frontal plane per year. Two progressive scoliotic quate for investigating potential trends. Additional analyses
visits were considered for each of the 28 subjects who could were performed for 3D scoliotic descriptors using multiple lin-
be recruited. The mean age at the first visit was 12.7 ⫾ 1.7 ear regressions.
years, and the average interval between the two assessments
was 22.8 ⫾ 10.8 months. The average overall scoliosis severity,
as measured by the initial thoracic frontal Cobb angle of the Results
recruited patients, was 35.3° ⫾ 8.4° (range, 14 –54°). For each
Overall, the mean frontal Cobb angle increased by
3D reconstructed scoliotic spine, regional descriptors were
evaluated on the thoracic segment, whereas local descriptors
16.1° ⫾ 9°, from 35.3° ⫾ 8.4° to 51.4° ⫾ 8.5°, between
were computed on the thoracic apical vertebra, generally the two assessments (Table 1). The corresponding Cobb an-
most deformed scoliotic vertebra.6,8,17 Absolute differences be- gle in the plane of maximum deformity (Cobbmax) was
tween the descriptors at two consecutive visits (denoted ⌬(D) slightly higher than the Cobb angle in the frontal plane,
for each descriptor D) were used to characterize the evolution but resulted in a similar curvature progression (15.9° ⫾
of scoliotic deformities. 9.7°) (Table 1). The spinal curves in the plane of maxi-
mum deformity increased for all the participants (Table
Statistical Analysis. The participants were partitioned with 2). The angular orientation of the plane of maximum
respect to the pattern in the variations of the descriptor (⌬(D) deformity (␪max) invariably remained on the right pos-
⬎ 0 or ⌬(D) ⬍ 0). Correlation analyses of descriptor variations terolateral side of the subject (Table 1). However, this
also were performed to analyze trends existing between the plane evolved toward the frontal plane in 71% of the
evolution of regional and local deformities. To investigate
subjects (Table 2). The mean kyphosis (⬇30°) was found
the evolution of vertebral wedging angles with respect to the
change in Cobb angles and kyphosis, the evolution of 3D max-
to be similar throughout the study period (Table 1), but
imum vertebral wedging orientation (␪␻3D) with respect to the with marked individual variability and with a kyphosis
change in regional descriptors, and the evolution of axial rota- that increased in 64% of the participants (Table 2). Fig-
tion (␪z) with respect to the change in regional and local de- ure 3 presents a schematic view of the changes in each
scriptors, Pearson correlation matrices were calculated with a descriptor. The percentage indicates the proportion of
significance level set at a P of 0.05, which is considered ade- participants showing the corresponding behavior.

Table 1. Descriptive Statistics for Regional and Local Descriptors as Well as Their Variations Between Scoliotic
Visits
Regional Descriptors (°) Local Descriptors (°)

Descriptor Cobb Cobbmax ␪max* Kt ␻PA ␻LAT ␻3D ␪␻3D† ␪z

Visit 1 35.3 ⫾ 8.4 38.7 ⫾ 7.4 62.4 ⫾ 11.1 28.3 ⫾ 9.9 5.7 ⫾ 3.5 1.8 ⫾ 2.6 6.5 ⫾ 3 80.3 ⫾ 30.4 ⫺9.7 ⫾ 8.4
Visit 2 51.4 ⫾ 8.5 54.6 ⫾ 9.3 69.5 ⫾ 9.1 29.3 ⫾ 11 11.2 ⫾ 4.6 3.6 ⫾ 3.9 11.6 ⫾ 4.3 78.1 ⫾ 19 ⫺17.4 ⫾ 7.4
Variation 16.1 ⫾ 9 15.9 ⫾ 9.7 7.1 ⫾ 11.7 1.0 ⫾ 6.7 5.5 ⫾ 4.6 1.8 ⫾ 4.9 5.1 ⫾ 4.2 2.3 ⫾ 38.4 ⫺7.8 ⫾ 8.4
* With respect to global sagittal plane.
† With respect to local sagittal plane.
Cobb ⫽ Cobb angle in the global posteroanterior plane; Cobbmax ⫽ Cobb angle in the plane of maximum deformity; ␪max ⫽ angular orientation of the plane of
maximum deformity; Kt ⫽ thoracic kyphosis; ␻PA ⫽ global posteroanterior wedging angle; ␻LAT ⫽ global lateral wedging angle; ␻3D ⫽ maximum three-dimensional
wedging angle; ␪␻3D ⫽ angular orientation of the maximum three-dimensional wedging angle; ␪z ⫽ vertebral axial rotation.
Progression of Scoliotic Deformities • Villemure et al 2247

