OVERVIEW

CLASSIFICATION SYSTEMS FOR ADOLESCENT

AND ADULT SCOLIOSIS

Justin S. Smith, M.D., Ph.D.
Department of Neurosurgery,
University of Virginia,
Charlottesville, Virginia
Christopher I. Shaffrey, M.D.
Department of Neurosurgery,
University of Virginia,
Charlottesville, Virginia
Charles Kuntz IV, M.D.
Department of Neurosurgery,
University of Cincinnati,
Mayfield Clinic and Spine Institute,
Cincinnati, Ohio
Praveen V. Mummaneni, M.D.
Department of Neurosurgery,
UCSF Spine Center,
University of California, San Francisco,
San Francisco, California
Reprint requests:
Praveen V. Mummaneni, M.D.,
Department of Neurosurgery,
Neurosurgery 63:A16–A24, 2008
UCSF Spine Center,
University of California San Francisco,
505 Parnassus Avenue, M-779, Box 0112,
San Francisco, CA 94143–0112.
OBJECTIVE: To review current classification systems for adolescent and adult scoliosis.
METHODS: The literature was reviewed in reference to scoliosis classification systems
for adolescent and adult scoliosis.
RESULTS: There are multiple classification systems for scoliosis. Classification of sco-
liosis is dependent on patient age, spinal abnormality, scoliotic curve, and global
spinal alignment. To date, classification systems have focused predominantly on ado-
lescent idiopathic scoliosis or adult/degenerative scoliosis; a single classification sys-
tem evaluating scoliotic deformities of different ages and spinal abnormalities has not
been identified.
CONCLUSION: The importance of scoliosis classification schemes lies in their ability
to standardize communication among health care providers. With regard to the classi-
fication of adolescent scoliosis, the Lenke system has addressed many of the signifi-
cant limitations of the King system and is now the standard classification scheme.
Classification schemes for adult scoliosis have been reported only recently, and each offers
specific advantages (the simple pathogenesis-based system of Aebi, the strong clinical
relevance of the Schwab system, and the richly descriptive Scoliosis Research Society
system). This article highlights the salient features of currently used scoliosis classifica-
tion systems.
KEY WORDS: Adult, Classification, Pediatric, Scoliosis, Spine deformity
DOI: 10.1227/01.NEU.0000320447.61835.EA www.neurosurgery-online.com

Email: mummanenip@neurosurg.ucsf.edu
Received, August 8, 2007.
Accepted, May 5, 2008.
T
here are four main purposes for a spinal
deformity classification system: system-
atic categorization of disorders, defini-
tion of natural history and outcomes of care,
correlation with health status or severity of
deformity, and a guide for treatment decisions
(6, 16). Multiple spinal deformity classifica-
tions have been reported over the last century.
New classification systems have been added
as advances in clinical understanding of scolio-
sis and advances in surgical techniques have
evolved. The first reported classification, by
Schulthess in 1905, introduced the idea of
curve patterns as a means of grouping (25).
This early description of curve patterns
included cervicothoracic, thoracic, thoracolum-
ABBREVIATIONS: AIS, adolescent idiopathic sco-
liosis; CSVL, central sacral vertical line; PUMC,
Peking Union Medical College; SRS, Scoliosis
Research Society
bar, lumbar, and combined double primary.
Curve type remains an important part of mod-
ern classification systems, attributable in large
part to the subsequent work of Ponseti and
Friedman in 1950 (20). They described the nat-
ural history of scoliosis based on curve type,
concluding that curve type and location are
readily recognized features that correlate with
natural history and rarely change as the curve
grows. Although fundamental to classification,
curve type and location alone do not capture
the complexity necessary to formulate strate-
gies for care, and further advancements have
aimed to address these needs.
Adolescent scoliosis and adult scoliosis are
fundamentally distinct, differing in clinical
presentation, radiographic features, therapeu-
tic approaches, and prognosis (17, 27). Perhaps
the most widely recognized classification sys-
tem, that of King et al. from 1983 (9), was
intended to provide guidance for treatment of
thoracic deformity in adolescents. The Lenke

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classification (14), subsequently developed in 2001 to overcome
several significant limitations of the King classification, also
primarily addresses adolescent idiopathic scoliosis (AIS).
