Scoliosis – a lateral (or sideways) curve of the spine in one or more places – is most frequently seen in children and adolescents. However, adults may also be diagnosed with scoliosis, either when a curve that existed in their youth progresses, or as a de novo (newly diagnosed condition) that can result from degenerative changes in the spine and osteoporosis.
Adults with scoliosis often experience painful symptoms that lead them to seek medical care. “Pain may be related to the curve itself or due to compression of the spinal nerves.
The latter condition, spinal stenosis, can produce inflammation of the nerves that in turn results in leg pain and numbness or weakness when walking or standing for a long period of time.
Scoliosis can affect the spine in three sections: the cervical (neck), thoracic (chest region), and lumbar (lower back). Patients are usually able to point to the site of their back pain, and a bulge may be visible due to muscle rotation or rib cage rotation. Asymmetry in the trunk as it relates to the pelvis may be pronounced. In addition, adults with scoliosis may experience:
Clinical Evaluation and Diagnosis
Evaluation for scoliosis includes a physical exam and x-rays taken from the front and side views, from which the degree of the curve is measured. Scoliosis is diagnosed when the curve exceeds 10 degrees, but by the time adults seek treatment, usually the curve exceeds 30 degrees.
In addition, bending x-rays are taken to assess the flexibility of the curve. By means of physical exam and x-rays, the patient is assessed for signs of spinal stenosis, or narrowing of the spinal canal.
If the orthopedist suspects that lung function has been affected, additional tests are conducted. Rarely, patients with a severe deformity may develop cor pulmonale (pulmonary heart disease), which requires evaluation and treatment.
Learning about the patient’s activities of daily living and how their scoliosis symptoms affect their quality of life is another important part of assessment.
Whenever possible, scoliosis in adults is treated non-operatively. Many patients experience significant relief of their pain from measures that may include:
Patients who continue to experience nerve pin may benefit from steroid injections in the facet joints (where the vertebrae meet at each level of the spine). Steroids, which reduce inflammation, may also be administered by an epidural (in which the needle is inserted into the spinal canal), which allows the drug to bathe the affected nerve root.
Braces are occasionally worn on a short-term basis by patients with muscle spasms, but their usefulness is limited since the support they provide gradually weakens the muscles in the trunk and spine.
Surgery may be recommended for selected patients, including those who do not respond to non-operative treatment after a period of time, those with curves that exceed 50 degrees and have significant impairment of daily function, and those with worsening lung or neurologic function.
The most common type of surgery in adults is a posterior spinal fusion with instrumentation. In this procedure, the orthopedic surgeon makes an incision from the back and essentially welds the vertebrae together using bone chips taken from elsewhere in the body (autograft) or from a bone bank (allograft). Rods, screws, or other implants may be used to hold the spine in alignment during the healing process, which may take a full year or longer. Once the fusion is complete, the instrumentation no longer serves a function but is left in place to avoid the need for additional surgery.
Depending on the nature of the curve and its location, the orthopedist may need to perform a fusion from both the front and the back of the body, a procedure that may be done as a single operation or in stages.
Adults with very large and rigid curves may also require osteotomies, in which stiff segments of the facet joints are released.
Some patients with lumbar and thoracolumbar curves may be candidates for thoracoscopic or minimally invasive lateral access surgery, in which incisions are made from the side of the torso or flank. As with the posterior and anterior approaches, instrumentation corrects the curve and the rotation of the spine. “The thorascoscopic approach offers the advantages of smaller incisions and shorter fusions, which in turn preserves more mobility in the spine,”
Adults with scoliosis and spinal stenosis require a decompression procedure in which the roof of the vertebral column is removed at the affected area, freeing the nerve from any material that is compressing it, prior to fusion.
Whenever surgery is considered, the orthopedic surgeon reviews the risks and benefits with the patient, taking into account their age and medical history. The presence of other conditions, including arthritis,kyphosis (forward curve of the spine) and osteoporosis (a condition in which bone density decreases and the bones become more fragile and likely to break on impact), as well as non-orthopedic issues, can pose additional surgical challenges.
In appropriately selected and prepared patients, good outcomes from surgery are achieved, according to Dr. Boachie. Correction of the curve falls in the range of 50-80%. Younger, healthier patients tend to have the best results. The SRS 22 patient questionnaire and ODI (Oswestry Disability Index) measure the level of pain relief and improvement of quality of life for each patient.