Table 2. Proportions of Subjects (%) as Partitioned in Positive and Negative Variations of Descriptors (e.g., for 82% of
the cases, the axial rotation ␪z evolves clockwise and for 18% of the cases, the axial rotation ␪z evolves
counterclockwise)
Regional Descriptors Proportion of Subjects (%) Local Descriptors Proportion of Subjects (%)
Descriptor
⌬(D) (mean) Cobb Cobbmax ␪max* Kt ␻PA ␻LAT ␻3D ␪␻3D† ␪z

⌬(D) ⬎ 0 100 (16.1) 100 (15.9) 71 (11.7) 64 (4.8) 89 (6.3) 61 (4.6) 93 (5.5) 54 (30.3) 18 (2.7)
⌬(D) ⬍ 0 0 (—) 0 (—) 29 (⫺4.1) 36 (⫺5.9) 11 (⫺1.4) 39 (⫺2.4) 7 (⫺0.9) 46 (⫺30.1) 82 (⫺10.0)
* With respect to global sagittal plane.
† With respect to local sagittal plane.
Cobb ⫽ Cobb angle in the global posteroanterior plane; Cobbmax ⫽ Cobb angle in the plane of maximum deformity; ␪max ⫽ angular orientation of the plane of
maximum deformity; Kt ⫽ thoracic kyphosis; ␻PA ⫽ global posteroanterior wedging angle; ␻LAT ⫽ global lateral wedging angle; ␻3D ⫽ maximum three-dimensional
wedging angle; ␪␻3D ⫽ angular orientation of the maximum three-dimensional wedging angle; ␪z ⫽ vertebral axial rotation.

In most cases, local intrinsic changes on the apical Statistical correlation (P ⱕ 0.05) was found for the
vertebra showed increasing wedging angles ␻PA (89% four combinations relating the variations of Cobb angles
increase) and ␻3D, (93% increase) (Table 2), with corre- to the changes in the wedging angles (Figure 4 and Table
sponding variations reaching respective means of 5.5° ⫾ 3). On the basis of the R2 value, the curve progression
4.6° and 5.1° ⫾ 4.2° over two consecutive scoliotic as- explained approximately 35% of the 2D wedging and
sessments (Table 1). The overall wedging difference was only about 20% of the 3D wedging phenomenon. None
slightly higher in the global frontal plane, although ␻3D of the relations involving the sagittal profiles regionally
was greater on the average than ␻PA (Table 1). Angular (⌬(Kt)) and locally (⌬(␻LAT)) were significant, with P
orientations (␪␻3D) were located consistently in the right values varying between 0.10 and 0.91. The change in the
lateral quadrant of the vertebra (Table 1), but they orientation of the line joining the maximum and mini-
showed variable evolutions, with 46% of the cases pro- mum vertebral body heights ⌬(␪␻3D) was not correlated
gressing clockwise and 54% counterclockwise (Table 2). statistically with the variations of all the regional de-
In 61% of the cases, there was an increase of vertebral scriptors, even if a relation with its regional homologue
wedging in the sagittal plane (Table 2), although the describing the angular orientation of the 3D curvature
standard deviation was quite high (Table 1). An average ⌬(␪max) might have been expected. Weak statistical rela-
axial rotation of 7.8° ⫾ 8.4° clockwise was obtained tions were obtained for vertebral axial rotation (P ⱕ 0.1)
(Table 1), indicating that the vertebral body was rotating relative to the wedging angles. A more significant corre-
toward the convexity of the curve. The vertebral axial lation with ⌬(␻3D) was obtained (Fig. 5a). Relations with
rotation showed a significant aggravating trend in 82%
of the cases (Table 2).

