Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors



To define the relationship between 3D radiological features, psychological factors, and back pain prevalence and intensity in patients with adolescent idiopathic scoliosis (AIS).


Consecutive AIS patients answered self-reported questionnaires and underwent simultaneous posterior–anterior and lateral scans of the spine (EOS Imaging, Paris, France). 3D reconstructions of the spine and pelvis reported 18 parameters in the coronal, sagittal, and axial plane.


Hundred and twenty-four patients with AIS were included in the study. Overall, 90% of AIS patients reported having some back pain over the last 6 months and 85.8% over the last 30 days. Pain intensity in the last month was reported to be mild in 37.5%, moderate in 31.8%, moderate to severe in 24.3%, and severe in 6.54% of cases. Location of back pain was associated with location of main curve (P = 0.036). Low back pain was associated with higher lumbar apical AVR and lower lumbar lordosis (P < 0.05). Independent risk factors for back pain in AIS were pain catastrophizing (B = 0.061, P = 0.035), poorer self-reported state of mental health (B = − 0.872, P = 0.023), decreased thoracic kyphosis (B = − 0.033, P = 0.044) and greater pelvic asymmetry (B = 0.146, P = 0.047). There was a significant association between self-reported pain intensity in the last 24 h and levels of catastrophizing. Pain catastrophizing level influenced the relationship between deformity severity and pain intensity. In low catastrophizers, there was a significant association between greater deformity severity and higher pain levels.


Back pain in AIS is multifactorial and associated with psychological and morphological parameters. Pain catastrophizing is an important construct in AIS-related pain and should be taken into consideration when evaluating these patients.

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  1. 1.

    Teles AR, Ocay DD, Bin Shebreen A, Tice A, Saran N, Ouellet JA, Ferland CE (2019) Evidence of impaired pain modulation in adolescents with idiopathic scoliosis and chronic back pain. Spine J 19:677–686.

    Article  PubMed  Google Scholar 

  2. 2.

    Landman Z, Oswald T, Sanders J, Diab M, Spinal Deformity Study G (2011) Prevalence and predictors of pain in surgical treatment of adolescent idiopathic scoliosis. Spine 36:825–829.

    Article  Google Scholar 

  3. 3.

    Ramirez N, Johnston CE, Browne RH (1997) The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am 79:364–368

    CAS  Article  Google Scholar 

  4. 4.

    Theroux J, Le May S, Fortin C, Labelle H (2015) Prevalence and management of back pain in adolescent idiopathic scoliosis patients: a retrospective study. Pain Res Manag 20:153–157

    Article  Google Scholar 

  5. 5.

    Morse LJ, Kawakami N, Lenke LG, Sucato DJ, Sanders JO, Diab M (2012) Culture and ethnicity influence outcomes of the Scoliosis Research Society Instrument in adolescent idiopathic scoliosis. Spine 37:1072–1076.

    Article  PubMed  Google Scholar 

  6. 6.

    Pellegrino LN, Avanzi O (2014) Prospective evaluation of quality of life in adolescent idiopathic scoliosis before and after surgery. J Spinal Disord Tech 27:409–414.

    Article  PubMed  Google Scholar 

  7. 7.

    Weiss HR (2008) Adolescent idiopathic scoliosis (AIS)—an indication for surgery? A systematic review of the literature. Disabil Rehabil 30:799–807.

    Article  PubMed  Google Scholar 

  8. 8.

    Balague F, Pellise F (2016) Adolescent idiopathic scoliosis and back pain. Scoliosis Spinal Disord 11:27.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Matamalas A, Bago J, D'Agata E, Pellise F (2014) Body image in idiopathic scoliosis: a comparison study of psychometric properties between four patient-reported outcome instruments. Health Qual Life Outcomes 12:81.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Bisson D, Lama D, Abduljabbar F, Rosenzweig DH, Saran N, Ouellet JA, Haglund L (2018) Facet joint degeneration in adolescent idiopathic scoliosis. JOR Spine.

    Article  Google Scholar 

  11. 11.