Complications of scoliosis surgery in adults can include pseudarthrosis (a non-union of the fusion) which may lead to loosening of the implanted instruments, as well as infections, neurological problems, blood clotting, and spinal imbalance, which refers to problems with the correction, including the inability of unfused segments to spontaneously correct and balance the spine.
Following surgery, most patients remain in the hospital for five to seven days [slightly longer for those who undergo combined anterior and posterior (front and back) surgery] and are on their feet in two days.
Pain medication is continued as needed. As recovery progresses, patients are advised to limit their activities to walking and to avoid bending and heavy lifting for the first four weeks.
By adhering to these guidelines and with the help of physical therapy, the patient should be able to resume normal activities at home by 4-6 weeks. Those with desk jobs may return to work. Adults may take a year or longer to achieve full functional recovery and some adults may still require pain medication for ongoing discomfort.
Patients should be aware that spinal fusion does result in some loss in range of motion; however, the degree varies depending on the site and length of the fusion. If the treatment is primarily in the thoracic spine, normal mobility is achieved after the healing process is completed. If the lumbar spine is the site of treatment, sideways movement will be more restricted, although the patient will still be able to bend forward from the hips. Similarly, fusion in the cervical spine places more restriction on movement.
Like many aspects of growth in young children, healthy development of the spine can vary slightly from child to child with small curves constituting a normal part of spine anatomy. But if curves are observed by a parent, teacher, school nurse, or physician, evaluation for early onset scoliosis is advisable.
Scoliosis is diagnosed as several types:
The vast majority of scoliosis cases are due to unknown causes and can develop during infancy, childhood or adolescence. Patients with syndromic scoliosis often have curves in the spine early in life. As children with this condition grow, the curvature can progress and worsen. It’s important for a pediatric orthopedic surgeon to monitor the condition closely, because in some cases the curvature may eventually need to be treated.
Pediatric orthopaedists use physical examination and x-rays to diagnose early onset scoliosis. An initial x-ray is taken to determine the magnitude, location, and direction of the curve. Based on that x-ray, a determination is made regarding the type of scoliosis present, as well as its possible cause, and a treatment strategy is instituted.
MRI of the entire spine is often recommended to ensure that there are no other problems affecting the spinal cord. Children with congenital scoliosis should be assessed for the presence of any cardiac or kidney problems associated with their condition.
Idiopathic Scoliosis: The most frequently seen form of the condition, idiopathic scoliosis may first be recognized during a routine pediatrician’s visit or in a school screening. While children with idiopathic scoliosis may not experience any pain, parents may see cosmetic signs of the condition, such as a shoulder that appears higher than the other or protruding ribs on one side, owing to a twisting aspect of the spine.
Patients with idiopathic scoliosis are further categorized by age: infantile scoliosis, affecting children from birth to three years of age; juvenile scoliosis from 3 to 9 years of age; and adolescent scoliosis, from 10 to18 years of age. Adolescent idiopathic scoliosis is seen more frequently in girls than in boys.
Syndromic Scoliosis: Children with syndromic scoliosis should also be evaluated by a geneticist and neurologist to determine which one of the disorders mentioned above, or others, could be the cause of the spine curvature.
Sometimes these patients may have respiratory and cardiac conditions, related to the syndrome or secondary to severe spinal curvatures. Due to this risk, it is also important for these patients to be evaluated by a pediatric pulmonologist and cardiologist.
Congenital Scoliosis: Children with congenital scoliosis should be assessed for the presence of any cardiac or kidney problems associated with their condition.
Treatment decisions must take into account the age of the patient, the type of scoliosis, the size of the deformity, and the anticipated progression of thecurve. “The period from birth to five years is crucial, because it is during this time that the lungs grow dramatically”. If the chest cavity is constricted owing to scoliosis or other spinal deformities, lung growth can be significantly restricted and serious pulmonary complications may develop.
For all patients with scoliosis, the goals of treatment are to slow or prevent progression of the curve and to achieve cosmetic improvement where possible. Based on all the information available, the pediatric orthopaedist may recommend one or more of the following:
For patients with smaller curves, those greater than 10 degrees and up to 20 degrees, the orthopaedist may recommend careful monitoring of the condition with physical examinations and follow-up x-rays taken at three to four month intervals. If the curve progresses, additional treatment measures are introduced.
