Diagnosis and follow-up: what the X-ray report says

Short answer: Scoliosis is diagnosed when the Cobb angle (the degree of curvature measured on an X-ray) is 10 degrees or more on a standing X-ray of the whole spine and the spine can be seen to have rotated around its own axis. The report in your hand usually carries three pieces of information at once: how many degrees the curve measures, where in the spine it sits and which way it turns, and the Risser stage, which describes skeletal maturity. Read together, those three allow the remaining growth and the risk of progression to be judged, and the interval to the next review follows from that judgement. Whether an X-ray is needed, how often it is repeated and what treatment is chosen are decisions for the physician. Physiotherapy is the step at which the physician's decision is carried out.

What happens at the appointment

The examination almost always comes before the X-ray. The child is looked at from behind with the back uncovered, and the physician checks the level of the shoulders, how far the shoulder blades stand out, whether the two waist triangles (the gaps left between the arms and the sides of the trunk) match, and whether the hips sit level. The child is then asked to bend forward without bending the knees, and the physician looks along the back to see whether one side stands higher than the other. That second step is the Adams forward bend test, and it makes visible the rotation of the spine around its own axis, which is one component of scoliosis.

When a raised area is seen, most centres then measure the trunk rotation angle with a scoliometer, a small levelling device laid across the back. How many degrees on that device should trigger further investigation is argued over in the literature. In a screening study of 1,000 high school students, Bunnell reported a rotation angle of 7 degrees at any level of the spine as a reasonable referral criterion, and showed in the same study that a 7 degree threshold referred 3 per cent of students onwards while a 5 degree threshold referred 12 per cent. That study also found a rotation angle of 3 degrees or more in 80 per cent of the students, which tells a parent something on its own: small asymmetry is ordinary in children. The screening study carried out in Turkey with 16,045 students across 40 provinces used 5 degrees as its referral threshold.

The physician also measures height, assesses the stage of puberty, asks girls the date of their first period, and asks whether anyone else in the family has scoliosis. Whether there is pain, whether that pain wakes the child at night, and whether any neurological finding is present are asked about in the same conversation. These sound like routine questions. In fact they form the frame on which the treatment decision is later built, as the sections below show.

The whole check takes a few minutes and needs no equipment beyond that small device, so a parent who arrived expecting something more elaborate can leave with the feeling that very little happened. In those few minutes, though, one decision was taken: whether an image is needed.

Orthopaedics or physical medicine and rehabilitation

This is the question families get stuck on most often, and the two specialties are not alternatives to each other. Orthopaedics and traumatology (in Turkish, ortopedi ve travmatoloji) is where the diagnosis is made and where any surgical decision is taken; paediatric orthopaedics and spine surgery are areas of interest within that specialty. Physical medicine and rehabilitation (fiziksel tıp ve rehabilitasyon, often shortened to FTR) is where non-surgical follow-up is run, where a brace is prescribed and from where a child is referred on to physiotherapy. A child seeing both is not a contradiction and does not mean that one of them was the wrong door.

One documented example shows that the first door is not orthopaedics in every province. In a school screening programme announced in Samsun in March 2022, the examinations were carried out by physiotherapists, and the children in whom scoliosis was suspected were sent on to a physical medicine and rehabilitation hospital. A programme of that kind does not exist in every province, and the next section explains why that matters more than it first appears.

In practice families often end up joining these two worlds together on their own. One habit makes that much easier: keep the films and the reports in a single folder, and carry it to every appointment, including the first one.

It also helps to know from the start what a physiotherapist does not do. A physiotherapist makes no diagnosis, requests no X-ray and prescribes no brace.

How the route works here

The first sign is almost never spotted in a consulting room. A parent sees the child at a swimming pool, at the beach or while a T-shirt is being changed, and picks out for themselves that one shoulder sits higher than the other, or that one side of the back rises when the child bends forward. Sometimes a screening at school or a remark from a physical education teacher takes the place of that moment.

Relying on school screening would be a mistake, though, and this is one of the least known pieces of information in this guide. The national screening programmes published by the Ministry of Health cover newborn screening, hearing, vision, developmental hip dysplasia and a small number of other conditions. Scoliosis is not on that list. Screening for scoliosis is carried out only in some provinces, under protocols signed between a provincial health directorate and the provincial directorate of national education. The consequence is plain: whether a child is looked at for scoliosis at school depends on which province and which year that child happens to be at school in. A family who has just moved here, and who is used to a school health service that checks for this, needs to know that the check may simply not take place.

