myScoliosis

Overview

Adult scoliosis is a condition where rotation of the spinal vertebrae leads to curvature of the spine in a person who has finished growing (usually by 18 - 21 years old). In order to be classified as scoliosis, the curve must exceed 10°.

Curves can occur in the chest area (thoracic spine) or the lower back area (lumbar spine). Curves involve areas of the spine which lie in between, such as thoracolumbar. The neck or cervical spine is rarely involved.

Causes of Adult Idiopathic Scoliosis

When curvature of the spine starts in adolescence in an otherwise healthy person, it is most commonly diagnosed as "adolescent idiopathic scoliosis". Idiopathic refers to the fact that the curve is not associated with other known problems such as cerebral palsy, spina bifida, neurofibromatosis, or a number of other conditions.

After age 18, adolescent idiopathic scoliosis becomes "adult idiopathic scoliosis". It is the same curve present during the teen years but the spine does not behave the same way as the teenage spine. As a person with scoliosis ages, the spine develops premature aging changes in the back joints such as bone spurs, degenerative discs, and thickened spinal ligaments. This leads to a condition known as "adult idiopathic scoliosis with degenerative changes". These degenerative changes superimposed on a curve that is already present can sometimes cause back pain, leg pain, spinal imbalance, and progression or worsening of the curve.

For adult curves greater than 50°, natural history studies suggest a higher likelihood of curve progressing at about 1° per year. For curves in the lumbar spine or lower back, there is a high chance of progression if the curve is greater than 35-40°.

Signs and Symptoms

The most common sign of scoliosis is a prominence in the ribs on one side of the thoracic spine. In the lumbar spine, there is sometimes a prominence on one side, though often not. The prominence or "rib hump" is most apparent when bending forward. Sometimes there seems to be an asymmetry in the waist, with one side being indented more than the other. Clothes begin to fit differently than before.

If the scoliosis is severe and unstable, spinal imbalance is common. Imbalance implies that patients lean to one side or forward when they try to stand straight upright. They may feel like they are tipping to one side, or have the sense that they are falling forward. Most people with adult scoliosis notice that they are not as tall as they used to be.

Most young adults with scoliosis do not have significant back pain. The curve usually does not hurt unless or until it becomes degenerative. Sometime in life, however, because arthritis is age related and develops prematurely in this group, the adult with scoliosis is likely to develop back pain. When it occurs, the pain is worse when upright and active, and better when the patient is resting.

Spinal instability occurs when the disc and facet joints are so worn out that they can no longer maintain normal spinal alignment. Pain comes from the arthritic joints as well as from the adjacent nerves, which are pinched and stretched as a result. Buttock pain can occur due to referred pain from the arthritic spine, or it could be a manifestation of a more significant problem with nerve compression. Spinal nerve roots become pinched when arthritic bone spurs form around them and block their exit route from the spinal column. This condition is called Spinal Stenosis. In addition to buttock pain, other symptoms such as leg pain, numbness, tingling, and weakness are common. If any of these findings are present, advice from a physician should be sought without delay.

If spinal stenosis or nerve compression in the back is severe enough, control of bowel and bladder function will be lost. This however is a rare event, but when it happens, it is a surgical emergency. If the pressure on the nerves is not relieved quickly, control of bladder and bowel may never be regained. Again, this is a very rare occurrence and we only see 2 or 3 cases each year.

Challenges

As the spine ages, it becomes stiffer. Flexibility is greatest in the teen years, and usually declines starting in the 40-50 age group. Stiffness of the spinal joints can become severe as bone spurs form and prohibit motion. In some cases, the bone spur formation is so severe that all motion is lost at one or more levels in the spine. We all achieve our maximum bone density at about age 30-35. After age 35-40, there is a slow decline in the amount of bone present in the spine. After age 60, and particularly after menopause in women, the loss of bone becomes visible on x-rays. This is osteoporosis. If the bone loss becomes severe, spontaneous fractures can occur in the spine. These fractures can lead to scoliosis or kyphosis.

