Wave-slope soaring of the brown pelican.

BACKGROUND: From the laboratory at Scripps Institution of Oceanography, it is common to see the brown pelican (Pelecanus occidentalis) traveling along the crests of ocean waves just offshore of the surf-zone. When flying in this manner, the birds can travel long distances without flapping, centimeters above the ocean's surface. Here we derive a theoretical framework for assessing the energetic savings related to this behavior, 'wave-slope soaring,' in which an organism in flight takes advantage of localized updrafts caused by traveling ocean surface gravity waves. METHODS: The energy cost of steady, constant altitude flight in and out of ground effect are analyzed as controls. Potential flow theory is used to quantify the ocean wave-induced wind associated with near-shoaling, weakly nonlinear, shallow water ocean surface gravity waves moving through an atmosphere initially at rest. Using perturbation theory and the Green's function for Laplace's equation in 2D with Dirichlet boundary conditions, we obtain integrals for the horizontal and vertical components of the wave-induced wind in a frame of reference moving with the wave. Wave-slope soaring flight is then analyzed using an energetics-based approach for waves under a range of ocean conditions and the body plan of P. occidentalis. RESULTS: For ground effect flight, we calculate a ∼15 - 25% reduction in cost of transport as compared with steady, level flight out of ground effect. When wave-slope soaring is employed at flight heights ∼2m in typical ocean conditions (2m wave height, 15s period), we calculate 60-70% reduction in cost of transport as compared with flight in ground effect. A relatively small increase in swell amplitude or decrease in flight height allows up to 100% of the cost of transport to be offset by wave-slope soaring behavior. CONCLUSIONS: The theoretical development presented here suggests there are energy savings associated with wave-slope soaring. Individual brown pelicans may significantly decrease their cost of transport utilizing this mode of flight under typical ocean conditions. Thus wave-slope soaring may provide fitness benefit to these highly mobile organisms that depend on patchy prey distribution over large home ranges.

A database of lumbar spinal mechanical behavior for validation of spinal analytical models.

Data from two experimental studies with eight specimens each of spinal motion segments and/or intervertebral discs are presented in a form that can be used for comparison with finite element model predictions. The data include the effect of compressive preload (0, 250 and 500N) with quasistatic cyclic loading (0.0115Hz) and the effect of loading frequency (1, 0.1, 0.01 and 0.001Hz) with a physiological compressive preload (mean 642N). Specimens were tested with displacements in each of six degrees of freedom (three translations and three rotations) about defined anatomical axes. The three forces and three moments in the corresponding axis system were recorded during each test. Linearized stiffness matrices were calculated that could be used in multi-segmental biomechanical models of the spine and these matrices were analyzed to determine whether off-diagonal terms and symmetry assumptions should be included. These databases of lumbar spinal mechanical behavior under physiological conditions quantify behaviors that should be present in finite element model simulations. The addition of more specimens to identify sources of variability associated with physical dimensions, degeneration, and other variables would be beneficial. Supplementary data provide the recorded data and Matlab® codes for reading files. Linearized stiffness matrices derived from the tests at different preloads revealed few significant unexpected off-diagonal terms and little evidence of significant matrix asymmetry.

Adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is the most common form of structural spinal deformities that have a radiological lateral Cobb angle - a measure of spinal curvature - of ≥10(°). AIS affects between 1% and 4% of adolescents in the early stages of puberty and is more common in young women than in young men. The condition occurs in otherwise healthy individuals and currently has no recognizable cause. In the past few decades, considerable progress has been made towards understanding the clinical patterns and the three-dimensional pathoanatomy of AIS. Advances in biomechanics and technology and their clinical application, supported by limited evidence-based research, have led to improvements in the safety and outcomes of surgical and non-surgical treatments. However, the definite aetiology and aetiopathogenetic mechanisms that underlie AIS are still unclear. Thus, at present, both the prevention of AIS and the treatment of its direct underlying cause are not possible.

Metabolic Effects of Angulation, Compression, and Reduced Mobility on Annulus Fibrosis in a Model of Altered Mechanical Environment in Scoliosis.