Figure 3. Diagram presenting percentages of subjects as parti-


tioned in positive and negative variations of descriptors. The
percentage indicates the proportion of subjects showing the cor-
responding behavior (e.g., for 82% of the cases, the axial rotation
(␪z) evolves clockwise, and implicitly, for 18% of the cases, the Figure 4. The relation between ⌬(␻ PA) and ⌬(Cobb) (r ⫽ 0.58) (A),
axial rotation (␪z) evolves counterclockwise. and between ⌬(␻ 3D) and ⌬(Cobbmax) (r ⫽ 0.45) (B).
2248 Spine • Volume 26 • Number 20 • 2001

Table 3. Correlations Between Variations of Regional Table 4. Multiple-linear Regressions for Descriptors
and Local Scoliotic Descriptors ⌬(␪Max), ⌬(␻3D), and ⌬(␪␻3D)
⌬(Kt) ⌬(Cobb) ⌬(Cobbmax) ⌬(␪max) ⌬(␪z) ⌬(Kt) ⌬(Cobb) ⌬(␪z)
P P P P P ␤ ␤ ␤ P

⌬(␻PA) 0.85 ⱕ0.001 0.05 0.09 ⌬(␪max) ⫺0.70 0.37 0.11 ⱕ0.001
⌬(␻LAT) 0.21 0.10 0.29 0.11 ⌬(␻3D) 0.06 0.68 ⫺0.35 ⱕ0.001
⌬(␻3D) 0.91 ⱕ0.001 0.02 0.05 ⌬(␪␻3D) ⫺0.01 ⫺0.09 ⫺0.03 0.98
⌬(␪␻3D) 0.91 0.66 0.58 0.43 0.90
Cobb ⫽ Cobb angle in the global posteroanterior plane; ␪max ⫽ angular orien-
⌬(␪z) 0.36 0.78 0.75 0.19
tation of the plane of maximum deformity; Kt ⫽ thoracic kyphosis; ␻3D ⫽
Cobb ⫽ Cobb angle in the global posteroanterior plane; Cobbmax ⫽ Cobb angle maximum three-dimensional wedging angle; ␪␻3D ⫽ angular orientation of the
in the plane of maximum deformity; ␪max ⫽ angular orientation of the plane of maximum three-dimensional wedging angle; ␪z ⫽ vertebral axial rotation.
maximum deformity; Kt ⫽ thoracic kyphosis; ␻PA ⫽ global posteroanterior
wedging angle; ␻LAT ⫽ global lateral wedging angle; ␻3D ⫽ maximum three-
dimensional wedging angle; ␪␻3D ⫽ angular orientation of the maximum
three-dimensional wedging angle; ␪z ⫽ vertebral axial rotation.
ing the orientation of 3D maximum vertebral wedging
(␪␻3D) indicated no statistical association, suggesting
that its evolution relies on factors other than ⌬(Cobb),
respect to regional descriptors were inconclusive, al-
⌬(Kt) and ⌬(␪z).
though a potential trend between ⌬(␪max) and ⌬(␪z) was
observed (Figure 5b). Discussion
Further investigation using multiple linear regressions
A longitudinal study of patients with scoliosis was con-
was conducted for ␪max, ␻3D, and ␪␻3D, which provide a
ducted to investigate progressive thoracic curves, both right
3D description of the scoliotic deformity. Variations of
thoracic and right thoracic left lumbar curve types. The
these scoliotic descriptors were analyzed with respect to
evolution of descriptors between two scoliotic visits was
the changes in 2D descriptors: Cobb Kt and ␪z (Table 4).
analyzed in terms of variations in regional and local scoli-
