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20 May 2023: Clinical Research  

Association Among Complete Blood Count Parameters, Bone Mineral Density, and Cobb Angle in Cases of Adolescent Idiopathic Scoliosis

Mehmet Murat Bala ORCID logo1ABCDEFG*, Keziban Aslı Bala ORCID logo2ABCDEFG

DOI: 10.12659/MSM.940355

Med Sci Monit 2023; 29:e940355




BACKGROUND: Improving the quality of life of scoliosis patients with appropriate preventive measures is critical. This study aimed to investigate the relationships among bone mass, Cobb angle, and complete blood count (CBC) parameters in patients with scoliosis.

MATERIAL AND METHODS: This joint study was conducted by the pediatric department and orthopedics clinics, which used the medical records of patients aged 10-18 years between 2018 and 2022. Patients were divided into 3 groups according to the Cobb angle. Patient blood count levels from medical records and bone mineral density (BMD) Z scores (g/cm²) were compared among groups. Notably, BMD Z scores were calculated using a (BMD) dataset from local Turkish children after adjusting for height and age.

RESULTS: A total of 184 individuals (120 females, 64 males) were included in the study. There were statistically significant differences among the groups in platelet-to-lymphocyte ratio (PLR). Significant differences in DXA Z scores among groups were found. There was a significantly strong and positive correlation between DXA Z scores and all CBC parameters in patients with severe scoliosis.

CONCLUSIONS: This study found that CBC parameters can predict BMD in adolescents. Furthermore, the association between vitamin D deficiency and low BMD may contribute to the follow-up of body adaptation in patients with scoliosis receiving conservative treatment.

Keywords: Bone Density, Blood Cell Count, Scoliosis, Male, Child, Female, Humans, Adolescent, Quality of Life, Bone Diseases, Metabolic, Kyphosis


Bone mineral density (BMD) has been increasingly investigated since the 1980s after 2 reports showed that children with adolescent idiopathic scoliosis (AIS) have lower bone mineral density than their peers [1–3]. Various studies have suggested an association between osteoporosis and scoliosis [2–7]. Notably, some studies have reported a significant association between scoliosis and osteopenia [2,6,8–15], and some studies have reported that scoliosis can even develop in adulthood [13]. Patients with osteopenia and AIS have been reported to have twice the risk of curve progression than those with normal BMD [16]. Because osteopenia poses a risk of curve progression and is thought to cause worsening scoliosis, it has been proposed as a potential prognostic factor [16,17].

Clonal hematopoiesis is a somatic mutation caused by various changes in the hematopoietic stem cells [18,19]. Any chronic inflammation in the body causes a suppression of erythropoiesis in the bone marrow and alters red blood cell heterogeneity [20]. Moreover, the inflammation directly or indirectly affects BMD and fracture risk [21].

Osteoimmunology has shown that the immune system and inflammatory factors play important roles in the development of osteoporosis [22]. Several studies of immune diseases have reported that monocyte-to-lymphocyte ratio (MLR) has diagnostic value and can reflect systemic inflammation and the severity of immune system damage [23]. Therefore, MLR has been recognized as a marker of inflammation [23]. Moreover, elevated MLR has been reported to be associated with osteoporosis and bone diseases [24,25].

Notably, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), which are novel markers of systemic inflammatory response [26,27], have also been found to be associated with low BMD [28,29].

Appropriate preventive measures are critical in preventing the development of scoliosis and improving the quality of life of patients [30,31]. The present study aimed to investigate the associations among bone mass, Cobb angle, and complete blood count (CBC) parameters in patients with scoliosis.

Material and Methods


The Cobb angle between the most inclined vertebrae was calculated by a single experienced orthopedist using a standard full-spine posteroanterior radiograph [32]. Specifically, scoliosis was defined as the presence of a curvature of ≥10°. Moreover, AIS was confirmed using erect and bending radiographs. Other causes of scoliosis were excluded by examination and investigations at the pediatric endocrinology clinic.

The 2016 Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment guidelines define mild and moderate scoliosis as a Cobb angle of <20° and 21–35°, respectively [33,34]. In this study, patients were divided into 3 groups according to the Cobb angle: less than 10 degrees (control group), 10–20 degrees, and over 20 degrees.


Demographic data of the patients were extracted from electronic medical records, and based on these data, calcium (CA), phosphorus (P), 25-hydroxyvitamin D (25-OH-D3), alkaline phosphatase (ALP), parathyroid hormone (PTH), NLR, MLR, and PLR were calculated.

Complete blood counts were obtained using an automated hematology analyzer (Abbott, Cell-Dyn Ruby, IL, USA). Moreover, biochemical parameters were measured using a clinical chemistry analyzer (Abbott, c16000, IL, USA). In addition, hormone parameters were measured using chemiluminescence immunoassay (Abbott, i2000sr, IL, USA). MLR, NLR, and PLR were calculated using monocyte count/lymphocyte count, neutrophil count/lymphocyte count, and platelet count/lymphocyte count, respectively.


