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Appendix I: Lenke etal. Classication System
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ofAdolescent Idiopathic Scoliosis
Denition: Lenke etal.’s classication identies six types of curves based on the
curve type, coronal lumbar modier, and thoracic sagittal prole. Four series of
plain radiographs are needed to apply Lenke etal.’s classication system: upright
anteroposterior, lateral, supine right-bending, and supine left-bending.
Content: Lenke etal. introduced for the rst time the concept of coronal lumbar (A,
B, C) and sagittal plane (−, N, +) modiers and of main/minor curves depending on
their magnitude and exibility on side-bending lms (structural/not structural). The
main curve is the largest curve; minor curves are dened as structural if coronal
plane rigidity is greater than 25° upon side-bending or kyphosis greater than 20° on
sagittal radiographs.
Clinical Relevance: This system aims to give accurate and reliable guidelines for
choosing the proper levels for fusion. Only main curve and structural minor curves
should be included in the instrumented fusion.
Type I: Main thoracic (MT)
Type II: Double thoracic (DT)
Type III: Double major (DM)
Type IV: Triple major (TM)
Type V: Thoracolumbar/lumbar (TL/L)
Type VI: Thoracolumbar/lumbar-main thoracic (TL/L-MT)
Lumbar coronal modier: (A) the central sacral vertical line (CSVL) is between
the pedicles of the apical vertebra; (B) the CSVL is between the medial border of
the concave pedicle and the lateral edge of the apical vertebra; (C) the CVSL is
medial to the lateral edge of the apical vertebra.
Sagittal plane modier: Normal (N): T5–T12 kyphosis is 10°–40°; minus (−):
T5–T12 kyphosis <10° (hypokyphotic); plus (+): T5–T12 kyphosis >40°
(hyperkyphotic).
In total, 42 different types of curves can be identied (type 5 and type 6 curves
are associated with a lumbar coronal modier type C) (Table I.1).
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
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Table I.1 Lenke etal.’s classication system
Curve type
I MT NS S NS A, B, C
II DT S S NS
III DM NS S S
IV TM S S S
V TL/L NS NS S C
VI TL/L-MT NS S S
Appendix I: Lenke etal. Classication System ofAdolescent Idiopathic Scoliosis
Proximal
thoracic Main thoracic
Thoracolumbar/
lumbar
Lumbar
modier
Sagittal
modier
−, N, +
Further Reading
1. Lenke LG, Betz RR, Harms J, etal. Adolescent idiopathic scoliosis: a new clas-
sication to determine extent of spinal arthrodesis. J Bone Joint Surg Am.
2001;83:1169–81.
Appendix J: Early Onset Scoliosis Classication
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(C-EOS)
Denition: The Classication of Early-Onset Scoliosis (C-EOS) was developed to
provide a comprehensive, practical, and predictive novel classication system
designed exclusively for young patients with scoliosis.
Content: The C-EOS is based on ve parameters: etiology, major curve, curve exibility, total kyphosis, and annual progression (Table J.1).
Clinical Application: The treatment options can be classied based on the mechanism of action as distraction-based technique, guided-growth procedures, and compression-based techniques; to these methods, serial casting can be added or selected
as a rst-choice treatment option (Table J.2).
Table J.1 C-EOS
Major curve
Etiology
Idiopathic 1: <20°
Syndromic
Neuromuscular
Low tone
Neuromuscular
High tone
Congenital or
structural
(Cobb angle)
2: 21°–50°
3: 51°–90°
4: >91°
Flexibility
modier (optional)
Flexible (F)
Rigid (R)
Maximum total
kyphosis
Negative (−): <20°
Neutral: 21°–50°
Positive (+): >51°
Progression
modier (optional)
P0: <10°/year
P1: 10°–20°/year
P2: >20°/year
Table J.2 Classication of EOS according to the treatment mechanism of action
Treatment: Mechanism of action
Distraction based Guided growth Compression based Serial casting
Growing rods Luque trolley Tether
VEPTR Shilla procedure Staples
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
449
450
https://t.me/medicina_free
Appendix J: Early Onset Scoliosis Classication (C-EOS)
Further Readings
1. Williams BA, etal. Development and initial validation of a novel classication
system for early-onset scoliosis: Classication of Early-Onset Scoliosis
(C-EOS). J Bone Joint Surg Am. 2014;96(16):1359–67.
2. Skaggs, etal. A classication of growth friendly spine implants. J Pediatr Orthop.
2014;34(3):260–74.
Appendix K: Classication Systems
L4
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forSpondylolisthesis
Meyerding Classification forSpondylolisthesis
Denition: The Meyerding classication is the most commonly used method of
assessing the amount of olisthesis of one vertebra (forward displacement) over the
vertebra below. In particular, Meyerding dened the slippage on plain radiographs
(lateral view) in accordance to the vertebra below.
Content: The classication divides the superior endplate of the vertebra below into
four quarters; the grade depends on the location of the posteroinferior corner of the
vertebra above.
Grade I: 0–25%
Grade II: 26–50%
Grade III: 51–75%
Grade IV: 76–100%
Grade V: >100% or spondyloptosis (complete displacement)
Clinical Application: Grading can help dictate the type of treatment depending on
whether it is a low (grades I–II) or high grade (grades III, IV, and V).