Regression results indicated that ⌬(␪max) was correlated
otic descriptors computed from 3D reconstructed spines.
significantly with the evolution of the sagittal profile
Several statistical analyses were performed to determine
⌬(Kt) (␤ ⫽ ⫺0.70). A statistical, but less important, re-
how thoracic curvatures and vertebral deformities change
lation was found to be associated with the development
during scoliosis progression. The results from this study
of frontal scoliotic curvature ⌬(Cobb), whereas the cor-
indicate that at the thoracic level, vertebral wedging
responding variation of vertebral axial rotation ⌬(␪z)
progresses concomitantly with curve severity in a relatively
showed no significant influence. The variation of verte-
typical pattern for most patients with scoliosis. This finding
bral wedging (⌬(␻3D)) was principally explained by the
is consistent with several cross-sectional studies that report
progression in the Cobb angle (␤ ⫽ 0.68) and by a sta-
wedging associated with scoliotic curvature.17,33,38 This
tistical association with ⌬(␪z). Regression results describ-
pattern, observed both in 2D and 3D, suggests that individ-
ual vertebral components and resulting curvatures of the
spine are geometrically and structurally interdependent.
In the thoracic scoliotic spine, apical vertebrae are
invariably rotated toward the curve convexity. This was
observed clinically and reported in different cross-
sectional studies.6,32,33 This axial rotation amplifies with
scoliosis severity toward curve convexity, but not in all
cases. The wedging phenomenon increases with verte-
bral rotation in a 3D manner. In fact, the 3D maximum
wedging intrinsically includes lateral and transverse
components, and is significantly correlated with frontal
curvatures. Whereas little influence is observed with the
sagittal plane, the relation with transverse plane defor-
mities is statistically significant.
Thoracic apical rotation evolves in a direction that
increases the vertebral body deformities. Vertebral axial
deformities that develop in scoliotic spines modify angu-
lar orientation of the facet joints, consequently altering
the normal biomechanical role of vertebrae and their
surrounding structures. In fact, it has been documented that
spinal motions rely mainly on the geometrical properties of
the facet joints, with the spatial orientation of these joints
Figure 5. The relation between: ⌬(␪ z) and ⌬(␻ 3D) (r ⫽ ⫺0.38) (A), primarily determining their biomechanical and motion
and between ⌬(␪ z) and ⌬(␪ max) (r ⫽ -0.26) (B). contributions.35,36 However, more investigation is needed
Progression of Scoliotic Deformities • Villemure et al 2249

