What Are Spinal Deformities?
Understanding abnormal curvatures of the spine
The spine normally has natural curves that allow it to distribute body weight efficiently and maintain balance. When these curves become exaggerated or appear in abnormal planes, however, we speak of spinal deformities.
Deformities can be classified according to the plane in which they occur:
Coronal Plane (Front View)
Scoliosis: A sideways curvature of the spine that should not normally be present. It may take the shape of a "C" or an "S."
Seen from the front or back, the spine should form a straight line. In scoliosis, it deviates to the sides.
Sagittal Plane (Side View)
Kyphosis: An excessive forward curvature, usually in the thoracic region, creating a "hunchback" or rounded upper back.
Lordosis: An excessive backward curvature, typically in the lumbar region, creating a pronounced arch.
Spondylolisthesis deserves special mention: although technically it is the slippage of one vertebra over another, when severe it can cause significant deformity and disrupt the spine's sagittal balance.
Scoliosis: Lateral Curvature of the Spine
The most common spinal deformity
Scoliosis is an abnormal sideways curvature of the spine. It is measured using the Cobb angle on X-rays: a curve greater than 10 degrees is considered scoliosis.
Types of Scoliosis
Idiopathic Scoliosis
Most Common (80%)Of unknown cause, typically diagnosed in adolescence. It is subdivided by age:
- Infantile: Before age 3
- Juvenile: Between ages 3 and 10
- Adolescent: Between age 10 and skeletal maturity
- Adult: After skeletal maturity
Congenital Scoliosis
Present at BirthCaused by vertebral malformations during fetal development:
- Wedge vertebrae: Incomplete formation
- Hemivertebrae: Partial vertebrae
- Unsegmented bars: Abnormal fusion
Requires follow-up from birth due to a high risk of progression.
Neuromuscular Scoliosis
Secondary to DiseaseAssociated with conditions that affect the nerves or muscles:
- Cerebral palsy
- Muscular dystrophy
- Spina bifida
- Spinal cord injuries
- Poliomyelitis
Tends to progress and may affect lung function and the ability to sit.
Adult Degenerative Scoliosis
Age-RelatedDevelops in adults due to degeneration of the discs and facet joints:
- Typically after age 50
- Can cause significant pain
- Frequently associated with spinal stenosis
- Affects balance and gait
📊 Progression Factors in Scoliosis
When does scoliosis get worse? Progression depends on multiple factors:
- Curve magnitude: Curves >25° carry a higher risk of progressing
- Skeletal maturity: Curves detected before puberty progress more
- Curve pattern: Thoracic curves progress more than lumbar ones
- Sex: Girls have a higher risk of progression than boys
- In adults: Curves >30° can progress 1-2° per year without treatment
Kyphosis: Excessive Forward Curvature
When the "hunchback" is more than just poor posture
Kyphosis is an increase in the natural curvature of the thoracic spine. Normally, this curvature measures between 20° and 50°. When it exceeds 50°, it is considered pathological kyphosis and may cause symptoms.
Postural Kyphosis
Generally BenignThe most common and least serious form:
- More common in adolescents
- Caused by poor posture and muscle weakness
- The vertebrae have a normal shape
- Flexible: corrects when bending forward
- Responds well to strengthening exercises
- Rarely requires surgical treatment
Scheuermann's Disease
Structural DeformityA structural kyphosis that appears in adolescence:
- Wedge-shaped vertebrae (≥5° in 3 consecutive vertebrae)
- A rigid curve that does not correct with posture
- Can cause back pain
- Affects males more often
- Cause unknown (possible genetic factor)
- May require a brace or surgery if severe
Congenital Kyphosis
Present at BirthCaused by vertebral malformation during fetal development:
- Abnormal formation of vertebrae
- High risk of rapid progression
- Can compress the spinal cord
- Requires close follow-up from birth
- Frequently requires early surgery
Iatrogenic and Secondary Kyphosis
Various CausesDeveloping as a result of other conditions:
- Post-laminectomy: After spine surgery
- Post-traumatic: Poorly healed vertebral fractures
- Infectious: Spinal tuberculosis (Pott's disease)
- Tumor-related: Vertebral destruction caused by tumors
- Metabolic: Osteoporosis with multiple fractures
⚠️ When Kyphosis Requires Urgent Attention
Seek immediate neurosurgical evaluation if you experience:
- Rapid progression of the deformity (especially in children)
- Severe pain that does not respond to conservative treatment
- Neurological symptoms: leg weakness, gait disturbances
- Difficulty breathing due to the deformity
- Spinal cord compression documented on MRI
Spondylolisthesis as a Deformity
When vertebral slippage disrupts spinal alignment
Spondylolisthesis is the displacement of one vertebra over the vertebra below it. Although it may be asymptomatic in mild degrees, in severe cases it can cause significant deformity and affect the spine's sagittal balance. Degenerative spondylolisthesis is a common cause in adults.