    Ferrero E, Lafage R, Diebo BG, Challier V, Illharreborde B, Schwab F, Skalli W, Guigui P, Lafage V (2017) Tridimensional analysis of rotatory subluxation and sagittal spinopelvic alignment in the setting of adult spinal deformity. Spine Deform 5:255–264.

    Article  PubMed  Google Scholar 

  12. 12.

    Trammell TR, Schroeder RD, Reed DB (1988) Rotatory olisthesis in idiopathic scoliosis. Spine 13:1378–1382

    CAS  Article  Google Scholar 

  13. 13.

    Shen J, Kadoury S, Labelle H, Roy-Beaudry M, Aubin CE, Parent S (2017) Geometric torsion in adolescent idiopathic scoliosis: a new method to differentiate between Lenke 1 subtypes. Spine 42:E532–E538.

    Article  PubMed  Google Scholar 

  14. 14.

    Shen J, Kadoury S, Labelle H, Parent S (2016) Geometric torsion in adolescent idiopathic scoliosis: a surgical outcomes study of lenke type 1 patients. Spine 41:1903–1907.

    Article  PubMed  Google Scholar 

  15. 15.

    Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC (2001) Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 17:52–64

    CAS  Article  Google Scholar 

  16. 16.

    Severeijns R, Vlaeyen JW, van den Hout MA, Weber WE (2001) Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain 17:165–172

    CAS  Article  Google Scholar 

  17. 17.

    Wojtowicz AA, Greenley RN, Gumidyala AP, Rosen A, Williams SE (2014) Pain severity and pain catastrophizing predict functional disability in youth with inflammatory bowel disease. J Crohns Colitis 8:1118–1124.

    Article  PubMed  Google Scholar 

  18. 18.

    Asmundson GJ, Noel M, Petter M, Parkerson HA (2012) Pediatric fear-avoidance model of chronic pain: foundation, application and future directions. Pain Res Manag 17:397–405

    Article  Google Scholar 

  19. 19.

    Vervoort T, Eccleston C, Goubert L, Buysse A, Crombez G (2010) Children's catastrophic thinking about their pain predicts pain and disability 6 months later. Eur J Pain 14:90–96.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Crombez G, Bijttebier P, Eccleston C, Mascagni T, Mertens G, Goubert L, Verstraeten K (2003) The child version of the pain catastrophizing scale (PCS-C): a preliminary validation. Pain 104:639–646

    Article  Google Scholar 

  21. 21.

    Guite JW, McCue RL, Sherker JL, Sherry DD, Rose JB (2011) Relationships among pain, protective parental responses, and disability for adolescents with chronic musculoskeletal pain: the mediating role of pain catastrophizing. Clin J Pain 27:775–781.

    Article  PubMed  Google Scholar 

  22. 22.

    Walker LS, Sherman AL, Bruehl S, Garber J, Smith CA (2012) Functional abdominal pain patient subtypes in childhood predict functional gastrointestinal disorders with chronic pain and psychiatric comorbidities in adolescence and adulthood. Pain 153:1798–1806.

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Miro J, Castarlenas E, Huguet A (2009) Evidence for the use of a numerical rating scale to assess the intensity of pediatric pain. Eur J Pain 13:1089–1095.

    Article  PubMed  Google Scholar 

  24. 24.

    Ruskin D, Lalloo C, Amaria K, Stinson JN, Kewley E, Campbell F, Brown SC, Jeavons M, McGrath PA (2014) Assessing pain intensity in children with chronic pain: convergent and discriminant validity of the 0 to 10 numerical rating scale in clinical practice. Pain Res Manag 19:141–148

    Article  Google Scholar 

  25. 25.

    Beausejour M, Joncas J, Goulet L, Roy-Beaudry M, Parent S, Grimard G, Forcier M, Lauriault S, Labelle H (2009) Reliability and validity of adapted French Canadian version of Scoliosis Research Society Outcomes Questionnaire (SRS-22) in Quebec. Spine 34:623–628.

    Article  PubMed  Google Scholar 

  26. 26.