The body that prepares preventive care recommendations in the United States concluded in 2018 that the evidence available was insufficient to weigh the benefits and harms of screening adolescents for scoliosis. That conclusion does not say screening causes harm. It says the studies that would follow screened and unscreened children over many years have not been done. A parent should take one thing from it: between the ages of about 10 and 14, watching at home is a more dependable way of catching a curve than waiting for a screening at school.

The route from suspicion to diagnosis is fairly standard here, and it runs differently from the systems many readers grew up with. Families begin at a family health centre (aile sağlığı merkezi), where the family physician they are registered with, or a paediatrician, examines the child and refers them onwards. The referral goes to orthopaedics and traumatology or to physical medicine and rehabilitation, and imaging follows only if the physician asks for it.

Appointments at state and university hospitals are made through the national appointment system, while private clinics are booked with the clinic directly. The difference between the two routes is mostly waiting time. The diagnosis itself rests on the same examination and the same film, and which route suits a family is not a decision this page can make for you. Whether your health cover pays for the appointment depends on the type of cover you hold, and that question is answered by your own insurer or by the hospital's patient services desk. It is better settled before the appointment than at the desk.

Families living in Bornova and the surrounding neighbourhoods have the university and state routes on the same transport axis, which makes regular review comparatively easy to keep up. Evka 3 is the eastern terminus of the M1 metro line, so a family travelling in from the western side of the city cannot miss the stop. Local practicalities of that kind are set out on the Bornova and Evka 3 page.

The real turning point comes after the diagnosis. If the measured angle sits below the range where bracing comes up for discussion, the family usually takes a review appointment a few months ahead and goes home. That answer is not neglect. Below a certain degree there is no evidence that makes intervention necessary, and unnecessary treatment is itself a harm. The parent, though, is left with no concrete task at all, and this is usually the point at which the internet searches begin. The purpose of this page is to make the one concrete document you do hold during those months, the report, readable.

Why an X-ray is taken, and how

The examination raises a suspicion. It does not make the diagnosis. The relationship between the trunk rotation angle measured with a scoliometer and the Cobb angle measured on an X-ray is approximate, and it varies from one child to another. Because the two measurements track each other only loosely, the scoliometer is used to decide whether an image is needed, not to put a number on the curve.

Standard imaging is a plain film taken with the child standing, framed so that the whole spine fits into a single image; a Turkish request slip or report will usually call this a tüm omurga grafisi. The film can be taken front to back or back to front. Which of the two a centre uses varies, and you can ask the imaging department which one they used. If information is needed about the spine seen from the side, meaning the kyphosis and lordosis angles (the natural backward and forward curves of the spine when viewed from the side), a lateral film may be requested as well. It matters that follow-up films are taken with the same technique and in the same position, because two measurements can only be compared if they were made the same way.

During the exposure the child is asked to stand with weight spread evenly over both feet and the knees straight. Different arm positions may be used. Once the film and the report are in hand, keeping a digital copy of both is the simplest precaution there is against the same image being taken again in later years.

The words used in the report

The report is a few lines long, and those few lines are written in a language you cannot read, in two senses at once: the terms are clinical, and here they are in Turkish. Most of them come from Latin roots, so they are partly decodable once you have seen them written down. The table below gives the ones that come up most often.

The direction of the curve and the apex are read together. Torakal dekstroskolyoz says that there is a curve in the upper back turning to the right. The vertebra reported as the apex marks the centre of the curve, and it largely explains which side of the back rises when the child bends forward.

Whether the curve is single or double appears in the report too. In the screening study carried out in Turkey, roughly 69 per cent of the adolescents found to have scoliosis had a single curve and roughly 29 per cent had a double curve. In a double curve two separate Cobb values are reported, and they are not added together. Each is followed on its own.

What the Cobb angle tells you

The Cobb angle is the angle between two lines drawn along the endplates of the most tilted vertebra at the top of the curve and the most tilted vertebra at the bottom. The measurement is taken from the ends of the curve, not from its peak. The single number in the report is the angle at which those two lines meet.