The T score indicates how much a person’s bone mass differs from the bone mass of an average healthy 30-year-old adult. In contrast, the Z score refers to standard deviations based on a comparison of a child’s BMD to the mean BMD of a standard population of the same sex and age [35]. When calculating age- and sex-adjusted Z scores, DXA measures the density of different bones in the body; however, the lumbar spine (L1–L4) and femoral neck are most commonly used [36]. In the present study, Z scores were obtained for the spine using BMD (g/cm2) from DXA scans. BMD Z scores were calculated using the BMD dataset of local Turkish children after adjustment for height and age [37,38]. All DXA procedures were performed using Lunar Prodigy (General Electric, GE Healthcare, Lunar DPX, NT+150301, USA) at a single institution.


Descriptive data are presented as number (percentages) or median and interquartile ranges (IQR: 25th–75th percentiles), according to data distribution. The normality of continuous variables was assessed with the Shapiro-Wilk test and histogram plots. Kruskal-Wallis and post hoc Dunn’s tests were used for the comparison of continuous variables among groups. Pearson correlation analysis was conducted to assess the relationship between DXA Z scores and hemogram parameters. The analyses were performed using SPSS 26.0 for Windows (SPSS, Inc., Chicago, Illinois, USA) and R 4.2.1 statistical software. The results were considered to be significant at a level of P<0.05.


A total of 184 individuals (120 females, 64 males) were included in the study. The median age of participants was 14 (IQR: 12–16) years. The comparison of hemogram parameters among the control group with no scoliosis (n=96), patients with mild scoliosis (n=72), and patients with moderate scoliosis (n=16) is presented in Table 1. There were statistically significant differences among the groups in terms of PLR (P=0.022). Post hoc comparisons revealed that the median PLR was significantly lower in patients with moderate scoliosis (median: 80.4, IQR: 76.3–194.4) compared to the patients with mild scoliosis (median: 104.2, IQR: 94.1–125.6) (P=0.024) and no scoliosis (median: 107.9, IQR: 89.3–125.5) (P=0.026).

The distribution of DXA Z scores among groups are displayed in Figure 1. Significant differences in terms of DXA Z scores among groups were found (P<0.001) – patients with moderate scoliosis had significantly lower DXA Z scores (median: −0.5, IQR: −1.38-0.06) compared to the patients with mild scoliosis (median: 1.12, IQR: 0.11–1.80) (P<0.001) and the control group (median: 1.02, IQR: −0.24–1.54) (P<0.001).

Correlations between DXA Z scores and hemogram parameters were evaluated separately for groups (Table 2). There was no significant correlation between DXA Z score and hemogram parameters in the control group. In the patients with mild scoliosis, a significant weak positive correlation was found between DXA Z Score and PLR (0.324, P=0.005). There was a strong and significant positive correlation between DXA Z scores and all hemogram parameters in patients with moderate scoliosis (NLR: r=0.814, P<0.001; MLR: r=0.544, P=0.029; PLR: r=0.714, P=0.002).

Other serum blood parameters were compared among groups in Table 3. Significant differences were found in 25-OH-D3 (P=0.023), ALP (P<0.001), and PTH (P=0.017) among groups. The patients with mild scoliosis had significantly lower 25-OH-D3 (median: 10.9, IQR: 7.0–17.7) compared to the control group (median: 16.7, IQR: 7.5–22.7) (P=0.021). For ALP, all pairwise comparisons were statistically significant. The median ALP was highest in the control group (median: 194.5, IQR: 108.5–269.3), followed by patients with mild scoliosis (median: 125.5, IQR: 95.0–176.0) and moderate scoliosis (median: 90.0, IQR: 76.3–100.8). ALP was significantly higher in the control group compared to the mild (P=0.011) and moderate (P<0.001) groups, and it was significantly higher in the mild group compared to the moderate group (P=0.005). PTH was significantly lower in the moderate scoliosis group (median: 38.5, IQR: 34.7–65.3) compared to the mild scoliosis group (medians: 63.7, IQR: 37.5–93.0) (P=0.032).



This study has some limitations. First, this was a single-center study and included a small number of patients. Longitudinal and molecular biology studies may be required to obtain clearer results. Second, BMD measured using DXA can be confusing because bone growth is three-dimensional and uneven [35,59]. Third, bone microarchitecture, particularly that of trabecular bone, is another critical mechanical quality of bone; however, our study performed a comprehensive and systemic study of BMD but failed to assess trabecular bone microarchitecture. In addition, although physical activity has an effect on bone health, the fact that patients were not classified according to their physical activities is another limitation of our study [60]. Nonetheless, this study used a heterogeneous patient population and attempted to identify the factors that best correlated with low BMD and high Cobb angle.


To the best of our knowledge, this is the first study to provide evidence of an association of PLR with the Cobb angle in patients with AIS. Moreover, this study reported that CBC parameters play a predictive role for BMD in adolescent. Furthermore, the association between vitamin D deficiency and low BMD may contribute to the follow-up of body adaptation in patients with scoliosis receiving conservative treatment.


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