to explain better how the 3D maximum wedging changes in plane curvature. A decrease in kyphosis tends to shift the
space along with scoliosis progression. plane of maximum deformity toward the frontal plane.
Whereas clockwise evolution of ␪␻3D was observed in a The highly variable kyphosis evolution then is the main
significant proportion of patients, the opposite behavior explanation for the discrepancy observed in the evolu-
also is observed in a proportion near 50%. Attempts to tion of the plane of maximum deformity.
establish relations of ␪␻3D evolution with other descriptors In this study, most of the patients with scoliosis were
were inconclusive, suggesting an independence of ␪␻3D. undergoing orthopedic treatment. Hence, the spinal ge-
Other factors not included in this study, such as muscular ometries used in this longitudinal study do not strictly
capacity or residual growth, might be implied and reflect reflect the natural history of scoliosis, and might induce
physiologic or biomechanical aspects involved in scoliosis. variability originating from the brace treatment. The lim-
Thoracic kyphosis presents considerable variability, itations of this study also include accuracy associated
with lateral curvatures varying overall between 6° and 58°. with the 3D reconstruction methods and the analytical
The sagittal profiles, however, remain within the wide cor- evaluation of regional and local scoliotic descriptors. Ac-
ridor observed in normal subjects.27 In the current study, cording to previous studies, the 3D reconstruction tech-
both increasing and decreasing kyphoses were observed in nique induces a mean variability of computerized Cobb
proportions greater than 35%, with comparable mean angles smaller than 1° in the different projection planes,
variations respectively of 4.8° and ⫺5.9°. This result con- and a variability of 2.3° to 5.9° for vertebral axial rota-
trasts with the findings of several authors who reported tion.10 As for the vertebral endplate modeling tech-
decreased kyphosis or even thoracic lordosis in human sco- nique1, a 2° accuracy was found for the wedging angle
liotic spines.6,7,8,18 However, most of their studies were not between endplates of the vertebral body, and an 11° ac-
conducted to assess the effect of progression on thoracic curacy for the angular orientation of the maximum
kyphosis. Other clinical investigations have indicated no wedging. The magnitude of the errors involved in the
significant hypokyphosis in scoliotic spines,20 as compared calculation of the different scoliotic descriptors, which
with the spines of normal children, and no association be- overall remain below the corresponding descriptor abso-
tween hypokyphosis and curve progression.4 In the current lute variations, do not invalidate the conclusions drawn
study, no patterns were found to show how sagittal curves for different statistical analyses.
evolve with scoliosis severity. The change in sagittal wedg- The analysis described in the current report differs
ing also was correlated weakly with the kyphosis evolution, from that of other studies quantifying geometrical scoli-
suggesting that disc wedging in the sagittal plane contrib- otic descriptors6,16,17,24 because they generally did not
utes to the deformity. Some authors have emphasized the explicitly report the accuracy of measurements. Within
relevance of viewing scoliotic curvatures in anatomic fron- the measurement accuracies reported for the current
tal and lateral views of the apex.6,18 In his 11 articulated study, correlation levels overall remained relatively low.
spines, Deacon et al6 observed that global sagittal views Separate studies for subgroups differentiating thoracic
create erroneous impressions of kyphosis, which indeed is curves developed in right thoracic and right thoracic left
lordosis when viewed in the anatomic sagittal view of the lumbar curve types, decreasing versus increasing kypho-
thoracic apex. sis, and the rotation side of the wedging might allow
In a nonpathologic spine, there is no lateral curve. more conclusive evaluation of scoliosis patterns.
Therefore, the plane of maximum deformity is in the Currently, very little is known about the patient-
sagittal plane and represents the normal thoracic kypho- specific evolution of scoliosis. This longitudinal study
sis. For subjects with scoliosis, most cross-sectional stud- allowed characterization of scoliotic evolution patterns,
ies report that the plane of maximum deformity is lo- as compared with the findings of cross-sectional studies.
cated in the right posterolateral quadrant (0° ⱕ ␪max ⱕ These results challenge the existence of a typical scoliotic
90°).32,33 In the current study, ␪max globally varied be- evolution pattern and suggest that scoliotic evolution is
tween 37° and 88° in both scoliotic assessments. quite variable and patient specific. Consequently, intra-
Scoliosis is a 3D phenomenon combining 2D spinal subject approaches should be preferred to intersubject
curvatures in the posteroanterior and lateral profiles, and clinical studies when the progression patterns and effec-
a transverse plane deformation. Results show that the tiveness of brace or surgical treatments of adolescents
kyphosis and frontal deviation are the most important with scoliosis are investigated. Factors such as the initial
variables characterizing the evolution of the plane of sagittal spinal configuration, the location of the apical
maximum deformity. Nevertheless, a significant vari- region, the individual muscular capacity, and the remain-
ability is found in its evolution with scoliosis progres- ing growth potential might influence the progression pat-
sion. The relative curve progression in each plane indeed tern of the patient with scoliosis. In relation to this as-
dictates the resulting evolution of the plane of maximum pect, future work also should consider relevant
deformity and the 3D curvature. This geometric relation physiologic parameters such as age, gender, Risser, men-
has been recognized by other authors.6,18 Although a arche, and peak growth velocity. These would provide
significant association was found between the progres- additional parameters potentially involved in scoliosis
sion of this plane and severity of the scoliosis, the greatest progression. In the long-term, this clinical work intends
relation is associated with the evolution of the sagittal to improve the understanding of the complex mecha-
2250 Spine • Volume 26 • Number 20 • 2001

