Can a scoliosis series be done with 3 X-rays of the cervical (neck), thoracic (mid-back), and lumbar (lower back) regions?

Scoliosis Series Imaging Protocol

A standard scoliosis series should be performed with standing full-spine radiographs (posteroanterior and lateral views) rather than separate cervical, thoracic, and lumbar X-rays to properly evaluate curve severity, pattern, and sagittal balance. 1, 2

Proper Imaging Technique for Scoliosis

The American College of Radiology (ACR) guidelines clearly specify the appropriate radiographic approach for scoliosis evaluation:

• Standing full-spine radiographs are essential for initial assessment and monitoring of scoliosis 1, 2
• PA (posteroanterior) technique should be used instead of anteroposterior views to reduce breast radiation exposure 1
• Lateral radiographs are recommended on initial examination and subsequently only when changes in sagittal balance occur 1
• Lower-dose radiography techniques should be employed, including computed or digital radiography 1
• Biplanar slot scanners may be used to further reduce radiation exposure 1

Why Separate Regional X-rays Are Inadequate

Separate cervical, thoracic, and lumbar X-rays are not appropriate for scoliosis evaluation because:

1. They fail to capture the entire spine in a single image, making accurate Cobb angle measurement impossible
2. They don't allow proper assessment of global spinal alignment and balance
3. They may miss transitional curves that cross anatomical regions
4. They prevent evaluation of pelvic parameters which are crucial for treatment planning
5. They don't allow assessment of the Risser index (iliac apophysis ossification), which is an important marker for skeletal maturity and potential curve progression 1

Radiation Considerations

While radiation exposure is a concern with repeated imaging, the ACR guidelines address this by recommending:

• PA technique to reduce breast dose
• Lower-dose radiography techniques
• Limiting lateral radiographs to only when necessary
• Using biplanar slot scanners when available 1

Studies indicate that the typical scoliosis patient receives 10-25 spinal X-rays over several years, with a maximum estimated dose of 10-25 mGy, which is well below thresholds associated with increased cancer risk 3.

Common Pitfalls to Avoid

• Inadequate visualization: Separate regional X-rays may miss critical portions of the curve
• Improper positioning: Non-standing images fail to account for gravitational effects on curve severity
• Inconsistent technique: Varying techniques between images make progression monitoring unreliable
• Unnecessary radiation: Obtaining separate regional X-rays may increase total radiation exposure compared to a single full-spine study
• Delayed referral: Inadequate imaging may lead to delayed specialist referral for patients who need it 2, 4

When Additional Imaging Is Warranted

After initial radiographic evaluation, additional imaging may be indicated in specific circumstances:

• MRI: When intraspinal abnormalities are suspected (Chiari malformation, syringomyelia, tethered cord) 1, 2
• CT: For presurgical planning, surgical navigation, or when MRI is contraindicated 1
• Bone scan: In cases of painful scoliosis where primary bone tumors or infection are suspected 1

Remember that scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more, and proper imaging is essential for accurate diagnosis, classification, and management 5, 6.