The 2016 SOSORT guideline states the diagnostic threshold plainly: the diagnosis is confirmed when the Cobb angle is 10 degrees or more and rotation of the spine around its own axis can be recognised, and below 10 degrees the diagnosis of scoliosis should not be made. If the report in your hand says 8 degrees, that is not scoliosis. That picture is called scoliotic posture, or asymmetry. Recommending a brace on the strength of such a value does not sit with the guideline.

The second piece of information, as important as the degree itself, is the stage of growth at which that degree was measured. The same 22 degrees means one thing in an adolescent whose growth is finished and something else entirely in a child at the start of the growth spurt, which is why no physician decides on the degree alone.

The figure should not be blown out of proportion either. In the study that screened 16,045 students in 85 schools across 40 provinces in Turkey, scoliosis was found in 2.3 per cent (3.1 per cent of girls and 1.5 per cent of boys), and 90.5 per cent of the cases identified were mild curves in the 10 to 19 degree range. The great majority of children who receive a diagnosis of scoliosis are a long way from the picture in which surgery is discussed.

The Risser stage and the growth that is left

The Risser sign describes how far the growth cartilage at the upper edge of the pelvis, the iliac apophysis, has turned to bone on the X-ray. Ossification begins at the front and outer side of the crest and moves inwards, and fusion then runs the other way, from the inside outwards. In a scoliosis report this sign is used to make an indirect estimate of how much growing the child has left to do.

The stages read roughly as follows. At Risser 0 no ossification is yet visible in the iliac apophysis and growth potential is at its highest. Stages 1 to 4 describe ossification advancing along the iliac crest. At Risser 5 the apophysis has fused completely to the crest and growth is finished. Clinically, stages 0 to 2 mark the period in which growth continues, the risk of progression is higher and a brace may come into the discussion, while stages 3 to 5 mark the period in which growth potential has largely gone.

Two weaknesses in this sign are worth knowing about, because a report almost never mentions them. The first is that the North American and French systems use different definitions, so the same child can be given a different stage under each. A report saying Risser 2 and another centre reading Risser 3 from the same film does not necessarily mean that one of them made a mistake. The second is that Risser 0 covers a very wide stretch of time. The months before the closure of the triradiate cartilage inside the pelvis and the months after it fall under the same stage, although what those two periods mean for remaining growth is markedly different. That is why no physician reads the Risser stage without the height chart and the puberty history beside it.

Bone age, Sanders staging and the first period

To measure the remaining growth more finely, some centres use Sanders staging, which is read from an X-ray of the hand and wrist. The simplified system developed by Sanders and colleagues has eight stages. In the original study it was reported to give highly consistent results between different readers and to predict the period of curve acceleration better than the traditional methods.

Its clinical value lies in the third stage, which corresponds to the peak of the pubertal growth spurt and is the moment at which the risk of a scoliosis worsening is at its highest. The eighth stage marks skeletal maturity.

Sanders staging has a cost, and there is no reason to hide it: it needs an additional wrist film, which means additional radiation exposure for the child. Not every centre uses it as a matter of routine. Whether it is used depends on whether the extra information would change the decision, and that is a judgement for the physician.

In girls the first period, the menarche, is a clinical sign that the peak of the growth spurt has been passed, and it is always asked about when the history is taken. Putting a figure in centimetres on the height gained after menarche would not be honest. The centimetre values in circulation cannot be traced to a dependable primary source. The growth remaining after menarche does decline markedly, and that piece of information is weighed together with the Risser stage, the Sanders stage where one exists, and regular measurement of height.

An honest look at the worry about X-rays

A parent who has to have films taken of a child year after year is right to ask about this, and the question deserves better than being brushed aside. The honest answer comes in several parts.

Whether an X-ray is needed is decided by the physician. A physiotherapist does not request films and has no authority to. Putting a number on the risk carried by a single film would also be wrong on this page, because that value depends on the technique and the equipment used. That question belongs to the centre doing the imaging, and you can ask for the information there.

Against that, there is one area a parent can influence directly. If a film that would give the same information already exists, a new one is generally not requested.

Keeping digital copies of the films and the reports prevents the same image being taken again when you move between centres. This is the most concrete and the easiest way of reducing unnecessary exposure.

Knowing that a film is not needed at every step of follow-up is also a relief. Interim reviews can be done with an examination and a scoliometer measurement, without an X-ray. Those measurements give a clue as to whether anything has changed noticeably. The degree, though, comes from the film.