nisms involved in scoliosis progression, and to provide 13. Marzan GT. Rational Design for Close-Range Photogrammetry. PhD The-
sis. Department of Civil Engineering, University of Illinois at Urbana-
additional clinical knowledge that could be profitable for Campaign, 1976.
the orthopedic and surgical treatments of scoliosis. 14. Millner PA, Dickson RA. Idiopathic scoliosis: biomechanics and biology.
Eur Spine J 1996;5:362–73.
15. Parent S, Labelle H, Mitulescu A, et al. Morphometric Analysis of One
Anatomic Scoliotic Specimen: Research Into Spinal Deformities. Amster-
Key Points dam: IOS Press, in press, 2001.
16. Perdriolle R. La scoliose. Son étude tridimensionnelle. In: Maloine SA, ed.
● The evolution of scoliotic descriptors was assessed Paris, 1979, 144 pages.
analytically from three-dimensionally reconstructed 17. Perdriolle R, Becchetti S, Vidal J, et al. Mechanical process and growth
spines and analyzed statistically in a group of 28 ad- cartilages. Spine 1993;18:343–9.
18. Perdriolle R, Vidal J. Morphology of scoliosis: three-dimensional evolution.
olescents with progressive idiopathic scoliosis. Orthopedics 1987;10:909 –15.
● At the thoracic level, vertebral wedging increases 19. Pope MH, Stokes IAF, Moreland M. The biomechanics of scoliosis. CRC
with curve severity in a relatively consistent pattern Crit Rev Biomed Eng 1984;11:157– 88.
20. Propst-Proctor SL, Bleck EE. Radiographic determination of lordosis and
for most scoliotic patients. kyphosis in normal and scoliotic children. J Pediatr Orthop 1983;3:344 – 6.
● Axial rotation mainly increases toward curve con- 21. Roaf R. Rotation movements of the spine with special reference to scoliosis.
vexity with scoliosis severity in a way that worsens J Bone Joint Surg [Br] 1958;40:312–32.
22. Roaf R. Scoliosis. Edinburgh: ES Livingstone, 1966.
the progression of vertebral body deformities. 23. Roaf R. Vertebral growth and its mechanical control. J Bone Joint Surg [Br]
● No consistent patterns are associated with the 1960;42:40 –59.
angular orientation of the plane of maximum de- 24. Ronchetti PJ, Stokes IAF, Aronsson DD. Vertebral body and disc wedging in
scoliosis: Research into spinal deformities 1. Amsterdam: IOS Press, 1997;
formity and the angular orientation of the maxi- 37:81– 4.
mum three-dimensional wedging angle. 25. Smith RM, Pool RD, Butt WP, et al. The transverse plane deformity of
● The evolution of the thoracic kyphosis varies structural scoliosis. Spine 1991;16:1126 –9.
26. Somerville EW. Rotational lordosis: the development of a single curve.
considerably among subjects. J Bone Joint Surg [Br] 1952;34:421–7.
27. Stagnara P, deMauroy JC, Dran G, et al. Reciprocal angulation of vertebral
bodies in a sagittal plane: approach to references for the evaluation of ky-
Acknowledgments phosis and lordosis. Spine 1982;7:335– 42.
28. Stagnara P, Queneau P. Scolioses évolutives en période de croissance: aspects
Special thanks to Mrs. Marie Beausejour for her scien- cliniques, radiologiques, propositions thérapeutiques. Rev Chir Orthop
tific and technical assistance in this project as well as to 1953;39:378 – 449.
29. Stokes IAF. Three-dimensional terminology of spinal deformity. Spine 1994;
Mr. Martin-Guy Durand for digitization of the Radio- 19:236 – 48.
graphs and drawing of some figures. 30. Stokes IAF, Aronsson DD, Urban JPG. Biomechanical factors influencing
