What exactly are spinal deformities, and which are the best known?

A spinal deformity is an alteration in the natural shape or alignment of the spine. Instead of having its normal, gentle curves, the spine can develop an abnormal curvature to the side, forward, or backward. The most common deformities we treat are: • Scoliosis: a sideways curvature of the spine that makes it look like an “S” or a “C.” The most frequent form is adolescent idiopathic scoliosis, which appears without a known cause. • Kyphosis: an exaggeration of the normal curvature of the upper (thoracic) spine, producing a “hunchback” appearance or a forward-stooped posture. • Spondylolisthesis: occurs when one vertebra slips forward over the vertebra below it, which can cause low-back pain and nerve compression.

How can I tell whether my child or I have scoliosis? What are the signs?

Detecting possible scoliosis early is very important. Often the first signs are subtle and cause no pain. You may notice the following when looking at a person’s back while they are standing and then bending forward: • Shoulders at different heights: one shoulder appears higher than the other. • A prominent shoulder blade: one shoulder blade sticks out more than the other. • An uneven waist: the waistline looks asymmetric, with a more pronounced crease on one side. • A higher hip: one hip appears more elevated than the other. • A rib hump: when bending forward, one side of the back looks higher than the other. If you notice any of these signs, an evaluation by a specialist is advisable.

Is a curve in the back only a cosmetic problem, or can it affect my health?

This is a fundamental question. While appearance is a valid concern for many patients, the main goal of treatment is to prevent long-term health problems. Depending on its severity and location, an untreated deformity can: • Cause chronic pain: from muscle imbalance and pressure on the joints and discs. • Lead to neurological problems: if the deformity compresses the spinal cord or the nerve roots, it can cause pain, weakness, or numbness in the legs. • Affect lung and heart function: in cases of very severe curves in the thoracic region, the space for the lungs and heart can be reduced, making breathing difficult. For this reason, proper monitoring and treatment are crucial to ensure a good quality of life.

Is a brace or surgery always needed to correct a deformity?

No. Most mild curves require no active treatment beyond observation. The treatment plan is fully personalized and depends on the patient’s age, the type of deformity, and—most importantly—the magnitude or degree of the curve. The management options are: • Observation: for small curves, especially in children who are still growing, periodic follow-up with X-rays is done to watch whether the curve progresses. • Bracing (orthosis): in growing adolescents with moderate curves, a brace can be very effective at stopping the curve from progressing. It does not correct the curve, but it prevents it from worsening. • Surgery: reserved for severe, progressive curves, or those that cause significant imbalance and neurological symptoms. Surgery aims to safely correct the deformity and stabilize the spine in a more aligned position.

What does scoliosis surgery involve, and what results can I expect?

Scoliosis surgery, known as arthrodesis or spinal fusion, is an advanced and safe procedure with two main goals: to correct the curvature as much as possible and to fuse the vertebrae so that the correction is maintained permanently. During surgery, a system of implants (titanium screws, rods, and hooks) is used to straighten and align the spine. Then a bone graft is placed that, over time, will unite the vertebrae into a single solid structure. Thanks to neuronavigation and neurophysiological monitoring, we can perform this surgery with millimeter precision, protecting the spinal cord and the nerves at all times. The result is a more balanced spine, improved posture, and—most importantly—a halt to the progression of the curve, ensuring a healthier and more active future.

Spinal Deformity Surgery: Scoliosis & Kyphosis

Understanding Your Deformity Is the First Step

Spinal deformities can affect your appearance, cause pain, and limit your function. It is essential to understand, however, that every deformity is unique and that multiple treatment options exist, tailored to your specific situation.

My goal is to help you understand your condition and, together with you, determine the best treatment plan—one that considers not only the medical issues, but also your quality of life, your expectations, and your personal goals.

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 Birth

Caused 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 Disease

Associated 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-Related

Develops 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 Benign

The 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 Deformity

A 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 Birth

Caused 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 Causes

Developing 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

Keep reading

Deformities