STUDY DESIGN: Comparison of disc tissue from rat tails in 6 groups with different mechanical conditions imposed. OBJECTIVES: To identify disc annulus changes associated with the supposed altered biomechanical environment in a spine with scoliosis deformity using an immature rat model that produces disc narrowing and wedging. BACKGROUND: Intervertebral discs become wedged and narrowed in a scoliosis curve, probably partly because of an altered biomechanical environment. METHODS: We subjected tail discs of 5-week-old immature Sprague-Dawley rats to an altered mechanical environment using an external apparatus applying permutations of loading and deformity for 5 weeks. Together with a sham and a control group, we studied 4 groups of rats: A) 15° angulation, B) angulation with 0.1 MPa compression, C) 0.1 MPa compression, and R) reduced mobility. We measured disc height changes and matrix composition (water, deoxyribonucleic acid, glycosaminoglycan, and hyaluronic acid content) after 5 weeks, and proline and sulphate incorporation and messenger ribonucleic acid expression at 5 days and 5 weeks. RESULTS: After 5 weeks, disc space was significantly narrowed relative to internal controls in all 4 intervention groups. Water content and cellularity (deoxyribonucleic acid content) were not different at interventional levels relative to internal controls and not different between the concave and convex sides of the angulated discs. There was increased glycosaminoglycan content in compressed tissue (in Groups B and C), as expected, and compression resulted in a decrease in hyaluronic acid size. We observed slightly increased incorporation of tritiated proline into the concave side of angulated discs and compressed discs. Asymmetries of gene expression in Groups A and B and some group-wise differences did not identify consistent patterns associating the discs' responses to mechanical alterations. CONCLUSIONS: Intervertebral discs in this model underwent substantial narrowing after 5 weeks, with minimal alteration in tissue composition and minimal evidence of metabolic changes.

Contributions of Remodeling and Asymmetrical Growth to Vertebral Wedging in a Scoliosis Model.

STUDY DESIGN: We performed a laboratory study of rats of 3 different ages with imposed angulation and compressive loading to caudal vertebrae to determine causes of vertebral wedging. OBJECTIVES: The purpose was to determine the percentage of total vertebral wedging that was caused by asymmetric growth, vertebral body, and epiphyseal wedging. Approval from the Institutional Animal Care and Use Committee, the University of Vermont, was obtained for the live animal procedures used in this study. BACKGROUND SUMMARY: Vertebral wedging from asymmetrical growth (Hueter-Volkmann law) is reported to cause vertebral wedging in scoliosis with little attention to the possible contribution of bony remodeling (Wolff's law). METHODS: In our study, an external fixator imposed a 30° lateral curvature and compression of 0.1 megapascal (MPa) in 5- and 14-week-old animals (Groups 1 and 2) and 0.2 MPa in 14- and 32-week-old animals (groups 3 and 4). Total vertebral wedging was measured from micro CT scans. Wedging due to asymmetrical growth and epiphyseal remodeling was calculated from fluorescent labels and the difference was attributed to vertebral body wedging. RESULTS: Total vertebral wedging averaged 18°, 6°, 10° and 5° in Groups 1, 2, 3, and 4, respectively. Metaphyseal asymmetrical growth averaged 8°, 1°, 4°, 0° (44%, 17%, 40% and 0% of total). Epiphyseal wedging averaged 9°, 0°, 3°, and -1°. The difference (vertebral body) averaged 1°, 5°, 3°, and 7° (6%, 83%, 30% and 140% of total). The growth of the loaded vertebrae as a percentage of control vertebrae was 56%, 39% and 25% in Groups 1, 2 and 3; negligible in Group 4. Vertebral body cortical remodeling, with increased thickness and increased curvature on the concave side was evident in young animals and 0.2 MPa loaded older animals. CONCLUSIONS: We conclude that asymmetrical growth was the largest contributor to vertebral wedging in young animals; vertebral body remodeling was the largest contributor in older animals. If, conversely, vertebral wedging can be corrected by appropriate loading in young and old animals, it has important implications for the nonfusion treatment of scoliosis.

Intervertebral disc changes with angulation, compression and reduced mobility simulating altered mechanical environment in scoliosis.

