Scoliosis refers to a curve of the spine when viewing the body from the front or back. As its name implies, Adult Scoliosis (AS) occurs after skeletal maturity which is generally 18 years of age. There are two types of adult scoliosis: 1) That which occurs in early adulthood from age 18 to age 40 or 50. This is usually Adolescent Idiopathic Scoliosis that was present during youth and continues into adulthood. Usually, if curves are less than 50 degrees at the end of growth there is little chance that the curves will progress as a person ages. 2) Scoliosis that occurs later in life generally in patients older than 50. This is usually the result of wear and tear or degeneration of the spine and the curves are rarely greater than 50 degrees.
Both types of AS may be associated with progressive degenerative changes in the spine as a person ages leading to back pain and in some cases spinal stenosis. Spinal stenosis is a narrowing of the canal through which the nerves pass and can lead to pain in the lower extremities with some numbness, tingling or weakness but usually not paralysis.
AS is diagnosed by examining a patient and noting a curve when viewing the patient from the front or back. The sized of curvature is confirmed by x-rays which are taken with the patient standing and then measuring the curve.
Treatment of AS depends upon whether a patient has pain. Patients without pain generally require no treatment other than follow-up x-rays every year or two. Patients that have low back pain severe enough to require treatment are usually treated with a non-steroidal medicine such as ibuprofen or naproxen, a walking program, a light exercise program, physical therapy and occasional bracing. Bracing in this population decreases motion in the spine thereby decreasing back pain but will not correct the curve. Patients with lower extremity pain require a MRI to confirm the diagnosis of stenosis. Patients whose lower extremity pain is from stenosis are initially treated with oral medication and if no relief is obtained an Epidural Steroid Injection (ESI). This involves placement of steroids around the irritated nerves under x-ray control to decrease inflammation and thereby decrease lower extremity pain.
Surgical treatment for AS is reserved for those patients that have a progressive curve which is somewhat unlikely and more commonly for patients with significant low back and lower extremity pain. Surgery typically consists of decompressing or un-pinching nerves followed by partial correction of the curve with metal screws and rods and fusing or welding the spine in the corrected position with bone graft. While total pain elimination doesn’t usually occur with surgery most patients can be made significantly better allowing them to resume an improved lifestyle.
Scoliosis refers to a curve of the spine when viewing the body from the front or back. Idiopathic refers to the fact that we as doctors do not know the exact cause of this condition. Adolescent refers to the occurrence of this condition in patients from 12-18 years of age. Adolescent Idiopathic Scoliosis (AIS) tends to run in families and is defined by a curve that measures 10 degrees or more. AIS occurs 5 times more commonly in females than males. Approximately 1 in a 100 people will have a curve of 10 degrees but only 1 in 1000 people will have a curve progress to 25 degrees which is the degree magnitude that requires treatment. In general, patients who are diagnosed at an early age or who have a large curve at the time of diagnosis are at increased risk for curve progression which may require treatment. AIS is not associated with spinal pain or any neurologic problems such as numbness, tingling or weakness.
The diagnosis of AIS is suggested on physical exam by noting a spine that is not straight particularly when the patient bends forward (Adam’s forward bending test). The diagnosis is confirmed by obtaining a standing xray of the entire spine from the front and side and noting a spine that is not straight and has a curve of least 10 degrees.
Treatment of AIS depends upon the severity of the curve and the age of the patient. In general, curves of less than 25 degrees are watched closely by the doctor and x-rays are obtained every 4 months to make sure that the curve is not worsening. Shielding the pelvic area with lead and having the x-ray beam enter the body from the back help protect the reproductive organs of the patient. If a curve progresses past 25 degrees and the patient has at least 1.5 years of growth remaining, then the patient is treated with a brace designed to hold the curve in a partially corrected positioned until growth has finished. A patient’s stage of growth may by estimated by looking at the calcification of the iliac apophysis on the scoliosis x-ray (Risser sign). If a growing patient’s curvature continues to progress despite bracing and exceeds 40 degrees, then surgery may be indicated. However, if a curve is 40 degrees at the end of growth then close observation rather than surgery is usually indicated.
The primary goal of surgical treatment is to prevent the curve from worsening and the secondary goal is correction of the curve. There are many different surgical techniques depending upon the individual patient’s curve but in general it consists of the placement of metal screws, rods and hooks in the spine to correct the curve followed by the placement of bone graft on the spine to fuse or weld the spine in the corrected position. With modern surgical techniques bracing is not usually necessary following surgery.