How the follow-up interval is decided

The review interval is set by the remaining growth, the current Cobb angle, the type of curve and the change that appears when the new film is compared with the previous one. Whether a brace is being worn affects it as well. There is no fixed calendar behind any of this.

The 2016 SOSORT guideline uses a decision table to support this judgement. It sets out follow-up intervals ranging from 3 to 36 months according to the stage of growth and the severity of the curve. The degree and month pairings in the individual cells of that table have not been carried across to this page, because passing those values on incompletely or approximately would leave a parent with a false expectation. Your physician will tell you the interval that applies to your child. This page can only explain why that interval differs from one child to the next.

The general tendency is easy enough to follow. During the period of fastest growth the interval shortens, as skeletal maturity approaches it lengthens, and once growth is finished reviews become infrequent. Asking the physician at the outset which developments should bring the review forward is useful, because it gives you something to watch for in the months in between.

Take a short list with you to the review:

• The earlier films and reports, with their digital copies where possible
• The height measurements taken over recent months, with the dates on which they were taken
• For girls, the date of the first period
• If a brace is being worn, a note of the hours it is worn each day
• A list of questions written down in advance

What comes up at which threshold

A threshold shows where a particular conversation opens. The decision itself comes later. The thresholds the guidelines state explicitly are these.

Ten degrees is the diagnostic threshold, and below that value a diagnosis of scoliosis is not made. Above it comes a second range: a brace comes into the discussion for progressive curves above roughly 25 degrees in a child who is still growing. That second range should be read as a limit widely accepted in clinical practice rather than as a numbered recommendation in a guideline. It helps here to know which children the BrAIST trial, the study that showed bracing to be effective, actually covered: patients aged 10 to 15, skeletally immature (Risser 0, 1 or 2), with a largest curve of 20 to 40 degrees. The evidence on bracing was produced for that profile.

Two further thresholds apply once skeletal maturity has been reached, and they look ahead to adult life. The 2016 SOSORT guideline states that above 30 degrees the risk of progression in adulthood increases, and that above 50 degrees there is a consensus that progression in adulthood is almost certain. Those two sentences explain what the effort during the growth years aims at. The goal is to reach skeletal maturity at the lowest degree that can be managed, because the degree a child arrives at maturity with shapes how the following decades go. How the back looks in the mirror this year is a smaller question than that one.

There is long-term follow-up data on what the adult picture looks like, and it puts part of the fear back in proportion. In a study that followed 117 patients with untreated idiopathic scoliosis over fifty years and compared them with a matched comparison group of 62 people, chronic back pain was reported by 61 per cent of the patients and 35 per cent of the comparison group. Most of that pain stayed mild or moderate. The same study found that lifespan was not affected. The fear behind the question "will my child's life be shorter" has no counterpart in the evidence.

The guideline also puts numbers on how the risk of progression shifts at the peak of the growth spurt. In that period, which corresponds to a bone age of about 13 in girls, the risk of progression was reported as 10 per cent for a curve of 10 degrees, 30 per cent for a curve of 20 degrees and 60 per cent for a curve of 30 degrees. In the final stage of puberty, once the child has reached at least Risser 2, that risk drops sharply.

The treatment goals table in the guideline consists of these three lines:

Which degree ranges these groups correspond to is defined in the decision tables of the guideline, and those cell values have not been reproduced here. The rows matter less than the logic behind them: the aim is to hold the curve below a set limit.

The severe-curve row points towards surgery. What an operation involves, what it can achieve and what it risks cannot be answered on this page. Those are questions for a spine surgeon, and which of them to take into that consultation is set out on the surgical decision page.

Reading a difference in degrees between two reports

The Cobb angle is measured either by hand or with software, and both methods carry a small amount of variation. When the same film is measured by two different people, a difference of a few degrees can appear. For that reason a threshold of five degrees has traditionally been used in clinical practice as the point at which a change is treated as meaningful.

If you hold two films taken six months apart, this is of direct use to you. One reading 21 degrees and the other 23 degrees does not show that the curve has progressed. Nor should 23 degrees dropping to 21 be read as a gain. That difference sits inside the variation that belongs to the measurement itself.