PURPOSE: The intervertebral discs become wedged and narrowed in scoliosis, and this may result from altered biomechanical environment. The effects of four permutations of disc compression, angulation and reduced mobility were studied to identify possible causes of progressive disc deformity in scoliosis. The purpose of this study was to document morphological and biomechanical changes in four different models of altered mechanical environment in intervertebral discs of growing rats and in a sham and control groups. METHODS: External rings were attached by percutaneous pins transfixing adjacent caudal vertebrae of 5-week-old Sprague-Dawley rats. Four experimental Groups of animals underwent permutations of the imposed mechanical conditions (A) 15° disc angulation, (B) angulation with 0.1 MPa compression, (C) 0.1 MPa compression and (R) reduced mobility (N = 20 per group), and they were compared with a sham group (N = 12) and control group (N = 8) (total of 6 groups of animals). The altered mechanical conditions were applied for 5 weeks. Intervertebral disc space was measured from micro-CT images at weeks 1 and 5. Post euthanasia, lateral bending stiffness of experimental and within-animal control discs was measured in a mechanical testing jig and collagen crimp was measured from histological sections. RESULTS: After 5 weeks, micro-CT images showed disc space loss averaging 35, 53, 56 and 35% of the adjacent disc values in the four intervention groups. Lateral bending stiffness was 4.2 times that of within-animal controls in Group B and 2.3 times in Group R. The minimum stiffness occurred at an angle close to the in vivo value, indicating that angulated discs had adapted to the imposed deformity, this is also supported by measurements of collagen crimping at concave and convex sides of the disc annuli. CONCLUSION: Loss of disc space was present in all of the instrumented discs. Thus, reduced mobility, that was common to all interventions, may be a major source of the observed disc changes and may be a factor in disc deformity in scoliosis. Clinically, it is possible that rigid bracing for control of scoliosis progression may have secondary harmful effects by reducing spinal mobility.

Abdominal muscle activation increases lumbar spinal stability: analysis of contributions of different muscle groups.

BACKGROUND: Antagonistic activation of abdominal muscles and increased intra-abdominal pressure are associated with both spinal unloading and spinal stabilization. Rehabilitation regimens have been proposed to improve spinal stability via selective recruitment of certain trunk muscle groups. This biomechanical analytical study addressed whether lumbar spinal stability is increased by such selective activation. METHODS: The biomechanical model included anatomically realistic three-layers of curved abdominal musculature, rectus abdominis and 77 symmetrical pairs of dorsal muscles. The muscle activations were calculated with the model loaded with either flexion, extension, lateral bending or axial rotation moments up to 60 Nm, along with intra-abdominal pressure up to 5 or 10 kPa (37.5 or 75 mm Hg) and partial bodyweight. After solving for muscle forces, a buckling analysis quantified spinal stability. Subsequently, different patterns of muscle activation were studied by forcing activation of selected abdominal muscles to at least 10% or 20% of maximum. FINDINGS: Spinal stability increased by an average factor of 1.8 with doubling of intra-abdominal pressure. Forcing at least 10% activation of obliques or transversus abdominis muscles increased stability slightly for efforts other than flexion, but forcing at least 20% activation generally did not produce further increase in stability. Forced activation of rectus abdominis did not increase stability. INTERPRETATION: Based on analytical predictions, the degree of stability was not substantially influenced by selective forcing of muscle activation. This casts doubt on the supposed mechanism of action of specific abdominal muscle exercise regimens that have been proposed for low back pain rehabilitation.

Refinement of elastic, poroelastic, and osmotic tissue properties of intervertebral disks to analyze behavior in compression.

Intervertebral disks support compressive forces because of their elastic stiffness as well as the fluid pressures resulting from poroelasticity and the osmotic (swelling) effects. Analytical methods can quantify the relative contributions, but only if correct material properties are used. To identify appropriate tissue properties, an experimental study and finite element analytical simulation of poroelastic and osmotic behavior of intervertebral disks were combined to refine published values of disk and endplate properties to optimize model fit to experimental data. Experimentally, nine human intervertebral disks with adjacent hemi-vertebrae were immersed sequentially in saline baths having concentrations of 0.015, 0.15, and 1.5 M and the loss of compressive force at constant height (force relaxation) was recorded over several hours after equilibration to a 300-N compressive force. Amplitude and time constant terms in exponential force-time curve-fits for experimental and finite element analytical simulations were compared. These experiments and finite element analyses provided data dependent on poroelastic and osmotic properties of the disk tissues. The sensitivities of the model to alterations in tissue material properties were used to obtain refined values of five key material parameters. The relaxation of the force in the three bath concentrations was exponential in form, expressed as mean compressive force loss of 48.7, 55.0, and 140 N, respectively, with time constants of 1.73, 2.78, and 3.40 h. This behavior was analytically well represented by a model having poroelastic and osmotic tissue properties with published tissue properties adjusted by multiplying factors between 0.55 and 2.6. Force relaxation and time constants from the analytical simulations were most sensitive to values of fixed charge density and endplate porosity.