    Parkerson HA, Noel M, Page MG, Fuss S, Katz J, Asmundson GJ (2013) Factorial validity of the English-language version of the Pain Catastrophizing Scale–child version. J Pain 14:1383–1389.

    Article  PubMed  Google Scholar 

  27. 27.

    Pielech M, Ryan M, Logan D, Kaczynski K, White MT, Simons LE (2014) Pain catastrophizing in children with chronic pain and their parents: proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure. Pain 155:2360–2367.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Canals J, Marti-Henneberg C, Fernandez-Ballart J, Cliville R, Domenech E (1992) Scores on the State-Trait Anxiety Inventory for children in a longitudinal study of pubertal Spanish youth. Psychol Rep 71:503–512.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Schisler T, Lander J, Fowler-Kerry S (1998) Assessing children's state anxiety. J Pain Symptom Manag 16:80–86

    CAS  Article  Google Scholar 

  30. 30.

    Julian LJ (2011) Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res (Hoboken) 63(Suppl 11):S467–472.

    Article  Google Scholar 

  31. 31.

    Sangole A, Aubin CE, Labelle H, Lenke L, Jackson R, Newton P, Stokes IA, Scoliosis Research Society DSC (2010) The central hip vertical axis: a reference axis for the Scoliosis Research Society three-dimensional classification of idiopathic scoliosis. Spine 35:E530–534.

    Article  Google Scholar 

  32. 32.

    Sekiya T, Aota Y, Yamada K, Kaneko K, Ide M, Saito T (2018) Evaluation of functional and structural leg length discrepancy in patients with adolescent idiopathic scoliosis using the EOS imaging system: a prospective comparative study. Scoliosis Spinal Disord 13:7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Ferrero E, Lafage R, Challier V, Diebo B, Guigui P, Mazda K, Schwab F, Skalli W, Lafage V (2015) Clinical and stereoradiographic analysis of adult spinal deformity with and without rotatory subluxation. Orthop Traumatol Surg Res 101:613–618.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Steib JP, Dumas R, Mitton D, Skalli W (2004) Surgical correction of scoliosis by in situ contouring: a detorsion analysis. Spine 29:193–199.

    Article  PubMed  Google Scholar 

  35. 35.

    Boyer L, Shen J, Parent S, Kadoury S, Aubin CE (2018) Accuracy and precision of seven radiography-based measurement methods of vertebral axial rotation in adolescent idiopathic scoliosis. Spine Deform 6:351–357.

    Article  PubMed  Google Scholar 

  36. 36.

    Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K (2001) Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 83:1169–1181

    CAS  Article  Google Scholar 

  37. 37.

    Theroux J, Le May S, Hebert JJ, Labelle H (2017) Back pain prevalence is associated with curve-type and severity in adolescents with idiopathic scoliosis: a cross-sectional study. Spine 42:E914–E919.

    Article  PubMed  Google Scholar 

  38. 38.

    Djurasovic M, Glassman SD, Sucato DJ, Lenke LG, Crawford CH 3rd, Carreon LY (2018) Improvement in scoliosis research society-22r pain scores after surgery for adolescent idiopathic scoliosis. Spine 43:127–132.

    Article  PubMed  Google Scholar 

  39. 39.

    Steyerberg EW, Vickers AJ, Cook NR, Gerds T, Gonen M, Obuchowski N, Pencina MJ, Kattan MW (2010) Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiology 21:128–138.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Topalis C, Grauers A, Diarbakerli E, Danielsson A, Gerdhem P (2017) Neck and back problems in adults with idiopathic scoliosis diagnosed in youth: an observational study of prevalence, change over a mean four year time period and comparison with a control group. Scoliosis Spinal Disord 12:20.

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, Tanabe N (2011) Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan. Eur Spine J 20:274–279.

    Article  PubMed  Google Scholar 

  42. 42.

    Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J (2013) Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr 13:14.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Kovacs FM, Gestoso M, Gil del Real MT, Lopez J, Mufraggi N, Mendez JI (2003) Risk factors for non-specific low back pain in schoolchildren and their parents: a population based study. Pain 103:259–268

    Article  Google Scholar 

  44. 44.