Although the vast majority of scoliosis study before the last
25 years has focused on the adolescent form, recent attention
has turned to improving the classification schemes for adult
scoliosis. Adult scoliosis has long been recognized, but few
surgeons offered treatment because surgery in these patients
was considered risky based on patient age, deficient bone
quality, and the lack of adequate instrumentation to enable
and maintain correction. Advances in surgical techniques and
anesthesia care, as well as the development of powerful seg-
mental instrumentation, have enabled significant progress in
the surgical care of adult scoliosis patients (18). These devel-
opments, coupled with longer life spans and a gradual shift
toward an aging society, have renewed interest in better
understanding and classifying adult scoliosis as a first step
toward evidence-based approaches and improved outcomes.
Toward these ends, three classification schemes have been
recently reported for adult scoliosis: the Aebi system (1), the
Schwab system (26), and the Scoliosis Research Society (SRS)
system (16).
The objective of this review is to provide the reader the back-
ground with which to classify scoliosis in different age groups
using the most modern and commonly applied classification
systems. Limited discussion regarding the benefits and limita-
tions of each approach is also provided.
PATIENTS AND METHODS
The literature pertaining to classification of scoliosis was reviewed
with a MEDLINE search from 1960 to February 2007 using the search
terms “scoliosis,” “classification,” and either “adolescent” or “adult.”
This search yielded 456 articles. This list was narrowed using the fol-
lowing inclusion criteria: studies presenting comprehensive classifica-
tion schemes for adolescent and/or adult deformity and English lan-
guage. The remaining seven articles, four for adolescent (4, 9, 14, 22)
and three for adult deformity (1, 16, 26), were reviewed in full and are
the basis of the present review.
RESULTS
Adolescent Idiopathic Scoliosis Classifications
King Classification
The King classification of AIS arose from a study designed
to facilitate selection of fusion levels in thoracic idiopathic sco-
liosis (9). King et al. retrospectively reviewed 405 patients from
their series who had undergone posterior spine fusion with
Harrington rod instrumentation for thoracic AIS. They
assessed curve type based on the central sacral line, a line
drawn through the center of the sacrum perpendicular to the
iliac crests (Fig. 1). They introduced the term “flexibility
index.” This was determined first by assessing the percentage
of flexibility of the thoracic and lumbar curves on maximum
lateral bending. The percentage of correction of the thoracic
curve was then subtracted from the percentage of correction of
NEUROSURGERY
SCOLIOSIS CLASSIFICATION SYSTEMS
FIGURE 1. Illustration of King classification for idiopathic scoliosis
(from, Richards BS, Sucato DJ, Konigsberg DE, Ouellet JA: Comparison
of reliability between the Lenke and King classification systems for adoles-
cent idiopathic scoliosis using x-rays that were not premeasured. Spine
28:1148–1156, 2003 [23]).
TABLE 1. King classification for idiopathic scoliosis
Group Criteria
Type I S-shaped curve in which both thoracic curve and
lumbar curve cross midline
Lumbar curve larger than thoracic curve on
standing radiograph
Flexibility index a negative value (thoracic curve 
lumbar curve on standing radiograph, but more
flexible on side-bending)
Type II S-shaped curve in which thoracic curve and
lumbar curve cross midline
Thoracic curve  lumbar curve
Flexibility index  0
Type III Thoracic curve in which lumbar curve does not
cross midline (so-called overhang)
Type IV Long thoracic curve in which L5 is centered over
sacrum but L4 tilts into long thoracic curve
Type V Double thoracic curve with T1 tilted into convexity
of upper curve
Upper curve structural on side-bending
From, King HA, Moe JH, Bradford DS, Winter RB: The selection of fusion levels in
thoracic idiopathic scoliosis. J Bone Joint Surg Am 65:1302–1313, 1983 (9).
the lumbar curve to yield the flexibility index. Final treatment
results were evaluated based on age at the time of surgery,
degree of curvature, curve patterns, vertebral rotation, flexibil-
ity index, and stable vertebra. These analyses resulted in a
classification scheme based on preoperative standing antero-
posterior or posteroanterior plain x-rays and a complete set of
preoperative supine side-bending x-rays (Table 1; Fig. 1).