Nonfusion treatment of adolescent idiopathic scoliosis by growth modulation and remodeling.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a common disorder in which the spine gradually develops a curvature that is first detected in patients between 11 and 17 years of age. The only accepted treatment methods are bracing and surgery. Whether brace treatment alters the natural history is being questioned, and patient compliance is low. Surgery usually includes a spinal fusion that creates a rigid spine and concentrates stresses at the ends. METHODS: This study focuses on correlating the laboratory results with clinical reports for treating patients with AIS. In the laboratory, scoliosis with vertebral wedging has been created by asymmetric mechanical loading and has been corrected by reversing the loading. In the clinic, bracing and derotational casting have been successful in some reports, but compliance has been a problem with bracing and derotational casts have mainly been used in young children. Operative treatment has been successful, but a nonfusion operation remains elusive. FINDINGS AND RESULTS: In the laboratory, axial loading of growth plates altered growth according to the Hueter-Volkmann law, which states that compression decreases and distraction increases growth. Asymmetric loading of the spine caused asymmetric growth resulting in scoliosis with vertebral wedging. Asymmetric loading of tail vertebrae created vertebral wedging according to Wolff's law, which states that the bone remodels over time in response to prevailing mechanical demands. In the clinic, studies have shown that bracing may work if patients wore the brace as prescribed. Derotational casting in young children has been shown to prevent progression and even correct the scoliosis in some patients. Convex vertebral stapling has been successful in mild curves, but the results in larger curves have been disappointing. Anterolateral tethering has been successful in mild curves in young patients, but there is limited experience with this technique in patients with large curves. CONCLUSIONS: A brace that applies the appropriate loading and is worn as prescribed may dramatically improve the results of brace treatment. A procedure using external fixation or adjustable anterolateral tethering may achieve a nonfusion correction of AIS. LEVEL OF EVIDENCE: Level II.

Terminology - glossary including acronyms and quotations in use for the conservative spinal deformities treatment: 8th SOSORT consensus paper.

BACKGROUND: This report is the SOSORT Consensus Paper on Terminology for use in the treatment of conservative spinal deformities. Figures are provided and relevant literature is cited where appropriate. METHODS: The Delphi method was used to reach a preliminary consensus before the meeting, where the terms that still needed further clarification were discussed. RESULTS: A final agreement was found for all the terms, which now constitute the base of this glossary. New terms will be added after being discussed and accepted. DISCUSSION: When only one set of terms is used for communication in a place or among a group of people, then everyone can clearly and efficiently communicate. This principle applies for any professional group. Until now, no common set of terms was available in the field of the conservative treatment of scoliosis and spinal deformities. This glossary gives a common base language to draw from to discuss data, findings and treatment.

Intra-abdominal pressure and abdominal wall muscular function: Spinal unloading mechanism.

BACKGROUND: The roles of antagonistic activation of abdominal muscles and of intra-abdominal pressurization remain enigmatic, but are thought to be associated with both spinal unloading and spinal stabilization in activities such as lifting. Biomechanical analyses are needed to understand the function of intra-abdominal pressurization because of the anatomical and physiological complexity, but prior analyses have been over-simplified. METHODS: To test whether increased intra-abdominal pressure was associated with reduced spinal compression forces for efforts that generated moments about each of the principal axis directions, a previously published biomechanical model of the spine and its musculature was modified by the addition of anatomically realistic three-layers of curved abdominal musculature connected by fascia to the spine. Published values of muscle cross-sectional areas and the active and passive stiffness properties were assigned. The muscle activations were calculated assuming minimized muscle stress and stretch for the model loaded with flexion, extension, lateral bending and axial rotation moments of up to 60 Nm, along with intra-abdominal pressurization of 5 or 10 kPa (37.5 or 75 mm Hg) and partial bodyweight (340 N). FINDINGS: The analysis predicted a reduction in spinal compressive force with increase in intra-abdominal pressurization from 5 to 10 kPa. This reduction at 60 Nm external effort was 21% for extension effort, 18% for flexion effort, 29% for lateral bending and 31% for axial rotation. INTERPRETATION: This analysis predicts that intra-abdominal pressure produces spinal unloading, and shows likely muscle activation patterns that achieve this.

The role of remodeling and asymmetric growth in vertebral wedging.

