Adult scoliosis is a condition where rotation of the spinal vertebrae leads to curvature of the spine in a person who has finished growing (usually by 18 - 21 years old). In order to be classified as scoliosis, the curve must exceed 10°. Curves can occur in the chest area (thoracic spine) or the lower back area (lumbar spine). Occasionally, curves involve areas of the spine which lie in between, such as thoracolumbar. The neck or cervical spine is rarely involved.

CAUSES

  Adult Idiopathic Scoliosis - When curvature of the spine starts in adolescence in an otherwise healthy person, it is most commonly diagnosed as "adolescent idiopathic scoliosis". Idiopathic refers to the fact that the curve is not associated with other known problems such as cerebral palsy, spina bifida, neurofibromatosis, or a number of other conditions.

  After age 18, adolescent idiopathic scoliosis becomes "adult idiopathic scoliosis". It is the same curve present during the teen years but the spine does not behave the same way as the teenage spine. As a person with scoliosis ages, the spine develops premature aging changes in the back joints such as bone spurs, degenerative discs, and thickened spinal ligaments. This leads to a condition known as "adult idiopathic scoliosis with degenerative changes". These degenerative changes superimposed on a curve that is already present can sometimes cause back pain, leg pain, spinal imbalance, and progression or worsening of the curve.

  For adult curves greater than 50°, natural history studies suggest a high likelihood of curve progressing at about 1° per year. For curves in the lumbar spine or lower back, there is a high chance of progression if the curve is greater than 35-40°.

  Degenerative Scoliosis

  As arthritis begins to affect the spine, the discs lose their water content and consequently their ability to serve as the "shock absorber" of the spine. The facet joints in the back of the spine begin to wear out and lose their ability to maintain normal spinal alignment. The vertebrae begin to slip or abnormally move. This may lead to spinal instability, nerve compression, and pain. As both the disc and the facet joints lose their ability to maintain normal spinal motion, the spine can settle asymmetrically, leading to scoliosis.

  When the lumbar spine was straight as an adult but develops a curve later in life (usually in the 60 years + age group), it is termed De Novo or spontaneous development of degenerative scoliosis. This can occur earlier in patients who have had spinal surgery for laminectomy. It never occurs without significant arthritis.

SIGNS AND SYMPTOMS

  The most common sign of scoliosis is a prominence in the ribs on one side of the thoracic spine. In the lumbar spine, there is sometimes a prominence on one side, though often not. The prominence or "rib hump" is most apparent when bending forward. Sometimes there seems to be an asymmetry in the waist, with one side being indented more than the other. Clothes begin to fit differently than before.

  If the scoliosis is severe and unstable, spinal imbalance is common. Imbalance implies that patients lean to one side or forward when they try to stand straight upright. They may feel like they are tipping to one side, or have the sense that they are falling forward. Most people with adult scoliosis notice that they are not as tall as they used to be.

  Most young adults with scoliosis do not have significant back pain. The curve usually does not hurt unless or until it becomes degenerative. Sometime in life, however, because arthritis is age related and develops prematurely in this group, the adult with scoliosis is likely to develop back pain. When it occurs, the pain is worse when upright and active, and better when the patient is resting.

  Spinal instability occurs when the disc and facet joints are so worn out that they can no longer maintain normal spinal alignment. Pain comes from the arthritic joints as well as from the adjacent nerves, which are pinched and stretched as a result.

  Buttock pain can occur due to referred pain from the arthritic spine, or it could be a manifestation of a more significant problem with nerve compression. Spinal nerve roots become pinched when arthritic bone spurs form around them and block their exit route from the spinal column. This condition is called Spinal Stenosis. In addition to buttock pain, other symptoms such as leg pain, numbness, tingling, and weakness are common. If any of these findings are present, advice from a physician should be sought without delay.

  If spinal stenosis or nerve compression in the back is severe enough, control of bowel and bladder function will be lost. This however is a rare event, but when it happens, it is a surgical emergency. If the pressure on the nerves is not relieved quickly, control of bladder and bowel may never be regained. Again, this is a very rare occurrence and we only see 2 or 3 cases each year.