Accordingly, treatment recommendations were made based
on the classification groups (9).
Although used as the primary classification scheme for AIS
for nearly two decades, it became apparent early on that the
King approach had several significant limitations. First, it did
not include thoracolumbar, lumbar, double major, or triple
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SMITH ET AL.

Simple, objective rules were

used to define six curve types
(Fig. 2). First, they defined the
curve location as proximal
thoracic, main thoracic, or
thoracolumbar/lumbar (Fig.
2). Curves were distinguished
as major if they had the
largest Cobb measurement;
otherwise, they were termed
minor. Structural curves were
those lacking normal flexibil-
ity, which they defined objec-
tively (Fig. 2).
A lumbar spine modifier
was included in the scheme in
recognition of the importance
of lumbar deformity. When
planning operative interven-
tion, the lumbar deformity
must be taken into account
because it may alter spinal
balance and affect proximal
curves. Use of the lumbar
modifier enables definition of
lumbar spine alignment in
relation to the curve type and
also allows assessment of the
lumbar spine position after
surgical treatment. This mod-
ifier was determined based on
the central sacral vertical line
FIGURE 2. Illustration of Lenke classification of adolescent idiopathic scoliosis. Summary of all necessary criteria (CSVL), a vertical line drawn
for curve classification (from, Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K: to bisect the proximal sacrum
Adolescent idiopathic scoliosis: A new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am and to be parallel with the lat-
83:1169–1181, 2001 [14]). eral edge of the x-ray (Fig. 2).
The most proximal lower tho-
major curves. Second, it focused solely on coronal imaging and racic or lumbar vertebra most closely bisected by the CSVL
did not take sagittal alignment into account. Third, the interob- was designated as the stable vertebra, and the apex of the curve
server and intraobserver reliability of the King classification was designated as the most horizontal and laterally placed ver-
system was found by multiple groups to have very limited tebral body or disc. Modifier A was used when the CSVL fell
validity, reliability, and reproducibility (5, 10, 14). between the lumbar pedicles up to the stable vertebra and
required the presence of a thoracic apex. If there is doubt
Lenke Classification regarding whether the CSVL touches the medial aspect of the
Recognizing the limitations of the King classification system, lumbar apical pedicle, the authors indicated that it is appropri-
Lenke et al., in conjunction with the SRS, set out to develop an ate to use Modifier B. Modifier B was used when the CSVL falls
improved classification scheme (14). Their system is based on between the medial border of the lumbar concave pedicle and
both coronal and sagittal planes and is designed to determine the lateral margin of the apical vertebral body. Modifier B also
the appropriate vertebral levels to be included in an arthrode- required the presence of a thoracic apex. Modifier C was used
sis (12, 15, 21). In addition, they assessed the interobserver and when the CSVL fell medial to the lateral aspect of the lumbar
intraobserver reliability of their approach. For each of 27 apical vertebral body. For Modifier C, cases could have a tho-
patients, they reviewed four x-rays: standing long-cassette racic, thoracolumbar, and/or lumbar apex.
coronal and lateral as well as right and left supine side- A sagittal thoracic modifier was included in recognition of
bending. The devised classification scheme included six curve the importance of thoracic spine alignment when planning
types (Number 1–6), a lumbar spine modifier (A, B, or C), and operative intervention. This modifier was determined by meas-
a sagittal thoracic modifier (–, N, or +). uring from the superior endplate of the fifth thoracic vertebra

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to the inferior endplate of the 12th thoracic vertebra on a stand-
ing lateral x-ray. Based on these criteria, the mean normal tho-
racic alignment has been reported to be +30 degrees, with a
range from +10 to +40 degrees (3). The following thoracic mod-
ifiers were designated: minus sign for a curve of less than +10
degrees, N (normal) for a curve of +10 to +40 degrees, and a
plus sign for a curve more than +40 degrees (Fig. 2).
Lenke et al. demonstrated good to excellent interobserver
and intraobserver reliability for their classification system
using two separate groups of surgeons drawn from the SRS.