BACKGROUND: Scoliosis with vertebral wedging is thought to be caused by asymmetric growth (Hueter-Volkmann law), but vertebral diaphyseal remodeling (Wolff's law) may also contribute to the deformity. We investigated whether vertebral wedging in scoliosis might involve both mechanisms. METHODS: An external fixator was used to impose a 30 degrees scoliosis and compression of 0.1 or 0.2 MPa to the tails of 10 5-week-old and 20 14-week-old Sprague-Dawley rats for 6 weeks. The rats were divided into three groups of 10 animals each: Group 1: 5-week-old animals with 0.1 MPa compression; Group 2: 14-week-old animals with 0.1 MPa compression; Group 3: 14-week-old animals with 0.2 MPa compression. Vertebral wedging and diaphyseal curvature were measured from micro CT scans performed at weeks 1, 3, and 6. Wedging due to asymmetrical growth and remodeling was calculated from a Calcein label administered at week 3 and a Xylenol label at week 6. RESULTS: The growth rate of the loaded vertebrae as a per cent of control vertebrae was 60% in Group 1, 40% in Group 2, and 30% in Group 3. The growth rate of control vertebrae in 14-week-old animals was 16% that of 5-week-old animals. The animals in all 3 groups developed a scoliosis with vertebral wedging that averaged 18.7 degrees in Group 1, 8.2 degrees in Group 2, and 10.1 degrees in Group 3. Asymmetric growth was much greater in Group 1 (5-week-old) animals. The ossified epiphyses became wedged and diaphyseal remodeling occurred in all groups. CONCLUSIONS: The major contribution to the vertebral wedging was asymmetric growth in the 5-week-old animals and diaphyseal remodeling in the 14-week-old animals. The results support the concept that if appropriate loads can be applied to human vertebrae through minimally invasive techniques, scoliosis and vertebral wedging can be corrected without a spinal fusion in both adolescents and adults.

The central hip vertical axis: a reference axis for the Scoliosis Research Society three-dimensional classification of idiopathic scoliosis.

STUDY DESIGN: Reliability comparison of 2 radiographic axis systems by inter- and intraobserver variability. OBJECTIVE: To determine whether the central hip vertical axis (CHVA) provides a more reliable reference axis for the evaluation of scoliosis. SUMMARY OF BACKGROUND DATA: Current practices in the evaluation of the scoliotic spine use the central sacral vertical line (CSVL), a true vertical drawn upward from the middle of S1, to assess the spinal deformity. However, the CVSL is defined only in the coronal radiographic view and has no corresponding definition in the sagittal view. Therefore, it represents a 2-dimensional positioning of the scoliotic segments relative to the pelvis. In view of this limitation, the Scoliosis Research Society 3-dimensional (3D) scoliosis committee proposed the CHVA, a true vertical bisecting the line segment joining the centers of the 2 femoral heads, as a reference line for the 3D evaluation of the spinal deformity. Unlike the CSVL, the CHVA can be identified in both radiographic views (coronal and sagittal) and has been shown to represent the physiologic center of balance of the spino-pelvic unit. METHODS: A vertical axis was established on preoperative radiographs of 68 Lenke 1 main thoracic curves twice by 5 members of the Scoliosis Research Society 3D scoliosis committee assisted by dedicated software. The user digitized separately on the postero-anterior radiographs, the lateral borders of the S1 facets (for the CSVL), and 3 points on the 2 femoral heads (for the CHVA). The software then drew lines representing both axes. Then the observers determined the lumbar modifier (A, B, and C) using both axes. RESULTS.: There was no intra- and interobserver difference in the position of the CHVA (P > 0.1; SD: 0.4 mm), whereas intraobserver differences were found for the CSVL (P < 0.00007; SD: 0.9 mm). The CHVA was more reproducible and showed better intra- and interobserver agreement (kappa: 0.86/0.75; both excellent reliability), when compared with the CSVL (kappa 0.77/0.61; excellent and good reliability, respectively) for the identification of the lumbar modifier. The CSVL was on average 3.2 mm to the left, when compared with the CHVA generating a shift (A-->B-->C) in the assignment of the lumbar modifier. CONCLUSION: The CHVA is more reproducible and showed better intra- and interobserver agreement, when compared with the CSVL for the identification of the lumbar modifier. The CHVA can be easily computed in 3D and represents the physiologic center of balance of the spino-pelvic unit because it takes into account femoral head support. We recommend keeping the CSVL for 2-dimensional measurement to adapt the measures relative to the CSVL to the proposed CHVA axis and adopting CHVA as the reference axis for 3D evaluation of idiopathic scoliosis.

Limitation of finite element analysis of poroelastic behavior of biological tissues undergoing rapid loading.