Challenges

  As the spine ages, it becomes stiffer. Flexibility is greatest in the teen years, and usually declines starting in the 40-50 age group. Stiffness of the spinal joints can become severe as bone spurs form and prohibit motion. In some cases, the bone spur formation is so severe that all motion is lost at one or more levels in the spine.

We all achieve our maximum bone density at about age 30-35. After age 35-40, there is a slow decline in the amount of bone present in the spine. After age 60, and particularly after menopause in women, the loss of bone becomes visible on x-rays. This is osteoporosis. If the bone loss becomes severe, spontaneous fractures can occur in the spine. These fractures can lead to scoliosis or kyphosis.

  As we get older, our general health can become more of a problem. Chronic disease processes such as high blood pressure, diabetes, and heart disease are prevalent among American Seniors. When scoliosis becomes a problem in seniors, other health issues must be considered when treatment options are considered.

CONSERVATIVE TREATMENT

  Nearly all patients with adult scoliosis will respond to conservative treatment and lead a normal, functional life. When pain is present, it is usually short term and manageable. Treatment for adult scoliosis should almost always begin with a non-invasive approach. Our philosophy is, "Try the easy things first."

  Non-steroid Anti-inflammatory Drugs (NSAIDS) have been the cornerstone of medical therapy for arthritic and inflammatory conditions. These medications can quiet the pain and stiffness caused by degenerating discs and joints.

  Physical Therapy is an excellent way to improve function, flexibility, endurance, and decrease pain. Usually the therapist will work with patients toward becoming less symptomatic, and maintaining the improvement with an active home exercise program. Working out in a supervised environment with the help of a physical therapist is the best way to achieve it. On average, therapy lasts 2-3 times per week for 4-8 weeks.

  It is very important that adult patients with scoliosis get into the habit of doing a daily exercise routine. This will improve the strength of the trunk muscles and take some of the stress off from the spine. Often when pain occurs, it is because the patient is not doing his or her exercises.

  Sometimes a back brace is helpful in getting some relief from back pain in patients with degenerative scoliosis. A word of caution is in order however: the brace should not be used without faithful compliance with an active exercise program. Brace wear without exercise tends to lead to a weaker spine that becomes dependent on the brace. Daily exercises and occasional (when needed) brace wear lead to the best results, where bracing is concerned.

  Medical management of osteoporosis and general health is important to maintaining an active lifestyle into old age, especially in patients with scoliosis. Solving small problems before they become big ones has always been good advice.

  Passive manipulation (Chiropractic) is not an acceptable treatment for scoliosis of any kind.  Passive manipulation of the spine provides short term symptomatic relief for muscle spasm, but does not impact the size of the curve or the rate of progression.  Patients with scoliosis are encouraged to not rely on chiropractic “adjustments” as a means of treatment since these are essentially equal to no treatment at all.

Reasons Surgery Might Be Considered

  Few patients with adult scoliosis will ultimately require surgery. When necessary, the goals of surgery are to stop curve progression, stabilize the spine, establish correct spinal balance, decrease back and leg pain, and increase function with as little surgery and as few complications as possible. Patients who require surgery to straighten, stabilize and fuse their spinal curvature are patients with:

• Increasing curvature over time (it will continue to get worse)
• Unstable spine that hurts despite conservative care
• Nerve compression causing pain, numbness, or weakness
• Spinal imbalance which is painful or progressive
• Large curve which will progress (better to do these earlier while health is good and before osteoporosis starts or worsens)

Surgical Options and Results

  If the main problem is leg pain caused from a disc herniation, this can usually be taken care of with a small surgery to remove the disc fragment and decompress the nerve. A large procedure to correct the scoliosis and fuse the spine is not necessary.

  Sometimes leg pain is caused by bone spurs that are compressing the spinal nerves. This is spinal stenosis. If stenosis is the problem, the solution usually will require removal of the offending bone spurs to get pain relief. If adequate bone is to be surgically removed to decompress the pinched nerves (laminectomy), the spine is often rendered somewhat unstable in the process. Back pain will increase, leg pain may return, and the spinal curvature will get bigger if the spine is not fused at the same time. In these cases, correction of the curve and fusion with bone graft and instrumentation is required to stabilize the spine and prevent what would be a certain need for future surgery.

  When back pain, progressive deformity, or spinal imbalance are primary factors, the curve should be straightened and fused. The amount of correction obtained with surgery is sometimes limited compared to the corrections seen in the pediatric patients.  This is due to increased spinal stiffness in adults.

