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.
Figures 1-4: Progression of adult scoliosis from age 14 (top left) to age 46 (lower right).
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,” explains Oheneba Boachie-Adjei, MD, Chief Emeritus of the Scoliosis Service at Hospital for Special Surgery (HSS). 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.
Figure 5: Diagram detailing the sections of the spine, with the neck (cervical) section at the top.
[Image courtesy of www.SpineUniverse.com]
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:
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.
Figures 6 & 7: Photo and x-ray of patient with severe curve progression and restrictive pulmonary disease.
“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,” notes Dr. Boachie, who adds that this information also helps guide treatment choices.
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.
Figures 8-10: Pre-op images of an adult with thoracic scoliosis
Figures 11-13: The same patient after posterior fusion and instrumentation
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.
Figures 14-16: Pre-op images of an adult with lumbar scoliosis
Figures 17-19: The same patient after anterior/posterior fusion and instrumentation
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 assess 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,” Dr. Boachie explains.
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.
To address these challenges, surgeons at HSS work with a multi-disciplinary team - one that includes internists, pulmonologists, neurologists, anesthesiologists, and nurses. Surgical patients are given antibiotics to help guard against infection, and their sensory and motor function is monitored throughout surgery to detect any changes in spinal code integrity during spinal manipulation and curve correction.
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, according to Dr. Boachie, 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.
While surgical treatment of scoliosis in adults can present a complex set of challenges, a team approach, and the use of refined operative techniques and instruments, help ensure a positive outcome. In addition, orthopedic surgeons are increasingly using bone morphogenic proteins (BMPs) in spinal fusions; these substances enhance and speed healing for a good long-term result.
If you would like more information about treatment of scoliosis in adults at HSS, please visit the Physician Referral Service or call 1 (877) 606-1555.
Summary prepared by Nancy Novick. Imaging studies provided by the HSS Department of Radiology.