THE

DEFORMITY

MADE

OF IDIOPATHIC

VISIBLE

BY COMPUTER

F. R. HOWELL,

From

We present
and computer
radiographs

a method

help

Radiography

of

structure

planes

spinal

projection.
lateral

measurements

of

1969;

1973;

in three

Leeds

dimensions

can be determined

using

from

the fundamental
lesion,
The method
is applicable

obtained
need

from
for

consistent

two

multiple

standard

inappropriate

1981).

two radiographic

By

MATERIALS

views

McNiece

population
of 15,793
followed
longitudinally,
cally. Postero-anterior

the apparent

image

viewpoint

The

depict

This

to be displayed

of the

conventional

the

can

views

deformity

then

in two

be manipulated

dimensions,

varying

observer.
of

idiopathic

obliquely

because

scoliosis

of

its

axial

rotation.
The size of the deformity
as measured
by the
Cobb
angle
(Cobb
1948) is thus an underestimate
of its
true size which
will be seen when the deformity
is viewed
en face
(du Peloux
et al. 1965 ; Deacon,
Flood
and
Dickson
project
The

1984).

Similarly,

the lateral

radiograph

the true lateral

view of the apex
computer
system
allows
multiple

deformity

to

be

reproduced

from

the

does

not

of the curve.
views
of the
information

Leeds

MA,

FRCS

Ed,

Medical

Research

Council

Research

Fellow

R. A. Dickson,
University
Hospital,

MA,

Department
Leeds
LS9

Correspondence

should

ChM,

FRCS,

Professor

ofOrthopaedic
7TF,
England.
be sent

to Mr

F.

1989 British
Editorial
Society
of Bone
030l-620X/89/308l
$2.00
J Bone Joint Surg [Br] l989;7l-B:399-403.

VOL.

71-B,

No.

3, MAY

1989

of Orthopaedic

Surgery,
R.
and

St. Jamess
Howell.
Joint

Surgery
University

MRC

history
of idiopathic
962 schoolchildren
truncal
asymmetry

and lateral
lordosis,
can be
deformities
and

radiographs,
The
lordosis

and

results
is

avoids

the

confirm
that
the
underlying

(Somerville

AND

METHODS

epidemiological

survey

of the

natural

scoliosis
has identified
a group
aged eight to 1 3 years with a degree
on forward
bend
testing,
from

of
of
a

children.
This
cohort
is being
both clinically
and radiographiand lateral
radiographs
are taken

each
year,
using
the low-dose
technique
and standardised positioning
ofArdran
et al. (1980),
and these form
the basis
for this study.
The computer
method
requires
identification
of the
same anatomical
points
on both views of the spine
(Suh
1974). The points
chosen
are the bases
of the pedicles,
and the mid points
of the upper
and lower
end plates
(Figs
1 and 2); these
have
been
shown
to be the most
consistent
(Brown
et al. 1976; De Smet et al. 1982). The

points are marked

on the radiograph,
and, by means
of a
sonic
digitising
device,
their
co-ordinates
are entered
into a microcomputer
for processing
and storage.
The
data

F. R. Howell,

radiographs

deformity
in late-onset
idiopathic
scoliosis
1952; Roaf 1966; Dickson
et al. 1984).

The

1980).

an abnormal
to other spinal

exposures.

ofthe
same deformity,
a three-dimensional
image
can be
reconstructed
with
the aid of a computer
(Suh
1974;
Brown
et al. 1976;
De Smet
et al. 1980;
Hindmarsh,
Larsson
and
Mattsson
1980;
Raso,
Gillespie
and
geometrically

conventional

the anteroposterior

Moe

and

Dahlborn

from

on

usually

(Nash

and

three-

to the patient,
be inferred
from

rotation

Aaro

the information

its

are

in reference
structure
can

Hospital,

shape.

depending

These

vertebral

scoliosis,
views.

displays

dimensions,

University

column

three-dimensional

GRAPHICS

R. A. DICKSON

deformities

idiopathic
for additional

deformity
in two

anteroposterior
and
but the three-dimensional
Mehta

their

spinal

of

combining

adolescent
the need

to elucidate

dimensional

the

Jamess

graphics.
The shape of the spinal
and displayed
in any projection.

