Detecting scoliosis at scale using automated cobb angle analysis in the UK biobank

PURPOSE: Adult degenerative scoliosis arises after skeletal maturity in an initially normal spine, primarily driven by age-related degeneration. The Cobb angle, the angle between the most tilted vertebrae typically derived from radiographs, remains the clinical standard for assessing curvature severity, yet large-scale evaluation using MRI has not been feasible. This study developed an automated method for Cobb angle estimation from chemical-shift-based water-fat separation (Dixon) MRI and applied it to the UK Biobank to characterise the prevalence and curvature within the general population. METHODS: Abdominal Dixon MRI data from 33,889 UK Biobank participants were analysed. Vertebral bone marrow compartments were segmented using a neural network based model, and spinal curvature was quantified using a centroid-based spline-fitting algorithm. Sex-stratified linear regression analyses were performed to explore associations between spinal curvature and anthropometric, socioeconomic, and health-related traits, including back pain and body composition. RESULTS: While scoliosis was clinically diagnosed or self-reported in only 0.5% of participants, the automated approach detected scoliosis (Cobb angle > 10°) in 28%, of which 95% were mild (< 25°). Females exhibited higher average Cobb angles and greater curvature across all age groups. Multivariable linear regression revealed significant associations between Cobb angle and age, paraspinal muscle fat infiltration, chronic back pain, and visceral adipose tissue in both sexes, and with iliopsoas muscle volume in males only (all p < 0.00055, Bonferroni-adjusted threshold). CONCLUSION: This fully automated approach enables large-scale, population-based assessment of spinal curvature, revealing adult scoliosis to be substantially under-recognised and closely linked to muscle quality and back pain.