Surgical Technique to Correct Scoliosis

  Once the decision for surgery has been made, the operative plan is formulated. Patients are routinely asked to donate blood before surgery to be stored and used during their surgery. The spinal cord function is usually monitored throughout the surgery to make sure there is no compromise to spinal cord function. Bone graft material and spinal instrumentation may need to be arranged for ahead of time.

  Surgery to correct adult scoliosis is the most challenging surgery done in orthopedics, and is likely among the most complex and demanding surgeries of any kind being performed today. This type of surgery requires at least one assisting surgeon and often a surgical team, and can take from 3-14 hours to accomplish.

Anterior Surgery

  If the spine must be fused anterior or from the front, a thoracic or general surgeon will be a part of the surgical team to safely mobilize the great blood vessels off the spine where the spine surgeon will work. The incision may be through the side of the chest, through the side of the abdomen, or through the front of the abdomen, depending on what is needed at the time of surgery. The purpose of anterior surgery is to remove the discs, and fill the space with bone graft or Bone Morphogenetic Protein (see below). This serves to improve the correction which can be achieved and improve the reliability of the fusion.

  Sometimes the spine is "instrumented" from the front, meaning that screws are placed into the vertebra and attached to a rod that will correct the deformity and stabilize the spine.

  More recently, the thoracoscope has been used in spine surgery. We can now remove discs from the thoracic spine and insert bone graft without making a large incision. All of the work is done through a few one-inch incisions on the side of the chest.

Posterior Surgery

  Most of the correction of scoliosis is done from the back of the spine. If nerves are compressed by bone spurs or a disc herniation, the offending structures can be removed to allow more room for the nerves. The spine is then "instrumented" by the placement of hooks or screws that attach to the vertebrae. These hooks and screws are then attached to rods that span the curve. The instrumentation is then distracted, compressed, or rotated in order to correct the spinal curvature. Without instrumentation, the curve cannot be corrected.

  Bone graft is always used in scoliosis surgery. The spine must be fused in its new corrected and straightened position. The graft most commonly comes from the patient's own pelvis. Sometimes bone-bank bone is used when there is not sufficient bone available form the patient. Newer uses for Bone Morphogenetic Protein include posterior scoliosis fusions.

RESULTS FROM SURGERY

  Adult patients who undergo major spinal surgery to correct their scoliosis generally do well. Pain is greatly improved or eliminated in the majority (80% in our series). The fusion is successfully achieved and the correction maintained long-term in 80-95% of people who have mild to moderate scoliosis corrected with or without nerve root decompression. In our series of recent patients, curve correction is averaging 67 – 79%, depending on the type of scoliosis.

  Complications can occur however, such as failure of the spine to solidly fuse, failure of the spinal hardware (<2%), infection (2-4%), nerve injury (<1%), medical complications, and others. The patients who are at greatest risk for complications are smokers, people taking steroids and those with severe osteoporosis or poor nutrition.

THE FUTURE

Our Research

  We regularly present the results of our research to our Orthopedic and Neurosurgical colleagues at national spine meetings such as the North American Spine Society, Scoliosis Research Society, International Meeting on Advanced Spine Techniques, and others. One of our research interests includes improved fusion techniques using Bone Morphogenetic Protein.  This is a protein carried in a collagen sponge that turns on the bone forming machinery of cells.  Our results are impressive in achieving fusions without having to remove bone graft from our patients’ pelvis.  This means less post-op pain and quicker rehabilitation for our patients.

  Another exciting area of research is in the development of a new spinal instrumentation system that allows easier and more effective correction of scoliosis than what has been achievable before.  We now have biomechanical testing, FDA approval, and enough long-term results to recommend and release the new instrumentation system for fuse by spine surgeons worldwide.  The system is called 3D with Multi-Planar Technology, or MPA for short.  It is marketed by Medtronic Sofamor Danek.  We are continuing to investigate improved ways of correcting spinal deformity, achieving a more reliable fusion, and improving the function of our patients.

  Spine surgery has made tremendous progress in just the past 15 years. The future looks just as bright, if not brighter.

© Copyright 2005. Arthritis Education by Professionals, Inc.