What is Adult Scoliosis?

The normal, healthy spine is straight when seen from the front or the back (frontal plane). When seen from the side, the healthy spine has several mild curvatures. By obtaining an X-ray of a standing person, the exact contour of the spine can be measured and then compared to normal values to determine if a significant spinal deformity is present. Scoliosis is defined as a lateral deviation of the spine. More precisely, if the spine, seen on an antero-posterior radiograph (abbreviated as "AP", ie. seen from the front), has a curvature that measures more than 10 degrees then a scoliosis is present. (figure 1)

When a curvature, or scoliosis, is mild then one may not be able to detect any abnormality without an X-ray. On the other hand, moderate or severe scoliosis can be noted due to an asymmetry of the back. A tilted waistline and skin folds may be present, as well as a hunching, or protrusion of the back. Frequently, such an asymmetry in the back is more noticeable with leaning forward.

There are many types of scoliosis, and people of all ages can be affected by scoliosis. In adults, scoliosis can result from several conditions, but most types fall into two different categories. In the first category is a person who had a scoliosis as a child/adolescent and the abnormal spine curve has increased into adult life or is becoming painful with aging. The second category of adult scoliosis is seen in patients who have never had a scoliosis as a child but begin to develop an abnormal curvature with aging. The spinal deformity in degenerative scoliosis is usually a mild side curvature involving predominantly the lower levels of the spine.

Symptoms related to adult scoliosis are mostly due to degeneration (wear and tear) of structures that support the spine. These changes which are often called "arthritis of the spine" can occur at all levels of the back (neck, upper back and lower back). With aging and arthritis, a gradual narrowing of the discspaces between vertebrae, wearing out of the joints, as well as narrowing of the space available for the nerves (a condition known as stenosis) can develop. Although degeneration of the spine is part of the normal aging process in all people, it appears that in most people the spine becomes stiffer with age but does not develop a lot of abnormal curvature and causes only minimal or no pain. In other people the spine loses its structural stability with aging and gradually develops abnormal curvatures that can be painful and lead to symptoms including back pain, stooped posture, leg problems (numbness, heaviness, tingling, pain and weakness) and progressive difficulty in walking which requires frequent rests and activity limitation.

How is Scoliosis evaluated?

An evaluation by a spine specialist is important when scoliosis is present. In addition to a comprehensive medical evaluation and examination, scoliosis is assessed by obtaining X-rays of the entire spine in the standing position. Scoliosis is confirmed when an X-ray reveals a lateral deviation (curve) measuring more than 10 degrees. (Figure 2) In patients who have leg symptoms or difficulty walking, further tests may be ordered by your physician to more closely evaluate the spinal canal and the nerves which lead from the spine to the legs. This may require an MRI or CAT scan, and possibly a myelogram.

Who needs treatment, and what are the treatment options for
Adult Scoliosis?

Treatment of adult scoliosis is directed at the particular problem, which is causing symptoms in a patient. In some patients the leg numbness or weakness is most bothersome while in others it may be back pain alone. The fact that someone has a scoliosis does not necessarily mean that pain or disability is present. Many people have scoliosis and require no particular treatment. Prior to any treatment a clear diagnosis and discussion of treatment options with a specialist is necessary.

Non-operative treatment options

Most commonly the first approach to treatment for adult scoliosis is 'conservative treatment' (ie. non-surgical). In general, patients who are experiencing back pain and fatigue, and are otherwise in good health, pursue a guided back strengthening program. With a rehabilitation program for re-conditioning muscles of the spine it may be possible to improve support and posture leading to a reduction of abnormal alignment and motion in the spinal column, thereby reducing pain. In order for the exercises to be effective they must be performed regularly. It may take weeks or months for exercises to lead to an improvement in symptoms. In addition to strengthening exercises it is important to maintain overall good health by eating properly, sleeping well and not smoking.

For patients with severe pain, and evidence of instability the addition of a back brace may be very helpful. Bracing may help reduce motion across the spine and provide the sensation of increased support. Bracing does not eliminate the need for physical therapy, and exercises can often be performed while wearing the brace.

Practical tips on living with a brace

If your physician has recommended a brace you must understand that this is not an easy treatment method and does not replace the need for other treatments such as physical therapy. It is essential that you have a customized brace made which will fit your body shape. Everyone has a unique body shape, and particularly a patient with scoliosis will have a shape that requires detailed attention in the making of a brace.

There are many types of braces and your physician will determine which is most suitable for you. Initially, any brace will seem awkward to wear and may even be quite uncomfortable. To give bracing a fair chance be patient and get used to wearing your brace in a gradual manner. It may be a good idea to start wearing the brace for only an hour at a time and then increasing this daily until after a week or so you can tolerate the brace for most of the day. During bathing and while in bed the brace can usually be removed, your physician will guide you in specific instructions.

Injection therapy has been applied to cases of adult scoliosis. Although injections have not been clearly proven to lead to long-term success for many patients, there are particular cases where some relief can be obtained.

Surgical treatment

Surgery should be reserved for those cases when a specific cause for discomfort has been identified and all non-operative treatments have failed. The patient must carefully consider the risks of surgery against the possible benefits. Detailed discussions with a spine specialist are essential prior to considering invasive treatments.

What types of surgery are performed for Adult Scoliosis?

Any surgical procedure for adult scoliosis should only be considered after careful review of all non-surgical options and failure of the 'conservative' treatment approaches. Only very rarely is surgery an emergency or first treatment.

The type of surgical procedure performed for adult scoliosis will depend upon several factors. Most importantly, a detailed pre-operative evaluation is essential to clearly define the problems at hand. The goal of surgery is to correct the abnormalities while providing a stable spine to avoid future problems.

Depending upon the main problems of a particular person, one of a variety of different surgical procedures may be performed. For instance, if the primary problem is spinal stenosis (narrowing of the spinal canal which leads to nerve compression/irritation) then decompression alone may be performed. For a problem of spinal instability such as spondylolisthesis (forward slippage of one portion of the spine over another), a surgeon may recommend a decompression accompanied by a fusion and possible instrumentation (placement of screws and rods). In cases of progressive deformity with severe pain and nerve symptoms a surgeon may recommend a correction of the scoliosis and a spinal fusion from the front and back of the spine.

Frequently Asked Questions

Reference:

1. Schwab, F.J.; Gamez, L.; Levine, E.; Farcy, J-P.; Strongwater, A.: Pain Predictors in Adult Scoliosis: a Quantitative Radiographic and Clinical Analysis. Annual Meeting of the Scoliosis Research Society. San Diego. September, 1999.
2. Schwab, F.J.; Gamez, L.; Levine, E.; Farcy, J-P.; Strongwater, A.: Pain Predictors in Adult Scoliosis: a Quantitative Radiographic and Clinical Analysis. Annual Meeting of the North American Spine Society. Chicago. October, 1999.
3. Farcy, J-P. : Schwab, F.J.:Ideal Contour of the Fused Spine: Backtalk, 20(1), 1997
4. Schwab, F.J.; Farcy, J-P.: Rationale for Realignment Surgery for the Spine. In: J.Y. Marguiles, M. Aebi, J-P. Farcy editors: Revision Spine Surgery, St. Louis, 1999 , Mosby, pp 746-751.
5. Campello, M.; Nordin, M.; Wiser, S.: Physical Exercises and Low Back Pain; Scandinavian Journal of Medicine and Science in sports. 6:63-72, 1996
6. Kopp, M.: Caring for the Adult Patient Undergoing Anterior/Posterior Spinal Fusion. Orthopaedic Nursing, March/April,Vol.16/No.2. 1997