Classification by Grade (Meyerding)
| Grade | % Slippage | Severity | Typical Management |
|---|---|---|---|
| Grade I | 0-25% | Mild | Conservative treatment initially |
| Grade II | 25-50% | Moderate | Physical therapy; consider surgery if symptomatic |
| Grade III | 50-75% | Severe | Frequently requires surgery |
| Grade IV | 75-100% | Very Severe | Corrective surgery necessary |
| Grade V (Spondyloptosis) | >100% | Complete | Complex reconstructive surgery |
Spondylolisthesis as a Cause of Deformity
When spondylolisthesis is severe (Grades III-V), it can cause significant deformities:
- Loss of lumbar lordosis: The spine loses its normal backward curvature
- Sagittal imbalance: The body's center of gravity shifts forward
- Compensatory posture: Bending of the knees and hips to maintain balance
- Trunk shortening: Reduced distance between the ribs and pelvis
- Cosmetic change: A palpable "step" in the lower back
🎯 Goals of Surgical Correction
When spondylolisthesis causes significant deformity, surgery aims to:
- Restore alignment: Reduce the vertebral slippage
- Reestablish lordosis: Recover the normal lumbar curvature
- Decompress nerves: Free the compressed nerve roots
- Stabilize the spine: Fusion with instrumentation
- Improve balance: Restore the body's sagittal balance
When Are Deformities Problematic?
Not every deformity requires active treatment
Spinal deformities can cause problems across several aspects of health and quality of life:
💔 Pain
Mechanical pain: Caused by muscle imbalance and abnormal load on the joints and discs
Neuropathic pain: From compression of the nerve roots or spinal cord
Chronic pain: Significantly affects quality of life
📈 Progression
During growth: Deformities can worsen rapidly during growth spurts
In adults: Gradual but steady progression, especially with degeneration
Prediction: Certain patterns carry a higher risk of progression
🎭 Cosmetic Impact
Body asymmetry: Uneven shoulders, hips, or ribs
Visible deformity:"Hunchback" or "rib hump"
Psychosocial impact: Affects self-esteem, especially in adolescents
🫁 Lung Function
Severe curves: Scoliosis >70° can compress the lungs
Severe kyphosis: Reduces room for lung expansion
Cor pulmonale: In extreme cases, can affect heart function
🧠 Neurological Involvement
Spinal cord compression: Especially in severe congenital kyphosis
Radiculopathy: Compression of the nerve roots
Claudication: Limited walking due to associated stenosis
⚖️ Imbalance
Sagittal balance: Difficulty maintaining an upright posture
Compensation: Bending of the hips/knees consumes energy
Functional limitation: Difficulty with daily activities
Evaluation of Spinal Deformities
A comprehensive approach to understanding your condition
A complete evaluation of a spinal deformity includes multiple aspects that allow us to understand its severity, progression, and best treatment plan:
Clinical Examination
Physical Evaluation
- Adam's forward bend test: Forward bending to detect vertebral rotation
- Plumb line measurement: Assess coronal and sagittal balance
- Symmetry: Level of the shoulders, shoulder blades, and iliac crests
- Neurological examination: Strength, reflexes, sensation
- Flexibility: Range of motion of the spine
- Gait: Walking pattern and balance
Skeletal Maturity
- Risser sign: Degree of iliac crest ossification
- Menstrual status: In adolescent girls
- Bone age: Hand X-ray if in doubt
- Importance: Predicts the potential for progression
Remaining growth = Higher risk of progression
Imaging Studies
Full-Spine X-rays
The fundamental study for measuring and tracking deformities:
- Posteroanterior (PA) view: Measures the Cobb angle in scoliosis
- Lateral view: Assesses kyphosis, lordosis, and sagittal balance
- Side-bending X-rays: Determine the flexibility of the curve
- Supine X-rays: Predict the possible surgical correction
Key Measurements
- Cobb angle: Standard measurement of scoliosis (°)
- Thoracic kyphosis: Normal 20-50°, pathological >50°
- Lumbar lordosis: Normal 40-60°
- Coronal balance: Deviation of C7 over the iliac crest
- Sagittal balance (SVA): C7-S1 distance, normal <5cm