    Barrey C, Roussouly P, Le Huec JC, D'Acunzi G, Perrin G (2013) Compensatory mechanisms contributing to keep the sagittal balance of the spine. Eur Spine J 22(Suppl 6):S834–841.

    Article  PubMed  Google Scholar 

  45. 45.

    Quinn KP, Dong L, Golder FJ, Winkelstein BA (2010) Neuronal hyperexcitability in the dorsal horn after painful facet joint injury. Pain 151:414–421.

    Article  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Sabharwal S, Zhao C, McKeon JJ, McClemens E, Edgar M, Behrens F (2006) Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram. J Bone Joint Surg Am 88:2243–2251.

    Article  PubMed  Google Scholar 

  47. 47.

    Gurney B (2002) Leg length discrepancy. Gait Posture 15:195–206

    Article  Google Scholar 

  48. 48.

    Pasha S, Aubin CE, Sangole AP, Labelle H, Parent S, Mac-Thiong JM (2014) Three-dimensional spinopelvic relative alignment in adolescent idiopathic scoliosis. Spine 39:564–570.

    Article  PubMed  Google Scholar 

  49. 49.

    Winter RB, Pinto WC (1986) Pelvic obliquity. Its causes and its treatment. Spine 11:225–234

    CAS  Article  Google Scholar 

  50. 50.

    Levangie PK (1999) The association between static pelvic asymmetry and low back pain. Spine 24:1234–1242

    CAS  Article  Google Scholar 

  51. 51.

    Al-Eisa E, Egan D, Deluzio K, Wassersug R (2006) Effects of pelvic skeletal asymmetry on trunk movement: three-dimensional analysis in healthy individuals versus patients with mechanical low back pain. Spine 31:E71–79.

    Article  PubMed  Google Scholar 

  52. 52.

    Havran M, Scholten JD, Breuer P, Lundberg J, Kochersberger G, Newman D, Weiner DK (2016) Deconstructing chronic low back pain in the older adult-step-by-step evidence and expert-based recommendations for evaluation and treatment: part XII: leg length discrepancy. Pain Med 17:2230–2237.

    Article  PubMed  Google Scholar 

  53. 53.

    Rannisto S, Okuloff A, Uitti J, Paananen M, Rannisto PH, Malmivaara A, Karppinen J (2015) Leg-length discrepancy is associated with low back pain among those who must stand while working. BMC Musculoskelet Disord 16:110.

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Nault ML, Allard P, Hinse S, Le Blanc R, Caron O, Labelle H, Sadeghi H (2002) Relations between standing stability and body posture parameters in adolescent idiopathic scoliosis. Spine 27:1911–1917

    Article  Google Scholar 

  55. 55.

    Sahli S, Rebai H, Ghroubi S, Yahia A, Guermazi M, Elleuch MH (2013) The effects of backpack load and carrying method on the balance of adolescent idiopathic scoliosis subjects. Spine J 13:1835–1842.

    Article  PubMed  Google Scholar 

  56. 56.

    Jung JY, Cha EJ, Kim KA, Won Y, Bok SK, Kim BO, Kim JJ (2015) Influence of pelvic asymmetry and idiopathic scoliosis in adolescents on postural balance during sitting. Biomed Mater Eng 26(Suppl 1):S601–610.

    Article  PubMed  Google Scholar 

  57. 57.

    Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, Schubiner H, Keefe FJ (2011) Pain and emotion: a biopsychosocial review of recent research. J Clin Psychol 67:942–968.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Caes L, Vervoort T, Eccleston C, Goubert L (2012) Parents who catastrophize about their child's pain prioritize attempts to control pain. Pain 153:1695–1701.

    Article  PubMed  Google Scholar 

  59. 59.

    Caes L, Vervoort T, Eccleston C, Vandenhende M, Goubert L (2011) Parental catastrophizing about child's pain and its relationship with activity restriction: the mediating role of parental distress. Pain 152:212–222.