In patients
with
demonstrated
without
may

St.

ofvisualising

SCOLIOSIS

for

merged
points

each

point

to provide
per vertebra,

from

each

visualised.
A three-dimensional
thus recorded.
The

Surgery

projection

a two-dimensional
any

desired

direction

pair

of radiographs

three Cartesian
co-ordinates,
for all the vertebrae
which

of this model
image,
which

model

of

the

are
for four
can be
spine

is

on to a plane
produces
may then be rotated
in

by a mathematical

transformation.

399

400

F. R. HOWELL,

This

can

and

lateral

chosen

produce

images

relating

radiographic

to the

R. A. DICKSON

postero-anterior

projections,

or

to

any

other

viewpoint.

The
formula,

transformation
itself
is by a simple
algebraic
which
for rotation
of a point
x, y, z by an angle

A around
the vertical
y-axis,
will relate
the horizontal
projection
in the new vertical
plane,
xt, to the old, x, and
to the third co-ordinate,
z, as follows:

xt

The
using

. cosA

microcomputer

the

basic

sin

is programmed

language.

The

to perform

limiting

factor

this
in

the

technique
as we describe
it is the identification
of the
chosen
anatomical
points.
The errors
involved
have been
quantified
(Hindmarsh
et al. 1980).
Magnification
and
other
problems
have
been overcome
by other
Validation.
The
anteroposterior
and
lateral
mounted
scoliosis

museum
specimens
were
processed

representation
radiographed

from
above

as

cases
and

axis.

The

rotation
and the
can be compared,

computer

diagram

radiograph

taken

were then
around
a
at

at that

of

of idiopathic
a computer

created.
The same
specimens
at 10#{176}
intervals
of rotation

vertical

means.
views

any

same

given
rotation

and the similarity

is quite
obvious
(Figs 3 and 4). This confirms
that the two standard
views
contain
all the necessary
information
to visualise
the
spine
at any chosen
degree
of rotation.

The
identification
anteroposterior

RESULTS
In

the

cohort

of 962

children

type

followed

up

an idiopathic
then

towards

the convexity
ofthe
curve.
In all 69 cases there is
lordosis
at the apex of the curve.
There

of

a Cobb

nature.
Two
information

years,

69 have

rotation

with

two

greater

10#{176}
and

of curve,

for

the

vertebral

angle

plane and
radiographs

body

during

an inappropriate

may or may not

view,
but when
apical

lordosis

corresponds
(Dickson

be a frank
lordosis
visible
on the lateral
the computer
model
is rotated
then an
becomes

to the
1987).

obvious

Stagnara

A normal,
straight
lordosis,
but a rotated

curves.

These

type

curves

Fig.

6)

could

radiograph

If a progressive
of time,

increase

on

other

the

measures

spine
view

idiopathic

then

does
does

be confused

on a plain

period

(see

the

oblique
of the

Fig.

or Leeds

minor

if viewed
curve

is followed
can

(see

Fig.

cannot

adequately

demonstrate

scoliosis
single
its

of
the

the

observation

every
these,

case
the

the
four
points
lateral
radiographs.

(see

be seen

to

with

7).

is known
to be a
plane
radiographs

tion,

we

found

apparent
thoracic

a fundamental

idiopathic
was small

idiopathic

on

the

all the
in any

scoliosis

this

that

lordosis

was

not

practical

to positional
curves
declare

and reconstruction
an underlying

of their
lordosis
is

lordosis
is followed,
it increases
deformity
progresses
(Fig.

as the

there
overall

are greater
shape
of

to the sagittal

plane

bodies
definition

come
to face
of kyphosis,

of the patient

scoliosis
which
simulates
and lumbar
curve
(Fig.

JOURNAL

and
7).

degrees
of vertebral
rotathe patient
is spuriously

it has led to confusion

of these curves
in the
Bigalow
and Moreland
straight
spine,
viewed

THE

in

scoliosis.
In some of
(5#{176}
or less),
and a

of the curve
in relation
However,
these early

kyphotic,
as the vertebral
wards.
We do not use this

relates

digitised

can avoid
the need for multiple
the radiation
dosage
to a child

of progressive
initial
curve

spine,
because
pathogenesis
1984; Stokes,
A normal

be

or treatment.

cohort,

of early

When
the

to

views do however
contain
to describe
the deformity

use of this
and reduce

present. When
starts to rotate
a

three-dimensional

and

themselves
by progression,
early
deformities
shows

DISCUSSION
The deformity
of idiopathic
rotated
lordoscoliosis,
but

Fig.

because
of the size
and other variables.

over

in parallel

orthogonal
required

In our

diagnosis

idiopathic

obliquely

lordosis

reconstruction
deformity

view

projection

not show
any such
produce
artefactual
with

abnormal

5). This

lateral

Fig.

backwhich

and not of the

in discussion
of the
past (De Smet et al.
1987).
obliquely,
shows an
6).

