Scoliosis

Everyone’s spine has subtle natural curves. But some people have different curves, side-to-side spinal curves that also twist the spine. This condition is called “scoliosis”. On an x-ray with a front or rear view of the body, the spine of a person with scoliosis looks more like an “S” or a “C” than a straight line. These curves can make a person’s shoulders or waist appear uneven. These curves can’t be corrected simply by learning to stand up straight. You can’t cause scoliosis; it does not come from carrying heavy backpacks, participating vigorously in sports, or poor posture.

In addition to the two types of adult scoliosis discussed in this section—Adult Idiopathic Scoliosis and Adult Degenerative Scoliosis—types of scoliosis that develops early in life or that results from a separate syndrome also effect adults.

Adult idiopathic scoliosis is, in essence, a continuation of adolescent idiopathic scoliosis. Sometimes a spine curvature of an idiopathic (cause not known) nature that began during teenage years may progress during adult life. Curves may increase in size 0.5° to 2° per year. Adolescent curves less than 30° are unlikely to progress significantly into adulthood, while those over 50° are likely to get bigger, which is why adult scoliosis specialists should monitor the curves over time.

Locations

Occurs in the thoracic (upper) and lumbar (lower) spine, with the same basic appearance as that in teenagers, such as shoulder asymmetry, a rib hump, or a prominence of the lower back on the side of the curvature. Curves can worsen in the older patient due to disc degeneration and/or sagittal imbalance. Additionally, arthritis commonly affects joints of the spine and leads to the formation of bone spurs.

Symptoms

Adults with idiopathic scoliosis have more symptoms than teens because of degeneration in discs and joints leading to narrowing of the openings for the spinal sac and nerves (spinal stenosis). Some patients may lean forward to try and open up space for their nerves. Others may lean forward because of loss of their natural curve (lordosis, sway back) in their lumbar spine (low back). The imbalance causes the patients to compensate by bending their hips and knees to try and maintain an upright posture. Adult patients may have a variety of symptoms, which can lead to gradual loss of function:

• Low back pain and stiffness are the 2 most common symptoms
• Numbness, cramping, and shooting pain in the legs due to pinched nerves
• Fatigue results from strain on the muscles of the lower back and legs

Imaging Evaluation

Scoliosis defined with radiographs that can include the following:

• Standing x-ray of the entire spine looking both from the back as well as from the side so your physician can measure the radiographs to determine curve magnitude, measured in degrees using the Cobb method.
• Magnetic resonance imaging (MRI) study of the spine is rarely used for patients experiencing minimal symptoms with adult idiopathic scoliosis. An MRI is usually ordered if you have leg pain, your physician finds some subtle neurologic abnormalities on physical examination, or if you have significant pain or an “atypical” curve pattern.

Nonoperative treatment

The majority of adults with idiopathic scoliosis do not have disabling symptoms and can be managed with simple measures including the following:

• Periodic observation
• Over-the-counter pain relievers
• Exercises aimed at strengthening the core muscles of the abdomen and back and improving flexibility
• Braces, in short-term use for pain relief (long-term use in adults is discouraged because braces can weaken the core muscles)
• Epidurals or nerve block injections for temporary relief if the patient has persistent leg pain and other symptoms due to arthritis and pinched nerves. Patients should track their response to the various injections to help define their pain generators.

Stronger pain medications can also be habit-forming and must be used with caution. If narcotics are needed to control the pain, see a scoliosis surgeon to learn more about the possible causes of pain.

Operative treatment

Surgical treatment is reserved for patients who have:

• Failed all reasonable conservative (non-operative) measures.
• Disabling back and/or leg pain and spinal imbalance.
• Severely restricted functional activities and substantially reduced overall quality of life.

