Open research questions in Scoliosis diagnosis and treatment

What the literature leaves open

• The pelvic inclination angle (PIA) has been proposed as a PI-independent parameter; however, its clinical relevance in surgically treated ASD patients remains unclear.

  Clinical Utility of the Pelvic Inclination Angle in Surgically Treated Adult Spinal Deformity · 2026 · DOI

• BACKGROUND AND OBJECTIVES: Prolonged intubation is an unwanted occurrence after adult spinal deformity (ASD) surgery, yet its risk factors are poorly understood.

  Who Remains Intubated After Adult Spinal Deformity Surgery? A 5-Factor Scoring System With Dual Institution External Validation · 2026 · DOI

• While postoperative alignment is a recognized modifiable risk factor, objective methods for selecting the upper instrumented vertebra (UIV), a key modifiable factor, are lacking.

  Preoperative alignment and risk of proximal junctional failure · 2026 · DOI

• Abstract Introduction In adolescent idiopathic scoliosis (AIS), the choice of upper and lowest instrumented vertebrae and related complications remain debated.

  Vertebral bone quality in patients with adolescent idiopathic scoliosis · 2026 · DOI

• As the underlying etiology remains unclear, AIS is treated purely symptomatically, initially by bracing and ultimately by highly invasive, costly surgeries.

  Integrated Transcriptomic and Functional Analysis Reveals Tissue-Specific Molecular Pathology in Adolescent Idiopathic Scoliosis · 2026 · DOI

• This study has limitations. First, although the overall sample was substantial, subgroup analyses—particularly for Lenke 1C—were comparatively small and should be considered exploratory. Second, the study is retrospective and descrip- tive, and no clinical outcomes or postoperative decision variables were analyzed. Third, while the 3D reconstruc- tion workflow has been previously validated, all quantitative descriptors remain dependent on the fidelity of landmark identification and image reconstruction. Finally, although the distribution of points on the regression plots visually sug- gested predominantly linear relationships, nonlinear associa- tions caused by sample heterogeneity cannot be excluded and may warrant exploration in future work.

  Transverse-plane descriptors and modifiers of the SRS-Lenke-Aubin 3D classification provide complementary and clinically informative 3D features beyond 2D assessment in Lenke 1 AIS curves · 2026 · DOI

• Several limitations should be acknowledged. First, data contamination cannot be ruled out, a limitation inherent to most LLM benchmarking studies as noted by Kartal et al. [15]. Our patient-derived question set, sourced from pub- lic forums and professional portals, may have overlapped with LLM training corpora, potentially inflating accuracy estimates. Second, this study used expert judgment rather than direct patient assessment of comprehension; while expert evaluation provides rigorous clinical scrutiny, it does not capture how actual patients understand and use AI-generated information. Third, our findings represent a temporal snapshot; LLM performance may change with model updates, and generalisability is limited to the two models tested (Claude Sonnet 4.5 and GPT 5.2). Fourth, the Flesch-Kincaid Grade Level captures syntactic complex- ity but not full conceptual accessibility; a response with simple sentence structure may still be inaccessible due to unexplained medical jargon. Finally, although our rater panel included experienced clinicians, it excluded patient and caregiver perspectives, which should be incorporated in future research.

  An expert-led benchmark using common patient questions: evaluating large language models for adolescent idiopathic scoliosis education · 2026 · DOI