Interestingly, one of the groups was composed of the same five
reviewers who had previously reported on the reliability of the
King classification. For these five surgeons, the mean interob-
server reliability for determining curve type using the Lenke
system was 93% (range, 85–100%), with a mean κ value of 0.92
(range, 0.83–1.00). Using the King system, the interobserver
reliability was 64%, and the κ value was 0.49 (10). Despite the
initially reported good to excellent interobserver reliability of
the Lenke system, subsequent studies from independent inves-
tigators suggest an interobserver reliability in the moderate
range (19, 23). Richards et al. reported interobserver and
intraobserver reliabilities of 56% (κ  0.50) and 65% (κ  0.60),
respectively (23).
The Lenke classification overcomes many of the limitations
of the King system. Specifically, the Lenke system offers a more
objective and complete classification of curve types as well as
lumbar and sagittal thoracic modifiers to aid in surgical plan-
ning. Two potential criticisms of the Lenke system are the com-
plexity and the lack of three-dimensional classification.
Although the Lenke system introduces 42 different groups,
these are based on only six straightforward curve patterns with
two simple modifiers.
Other Classification Schemes
In 1998, Coonrad et al. studied 2000 consecutive idiopathic
scoliosis curve patterns and described 21 patterns that incorpo-
rated the five King curve types (4). This categorization comple-
mented the King classification system by incorporating the
curve types that had not been included in the original classifi-
cation. In the report detailing the Coonrad classification, the
authors reported interobserver and intraobserver reliability to
be 98.7% and 100%, respectively (4). A subsequent study found
the interobserver reliability of the Coonrad classification to be
only 46% (κ  0.38) (2). The Coonrad classification, like the
King system, focused only on coronal imaging and did not take
into account sagittal alignment. Although the study by Coonrad
et al. represented an outstanding description of a large series of
idiopathic scoliosis cases, its application was limited by the
introduction of the Lenke classification shortly thereafter.
The Peking Union Medical College (PUMC) classification
was proposed by Qiu et al. in 2005 (22). This system was
designed to facilitate selection of a surgical approach and
fusion level, and consists of three major categories, termed
Types I, II, and III, having single, double, and triple curves,
respectively. These categories include a total of 13 subtypes
that are based primarily on apex location, curve flexibility, and
NEUROSURGERY
SCOLIOSIS CLASSIFICATION SYSTEMS
curve magnitude. Interobserver and intraobserver reliability
testing for the PUMC classification were 85% (κ  0.83) and
91% (κ  0.90), respectively (22). It remains too early to judge
the extent to which the PUMC classification will gain accept-
ance and application as a clinical and research tool.
Classification Example
Shown in Figure 3 are x-rays of an adolescent with idiopathic
scoliosis. Based on the King classification, this represents a Type
II curve. Using the Lenke classification, this case is classified as
a Type 1 curve type, lumbar modifier B, and a sagittal thoracic
modifier of N (normal).
Adult Scoliosis Classifications
Aebi Classification
The Aebi classification system of adult scoliosis is composed
of four groups (Types I, II, IIIa, and IIIb), distinguished prima-
rily based on cause rather than on specific details of the defor-
mity (1) (Table 2). Type I is used to designate primary degener-
ative scoliosis, which is most commonly associated with curves
having an apex at L2–3 or L3–4. Degenerative scoliosis is
thought to derive from asymmetric degenerative change of the
disc, with attendant frontal deviation and rotation with the
facet joints on one side acting as a pivot. Type II designates pro-
gressive idiopathic scoliosis, resulting from idiopathic scoliosis
present since adolescence or childhood that progresses in adult-
hood because of mechanical, bony, or degenerative changes.
Type III is subdivided into two subgroups. Type IIIa consists of
secondary adult scoliosis cases, resulting from disease either
within the spine, such as an adjacent thoracic or thoracolumbar
curve, or from disease outside of the spine, such as pelvic obliq-
uity caused by leg length discrepancy. Type IIIb designates
deformities resulting from bone weakness, such as a deformity
resulting from an osteoporotic fracture.
