Adult Scoliosis Management
Scoliosis refers to an abnormal curvature of the spine. Adult scoliosis is defined as a curvature of the spine greater than 10 degrees in a skeletally mature patient (essentially any individual greater than the age of 20). Unlike pediatric scoliosis conditions, adult scoliosis patients often present with symptoms associated with back pain, leg pain or both. The reason for this is that arthritis and nerve entrapment syndromes such as spinal stenosis often occur in the adult population. There two distinct types of adult scoliosis, adult idiopathic scoliosis and de novo or degenerative scoliosis.
Adult idiopathic scoliosis patients have been diagnosed with scoliosis during their childhood and now present for evaluation in a skeletally mature state. Adult idiopathic scoliosis can be associated with or without degenerative changes as well.
What is Degenerative Scoliosis?
De novo or degenerative scoliosis has its onset in adulthood. This form of scoliosis usually develops secondary to degenerative changes of the lumbar spine and usually occurs in elderly patients. The prevalence of de novo scoliosis is roughly 6 to 7%, and the average age at which symptoms develop is usually the 6th or 7th decade of life.
Initial treatment of both types of scoliosis starts with a thorough history and physical exam. Both adult idiopathic and de novo scoliosis conditions are also evaluated initially with x-rays of the entire spinal column. The treatment of adult scoliosis depends on curve type, magnitude, flexibility, and spinal balance. Smaller curves and those patients deemed medically unfit to tolerate surgery are placed through a course of non-operative treatment.
This non-operative treatment might consist of observation, oral medications, injections, physical therapy, and/or symptomatic bracing. Larger curves or curves which are progressing rapidly require operative treatment.
This involves large fusions spanning the entire deformity. The surgical goals in the adult population are fivefold:
1. To improve or restore coronal (frontal plane) and/or sagittal imbalance (side plane).
2. To correct and stabilize a progressive spinal deformity
3. To obtain a solid arthrodesis (fusion of the spinal deformity).
4. To decompress the neural elements associated with the claudication (nerve root compression) symptoms.
5. To relieve the patient’s pain.
The treatment of adult deformity can be more challenging than that of adolescent deformity for several reasons. Adult curves demonstrate greater curve stiffness, often have advanced degenerative changes, and require the need for neural element decompression. Additionally, these patients often present with multiple medical comorbidities including cardiac disease, diabetes, obesity, osteopenia or osteoporosis.
Finally, adult scoliosis surgery usually involves correction to both sagittal (front to back) and coronal (side to side) plane imbalance, requiring longer fusions with longer surgical times. Each patient with severe progressive adult scoliosis is evaluated and given a risk/benefit analysis. If a patient is deemed medically stable and fit to undergo surgical correction of this debilitating deformity, then surgery might be recommended. Technology and surgical advances have come a long way allowing for these complicated surgeries to be performed in a safe and effective manner to optimize patient’s results and long-term outcomes.