• a. Longitudinal tracking of LLM performance across versions. b. Scale development for patient-centred assessment of clarity and coverage. c. Specialised medical LLMs: The demonstrated gap sup- ports developing models fine-tuned for health com- munication, including retrieval-augmented generation systems grounded in evidence-based knowledge bases (e.g., Med-PaLM 2 [28]). d. End-user impact studies measuring comprehension, anx- iety, and decision-making. e. Multimodal integration (visual aids, diagrams) to enhance clarity for anatomical and procedural explanations. This multidimensional benchmark reveals that while con- temporary LLMs contain robust factual knowledge about AIS, they fall short as standalone patient education resources due to systemic clarity deficits and considerable variability in conceptual coverage. Expert judgment must be validated through direct patient evaluation before conclusions about real-world utility can be drawn. LLMs hold promise as adjuncts to clinical knowledge resources, but their integra- tion into patient care requires judicious caution. Effective and ethical use necessitates mandatory mediation by health- care professionals, who must vet, interpret, and contextual- ise AI-generated information to ensure it is accurate, clear, and personally relevant. The path forward lies not in uncriti- cal adoption, but in informed application guided by rigorous understanding of these tools’ capabilities and limitations. Author contributions 1. CA, ABK, AMO, FG, MAO: Conceptualiza- tion, writing original draft, visualization. 2. CA, ABK, AMO: Formal analysis, data curation, methodology. 3. FG, AMO, MAO: Supervi- sion, project administration, validation. 4. All Authors: Writing-re- view-editing, and approval of the final manuscript for submission. Funding Open access funding provided by the Scientific and Techno- logical Research Council of Türkiye (TÜBİTAK). This research re- ceived no specific grant or financial support from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets generated and/or analyzed during the current study are available from the corresponding author upon reason- able request.

  An expert-led benchmark using common patient questions: evaluating large language models for adolescent idiopathic scoliosis education · 2026 · DOI

• This is the first feasibility study comparing template-based rod bending using doublecurved rods for sagittal realignment against freehand techniques, providing a controlled baseline for subsequent 3D and software-integrated studies. We included surgeons from diverse backgrounds following standardized protocols. This approach may support junior spine surgeons intraoperatively. However, our controlled laboratory design may overestimate template benefits. Surgeons bent rods under ideal conditions: ample light, no tissue resistance, blood loss, or fatigue. In reality, rod bending occurs late in complex cases under challenging circumstances; the absence of these stressors may bias results toward 2D templates. Although we controlled for fatigue using a Latin square design, continuously bending 24 rods is atypical and may introduce cumulative fatigue or learning effects. Two participants (F.S., L.B.) interrupted tasks and resumed later, introducing unaccounted variability. We randomized the order of the lumbar and cervical rods before bending for all participants to minimize learning and fatigue effects, but we cannot entirely exclude them. We asked the surgeons who performed the bending to be as precise and quick as possible. However, intra-surgeon correlation was not investigated, as the surgeons only bent the same rod twice (once with and once without the template), precluding repeated-measures comparison. Future studies should consider this. We attempted to minimize coronal deviation during scanning and angle calculation, though some inaccuracies may exist. Our decision to assess rod contouring accuracy using a twodimensional sagittal template was deliberate and methodologically motivated, but it represents a simplification that warrants explicit clarification. The primary objective of this feasibility study was to isolate the sagittal rod contouring as a single, measurable variable under controlled conditions. Sagittal alignment, particularly in lumbar lordosis restoration, remains a predominant determinant of postoperative mechanical behaviour and clinical outcome in adult deformity surgery. By restricting the analysis to the sagittal plane, we aimed to reduce confounding influences and improve internal validity when assessing differences in contour precision and bending manoeuvres. This approach allowed us to quantify the RCA, bending frequency, and contour deviation reproducibly. ARTICLE IN PRESS ARTICLE IN PRESS ACCEPTED MANUSCRIPT However, we fully acknowledge that this model does not capture the complexity of in vivo rod shaping during deformity surgery. In practice, rod contouring frequently involves combined sagittal and coronal curvature, axial rotation/derotation manoeuvres, asymmetric segmental corrections, and coupled plane interactions during screw reduction.