Postero-inferior
1
2
QUARTERS
3
4
SACRUM
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
corner
L5
5
Spondyloptosis
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Appendix K: Classication Systems forSpondylolisthesis
Spinal Deformity Study Group (SDSS) Classification
Denition: The SDSS classication is based on the sacropelvic morphology, slip
grade, and spinal balance.
Content: The classication identies two main groups: low- and high-grade spondylolisthesis; each group has three subtypes (I–III and IV–VI).
Low grade: Type I: Pelvic incidence <45° (nutcracker)
Type II: Pelvic incidence 45°–60°
Type III: Pelvic incidence >60°
High grade: Balanced pelvis: Type IV
Retroverted pelvis: Type V: balanced spine
Type VI: unbalanced spine
Clinical Application: SDSS classication can identify spondylolisthesis at the risk
of progression and those requiring treatment. In particular, type 1 and type 2 spondylolisthesis have a lower risk of progression compared with type 3; reduction is
indicated for type 5 and type 6.
Further Readings
1. Meyerding HW.Spondylolisthesis. Surg Gynecol Obstet. 1932;54:371–7.
2. Mac-Thiong JM, Labelle H.A proposal for a surgical classication of pediatric
lumbosacral spondylolisthesis based on current literature. Eur Spine
J. 2006;15:1425–35.
Appendix L: Castellvi Classication
Ia Ib IIa IIb
IIIa
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ofLumbosacral Transitional Vertebrae
Denition: Castellvi identies the lumbosacral transitional vertebrae according to
the shape of the mega-transverse process and the presence/absence of a neo-joint
(pseudo-joint).
Content: The classication identies four types of lumbosacral transitional
vertebrae:
• Type I: enlarged and dysplastic transverse process (≥19mm); Ia: unilateral, Ib:
bilateral
• Type II: pseudo-joint between the mega-transverse process and sacrum (incom-
plete sacralization); IIa: unilateral, IIb: bilateral
• Type III: mega-transverse process fused with the sacrum (complete sacraliza-
tion); IIIa: unilateral, IIIb: bilateral
• Type IV: type IIa on one side and type III on the contralateral side
IIIb IV
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
453
454
https://t.me/medicina_free
Appendix L: Castellvi Classication ofLumbosacral Transitional Vertebrae
Further Reading
1. Castellvi AE, Goldstein LA, Chan DP.Lumbosacral transitional vertebrae and
their relationship with lumbar extradural defects. Spine (Phila PA 1976).
1984;9(5):493–95.
Appendix M: Bone Age—Ossication ofHand,
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Olecranon, andIliac Apophysis
1.1 Ossification ofHand (Sanders etal.) andOssification
oftheOlecranon (Dimeglio etal.)
1.1.1 Ossification oftheHand
Denition: The ossication of the hand is evaluated on standard anteroposterior
radiograph of the hand.
Content: The ossication of the hand correlates highly with scoliosis behavior; the
method is rapid and reliable in clinical practice.
1.1.1.1 Ossification oftheOlecranon
Denition: The ossication of the olecranon is evaluated on standard lateral radiograph of the elbow.
Content: The ossication of the olecranon correlates highly with scoliosis behavior; the method is rapid and easy to use in clinical practice.
Clinical relevance: Both methods allow to assess skeletal maturation, and help to
estimate the risk of progression of several orthopedic disorders, including idiopathic
scoliosis (Table M.1). The methods can complement each other for more precise
bone age assessment. The olecranon method offers detailed information during the
pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossied
(Table M.2).
Ossification oftheIliac Apophysis (Risser Sign)
Denition: The Risser sign is the ossication of the iliac apophysis (left side); it
progresses from the anterior iliac spine (lateral on anteroposterior radiographs of
the pelvis) to the posterior end of the iliac crest (medial).
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spıne Surgery,
https://doi.org/10.1007/978-3-030-80356-8
455
456
Dimeglio SandersRisser
8 5
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Appendix M: Bone Age—Ossication ofHand, Olecranon, andIliac Apophysis
Table M.1 Summary of olecranon, hand, and iliac apophysis methods of assessing bone age
Iliac
Dimeglio
1 Double-ossic
2 Single-ossic
Olecranon Sanders Hand Risser
nucleus
nucleus
1 (juvenile slow) Distal epiphysis
not covered
2 (adolescent slow) All epiphyses are
covered
0 No
1 <25%
apophysis
ossication
ossication
(half-moon)
3 Single-ossic
nucleus
(quadrangular)
3 (adolescent rapid,
early)
Most digits are
capped
Metacarpal
2 25–50%
ossication
epiphysis is wider
than metaphysis
4 Partial fusion 4 (adolescent rapid;
late)
Any distal
phalangeal physes
3 50–75%
ossication
are beginning to
close
5 Complete fusion 5 (adolescent
steady; early)
All distal
phalangeal physes
4 >75%
ossication
are closed; others
are open
6 (adolescent
steady; late)
Middle or
proximal
5 Complete
fusion
phalangeal physes
are closing
7 (early mature) Only distal radial
physis is open
8 (mature) Distal radial
physis is closed
Table M.2 Correlation
between Dimeglio etal.,
Sanders etal., and Risser
methods. The pubertal growth
spurt is in gray
0 1
0 2
1-2-3-4-5
5
3
4
5
6 >1
7 4
0
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