OF BONE

a double
structural
On a plain
radio-

AND

JOINT

SURGERY

THE

DEFORMITY

OF IDIOPATHIC

SCOLIOSIS

Fig.

MADE

VISIBLE

BY COMPUTER

GRAPHICS

401

L
>

_
_

Fig.

Radiographs
specimen

VOL.

71-B,

No.

of a museum
specimen
of a scoliotic
at the same
positions
of rotation.

3, MAY

1989

spine

taken

at 0, 40, 90 and

1 30

of rotation,

with

computer

reconstructions

of the

402

F. R. HOWELL,

R. A. DICKSON

vt:
c

7
7

c;

cz:i

p
E

L
L::

i
4

4
4

L
1

4
:N
4

c:

Fig.

L::

&
A
z1
L

#{163}

L
Fig.

Reconstruction
of a case with right thoracic
idiopathic
scoliosis:
projections
at 0, 35,
and
90
of rotation,
equivalent
to
anteroposterior,
oblique
and
lateral
views.
An
abnormal
lordosis
is visible
in the oblique
view.

Reconstruction
oblique

450

and

of a normal
straight
lateral
projections.

in anteroposterior,

r
1
#{163}:

#{163}

&

#{163}

Fig.

Reconstructions
of the curve
successive
years,
all viewed
progression
of the lordosis.

at

Fig. 8

shown
the

in Figure
5 over
three
same
obliquity,
showing

graph,
the lumbar
component
true
idiopathic
scoliosis,
and

is indistinguishable
is apparently

lordosis
convexity
however,

vertebral
body
to the
thoracic
component,
because
rotation
is in the

with
rotation
of
of the
curve.
can be differentiated

the
The

from
a rotated

opposite
direction;
the displacement
of the vertebral
body is to the concavity
of the curve,
showing
it to be a
rotated
kyphosis,
not a rotated
lordosis.
This
phenortienon may explain,
in part at least, the observation
of a

group of curves within

a screened
vertebral
rotation
is non-standard

population,

(Armstrong

in which

et al.

Top
view
scoliosis.

1982).
flexible

of

left

thoracic

The concept
of Eulerian
column
as the cause

(Gordon
progress

idiopathic

buckling
of a unstable
of idiopathic
scoliosis

1978) would
predict
that these
curves
as the idiopathic
type may well do.

will

not

We have used rotation

about
the vertical
axis to
show the lordotic
deformity
in idiopathic
scoliosis,
but it
is as easy to reproduce
a top view of the spine (Fig. 8),
and

this

claimed
to monitor
the deformity
(De
Again,
the lordosis
may be seen.
Scoliotic
deformity
is complex

more
Smet
and

does

not

THE

AND

JOINT

SURGERY

progression

has

been

of

JOURNAL

OF

BONE

accurately
et al.

the
1983).
lend

F. R. HOWELL,

R. A. DICKSON

403

itself readily
to quantification.
The Cobb angle at least
has the merit that it is widely
used. The computer
method
we have
described
goes
no further
in quantifying
the
deformity,
nor is it intended
that
it should.
It does,

De Smet

however,

De Smet AA, Tariton

MA,
view
for
analysis
1983:147:369-72.

easily

make

the

qualitative

nature

of the

deformity

visible.

No benefits
commercial

in any
party

form have been

related
directly

received
or will be received
or indirectly
to the subject

from a
of this

article.

AA,

De Smet AA, Asher

right
thoracic

and rib cage deformity

1981 ;6:460-7.

Ardran

GM,

Coates

Assessment
technique.
Armstrong

scoliosis
Br J Radiol
GWD,

by computer

and

NB

rotation

relation

to

III,

Suzuki

in scoliosis
the

and

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RA, Dixon-Brown
in children
: low
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of

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in scoliosis

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Harding
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clinical

JG.

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