  Template guided versus freehand rod bending in spinal deformity surgery: a feasibility study · 2026 · DOI

• Among several limitations, the cross-sectional nature of this study precludes causal inference. Gluteal muscle degen- eration is suggested to be strongly associated with the fail- ure of sagittal alignment compensation, but longitudinal re- search is required to determine whether such muscular changes precede or follow alignment deterioration. Further- more, compensation was defined solely based on static ra- diographic parameters (SVA and PT), although compensa- tory mechanisms are inherently functional phenomena in- volving dynamic posture control and coordinated muscle ac- tivation. Given that no objective functional assessments― such as gait analysis, electromyography, or balance testing― were included, the functional aspects of compensation could not be evaluated. Also, although CT provides a reliable and reproducible assessment of muscle morphology, it cannot as- sess neuromuscular activation or dynamic biomechanical function, functional further underscoring the absence of evaluation in the present study. Future studies might incor- porate magnetic resonance imaging, gait analysis, or electro- myography for a better understanding of muscle involve- ment in spinal alignment. Moreover, our cohort was drawn from a clinical outpatient population with spinal symptoms, which may limit generalizability. In addition, although acute vertebral fractures were excluded to avoid transient posture- related effects, we did not collect data on the number of pre-existing vertebral fractures, other osteoporosis-related fractures, or bone mineral density. These unmeasured factors 492 https://doi.org/10.22603/ssrr.2025-0368 Spine Surg Relat Res 2026; 10(3): 486-494 may influence both muscle status and sagittal alignment and limitation of the present therefore represent an important study. Finally, various potentially confounding factors were not assessed here, and they should be accounted for in fu- ture research because they may influence the interpretation of the associations between muscle degeneration and sagittal alignment.

  Gluteal Muscle Degeneration Is Associated with Compensation Failure in Age-Related Spinopelvic Malalignment: A Cross-Sectional Study · 2026 · DOI

• Surgical correction of idiopathic scoliosis and using translation demonstrated satisfactory radiological and functional study. Significant outcomes correction of Cobb angle, improvement in spinal balance, reduction of rib hump deformity, and enhanced quality of life were achieved with acceptable postoperative rates. Younger patients, complication earlier presentation, smaller preoperative of curve magnitude, postoperative were associated with better surgical outcomes.

  Outcomes of Surgical Correction of Idiopathic Scoliosis by Rod Derotation and Translation Technique - An Experience in a Tertiary Medical College Hospital · 2026 · DOI

• This study had several limitations that must be seriously con- sidered. It was a retrospective study based on clinical records recorded during the process of routine follow-up in orthopedic clinics. This has the intrinsic limitation of incomplete record- ing, errors in transcription, and variability between what was verbalized by patients or relatives and what was formally recorded by the treating physician. Adherence was rather approximated from patient self-reports or caregiver-reported information, recorded by the clinician. This practice is subject to social desirability and recall bias, which potentially led to overreporting adherence or underreporting treatment conflict. In addition, primary behavioral and psychosocial indicators such as conflict with family and participation in physical activ- ity were collected in open-ended narrative format, rather than by using standardized tools. The study was conducted at a single Italian orthopedic outpatient clinic, a country classified by the United Nations as having "Very High Human Develop- ment" based on its Human Development Index (HDI). This setting, in which there is broad accessibility of healthcare and follow-up therapy, may not be generalizable to what is avail- able in lower-resource or under-resourced environments. As a retrospective study, no a priori power analysis was performed, and the sample size reflected all eligible patients available within the predefined study period. Consequently, the study may be underpowered to detect small effect sizes, particu- larly in multivariate models and subgroup analyses. Some studies have suggested that differences in skeletal maturity between males and females at the time of brace prescription may influence prescribed brace hours and treatment adher- ence. Although this represents a plausible biological explana- tion, detailed markers of skeletal maturity such as PHV timing were not available in our dataset [29, 30]. Because this study was retrospective, data were available only for patients who attended follow-up visits, preventing accurate identification of those lost to follow-up. Additionally, patients with incomplete records or missed follow-up visits could not be systematically identified or quantified within the available dataset. This may introduce selection bias. Future prospective studies would allow more complete tracking of follow-up and reduce this limitation.

  Gender-related differences in brace adherence among adolescents with idiopathic scoliosis · 2026 · DOI

• investigate longitudinal The age-stratified results suggest children may be more low PA. These findings vulnerable to the effects of very highlight importance of balanced, moderate the potential physical activity for spinal health in youth and provide a basis for causal relationships and refine activity guidelines. In conclusion, this study found that moderate physical activity is associated with the lowest odds of scoliosis screening positivity (SSP) among children and adolescents, whereas both low and vigorous activity levels, as well as certain activity patterns, are associated with higher odds. These associations, observed with SSP as a screening outcome rather than a clinical diagnosis, warrant confirmation in longitudinal studies with clinically confirmed scoliosis.