    CAS  Article  PubMed  Google Scholar 

  60. 60.

    Vardeh D, Mannion RJ, Woolf CJ (2016) Toward a mechanism-based approach to pain diagnosis. J Pain 17:T50–69.

    Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Misterska E, Glowacki J, Okret A, Laurentowska M, Glowacki M (2017) Back and neck pain and function in females with adolescent idiopathic scoliosis: a follow-up at least 23 years after conservative treatment with a Milwaukee brace. PLoS ONE 12:e0189358.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  62. 62.

    Smorgick Y, Mirovsky Y, Baker KC, Gelfer Y, Avisar E, Anekstein Y (2013) Predictors of back pain in adolescent idiopathic scoliosis surgical candidates. J Pediatr Orthop 33:289–292.

    Article  PubMed  Google Scholar 

  63. 63.

    Joncas J, Labelle H, Poitras B, Duhaime M, Rivard CH, Le Blanc R (1996) Dorso-lumbal pain and idiopathic scoliosis in adolescence. Ann Chir 50:637–640

    CAS  PubMed  Google Scholar 

  64. 64.

    Deceuninck J, Bernard JC (2012) Quality of life and brace-treated idiopathic scoliosis: a cross-sectional study performed at the Centre des Massues on a population of 120 children and adolescents. Ann Phys Rehabil Med 55:93–102.

    CAS  Article  PubMed  Google Scholar 

  65. 65.

    Holley AL, Wilson AC, Palermo TM (2017) Predictors of the transition from acute to persistent musculoskeletal pain in children and adolescents: a prospective study. Pain 158:794–801.

    Article  PubMed  PubMed Central  Google Scholar 

  66. 66.

    Simons LE, Claar RL, Logan DL (2008) Chronic pain in adolescence: parental responses, adolescent coping, and their impact on adolescent's pain behaviors. J Pediatr Psychol 33:894–904.

    Article  PubMed  PubMed Central  Google Scholar 

  67. 67.

    Claar RL, Baber KF, Simons LE, Logan DE, Walker LS (2008) Pain coping profiles in adolescents with chronic pain. Pain 140:368–375.

    Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Al-Aubaidi Z, Lebel D, Oudjhane K, Zeller R (2013) Three-dimensional imaging of the spine using the EOS system: is it reliable? A comparative study using computed tomography imaging. J Pediatr Orthop B 22:409–412.

    Article  PubMed  Google Scholar 

  69. 69.

    Gille O, Champain N, Benchikh-El-Fegoun A, Vital JM, Skalli W (2007) Reliability of 3D reconstruction of the spine of mild scoliotic patients. Spine 32:568–573.

    Article  PubMed  Google Scholar 

  70. 70.

    Ilharreborde B, Steffen JS, Nectoux E, Vital JM, Mazda K, Skalli W, Obeid I (2011) Angle measurement reproducibility using EOS three-dimensional reconstructions in adolescent idiopathic scoliosis treated by posterior instrumentation. Spine 36:E1306–1313.

    Article  PubMed  Google Scholar 

  71. 71.

    Glaser DA, Doan J, Newton PO (2012) Comparison of 3-dimensional spinal reconstruction accuracy: biplanar radiographs with EOS versus computed tomography. Spine 37:1391–1397.

    Article  PubMed  Google Scholar 

  72. 72.

    Quartana PJ, Campbell CM, Edwards RR (2009) Pain catastrophizing: a critical review. Expert Rev Neurother 9:745–758.

    Article  PubMed  PubMed Central  Google Scholar 

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The study was financially supported by AOTK (CEF, JAO and MSG) and the Shriners Hospitals (CEF and JAO).

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Correspondence to Catherine E. Ferland.

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Teles, A.R., St-Georges, M., Abduljabbar, F. et al. Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors. Eur Spine J 29, 1959–1971 (2020).

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  • Scoliosis
  • Back pain
  • Pain catastrophizing
  • Anxiety
  • Adolescents
  • Pain
  • Spine