As we get older, our general health can become more of a problem. Chronic disease processes such as high blood pressure, diabetes, and heart disease are prevalent among American Seniors. When scoliosis becomes a problem in seniors, other health issues must be considered when treatment options are considered.

Conservative Treatment

Nearly all patients with adult scoliosis will respond to conservative treatment and lead a normal, functional life. When pain is present, it is usually short term and manageable. Treatment for adult scoliosis should almost always begin with a non-invasive approach. Our philosophy is, "Try the easy things first."

Non-steroid Anti-inflammatory Drugs (NSAIDS) have been the cornerstone of medical therapy for arthritic and inflammatory conditions. These medications can quiet the pain and stiffness caused by degenerating discs and joints.

Physical Therapy is an excellent way to improve function, flexibility, endurance, and decrease pain. Usually the therapist will work with patients toward becoming less symptomatic, and maintaining the improvement with an active home exercise program. Working out in a supervised environment with the help of a physical therapist is the best way to achieve it. On average, therapy lasts 2-3 times per week for 4-8 weeks.

It is very important that adult patients with scoliosis get into the habit of doing a daily exercise routine. This will improve the strength of the trunk muscles and take some of the stress off from the spine. Often when pain occurs, it is because the patient is not doing his or her exercises.

Sometimes a back brace is helpful in getting some relief from back pain in patients with degenerative scoliosis. A word of caution is in order however: the brace should not be used without faithful compliance with an active exercise program. Brace wear without exercise tends to lead to a weaker spine that becomes dependent on the brace. Daily exercises and occasional (when needed) brace wear lead to the best results, where bracing is concerned.

Medical management of osteoporosis and general health is important to maintaining an active lifestyle into old age, especially in patients with scoliosis. Solving small problems before they become big ones has always been good advice.

Passive manipulation (Chiropractic) is not an acceptable treatment for scoliosis of any kind. Passive manipulation of the spine provides short term symptomatic relief for muscle spasm, but does not impact the size of the curve or the rate of progression. Patients with scoliosis are encouraged to not rely on chiropractic “adjustments” as a means of treatment since these are essentially equal to no treatment at all.

Correction of Spinal Deformity - Surgery for Adult Scoliosis

Reasons Surgery Might Be Considered

Few patients with adult scoliosis will ultimately require surgery. When necessary, the goals of surgery are to stop curve progression, stabilize the spine, establish correct spinal balance, decrease back and leg pain, and increase function with as little surgery and as few complications as possible. Patients who require surgery to straighten, stabilize and fuse their spinal curvature are patients with:

• Increasing curvature over time (it will continue to get worse)
• Unstable spine that hurts despite conservative care
• Nerve compression causing pain, numbness, or weakness
• Spinal imbalance which is painful or progressive
• Large curve which will progress (better to do these earlier while health is good and before osteoporosis starts or worsens)

Surgical Options and Results

If the main problem is leg pain caused from a disc herniation, this can usually be taken care of with a small surgery to remove the disc fragment and decompress the nerve. A large procedure to correct the scoliosis and fuse the spine is not necessary. Sometimes leg pain is caused by bone spurs that are compressing the spinal nerves. This is spinal stenosis. If stenosis is the problem, the solution usually will require removal of the offending bone spurs to get pain relief. If adequate bone is to be surgically removed to decompress the pinched nerves (laminectomy), the spine is often rendered somewhat unstable in the process. Back pain will increase, leg pain may return, and the spinal curvature will get bigger if the spine is not fused at the same time. In these cases, correction of the curve and fusion with bone graft and instrumentation is required to stabilize the spine and prevent what would be a certain need for future surgery.

When back pain, progressive deformity, or spinal imbalance are primary factors, the curve should be straightened and fused. The amount of correction obtained with surgery is sometimes limited compared to the corrections seen in the pediatric patients. This is due to increased spinal stiffness in adults.

