Background Context. There is no general accepted theory on the etiology of idiopathic scoliosis (IS). An important role of the vertebrae endplate physes (VEPh) and intervertebral discs (IVD) in spinal curve progression is acknowledged, but ultrastructural mechanisms are not well understood. Purpose. To analyze the current literature on ultrastructural characteristics of VEPh and IVD in the context of IS etiology. Study Design/Setting. A literature review. Results. There is strong evidence for multifactorial etiology of IS. Early wedging of vertebra bodies is likely due to laterally directed appositional bone growth at the concave side, caused by a combination of increased cell proliferation at the vertebrae endplate and altered mechanical properties of the outer annulus fibrosus of the adjacent IVD. Genetic defects in bending proteins necessary for IVD lamellar organization underlie altered mechanical properties. Asymmetrical ligaments, muscular stretch, and spine instability may also play roles in curve formation. Conclusions. Development of a reliable, cost effective method for identifying patients at high risk for curve progression is needed and could lead to a paradigm shift in treatment options. Unnecessary anxiety, bracing, and radiation could potentially be minimized and high risk patient could receive surgery earlier, rendering better outcomes with fewer fused segments needed to mitigate curve progression. 1. Introduction There is no generally accepted scientific theory for the etiology of idiopathic scoliosis (IS). Treatment of this disease remains pragmatic with an incomplete scientific basis [1]. The current strategy of treatment depends on a patient’s age [2]. In children, scoliotic deformity causes a persistent stress in the motion segments, which induces a progressive elastoplastic strain that modifies the geometry of the motion segment, which in turn worsens the excessive strain [2, 3]. Thus, in the pediatric spine the aim of treatment is to prevent the motion segment deformity. In adult scoliosis, significant deformation of the intervertebral disc (IVD) and the capsuloligamentous structures produce instability of the motion segments and slow deformation of the vertebrae through remodeling with disc herniation and neural compression. Hence in adult scoliosis a stable balance is necessary to prevent further deformation of the spine [3–5]. IS may be observed in the infantile, juvenile, or adolescent period, but the trigger factor for curve onset is unknown. There is evidence that the spinal growth spurt plays a significant role in the onset
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