The finite element method is used in biomechanics to provide numerical solutions to simulations of structures having complex geometry and spatially differing material properties. Time-varying load deformation behaviors can result from solid viscoelasticity as well as viscous fluid flow through porous materials. Finite element poroelastic analysis of rapidly loaded slow-draining materials may be ill-conditioned, but this problem is not widely known in the biomechanics field. It appears as instabilities in the calculation of interstitial fluid pressures, especially near boundaries and between different materials. Accurate solutions can require impractical compromises between mesh size and time steps. This article investigates the constraints imposed by this problem on tissues representative of the intervertebral disc, subjected to moderate physiological rates of deformation. Two test cylindrical structures were found to require over 10(4) linear displacement-constant pressure elements to avoid serious oscillations in calculated fluid pressure. Fewer Taylor-Hood (quadratic displacement-linear pressure elements) were required, but with complementary increases in computational costs. The Vermeer-Verruijt criterion for 1D mesh size provided guidelines for 3D mesh sizes for given time steps. Pressure instabilities may impose limitations on the use of the finite element method for simulating fluid transport behaviors of biological soft tissues at moderately rapid physiological loading rates.

Cobb angle progression in adolescent scoliosis begins at the intervertebral disc.

STUDY DESIGN: Longitudinal radiographic study of patients with progressive idiopathic scoliosis. OBJECTIVE: To determine the relative contributions of vertebral and disc wedging to the increase in Cobb angle during 3 phases of adolescent skeletal growth and maturation. SUMMARY OF BACKGROUND DATA: Both disc wedging and vertebral body wedging are found in progressive scoliosis, but their relative contribution to curve progression over time is unknown. Which occurs first is important for understanding how scoliosis progresses and for developing methods to halt progression. Previous studies have not properly identified maturity, and provide conflicting results. METHODS: Eighteen girls were followed through their adolescent growth spurt with serial spine and hand skeletal age radiographs. Each Cobb angle was divided into disc wedge angles and vertebral wedge angles. The corresponding hand radiographs provided a measure of maturity level, the Digital Skeletal Age (DSA). The disc versus bone contributions to the Cobb angle were then compared during 3 growth phases: before the growth spurt, during the growth spurt and after the growth spurt. Significance of relative changes was assessed with the Wilcoxon 2-sided mean rank test. RESULTS: Before the growth spurt, there was no difference in relative contributions of the disc and the bone (3 degrees vs. 0 degrees, P = 0.38) to curve progression. During the growth spurt, the mean disc component progressed significantly more than that of the vertebrae (15 degrees vs. 0 degrees, P = 0.0002). This reversed following the growth spurt with the vertebral component progressing more than the disc (10 degrees vs. 0 degrees, P = 0.01). CONCLUSION: Adolescent idiopathic scoliosis initially increases through disc wedging during the rapid growth spurt with progressive vertebral wedging occurring later.

Interobserver and intraobserver variability in the identification of the Lenke classification lumbar modifier in adolescent idiopathic scoliosis.

STUDY DESIGN: Interobserver and intraobserver reliability study for the identification of the Lenke classification lumbar modifier by a panel of experts compared with a computer algorithm. OBJECTIVES: To measure the variability of the Lenke classification lumbar modifier and determine if computer assistance using 3-dimensional spine models can improve the reliability of classification. SUMMARY OF BACKGROUND DATA: The lumbar modifier has been proposed to subclassify Lenke scoliotic curve types into A, B, and C on the basis of the relationship between the central sacral vertical line (CSVL) and the apical lumbar vertebra. Landmarks for identification of the CSVL have not been clearly defined, and the reliability of the actual CSVL position and lumbar modifier selection have never been tested independently. Therefore, the value of the lumbar modifier for curve classification remains unknown. METHODS: The preoperative radiographs of 68 patients with adolescent idiopathic scoliosis presenting a Lenke type 1 curve were measured manually twice by 6 members of the Scoliosis Research Society 3-dimensional classification committee at 6 months interval. Intraobserver and interobserver reliability was quantified using the percentage of agreement and kappa statistics. In addition, the lumbar curve of all subjects was reconstructed in 3-dimension using a stereoradiographic technique and was submitted to a computer algorithm to infer the lumbar modifier according to measurements from the pedicles. RESULTS: Interobserver rates for the first trial showed a mean kappa value of 0.56. Second trial rates were higher with a mean kappa value of 0.64. Intraobserver rates were evaluated at a mean kappa value of 0.69. The computer algorithm was successful in identifying the lumbar curve type and was in agreement with the observers by a proportion up to 93%. CONCLUSIONS: Agreement between and within observers for the Lenke lumbar modifier is only moderate to substantial with manual methods. Computer assistance with 3-dimensional models of the spine has the potential to decrease this variability.