  The dose-response relationship between physical activity and school scoliosis screening positive in children and adolescents: a preliminary cross-sectional study · 2026 · DOI

• While further research is needed for specific clini- cal applications, these findings confirm the potential for high-quality imaging of the bone morphology in AIS and its possible application in surgical treatment planning and potentially navigated surgery. Never- theless, while sCT presents an exciting opportunity for the future, further research is needed to generate robust evi- dence for its accuracy and safety in both pre-operative plan- ning and surgical navigation, ensuring its reliable clinical implementation.

  Radiation-free assessment of the 3D morphology of the adolescent scoliotic spine: a feasibility study using MRI derived quantitative synthetic CT · 2026 · DOI

• agenda This review has several limitations. First, our analysis primarily focused on sagittal plane imbalance, which is most closely linked to clinical symptoms and compensatory mechanisms. The potential impact of coronal malalignment on lower limb joint degeneration was not systematically addressed, representing an important direction for future investigation.

  Biomechanical compensatory chain and residual compensation potential in aging spinal deformity: a narrative review and multimodal assessment framework · 2026 · DOI

• Background and AimsWhile standard care for adolescent idiopathic scoliosis (AIS) includes observation and bracing, the specific benefits of tailored exercise warrant further investigation.

  THE UNTAPPED POTENTIAL: ADAPTED PHYSICAL ACTIVITY AND FUNCTIONAL IMPROVEMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS · 2025 · DOI

• While posterior spinal fusion (PSF) is the standard treatment, long-term outcomes beyond 10 years and the impact of Lenke classification and fusion length on patients' quality of life remain underexplored.

  Long-term Life-Quality Outcomes after Corrective Adolescent Idiopathic Scoliosis Surgery: 10-Year Postoperative Assessment Comparing Lenke Classification and Fused Levels · 2025 · DOI

• There was also moderate, irregular periosteal new bone formation on the fifth and sixth cervical vertebrae with a poorly defined mildly hyperattenuating soft tissue structure adjacent to the right pedicle of C5 and extending into the right side of the vertebral canal, compressing the spinal cord to the left side.

  Acquired scoliosis of the cervical spine secondary to vertebral neoplasia in an aged pony gelding · 2022 · DOI

• Post‐mortem computed tomographic examination showed heterogeneously increased attenuation surrounding small, poorly defined regions of reduced attenuation in the trabecular bone of the vertebral body and right transverse process of C5.

  Acquired scoliosis of the cervical spine secondary to vertebral neoplasia in an aged pony gelding · 2022 · DOI

• Although cervical SD has rarely been reported, this report highlights that may be associated with orthopedic abnormalities such as scoliosis as well as cutaneous, neurologic and urogenital disorders.

  Report of two adult with occult cervical spinal dysraphism and scoliosis · 2014 · DOI

• However, few studies have examined whether the erector spinae (ES) activation status during unilateral spinal extensor strengthening meets the guideline for patients with spinal scoliosis.

  Comparison of the electromyographic activation level and unilateral selectivity of erector spinae during different selected movements · 2012 · DOI

• is already taken Other factors that were not taken into account which are considered as one of limitations of this study, these factors had a direct or indirect influence on volume of www.

  EVALUATION OF THE EFFECTS OF THE VOLUMES OF THE POSTERIOR AND ANTERIOR VERTEBRAL MUSCLES ESTAMAIATED FROM THE COMPUTED TOMOGRAPHY IMAGES ON THE LUMBAR LORDOSIS · 2026 · DOI

• Although previous studies have predominantly addressed coronal deformities such as scoliosis, changes in sagittal alignment, particularly thoracic kyphosis, remain poorly characterized.

