Standard X-ray Views for Scoliosis Imaging
For scoliosis imaging, order upright posteroanterior (PA) and lateral radiographs of the complete spine. 1, 2, 3
Primary Imaging Protocol
Essential Views
- Upright PA (posteroanterior) view of the complete spine is the primary view for scoliosis assessment, used to diagnose, classify, and measure curve severity using the Cobb angle 1, 3
- Upright lateral view of the complete spine is essential to evaluate sagittal plane alignment and differentiate congenital from idiopathic scoliosis 1, 3
- Both views must be obtained in the standing/upright position to assess the spine under physiologic loading 1
Why PA Rather Than AP
- PA radiographs are preferred over anteroposterior (AP) views because they reduce radiation dose to radiosensitive breast tissue in young patients 1
- The ACR specifically recommends PA projections for serial follow-up imaging to minimize cumulative radiation exposure 1
Coverage Requirements
- Complete spine imaging (cervical, thoracic, and lumbar regions) should be obtained on a single 36-inch standing radiograph to assess the entire spinal curvature and balance 1, 2
- This allows evaluation of coronal balance, curve magnitude, and identification of vertebral anomalies across all spinal segments 1
Additional Views NOT Routinely Needed
Oblique Views
- Oblique sacroiliac joint views are NOT beneficial for scoliosis assessment, as studies show no added value over standard PA views 1
Flexion-Extension Views
- Flexion-extension views are rarely needed in children and are unlikely to yield additional diagnostic information in acute settings 1
- These views are limited by pain and muscle spasm, preventing accurate assessment of ligamentous injury 1
Swimmer's View
- Only indicated if the upper thoracic spine is obscured by shoulders on standard lateral views, which is more relevant in trauma imaging than routine scoliosis assessment 1
Serial Monitoring Protocol
- Limit follow-up radiographs to no more than once every 6 months for patients requiring curve progression monitoring 1
- For skeletally immature patients at Risser stages 0-3, obtain radiographs every 12 months; for Risser stages 4-5, every 18 months to reduce radiation exposure 3
- Serial PA spine radiographs are the standard for detecting progression and guiding treatment decisions 1, 3
Common Pitfalls to Avoid
- Do not order CT as initial imaging for routine scoliosis evaluation—it delivers significantly higher radiation dose and is reserved for presurgical planning or characterizing complex bony anomalies 1, 2, 3
- Avoid supine radiographs for initial assessment, as they do not reflect the true deformity under physiologic loading 1
- Do not skip the lateral view—sagittal balance is the most reliable predictor of clinical symptoms and surgical outcomes in scoliosis patients 4