The Aebi classification offers a relatively simple means of
classifying adult deformity based on cause. Because cause may
help predict the natural history of a deformity, the Aebi system
may allow tempered broad generalizations about treatment
approaches. However, the system does not reflect the complex-
ity of specific deformities to a degree adequate to be used for
detailed surgical planning.
Schwab Classification
Schwab et al. recently reported a clinical impact classification
of scoliosis in adults based on a multicenter, prospective, clini-
cal series of 947 adult patients with spinal deformity (26).
Radiographic assessments included frontal Cobb angle, defor-
mity apex, lumbar lordosis, and intervertebral subluxation.
These parameters were correlated with clinical outcomes meas-
ures, including the Oswestry Disability Index and the SRS out-
come measure. Three parameters proved useful for classifying
their patients: deformity apex, lordosis, and intervertebral sub-
luxation (Table 3). In the Schwab classification, patients are first
grouped by apical level and assigned a specific type from I to V
(Table 3). A simple lumbar lordosis modifier was added, with A,
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SMITH ET AL.
A B
D E
FIGURE 3. Posteroanterior (A) and lateral (B) and side-bending (C and D) x-ray scans of a patient with
adolescent idiopathic scoliosis, classified as King Type II; Lenke 1BN (curve Type 1 with a lumbar modi-
fier of B and a sagittal thoracic modifier of N). The CSVL is indicated in A. The sagittal C7 plumb line is
drawn in B. Posteroanterior (E) and lateral (F) x-ray scans following surgical correction of the deformity.
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B, and C indicating marked, moderate,
C and no lordosis, respectively. A sublux-
ation modifier was also added, with
measurement based on maximal inter-
vertebral subluxation at any level of the
spine in either the coronal or sagittal
plane (Table 3).
Schwab et al. also offered assessment
of the reliability of their classification
system (26). Eight surgeons read a
series of 20 adult scoliosis patient x-
rays, with four of these surgeons per-
forming a second classification of the
same x-rays 2 weeks later. These meas-
ures identified excellent reliability with
κ  0.6 interobserver/0.8 intraobserver
for apical level (type) and κ  0.9 for
lordosis and subluxation scores.
Perhaps the greatest strength of the
Schwab classification scheme is that it
distinguishes groups of adult scoliosis
patients with clinically relevant differ-
ences. Higher grades of lumbar lordosis
and subluxation were closely linked to
increased surgical rates and increased
disability and pain based on outcomes
F tools. There are two main limitations of
this classification scheme. First, although
it was designed based on nearly 1000
patients, some subcategories of curve
description contained few patients.
Second, the classification is not fully
descriptive; rather, it focuses on the clin-
ical impact factors. Thus, for the pur-
poses of recording and communicating
specific deformities, it may be important
to include additional information, such
as Cobb angle and end level.
SRS Classification
The SRS recently reported a classifica-
tion with the intent of providing a
framework for an evidence-based
approach to the management of adult
scoliosis patients (16). This system relies
on standing full-length x-rays in the
coronal and sagittal planes and classifies
based on curve type as well as three
additional modifiers (Table 4). Six major
coronal curve types—as well as a single
sagittal plane deformity that lacks any
associated thoracic or lumbar coronal
deformities that would meet require-
ments of a primary deformity—are dis-
tinguished (Table 4). Coronal curve clas-
sification is based on apex location, and
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TABLE 2. Aebi adult deformity classification
Type Description
I Primary degenerative scoliosis;
Most commonly has curve apex L2–3 or L4
II Idiopathic scoliosis that has progressed;
Lumbar and/or thoracolumbar
IIIa Secondary adult scoliosis;
Typically thoracolumbar or lumbar-lumbosacral
IIIb Deformity resulting from bone weakness
(e.g., osteoporotic fracture)
Modified from, Aebi M: The adult scoliosis. Eur Spine J 14:925–948, 2005 (1).
criteria for specific major curve type are defined objectively (Table
4). To be classified as a sagittal plane deformity, there must be a
kyphosis present that meets the criteria under the regional sagit-
tal modifier (Table 4).