The same threshold is needed when reading the results of exercise studies. A meta-analysis of Schroth exercises, pooling 11 randomised trials with 446 participants between them, found a combined mean difference in the Cobb angle of about 3.2 degrees, and the authors stated plainly that this value does not reach the five degree threshold accepted as clinically meaningful. In the same analysis the difference in the trunk rotation angle was not statistically significant, while a significant difference was found in the quality of life measures. All three of those results belong in the same paragraph if the evidence is to be reported as it stands.

Is an X-ray enough, or is an MRI needed

Idiopathic simply means that the cause is not known, and in the great majority of these cases the history, the physical examination and a plain X-ray are enough. Further investigation is not needed in every child.

The most useful data on this comes from a study of 2,442 patients with idiopathic scoliosis. Back pain was present in 560 of them (23 per cent) at the first visit, and developed during follow-up in a further 210 (9 per cent). In most children, then, scoliosis causes no pain. In 48 of the 560 patients who did have pain (9 per cent), however, the source of the pain turned out to be not the scoliosis but another condition in the spine or the spinal cord.

In everyday terms this is simple. If your child has marked back pain, do not set it aside as "the pain of the scoliosis". Tell the physician. The authors of the same study noted that history, physical examination and plain X-ray are enough in most patients and that extensive investigation is not required in every one. The right behaviour sits between the two: report the pain, and leave the decision about investigation to the physician.

Among the situations in which magnetic resonance imaging may come up are pain that wakes the child at night, a finding on neurological examination, progression faster than expected, and a curve that began at a very early age. That decision belongs entirely to the physician, and this page should not be read as a list of requirements.

Questions you can ask at the appointment

Outpatient appointments are short, and a parent often realises what they forgot to ask only after walking out of the door. Taken in written form, the questions below are the kind that can be answered even in a brief consultation. They can be asked in Turkish or, where the physician speaks it, in English, and writing them down beforehand helps in either language.

• How many degrees is the measured Cobb angle, in which region is the curve and which way does it turn? Is it a single curve or a double curve?
• What was the Risser stage assessed as?
• What can you tell me about the growth my child has left? Is a separate film needed for bone age?
• When is the next review, and what decided that interval?
• Will an X-ray be taken again at the next review, or will an examination be enough?
• What should I notice in the meantime that would mean bringing the review forward?
• Does a brace come into the discussion at this degree? If it does, which type and how many hours a day?
• Do you think it appropriate for us to start scoliosis-specific physiotherapy?
• Do you see any objection to my child carrying on with the sport they play?
• May I have a copy of the film and the report?
• Should their brother or sister be checked as well?

The last two are the ones most often skipped. A copy of the report is the only way of making a comparison possible in later years. The question about a sibling comes from what is known about idiopathic scoliosis being multifactorial and linked to genetic predisposition, and it deserves to be put to the physician.

Where physiotherapy sits in this process

Diagnosis, imaging, bracing and any surgical decision belong to the physician. Physiotherapy comes into the picture after those decisions and carries them out. Writing that order down plainly makes it easier for a parent to know who to ask what.

A physiotherapy assessment looks at trunk symmetry, the rotation angle measured with a scoliometer, flexibility, muscle endurance and breathing, and the programme is built around the individual pattern of the child's curve. That assessment describes the state of the trunk as it appears from the outside. How many degrees the curve measures is written in the X-ray report.

The evidence has to be passed on as it stands. A 2024 Cochrane review covering 13 randomised trials and 583 participants concluded that the benefits of therapeutic exercise in idiopathic scoliosis are uncertain and that the evidence is of low certainty. The same review reports that adding exercise to a brace, in participants wearing one, may reduce the progression of the curve. Another meta-analysis of scoliosis-specific exercises found that the effect of exercise on the Cobb angle was not significant compared with controls in patients whose curve was 30 degrees or more.

Scoliosis-specific exercises may help to slow the progression of a curve, and they may support trunk symmetry and quality of life. In a child for whom a brace has been decided on, exercise is a second piece of work added alongside the brace rather than a replacement for it.

Assessments and sessions can be held in English, which matters for a family who would otherwise be working through a clinical conversation in a second or third language while also trying to follow the reasoning behind a decision.

If you have read your report and are wondering what comes next, the bracing and exercise page explains how a bracing decision is reached, and the Schroth method page explains how the physiotherapy itself works. If no diagnosis has been made yet, the checking steps on spotting the signs at home may help before you see a physician. The growth period and the risk of progression are dealt with as a whole on scoliosis in children and adolescents.