- Pelvic incidence: A crucial parameter in surgical planning
Magnetic Resonance Imaging (MRI)
Indicated when there is:
- Neurological symptoms
- Significant pain
- Atypical curves (e.g., left thoracic scoliosis)
- Unexpected rapid progression
- Pre-surgical planning
Assesses: The spinal cord, nerve roots, discs, and malformations
Computed Tomography (CT)
Useful for:
- Detail of the bony anatomy
- Congenital vertebral malformations
- Surgical planning (screw trajectory)
- Assessment of bone fusion after surgery
Functional Evaluation
- Pulmonary function tests: In thoracic curves >70°
- Quality-of-life questionnaires: SRS-22, ODI
- Pain assessment: Visual Analog Scale (VAS)
- Functional capacity: Limitations in daily activities
Treatment Options Based on Severity
From observation to complex surgical correction
The treatment of spinal deformities must be individualized, taking into account multiple factors: the type and magnitude of the deformity, the patient's age, skeletal maturity, symptoms, progression, and personal expectations.
Treatment Algorithm by Magnitude
| Curve Magnitude | Scoliosis in Adolescents | Scoliosis in Adults | Kyphosis |
|---|---|---|---|
| <10° | Observation every 6-12 months | No follow-up needed if asymptomatic | Generally normal |
| 10-25° | Observation every 4-6 months; physical therapy | Conservative treatment if symptomatic | Postural exercises |
| 25-40° | Bracing if skeletally immature; physical therapy | Intensive conservative treatment; consider surgery if symptomatic | Bracing in Scheuermann's; intensive physical therapy |
| 40-50° | Surgery generally indicated | Surgery if symptomatic or progressive | Consider surgery if symptomatic |
| >50° | Surgery recommended | Surgery frequently necessary | Surgery if neurological involvement or pain |
| >70° | Urgent surgery | Complex reconstructive surgery | Urgent surgery if respiratory compromise |
Conservative Treatment
Learn in depth about conservative treatment with bracing and physical therapy for spinal deformities.
Observation
Indicated for:
- Stable mild curves (<25°)
- Patients with skeletal maturity
- Asymptomatic deformities
Includes:
- Periodic X-rays to monitor progression
- Regular clinical examinations
- Education on warning signs
Specialized Physical Therapy
Goals:
- Selective muscle strengthening
- Improved posture
- Increased flexibility
- Education on body mechanics
Specific methods:
- Schroth (scoliosis-specific exercises)
- Extension exercises for kyphosis
- Core stabilization
Note: Exercises do NOT correct the structural deformity, but they can improve function and reduce progression.
Bracing (Orthotics)
Indicated in:
- Scoliosis 25-40° in immature patients
- Kyphosis >55° in Scheuermann's
- Documented curve progression
Types of brace:
- Boston: Low lumbar scoliosis
- Milwaukee: High thoracic curves
- Charleston: Nighttime use
- Providence: Nighttime use
Effectiveness: 70-90% stop progression if worn >18 hours/day
Pain Management
Especially relevant in adult degenerative scoliosis:
- Medications: Analgesics, anti-inflammatories
- Injections: Epidural, facet
- Physical therapies: Heat, ultrasound, TENS
- Activity modification: Ergonomics
- Weight loss: Reduces load on the spine
Surgical Treatment
Surgery is indicated when conservative treatment fails, the deformity is severe, or there is neurological or respiratory compromise. Learn about the surgical spine treatments available.
Goals of Corrective Surgery
- Deformity correction: Reduce the abnormal curvature angle
- Restore balance: Sagittal and coronal
- Prevent progression: Through spinal fusion
- Decompress neural structures: If there is compromise
- Relieve pain: Caused by the deformity
- Improve function: Respiratory and overall physical
- Cosmetic appearance: Important in adolescents
Posterior Instrumented Fusion
The most common approach:
- Midline incision in the back
- Placement of pedicle screws
- Rods to correct the curvatures
- Bone graft for fusion
- Instrumentation with multiple anchor points
Advantages: Powerful correction in 3 dimensions. More on fusion with instrumentation and spinal stabilization.