The SRS classification also includes three radiographic mod-
ifiers. A regional sagittal modifier was added in recognition of
the impact that regional kyphosis or hypolordosis has on health
status and surgical strategies. The sagittal modifier is included
only if the curve lies outside of the designated normal range,
and separate modifiers are listed for each of the four regions of
the spine (Table 4). Because degenerative changes of the lumbar
spine are common in adults with scoliosis and because these
changes are often the reason for clinical presentation, a lumbar
degenerative modifier was added to the classification. This
modifier is only included if the patient exhibits disc space nar-
rowing, facet arthropathy, degenerative spondylolisthesis, or
rotatory subluxation of 3 mm or more in any plane. The third
modifier, based on global balance, describes imbalance in either
the coronal or the sagittal plane. For the purposes of this clas-
sification, sagittal imbalance was considered significant if the
C7 plumb line is 5 cm or more anterior or posterior to the sacral
promontory. Coronal imbalance was significant if the C7 plumb
line was 3 cm or more to either side of the CSVL.
The authors of the SRS classification also offered validation
of interobserver reliability. Fourteen surgeons evaluated 25
radiographic cases, with good interobserver reliability for curve
type (κ  0.64), sagittal modifier (κ  0.73), degenerative lum-
bar modifier (κ  0.65), and global balance modifier (κ  0.92).
The primary limitation of the SRS classification system is
that it does not take into account clinical parameters such as
presenting symptoms, age, and comorbidities including osteo-
porosis and systemic disease. Such parameters certainly affect
the management process.
Classification Example
Figure 4 shows anteroposterior and lateral x-rays of an adult
patient with a history of adolescent idiopathic scoliosis who
presented at the age of 60 with symptomatic stenosis, L4–5 lis-
thesis (approximately 5 mm), and mild curve progression.
NEUROSURGERY
SCOLIOSIS CLASSIFICATION SYSTEMS
Cause
Disc degeneration (asymmetric);
Facet joint degeneration
Progression of idiopathic scoliosis (present since childhood) caused
by degenerative disease and/or mechanical/bony reasons
Secondary to an adjacent curve of idiopathic,
neuromuscular or congenital origin;
Obliquity of pelvis caused by leg length discrepancy or hip abnormality;
Lumbosacral transitional anomaly
Metabolic bone disease, osteoporosis
TABLE 3. Schwab adult deformity classification
Classification Radiographic criteria
Type
I Thoracic-only curve (no other curves)
II Upper thoracic major, apex T4–T8
III Lower thoracic major, apex T9–T10
IV Thoracolumbar major curve, apex T11–L1
V Lumbar major curve, apex L2–L4
Lumbar lordosis modifier
A Marked lordosis (40 degrees)
B Moderate lordosis (0–40 degrees)
C No lordosis present (Cobb  0 degrees)
Subluxation modifier
0 No intervertebral subluxation any level
+ Maximal measured subluxation 1–6 mm
++ Maximal subluxation  7 mm
From, Schwab F, Farcy JP, Bridwell K, Berven S, Glassman S, Harrast J, Horton W: A
clinical impact classification of scoliosis in the adult. Spine 31:2109–2114, 2006 (26).
Based on the Aebi classification, this is categorized as Type II,
because it represents progression of an idiopathic scoliosis pres-
ent since adolescence. Based on the Schwab classification, this
case is classified as VB+, based on a Type V curve (lumbar
major curve with apex L2–L4), lumbar lordosis Modifier B
(moderate lordosis, 0–40 degrees), and subluxation Modifier +
(maximal measured subluxation 1–6 mm). Based on the SRS
classification, this case is classified as L (lumbar curve), +DDD
(degenerative disc disease) lumbar modifier (L1–S1), and +LIS
(listhesis) Modifier L4–5.
