Focus On
Classification of adolescent
idiopathic scoliosis
Scoliosis Research Society defined scoliosis deformity as a
lateral curvature of the spine on a radiograph of the spine taken
in standing position.1 The degree of the curve is measured
as the angle between the most inclined vertebral end-plates
at each end of the curve (the Cobb angle). There are many
causes of scoliosis deformity. It can be structural due to spinal
pathologies or non-structural as a result of other skeletal
abnormalities, for example leg-length discrepancy and pelvic
obliquity. Scoliosis with Cobb angle more than 10, associated
with vertebral rotational deformity, is regarded as structural
scoliosis.2 Many conditions can lead to structural scoliosis
deformity: neuromuscular diseases like cerebral palsy and polio
myelitis causing neuromuscular scoliosis; congenital vertebral
abnormalities including hemi-vertebra and unsegmented bar
causing congenital scoliosis; syndromal disorders like Marfan
syndrome and neurofibromatosis that lead to syndromal
scoliosis. Idiopathic scoliosis is a diagnosis of exclusion that can
only be made after other causes of scoliosis deformity have been
excluded. It is the most common type of spinal deformity and
accounts for about 75% of patients with scoliosis. This article
focuses on classifications of adolescent idiopathic scoliosis and
their clinical applications.
Classification systems
What are the aims for classifying idiopathic scoliosis? First, it
should categorise the disease into different patterns to help
communication; secondly, it should guide us in managing the
disease; thirdly, it should help us to prognosticate the outcome.
Classically, idiopathic scoliosis can be sub-classified based
on the patients age at onset of the disease: infantile ( three
years), juvenile (four to nine years) and adolescent (ten years
to maturity). These three sub-classifications correspond to the
period of increased growth velocity of the spine which also
coincides with times of maximal scoliosis progression. Various
classification systems have been described for adolescent
idiopathic scoliosis, however, there are still limitations in each
system and room for further improvements.
1. Ponseti Classification The initial attempt in classification of
idiopathic scoliosis was made by Ponseti and Friedman3 in 1950,
and divided cases into single-curve, double-curve, and triple-
curve patterns. This early description of curve patterns included
cervico-thoracic, thoracic, thoraco-lumbar, lumbar and combined
double primary. The curve types were named after the location
of the curve apex. Thoraco-lumbar curves had the apexes at T12
to L1, thoracic curves had the apexes above and lumbar curves
have the apexes below these levels. They described the natural
history of scoliosis based on curve type, suggesting that curve
type and location correlate with the natural history and the curve
2013 The British Editorial Society of Bone and Joint Surgery
pattern rarely changes as the curve grows. The double curves
had a higher chance to progress than single curves, and thoraco-
lumbar and lumbar curves had a higher chance to progress than
thoracic curves. Although fundamental to classification, curve
type and location alone do not capture the complexity necessary
to formulate strategies for care, and further advancements
aimed to address these deficiencies were made.
2. Kings Classification Taking into consideration the curve
pattern, magnitude and flexibility of the scoliosis deformity, King
et al4 described their classification system in 1983, commonly
known as the Kings classification system for adolescent
idiopathic scoliosis (Fig. 1). It is useful for communication and
helps in prognosticating the disease. It also provides some
guidance about treatment strategy. If surgery is indicated, the
authors propose fusion from one level above the upper end
vertebra to the stable vertebra distally using the Harrington
instrumentation. They also recommended selective thoracic
fusion for Kings Type II curves. Kings classification was widely
accepted and seemed to offer sound fusion guidelines when
used with the Harrington distraction instrumentation; the
standard idiopathic scoliosis instrumentation used in the early
1980s.5-7 However, the King classification is not comprehensive
enough to include all scoliosis curve patterns, as double major
and triple curves are not included. This classification system has
also been challenged in that there was only fair to poor inter- and
intra-observer reliability.8 Furthermore, selective thoracic fusion
for all Kings II curves was found to have a high chance of post-
operative lumbar decompensation when used with more modern
instrumentation systems. Bridwell et al9 reviewed 31 patients
suffering from Kings Type II adolescent idiopathic scoliosis
treated with selective thoracic posterior spinal fusion using the
Cotrel-Dubousset system with hooks and derotational maneuver
in which 29% of patients developed coronal decompensation
because the lumbar curve failed to match up with the good
correction of the thoracic curve. Similarly, Lenke et al10 reviewed
50 Kings Type II curves treated with selective thoracic fusion
with Cotrel-Dubousset instrumentation system, 26% of patients
developed post-operative coronal decompensation.