progression of angular skeletal deformities during growth. Eur J Musculo-
References skel Res 1994;3:51– 60.
31. Stokes IAF, Bigalow LC, Moreland MS. Measurement of axial rotation of
1. Aubin CE, Dansereau J, Petit Y, et al. Three-dimensional measurement of vertebrae in scoliosis. Spine 1986;11:213– 8.
wedged scoliotic vertebrae and intervertebral disks. Eur Spine J 1998;7:59 – 32. Stokes IAF, Bigalow LC, moreland MS. Three-dimensional spinal curvature
65. in idiopathic scoliosis. J Orthop Res 1987;5:102–13.
2. Burwell RG, Cole AA, Cook TA, et al. Pathogenesis of idiopathic scoliosis: 33. Villemure I, Aubin CE, Dansereau J, et al. A correlation study between spinal
the Nottingham concept. Acta Orthop Belg 1992;58(Suppl 1):33–58. curvatures and vertebral and intervertebral deformities in idiopathic scolio-
3. Burwell RG, Dangerfield PH. Adolescent idiopathic scoliosis: Hypotheses of sis (in French). Ann Chir 1999;53:798 – 807.
causation. In: Hanley, Belfus, eds. Spine State of the Art Reviews: The Etiol- 34. White AA. Kinematics of the normal spine as related to scoliosis. J Biomech
ogy of Adolescent Idiopathic Scoliosis. 2000:319 –33. 1971;4:405–11.
4. Carr AJ, Jefferson RJ, Turner-Smith AR, et al. Surface stereophotogramme- 35. White AA, Hirsch C. The significance of the vertebral posterior elements in
try of thoracic kyphosis. Acta Orthop Scand 1989;60:177– 80. the mechanics of the thoracic spine. Clin Orthop 1971;81:2–14.
5. Dansereau J, beauchamp A, deGuise JA, et al. Three-dimensional reconstruc- 36. White AA, Panjabi MM. Clinical Biomechanics of the Spine. Philadelphia: JB
tion of the spine and rib cage from stereoradiographic and imaging tech- Lippincott, 1990, 722 pages.
niques. Proc 16th Conf Canadian Society of Mechanical Engineering 1990; 37. Xiong B, Sevastik B, Sevastik JA, et al. Horizontal plane morphometry of
2:61– 4. normal and scoliotic vertebrae: a methodological study. Eur Spine 1995;4:
6. Deacon P, Flood BM, Dickson RA. Idiopathic scoliosis in three dimensions: 6 –10.
a radiographic and morphometric analysis. J Bone Joint Surg [Br] 1984;66: 38. Xiong B, Sevastik JA, Hedlund R, et al. Radiographic changes at the coronal
509 –12. plane in early scoliosis. Spine 1994;19:159 – 64.
7. Deane G, Duthie B. A new projectional look at articulated scoliotic spines.
Acta Orthop Scand 1973;44:351– 65.
8. Graf H, Mouilleseaux B. Analyse Tridimensionnelle de la Scoliose. France:
Safir, 1990, 48 pages. Address reprint requests to
9. Kojima T, Kurokawa T. Quantification of three-dimensional deformity of
idiopathic scoliosis. Spine 1992;17(Suppl):22–9. Carl-Eric Aubin, PhD
10. Labelle H, Dansereau J, Bellefleur C, et al. Variability of geometric measure- Ecole Polytechnique of Montreal
ments from three-dimensional reconstructions of scoliotic spines and rib Mechanical Engineering Department
cages. Eur Spine J 1995;4:88 –94.
11. Landry C, deGuise JA, Dansereau J, et al. Computer graphics analysis of the
P.O. Box 6079, Station “Centre-ville”
three-dimensional deformities of scoliotic vertebrae. Ann Chir 1997;51: Montreal, Quebec
868 –74. H3C 3A7 CANADA
12. Le Borgne P, Skalli W, Zeller R, et al. Three-Dimensional Measurement of E-mail: carl-eric.aubin@polymtl.ca
Vertebral Deformity Using Helicoidal Axis: Research Into Spinal Deformi-
ties 1. Amsterdam: IOS Press, 1997;169 –72.

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