DISCUSSION
Spinal deformity classifications provide the fundamental
nomenclature that enables systematic organization of these
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TABLE 4. Scoliosis Research Society adult deformity classificationa

A B
Primary curve types
Single thoracic (ST)
Double thoracic (DT)
Double major (DM)
Triple major (TM)
Thoracolumbar (TL)
Lumbar “de novo”/idiopathic (L)
Primary sagittal plane deformity (SP)
Adult spinal deformity modifiers: regional sagittal modifier (include
only if outside normal ranges as listed)
Proximal thoracic (T2–T5):  +20 degrees (PT)
Main thoracic (T5–T12):  +50 degrees (MT)
Thoracolumbar (T10–L2):  +20 degrees (TL)
Lumbar (T12–S1):  –40 degrees (L)
Lumbar degenerative modifier (include only if present)
Decreased disc height and facet arthropathy based on x-ray:
include lowest involved level between L1 and S1 (DDD)
Listhesis (rotational, lateral antero, retro) 3 mm: include lowest
level between L1 and L5 (LIS)
Junctional L5–S1 curve 10 degrees (intersection angle superior
endplates L5 and S1) (JCT)
Global balance modifier (include only if imbalance present)
Sagittal C7 plumb  5 cm anterior or posterior to sacral
promontory (SB)
Coronal C7 plumb  3 cm right or left of CSVL (CB)
SRS definition of regions C D
Thoracic: apex T2–T11–T12 disc
Thoracolumbar: apex T12–L1
Lumbar: apex L1–L2 disc–L4
Criteria for specific major curve types
Thoracic curves: 1) curve  40 degrees; 2) apical vertebral body
lateral to C7 plumbline; 3) T1 rib or clavicle angle  10
degrees upper thoracic curves
Thoracolumbar and lumbar curves: 1) curve  30 degrees; 2)
apical vertebral body lateral to CSVL
Primary sagittal plane deformity: no major coronal curve

a
SRS, Scoliosis Research Society; ↓ , XXX; CSVL, center sacral vertical line. Adapted
from, Lowe T, Berven SH, Schwab FJ, Bridwell KH: The SRS classification for adult
spinal deformity: Building on the King/Moe and Lenke classification systems. Spine
31:S119–S125, 2006. (16), with permission.
FIGURE 4. Anteroposterior (A) and lateral (B) x-ray scans of an
disorders. Perhaps more importantly, beyond the simple adult patient with scoliosis. Aebi Type II; Schwab Type VB+ (lumbar
grouping of various curve patterns, a classification system major curve, lumbar lordosis Modifier B, subluxation Modifier +);
SRS curve Type L (lumbar) with +DDD (degenerative disc disease)
should also serve as a guide for patient management and a
lumbar Modifier L1–S1 and +LIS (listhesis) Modifier L4–5.
foundation for evidence-based care. The earliest of the classi- Posteroanterior (C) and lateral (D) x-ray scans following surgical cor-
fication schemes for AIS described in this article, the King rection with segmental instrumentation from T8–S1 and pelvis poste-
system, was originally devised as a means of facilitating selec- riorly as well as L4–S1 anterior lumbar interbody fusion.
tion of fusion levels in thoracic AIS (9). The tenets of the King

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system guided the surgeon in selecting the appropriate fusion
levels for a selective thoracic fusion, with the goal of center-
ing the lower level of fusion over the sacrum and the expec-
tation that the lumbar curve spontaneously corrects to balance
the thoracic curve (9, 11, 24).
The Lenke classification system for AIS has replaced the King
classification and offers significant assistance in determination
of optimal surgical management (12–15, 21). In the Lenke clas-
sification, it is proposed that spinal arthrodesis includes only
the major curve and structural minor curves (14). Validation for
this recommendation and the Lenke classification on which it
rests was provided by a retrospective review of patients treated
by Lenke et al., in which the structural regions included in the
arthrodesis were found to be consistent with the predictions
derived from the classification system in 284 of 315 consecutive
patients (14). As further validation, Lenke et al., in a retrospec-
tive multicenter consecutive case review, evaluated 606 cases
classified by the Lenke system (12). They noted that all 606
cases were classifiable and that 90% of the operative cases had
surgically structural regions of the spine included in the instru-
mentation and fusion as predicted by curve type. Lenke et al.
have also demonstrated the use of the Lenke classification to
select AIS cases that are candidates for selective spine fusions
(15). In an independent investigation, Puno et al. reviewed 135
patients treated with fusion and instrumentation in accordance
with the Lenke classification and 48 patients whose treatments
were not based on the Lenke classification (21). They reported
that better radiological results were achieved through the use of
the Lenke classification to select the levels of fusion, specifically
avoiding unnecessary fusion of the nonstructural lumbar or
thoracic spine and avoiding undercorrection of the structural
secondary curves.