  The Effects of Breast Cancer Surgery on Thoracic Kyphosis and the Correlation Between Supine CT and Standing X-Rays: A Single-Center Retrospective Study · 2026 · DOI

• However, current evidence is limited by heterogeneity, highlighting the need for high-quality RCTs with standardized protocols and long-term follow-up.

  The Evidence of Physiotherapy Scoliosis-Specific Exercises in Treating Secondary Postural Deviations in Mild and Moderate Idiopathic Scoliosis: A Scoping Review · 2026 · DOI

• To further elucidate the mechanisms underlying each type of age-related strabismus, future studies with larger sample sizes and comprehensive evaluations, including assessment of functional visual changes, are warranted.

  Age-related changes in the orbital pulley array of older Japanese adults with acquired exotropia · 2026 · DOI

Most-cited papers in Scoliosis diagnosis and treatment

• Reliability of Thoracic Spine Rotation Range-of-Motion Measurements in Healthy Adults · Journal of Athletic Training · 2012 · 70 citations
• Changes in spinal curvature and proprioception of schoolboys carrying different weights of backpack · Ergonomics · 2007 · 60 citations
• Adolescents’ Experiences of Idiopathic Scoliosis in the Presurgical Period: A Qualitative Study · Journal of Pediatric Psychology · 2021 · 34 citations
• Screening for scoliosis · International Journal of Rehabilitation Research · 2011 · 27 citations
• Effects of inspiratory muscle training on respiratory muscle strength, respiratory function and functional capacity in adolescents with idiopathic scoliosis · Wiener klinische Wochenschrift · 2023 · 17 citations
• The Tampa Scale of Kinesiophobia: Structural Validation among Adolescents with Idiopathic Scoliosis Undergoing Spinal Fusion Surgery · Physical & Occupational Therapy In Pediatrics · 2020 · 17 citations
• Preservice Teachers in Two Different Multicultural Field Programs: The Complex Influences of School Context. · Research in the schools · 1996 · 17 citations
• A research design in technology-enhanced scaffolding in language teaching: What lessonLAMS can offer at the interface of educational and language learning research · Teaching English With Technology · 2012 · 14 citations
• The role of school medicine in the early detection and management of adolescent idiopathic scoliosis · Wiener klinische Wochenschrift · 2022 · 13 citations
• Beyond the Interview Guide: Experiences of Practically and Mindfully Implementing Interview Guidelines When Conducting Research With Children and Adolescents With Chronic Conditions and Their Siblings · International Journal of Qualitative Methods · 2021 · 13 citations

Most recent work

• Patient-perceived recovery after posterior spinal fusion: evaluating minimum clinically important difference (MCID) in adolescents with idiopathic scoliosis · Spine Deformity · 2026
• Comment on “Sagittal misalignment patterns and pathomechanical hypothesis of adolescent idiopathic scoliosis: a radiographic analysis” · Spine Deformity · 2026
• Biomechanical compensatory chain and residual compensation potential in aging spinal deformity: a narrative review and multimodal assessment framework · Frontiers in Medicine · 2026
• Exosome-mediated cholesterol flow drives scoliosis progression via promoting the spinal cartilage-bone positive feedback · Communications Biology · 2026
• Methodological exploration of stress-based finite element growth modeling for long-term brace treatment evaluation in adolescent idiopathic scoliosis · Medical & Biological Engineering & Computing · 2026
• Advanced machine learning model for Cobb angle progression in adolescent idiopathic scoliosis with surface topography: a multicenter, prospective, observational study · European Spine Journal · 2026
• Radiation-free assessment of the 3D morphology of the adolescent scoliotic spine: a feasibility study using MRI derived quantitative synthetic CT · Spine Deformity · 2026
• Biomechanical characteristics and therapeutic effects of Traditional Chinese Medicine manual therapy in adolescent idiopathic scoliosis: study protocol for a randomized controlled trial · Frontiers in Medicine · 2026
• The dose-response relationship between physical activity and school scoliosis screening positive in children and adolescents: a preliminary cross-sectional study · Frontiers in Pediatrics · 2026
• Relationship between idiopathic scoliosis and body composition -a case-control study · Frontiers in Physiology · 2026

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