For curves in the range of 20-40 degrees, bracing can be an effective means of controlling some forms of early onset scoliosis, such as idiopathic scoliosis and some syndromic forms of the condition. (However, bracing is not appropriate for neuromuscular or congenital scoliosis.) Moreover, it must be emphasized that bracing does not correct the curve. Bracing is intended to prevent progression.
A renewed interest in casting for early onset scoliosis has occurred. Casting can produce good results in children with infantile idiopathic scoliosis and those with syndromic scoliosis, the technique employs a series of body casts to correct the curve called the Risser Cast. Extending from just under the arm pit – some also have “straps” that go over the shoulders – to the curve of the waist area, Risser casts remain on the patient for six weeks at a time. The cast is then changed to increase the amount of correction.
The theory behind the technique is that by keeping the child in the cast around the clock, you actually help the spine start growing in a more normal way,” .This process continues for several months to years, usually with a two- or three-day interval between castings to allow the patient to bathe and to address any skin problems that may develop.
Young children with curves that exceed 40 degrees and that are progressing despite non-operative treatment are in danger of developing cardiac and/or respiratory problems and are therefore candidates for surgical intervention. orthopaedists use two primary devices: growing rods and vertical expandable prosthetic titanium rib prostheses (VEPTR). These are growth-sparing techniques that allow for control and correction of the scoliosis while the spine continues to grow.
While the initial surgery to attach the growing rods lasts two or more hours, subsequent adjustments are brief procedures involving only a small incision and, in otherwise healthy children, may not require an overnight stay in the hospital. When the device has reached its full extension, the child may require another surgery to introduce a new longer set of growing rods.
The VEPTR (Vertical Expandable Prosthetic Titanium Rib) technique works to straighten the spine and separate the ribs, to prevent respiratory problems. For children with chest wall deformities, such as those seen in congenital scoliosis, the VEPTR device is usually the best option since bracing is ineffective in this population.
In contrast to growing rods, the VEPTR is attached to the patient’s ribs. It not only helps to straighten the spine, but also separates the ribs to prevent deterioration of breathing function that can develop with untreated scoliosis. As with growing rods, small adjustments are made to the VEPTR every six months to allow for growth.
While most patients with growing rods or VEPTR devices will eventually undergo a fusion to permanently maintain the correction.
In spinal fusion, two or more vertebrae are fused together with bone grafts and internal devices, such as metal rods, to stabilize the spine or correct a deformity. Sophisticated fusion techniques and new instrumentation to surgically correct progressive curves, enhances the recovery of patients.
Degenerative changes of the vertebrae and disks that make up the spine are common in the aging population and may be associated with either osteoarthritis or osteoporosis. However, when these changes result in an asymmetry, a sideways curve of the spine measuring 10 degrees or greater, the condition is described as degenerative scoliosis.
The cause of spinal osteoarthritis and degenerative scoliosis is not known, but clearly the condition is accentuated by daily “wear and tear” or micro-trauma, and activities that jar the spine repeatedly – for example, as in a person who operates a jackhammer. Less frequently, a fall or other traumatic accident can ultimately lead to a diagnosis of degenerative scoliosis.
To understand how this process occurs, it is helpful to think of the spine as a series of bony blocks, the vertebrae, which are connected by facet joints that permit movement in the spine. Disks sit between the vertebrae and provide cushioning and protection. The spinal cord runs through the spinal canal, a passage created by the vertebrae.
Degenerative changes can occur in the discs or the facets. When arthritis develops in the facet joints, it is very similar to the process that occurs in the other joints of the body, with thinning of the joint cartilage and rubbing together of the bone ends.
Disc degeneration includes the inner part of the disk: a jelly-like substance called the nucleus pulposis that begins to dry out as it ages, or the outer part of the disk: the thickly ligamentous annulus fibrosis, which develops rips and cracks as it wears. The cumulative degenerative changes in all three of these can result in spinal stenosis, in which the passage surrounding the spinal cord and cauda equina become constricted and the nerves circumferentially compressed.
Patients with degenerative scoliosis usually seek medical attention when they experience pain or other symptoms in the back, hip, buttocks, or legs.
Pain in the back is typically related to spine arthrosis or muscle spasms, and can radiate into the buttocks, the thighs, and the hips. These are referred to as axial symptoms.