The classification system for AIS proposed by Coonrad et
al. was a purely descriptive classification that did not include
correlation with treatment recommendations (4). The PUMC
classification of AIS includes detailed recommendations
regarding surgical management of each proposed subtype
(22). The authors also performed a prospective study of 152
cases that were treated surgically commensurate with the
recommendations of the PUMC classification. At a minimum
follow-up of 18 months, none of the cases had developed
decompensation or other complications related to selection of
fusion level.
Classification systems for adult scoliosis have only very
recently been introduced, and further study is necessary to
assess the clinical and treatment correlations of these systems.
Although the Aebi classification was not designed to predict
specific optimal surgical management, it may ultimately prove
to have a correlation with natural history of the deformity
because of its basis in pathogenesis (1).
The clinical relevance of the Schwab classification is inherent,
because the criteria, including lumbar lordosis and subluxation
modifiers, were selected based on correlation with pain scores
and disability (26). Importantly, this classification demonstrates
significant correlation with patient management. Using the
NEUROSURGERY
SCOLIOSIS CLASSIFICATION SYSTEMS
Spinal Deformity Study Group database, Schwab et al. divided
947 adult patients with deformity into two groups: those treated
surgically and those managed nonoperatively. Although curve
type was not predictive of surgical management, they did note
a significant increase in surgical rate with increasing lordosis
modifier (A versus C, 36% versus 54%, respectively; P  0.04)
and with higher intervertebral subluxation (Modifier 0 versus
++, 36% versus 52%, respectively; P  0.001).
In the original report of the SRS classification of adult defor-
mity, the surgeons who reviewed the cases for interobserver
and intraobserver reliability also had considerable reliability
in interobserver recommendations for a caudad fusion level
(κ  0.77) and were within one level for a cephalad level with
moderate reliability (κ  0.56) (16). These latter reliabilities
suggest that this classification system, designed to emphasize
degenerative, regional, and global modifiers, promotes consen-
sus with regard to treatment, despite the lack of specific sur-
gical treatment recommendations based on classification.
Furthermore, sagittal balance, a factor emphasized through a
modifier in the SRS system, has been shown to be of clinical rel-
evance. In a study by Glassman et al., positive sagittal balance
was the most reliable predictor of clinical symptoms among 298
adult patients with deformity, including 172 with no prior sur-
gery and 126 who had undergone prior spine fusion (7).
Further study, including refinement and validation through
study of treated cases, will be necessary for complete validation
of the SRS system as a guide for treatment approach, including
choice of fusion levels.
CONCLUSION
The importance of scoliosis classification schemes lies in their
ability to standardize communication among health care
providers and to facilitate comparison of management ap-
proaches and outcomes. With regard to the classification of
AIS, the Lenke system has addressed many of the significant
limitations of the King system and is now the standard classi-
fication scheme. Further study will be necessary to assess its
utility in clinical practice and its ability to aid in treatment deci-
sions, although preliminary studies suggest favorable results.
The adult classification schemes described in this article have
been reported only recently. Each offers specific advantages: the
simple pathogenesis-based approach of Abei, the strong clini-
cal relevance of the Schwab approach, and the richly descrip-
tive SRS system. Regardless of its current strengths and utility,
the durability of any classification scheme will require flexibil-
ity to adapt as significant advances continue to be made in the
care of scoliosis patients.
Disclosures
Christopher Shaffrey, M.D., is a consultant for DePuy Spine and Medtronic
and has received honoraria from DePuy Spine, Medtronic, and Synthes Spine,
Inc. Charles Kuntz IV, M.D., has received grants from AO North America,
BioAxone, Stryker, and Synthes Spine, Inc. Praveen Mummaneni, M.D., is a con-
sultant for DePuy Spine and Medtronic and has received grants from DePuy
Spine and Medtronic.
VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 SUPPLEMENT | A23
SMITH ET AL.
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