Anterior Fusion
Considered in specific cases:
- Thoracic curves in adolescents
- Very rigid curves requiring release
- High-grade spondylolisthesis
Access:
- Thoracotomy for thoracic curves
- Thoracoabdominal approach for thoracolumbar curves
- Retroperitoneal for lumbar curves
Osteotomies for Severe Deformities
Techniques for major corrections:
- Smith-Petersen (SPO): Posterior osteotomy, 10° correction per level
- Pedicle Subtraction Osteotomy (PSO): 30-40° correction at one level
- Vertebral Column Resection (VCR): For very severe deformities
Indicated in: Rigid deformities, severe kyphosis, poor sagittal balance. Osteotomies in open surgery make these major corrections possible.
Growth-Friendly Techniques
For children with significant remaining growth:
- Growing rods (VEPTR, MAGEC): Lengthened periodically
- Vertebral stapling: Modulates asymmetric growth
- Vertebral body tethering (VBT): A fusionless technique for adolescents
Goal: Control the deformity while preserving growth
⚠️ Risks of Deformity Surgery
Deformity correction surgeries are major procedures. The risks include:
- Neurological complications: Injury to the spinal cord or nerves (rare, 0.5-1%)
- Bleeding: May require a transfusion
- Infection: 2-5% of cases
- Nonunion: Failure of fusion (5-10%)
- Instrumentation failure: Rod breakage, screw loosening
- Flatback syndrome: If lumbar lordosis is lost
- Proximal/distal junctional syndrome: Degeneration at adjacent levels
Intraoperative neuromonitoring(motor and somatosensory evoked potentials) is used to minimize neurological risk.
Prognosis and Recovery After Correction
What to expect after treatment
Post-Surgical Recovery
Hospitalization (3-7 days)
- Initial intensive care (24-48h)
- Pain management with multimodal analgesia
- Early mobilization (sitting up on day 1-2)
- Walking with assistance on day 2-3
- Follow-up X-rays
- Discharge once pain control is adequate and you can walk
First 6 Weeks
- Activity restriction: no lifting >2-5 kg
- Walking progressively longer distances
- No bending, twisting, or forced extension
- Gradually decreasing pain
- Office follow-up at 2 and 6 weeks
- Follow-up X-rays
6 Weeks to 3 Months
- Start of formal physical therapy
- Gradual increase in activities
- Return to school/work for light duties
- Continue walking
- Begin swimming (with medical approval)
- Minimal to moderate residual pain
3-6 Months
- Return to most normal activities
- Advanced physical therapy
- Increase in strength and endurance
- X-rays to assess consolidation
- Minimal or absent pain
6-12 Months
- Complete consolidation of the fusion
- Return to low-impact sports
- Assessment of final correction on X-rays
- Full adaptation to the new alignment
1 Year and Beyond
- Full return to activities
- Annual follow-up
- Monitoring of adjacent levels
- Maintenance of physical conditioning
Long-Term Results
Success and Satisfaction Rates
- Average correction: 50-70% of the original curve
- Loss of correction: 5-10° over the years (normal)
- Successful fusion:>90% of cases
- Patient satisfaction: 80-90% at >5-year follow-up
- Pain improvement: 70-80% report significant improvement
- Quality of life: Documented improvement on validated questionnaires
💪 Factors That Improve the Outcome
- Adherence to restrictions: Follow post-operative instructions
- Consistent physical therapy: Essential for optimal recovery
- Maintaining a healthy weight: Reduces stress on the spine
- Not smoking: Tobacco compromises bone fusion
- Realistic expectations: Understanding the goals and limitations
- Psychosocial support: Family, friends, support groups
- Regular follow-up: Detect and address problems early
Special Considerations
Pregnancy After Scoliosis Surgery
Women with spinal fusion can have successful pregnancies:
- Wait at least 1 year after surgery
- Vaginal delivery is generally possible
- Epidural anesthesia may be more complex
- Greater lower back pain during pregnancy
- Coordination with the obstetrician and neurosurgeon
Sports and Physical Activity
After full recovery:
- Allowed: Swimming, cycling, walking, modified yoga
- With caution: Tennis, golf, skiing
- Generally discouraged: Contact sports, gymnastics, trampoline
- Individualized: Depending on the extent of fusion and the specific activity