3. Lenkes Classification In view of the incompleteness and low
inter- and intra-observer reliability with the King classification,
and high incidence of coronal decompensation with selective
thoracic fusion for Kings Type II curves, Lenke et al11 proposed a
new classification system to address these problems, commonly
known as the Lenke classification. It is composed of three
components: curve type (Type 1 to 6), a lumbar spine modifier
(A, B or C) and a sagittal thoracic modifier (, N or +). The six
curve types have specific characteristics on coronal and sagittal
radiographs that differentiate structural and non-structural
1
2 W. Y. CHEUNG, K. D. K. LUK

curves in the proximal thoracic, main thoracic, thoraco-lumbar

and lumbar regions. The lumbar spine modifier is based on the
relationship of the center sacral vertical line to the apex of the
curve and the sagittal thoracic modifier is based on the sagittal
curve measurement from the fifth to the twelfth thoracic level
(Fig. 2). The authors proposed that only the structural curves
should be fused if surgery is indicated. Studies showed that
the Lenke12 classification has high inter-observer reliability in
curve types (84%), lumbar modifier (86%) and sagittal thoracic
modifier (90%). Lenkes13 classification was also shown to have
higher inter- (Kappa value = 0.92) and intra-observer error
(Kappa value = 0.83) compared with Kings classification. Puno
et al14 demonstrated good results following the surgical strategy
proposed by Lenkes classification. They compared patients with
fusion levels according to the Lenke classification with those
not according to the Lenkes classification. They found that
Lenke classification can produce shorter fusion in Lenkes Type
1 and Type 5 curves, better shoulder balance in Lenkes Type Fig. 1a Fig. 1b
2 curves and better trunk balance in Lenkes Type 3 curves.
Compared with Kings classification, Lenkes classification is
more comprehensive; it separates the Kings Type 2 curves to
Lenkes Type 1 and Type 3 curves and selective thoracic fusion
is only indicated in Type 1 curves. It addresses the sagittal
alignment which was not mentioned in the King classification.
It has high inter- and intra-observer reliability and is useful for
surgical planning. However, it does not take into consideration
the rotational deformity which is an important element of the
three-dimensional deformity of scoliosis. Another defect of this
classification is that a structural curve is defined as a curve
which is greater than 25 on side bending. Conventionally a
structural curve is one that has a rotational component which
distinguishes it from the absence of rotation in a non-structural
curve or a postural scoliosis. Flexibility of the curve should not
be confused with the structural character of the curve.
4. PUMC (Peking Union Medical College) Classification In
addition to the deformity in the coronal and sagittal planes,
scoliosis also has rotational deformity in the axial plane. A
grading system for such rotational deformity was first described
by Nash and Moe15 in 1969 (Fig. 3). Taking into consideration the Fig. 1c Fig. 1d
rotational deformity of scoliosis, surgeons at the Peking Union
Medical College in China proposed the PUMC classification16 in
Fig. 1. Kings Classification
2005. This classification is based on the location of the apexes, 1a) Kings type 1 curve: Thoracic
magnitude and flexibility of the scoliosis deformity, amount of and lumbar curve, the lumbar
apical vertebral rotation and presence of a thoraco-lumbar curve has higher magnitude and
more rigid.
kyphosis. It defines stricter criteria for selective thoracic fusion 1b) Kings type 2 curve: Thoracic
for patients with double curve pattern with thoraco-lumbar or and lumbar curve, the thoracic
lumbar curves less than 45, flexibility greater than 70% and curve has higher magnitude and
more rigid.
apical vertebral rotation less than Nash and Moe Grade 2. The 1c) Kings type 3 curve: Single
paper reviews 152 patients treated according to the PUMC thoracic curve without lumbar
classification. No patient developed truncal decompensation curve
1d) Kings type 4 curve: Long
after surgery.16 thoracic curve with L4 tilted into
5. Three-dimensional Classification Rotational deformity the curve
in scoliosis is getting more attention in recent years. It is of 1e) Kings type 5 curve: Double
thoracic curve
paramount importance in determining the structurality of the
scoliosis deformity and guide on management. Poncet et al17
described three types of rotational malalignment in idiopathic
scoliosis. In Type A curves, the maximum torsion is located in Fig. 1e
 CLASSIFICATION OF ADOLESCENT IDIOPATHIC SCOLIOSIS
Fig. 2. Lenke Classification for idiopathic scoliosis11
Fig. 3. Nash and Moe Classification of vertebral rotation15
3
the upper-end vertebrae (UEV) region, whereas in Types B and
C curves, this occurs in both the UEV and lower-end vertebrae
(LEV) regions. In Types A and C curves, the geometric torsion is
unidirectional, whereas Type B curves are subjected to torsion in
opposite directions. More recently, Sangole et al18 showed that
right-sided thoracic idiopathic scoliosis can be sub-classified
into two groups with different rotational orientation in the plane
of maximum curvature. Although clinical applications of these
rotational deformity assessments are still under investigation, it
is a direction for further improvement of classification systems
for idiopathic scoliosis.
Conclusion
Classification can help to categorise idiopathic scoliosis for
easier communication, prognosticate the disease and guide
the treatment strategy. It has evolved over the past six decades
from coronal curve pattern recognition by Ponseti and King, to
Lenkes classification with inclusion of flexibility and sagittal
mal-alignment, to the PUMC classification with further inclusion
of axial rotation. Recently, more detailed assessment of the
rotational deformity enabled further sub-classification of the
3-D deformity which brings relevance to the three-dimensional
correction in scoliosis management.17-19
W. Y. Cheung (FRCSEd, FHKAM)
K. D. K. Luk (MCh Orth, FRCSEd, FRACS, FHKAM)
The Department of Orthopedics & Traumatology
The University of Hong Kong
Pokfulam
Hong Kong SAR
China
E-mail: lcheung2@netvigator.com
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