Radicular symptoms result from compression or pinching of a nerve, and may include shooting pains, sometimes described by patients as “lightning bolts,” sciatica, or numbness in the legs. These pains may take different pathways down the leg and foot, depending on the specific nerves compressed in the affected area of the spine.
Another manifestation of a compressed nerve is muscle weakness in the leg or foot; an example may be a condition called foot drop, in which the patient has difficulty lifting the front part of the foot. Patients with degenerative scoliosis who have developed stenosis may also experience fatigue when walking or a heaviness in the legs that subsides when he or she leans forward or sits down.
In addition to a physical exam and patient history, orthopedic surgeons use imaging techniques to confirm the diagnosis of degenerative scoliosis. These will include: full spine x-rays from the front and from the side and in some cases a CT scan, which can provide additional detail including evidence of arthrosis of the facet joints. CT images may also reveal the presence of small fractures that may not be visible on x-ray images.
Magnetic resonance imaging (MRI) may also be used to obtain information about the nerves, disks, and soft tissue in the spine. This is particularly helpful in determining the cause of radicular symptoms in the legs.
When assessing a patient in whom degenerative scoliosis is suspected, the orthopedic spine surgeon looks at the angles in the spine as well as the balance of alignment between the head, spine, and hips. If a curve is present, it’s important to assess whether it is likely to progress and to find other factors that may be contributing to the patient’s deformity, such as spondylolisthesis, a condition in which one vertebra slides forward, backward, or sideways relative to the vertebra below.
Spondylolisthesis suggests instability of the spine and can produce stenosis (abnormal narrowing of the spinal canal), pain, and sometimes nerve injury.
Many patients with degenerative scoliosis achieve pain relief from one of a number of non-surgical treatments, including:
Patients who do not respond to activity avoidance or physical therapy measures may find relief with oral medications. For back pain, the orthopaedic surgeon may recommend either a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen, or a drug from the COX-2 inhibitor class of medications, such as celecoxib.
For radicular symptoms, drugs that reduce inflammation in the nerves and surrounding soft tissues may be prescribed, or drugs that reduce “overactivity” in nerves (neuroleptics) can be used to limit symptoms.
If oral drugs do not offer sufficient relief for axial and/or radicular symptoms in the back and legs, the patient may be referred to a physician specially trained in pain management for injection-based treatment.
For back pain due to symptoms coming from the facet joints, the specialist may decide to perform a facet injection. Facet injections deliver two medications directly into the joint: a numbing agent and a corticosteroid which is intended to reduce inflammation.
Injections can be helpful in two ways, “If the patient feels numb in the injected area, but the pain is still there, we know we have not found the problematic facet joint. However, if the pain does goes away, we know we’ve found the correct facet joint responsible for causing the pain symptoms. At this point, the cortisone reduces inflammation and diminishes – or in some cases completely relieves – pain for a matter of weeks to months.” Because more than one facet joint may be affected in degenerative scoliosis, the patient may require multiple injections.
If pain returns after the facet injections, the specialist may consider a facet rhizotomy, in which a special thermal probe is inserted near a small nerve just outside of the painful facet joint. The probe can then be heated up where it contacts the nerve and serves to destroy the nerve. This process of rhizotomy effectively “turns off” pain signals to the brain. This procedure can provide several months to years of relief.
In patients who are experiencing leg symptoms only, an epidural steroid injection can be considered. The concept of an epidural injection is that the needle is guided either from the midline skin or from the side, and the tip of the needle is advanced to an area near one of the spinal nerves that is either inflamed or is being irritated by inflammatory tissue. A slightly different epidural technique is called a caudal, where the needle is inserted at the base of the spine. With any of the techniques used, the purpose is to deliver corticosteroids to bathe the affected nerve roots, thereby reducing inflammation and pain.
Injection therapy may continue to be effective for some time; however, patients in whom it is ineffective, or in whom it becomes ineffective, may eventually be candidates for surgery.
Surgical treatment for degenerative scoliosis may involve a fusion, a decompression, or both. If the patient’s pain is restricted to the back and degenerative changes in the facet joints, fusion in the affected area may be recommended. In essence, the vertebrae are “welded” together and screws or other instrumentation are used to secure and immobilize the bone, with the goal of eliminating the pain associated with movement in that area.