Vol. 12 Issue 5
Treating Adult Scoliosis
Chronic and severe back pain is the primary complaint among adults with this condition.
Scoliosistypically considered a childhood disorderisn't just for kids. Nearly 4 percent to 8 percent of adults experience the condition, according to the Scoliosis Research Society. A curvature of the spine, scoliosis usually occurs in the mid-back (thoracic spine) or lower back (lumbar spine). The spine is often twisted.
Adult scoliosis can be caused by a progression of the disease from childhood, which occurs if it isn't treated early or goes undetected. Another cause is the asymmetric degeneration of spinal elements from osteoporosis (porous bone), disc degeneration, compression fracture or a combination of these factors.
Left untreated, adult scoliosis can eventually lead to severe, persistent pain, deformity progression and, in rare cases, reduced cardio.pulmonary (heart and lung) function. But there's good news for adults with scoliosis. A 50-year study showed that untreated adults with long-term idiopathic scoliosis were still productive and functional decades later, with little physical impairment other than back pain.1
Among the physical effects of scoliosis are rib prominence on one side and leg length discrepancy, which can adversely affect walking or running. In addition, adults with scoliosis may have difficulty sitting or standing, experience stiffness and spinal rigidity and develop a humpback. An asymmetric pelvis can lead to trunk imbalance, making it appear as though the patient is listing to one side.
For adults with scoliosis, back pain is and always has been the primary complaint. Although most of us will experience occasional back pain during our lives, the back pain caused by scoliosis is chronic and much more severe. Pain is more common and intense in the lumbar or lower spine. When the pain is centered in the thoracic area, simple rest often alleviates it.
Before treatment can be prescribed, clinicians must determine the location and duration of the pain. The following types of pain occur from scoliosis:
· muscle fatigue pain, which originates on the outer side of the curve and worsens as the day goes on
· pedicular pain, which occurs on the concave side due to pedicular kinking at the apex of the curve
· junctional zone pain, which patients feel between two curves
· Facet disease, which causes pain upon rising from bed and standing upright.
A thorough physical and neurological examination by a physician trained in adult scoliosis is essential and will help pinpoint the sources of pain, allowing for proper treatment.
Several factors cause severe and chronic pain in adults with scoliosis. As the degree of curvature increases, the body's posture worsens. Muscles in the back, neck, shoulders, hips and legs are constantly stretched or constricted out of alignment, leading to pain and fatigue. The imbalance of the curves also can cause arthritis of the spine, called spondylosis, in the spine vertebrae.
Nearly all adults with scoliosis will develop spondylosis over time, with the risk increasing with age. With spondylosis, bone spurs develop on the facet joints of the spine, as the joints become inflamed and enlarged. In more advanced cases, the vertebral joints may fuse together on their own, locking the spine into the curved position. Bone cartilage also thins, making movement more difficult, and nerve damage can occur as the misaligned vertebrae begin to press on nerves that exit the spinal canal, leading to numbness and tingling down the legs.
Beyond age 50, adults with scoliosis also will begin to experience the effects of osteoporosis and compression fractures, particularly among womenwho comprise 90 percent of those with scoliosis, according to the Scoliosis Research Society. Many of my adult surgical patients had adolescent scoliosis that went treated; they're now reaching an age in which the pain can no longer be controlled with conservative treatment methods.
Fortunately, most patients with adult scoliosis don't require surgery. The nonoperative mainstay for treatment and pain management focuses on correcting pre-existing conditions that can cause or aggravate the pain. Treatment may include weight loss, which reduces the vertical load on the spine while standing or sitting; exercise and re-conditioning, such as low-impact aerobics and Pilates, which improve overall muscle tone; and muscle strengthening to maintain strength of the back muscles. (Older adults tend to lose strength due to reduced activity.) Jogging is contraindicated because of its pounding effect on the spine.
Other treatment methods involve applying moist heat to painful areas and nonsteroidal anti-inflammatory medication, as well as osteoporosis treatment to prevent small compression fractures of the spine and reduce pain.
Osteoporosis treatment includes exercise, calcium and Vitamin D supplements and prescribed medications, such as Fosamax.
As another treatment, some patients have turned to chiropractic care. Although it's popular, there is no evidence that chiropractic treatment improves scoliosis.
Bracing is rarely used to help control pain because most older adults won't tolerate wearing one. In my experience, more than 90 percent of adults will abandon a brace in a very short time due to the discomfort and inconvenience. Bracing also will not correct or cure scoliosis. Rather, it's designed for immature skeletons in adolescents and has no role in treating adult scoliosis.
Surgery is not normally recommended for adults with moderate spinal curvatures (in the 30 degree to 50 degree range) as long as their curves are stable and not causing disability. Adults with spinal curvatures greater than 50 degrees have the greatest risk of worsening deformity, while those with curves of less than 30 degrees have the least risk. An X-ray can help physicians predict whether curves can be expected to worsen over time. Typically, if the disease is progressing, curves will increase at a rate of 1 degree to 3 degrees annually.
Surgery is generally considered for adults if any of the following conditions exist:
· thoracic curve is greater than 50 degrees with persistent pain
· progressive thoracolumber (mid and low back) curve
· lumbar (low back) curve with persistent pain
· decreased cardiopulmonary function due to thoracic curve.
Pain control and increasing disability are the primary reasons most adults decide to have surgery, although appearance and deformity are also factors. Because our spines become much more rigid as we age, adults can typically expect no more than a 50 percent to 60 percent correction in the curve of the spine. Therefore, adults must understand that spinal surgery won't create a perfectly straight spine. Rather, it will help them achieve balance and relieve pain.
Surgery may include removing an intervertebral disc (e.g., discectomy), combined with spinal instrumentation and fusion. Spinal instrumentation involves rods, bars, wires, screws and other types of medical hardware to stabilize the spine, enhance the fusion and provide a more permanent solution.
When considering spinal surgery, we should not let age be a deterrent. Forty percent of spinal surgery to correct adult scoliosis is now being performed on patients older than 50, according to data from the Scoliosis Research Society.
In my practice, the average age of my patients is 65, and I have successfully operated on patients 80 and older.
Typically, patients older than 80 choose surgery because they can no longer walk, and it's the only option to regain mobility. The average recovery period for older adults undergoing spinal surgery is five days in the hospital, depending on their prior physical condition. However, it may take up to a year to get back to a high level of function, depending on how strong the patient was before surgery.
Given today's advanced medical techniques, spinal surgery has a higher level of success and lower complication rates than ever before. But spinal fusion is an irreversible procedure and should not be considered lightly. Because this surgery is so specialized, patients should choose a surgeon who is trained and experienced in treating adult scoliosis.
Whether the recommended treatment course is conservative or surgical, I recommend that patients incorporate physical therapy whenever possible to help build muscle strength, increase their range of motion and maintain flexibility.
1. Weinstein, S.L., Dolan, L.A., Spratt, K.F., et al. (2003). Health and function of patients with untreated idiopathic scoliosis; A 50-year natural history study. Journal of the American Medical Association, 289(5), 559-567.
Edgar G. Dawson, MD, is a board-certified orthopedic surgeon specializing in the treatment of complex spinal disorders, including scoliosis, at The Spine Institute at Saint John's Health Center in Santa Monica, Calif. A fellow of the American Academy of Orthopedic Surgeons, Dr. Dawson is a member and past president of the Scoliosis Research Society and the American Orthopedic Association. For more information, contact www.espineinstitute.com