The goals of surgery are to restore spinal balance and reduce pain and discomfort by relieving nerve pressure (decompression) and maintaining corrected alignment by fusing and stabilizing the spinal segments. When patients are carefully chosen and mentally well-prepared for surgery, excellent functional outcomes can be achieved which can provide positive life-changing experience for a given individual patient. When larger surgeries—those greater than 8 hours—are necessary, surgery may be divided into 2 surgeries 5 to 7 days apart. Surgical procedures include:

• Microdecompression relieves pressure on the nerves; A small incision is made and magnification loupes or a microscopic assists the surgeon in guiding tools to the operation site. This type of procedure is typically used only at one vertebra level, and carries a risk of causing the curve to worsen, especially in larger curves >30 degrees.
• Surgical stabilization involves anchoring hooks, wires or screws to the spinal segments and using metal rods to link the anchors together. They stabilize the spine and allow the spine to fuse in the corrected position.
• Fusion uses the patient’s own bone or using cadaver or synthetic bone substitutes to “fix” the spine into a straighter position
• Osteotomy is a procedure in which spinal segments are cut and realigned
• Vertebral column resection removes entire vertebral sections prior to realigning the spine and is used when an osteotomy and other operative measures cannot correct the scoliosis.

Also known as de novo (new) scoliosis. This type of scoliosis begins in the adult patient due to degeneration of the discs, arthritis of the facet joints and collapse and wedging of the disc spaces.

Locations

It is typically seen in the lumbar spine (lower back), and usually accompanied by straightening of the spine from the side view (loss of lumbar lordosis).

Symptoms

Disc degeneration and spinal stenosis associated with adult degenerative scoliosis can cause the following symptoms:

• Back pain
• Numbness
• Shooting pain down the legs

Imaging Evaluation

• X-rays, front and standing, must include all segments of the spine as well as the pelvis and hips to measure alignment, curvatures, and balance. For the side x-rays, hips and knees must be straight. Focused x-rays of the cervical, thoracic, and lumbar spine may also be necessary.
• Magnetic resonance imaging (MRI) or computerized tomography (CT), advanced imaging techniques to assess patients with lower extremity symptoms or other neurologic signs or symptoms.

Nonoperative treatment is appropriate for the majority of adults with degenerative scoliosis who don’t have disabling symptoms. Treatments include:

• Periodic observation
• Over-the-counter pain relievers
• Exercises aimed at strengthening the core muscles of the abdomen and back and improving flexibility
• Braces with short-term use of for pain relief (long-term use in adolescents is discouraged because braces can weaken the core muscles)
• Epidurals or nerve block injections for temporary relief of leg pain and other symptoms

Stronger pain medications can also be habit-forming and must be used with caution. If narcotics are needed to control the pain, see a scoliosis surgeon to learn more about the pain generators.

Operative treatment

Surgical treatment is reserved for patients who have:

• Failed all reasonable conservative (non-operative) measures.
• Disabling back and/or leg pain and spinal imbalance.
• Severely restricted functional activities and substantially reduced overall quality of life.

The goals of surgery are to restore spinal balance and reduce pain and discomfort by relieving nerve pressure (decompression) and maintaining corrected alignment by fusing and stabilizing the spinal segments. When patients are carefully chosen and mentally well-prepared for surgery, excellent functional outcomes can be achieved which can provide positive life-changing experience for a given individual patient. When larger surgeries—those greater than 8 hours—are necessary, surgery may be divided into 2 surgeries 5 to 7 days apart. Surgical procedures include:

• Decompression surgery removes the roof of the spinal canal (laminectomy) and enlarging the spaces where the nerve roots exit the canal (foraminotomy), resulting in decompressed nerve roots and pain relief. Typically only used at one or two vertebral levels in patients with leg pain from stenosis and smaller curves (< 30 degrees). In patients with more than two levels of stenosis and larger curves >30 degrees, a decompression without fusion has a risk of destabilizing the spine and causing the curve to worsen.
• Surgical stabilization involves anchoring hooks, wires or screws to the spinal segments and using metal rods to link the anchors together. They stabilize the spine and allow the spine to fuse in the corrected position, and is always performed with the addition of a fusion.
• Fusion uses the patient’s own bone or using cadaver or synthetic bone substitutes to “fix” the spine into a straighter position
• Osteotomy is a procedure in which spinal segments are cut and realigned
• Vertebral column resection removes entire vertebral sections prior to realigning the spine and is used when an osteotomy and other operative measures cannot correct the scoliosis

Adapted from http://www.srs.org/patients-and-families/conditions-and-treatments/adults/scoliosis