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Purpose The complex three-dimensional spinal deformity in AIS consists of rotated, lordotic apical areas and neutral junctional zones that modify the spine’s sagittal profile. Recently, three specific patterns of thoracic sagittal ‘malalignment’ were described for severe AIS. The aim of this study is to define whether specific patterns of pathological sagittal alignment are already present in mild AIS. Methods Lateral spinal radiographs of 192 mild (10°–20°) and 253 severe (&gt; 45°) AIS patients and 156 controls were derived from an international consortium. Kyphosis characteristics (T4–T12 thoracic kyphosis, T10–L2 angle, C7 slope, location of the apex of kyphosis and of the inflection point) and sagittal curve types according to Abelin-Genevois were systematically compared between the three cohorts. Results Even in mild thoracic AIS, already 49% of the curves presented sagittal malalignment, mostly thoracic hypokyphosis, whereas only 13% of the (thoraco) lumbar curves and 6% of the nonscoliosis adolescents were hypokyphotic. In severe AIS, 63% had a sagittal malalignment. Hypokyphosis + thoracolumbar kyphosis occurred more frequently in high-PI and primary lumbar curves, whereas cervicothoracic kyphosis occurred more in double thoracic curves. Conclusions Pathological sagittal patterns are often already present in curves 10°–20°, whereas those are rare in non-scoliotic adolescents. This suggests that sagittal ‘malalignment’ patterns are an integral part of the early pathogenesis of AIS.

Specific sagittal alignment patterns are already present in mild adolescent idiopathic scoliosis