Surgical Technique to Correct Scoliosis

Once the decision for surgery has been made, the operative plan is formulated. Patients are routinely asked to donate blood before surgery to be stored and used during their surgery. The spinal cord function is usually monitored throughout the surgery to make sure there is no compromise to spinal cord function. Bone graft material and spinal instrumentation may need to be arranged for ahead of time. Surgery to correct adult scoliosis is the most challenging surgery done in orthopedics, and is likely among the most complex and demanding surgeries of any kind being performed today. This type of surgery requires at least one assisting surgeon and often a surgical team, and can take from 3-14 hours to accomplish.

Anterior Surgery

If the spine must be fused anterior or from the front, a thoracic or general surgeon will be a part of the surgical team to safely mobilize the great blood vessels off the spine where the spine surgeon will work. The incision may be through the side of the chest, through the side of the abdomen, or through the front of the abdomen, depending on what is needed at the time of surgery. The purpose of anterior surgery is to remove the discs, and fill the space with bone graft or Bone Morphogenetic Protein (see below). This serves to improve the correction which can be achieved and improve the reliability of the fusion.

Sometimes the spine is "instrumented" from the front, meaning that screws are placed into the vertebra and attached to a rod that will correct the deformity and stabilize the spine.

More recently, the thoracoscope has been used in spine surgery. We can now remove discs from the thoracic spine and insert bone graft without making a large incision. All of the work is done through a few one-inch incisions on the side of the chest.

Posterior Surgery

Most of the correction of scoliosis is done from the back of the spine. If nerves are compressed by bone spurs or a disc herniation, the offending structures can be removed to allow more room for the nerves. The spine is then "instrumented" by the placement of hooks or screws that attach to the vertebrae. These hooks and screws are then attached to rods that span the curve. The instrumentation is then distracted, compressed, or rotated in order to correct the spinal curvature. Without instrumentation, the curve cannot be corrected.

Bone graft is always used in scoliosis surgery. The spine must be fused in its new corrected and straightened position. The graft most commonly comes from the patient's own pelvis. Sometimes bone-bank bone is used when there is not sufficient bone available form the patient. Newer uses for Bone Morphogenetic Protein include posterior scoliosis fusions.

Results From Surgery

Adult patients who undergo major spinal surgery to correct their scoliosis generally do well. Pain is greatly improved or eliminated in the majority (80% in our series). The fusion is successfully achieved and the correction maintained long-term in 80-95% of people who have mild to moderate scoliosis corrected with or without nerve root decompression. In our series of recent patients, curve correction is averaging 67 – 79%, depending on the type of scoliosis.

Complications can occur however, such as failure of the spine to solidly fuse, failure of the spinal hardware (<2%), infection (2-4%), nerve injury (<1%), medical complications, and others. The patients who are at greatest risk for complications are smokers, people taking steroids and those with severe osteoporosis or poor nutrition.

Overview

Idiopathic: When there is no clear cause of the curvature in a healthy person, it is called Idiopathic Scoliosis. This type of scoliosis is the result of an abnormal rotation of the vertebra. Scoliosis can involve the upper back (thoracic), mid-back (thoracolumbar), or in the lower back (lumbar). The neck is seldom involved in scoliosis, and is never part of idiopathic scoliosis.

Adolescent idiopathic scoliosis is the most common type of spinal curvature. It occurs between the onset of puberty and age 18 in otherwise healthy boys and girls. The prevalence of scoliosis in the USA is 2 – 4% for curves as little as 10°. Girls are far more likely to have larger curves and curve progression than boys. We don't know why. For boys, curves are more likely to progress through the late teen years as long as skeletal growth continues.

Causes

Unlike many types of scoliosis, the cause of adolescent idiopathic scoliosis is unknown. It does seem to run in families but is not strictly inherited. The likelihood of scoliosis is greater where there is a family history. Cases can also occur where there is no family history of scoliosis. The more that is learned about causation, the more complicated this deformity appears to be. Research is ongoing to try and connect the disorder to a specific gene or group of genes.

Signs and Symptoms

Adolescent idiopathic scoliosis is a painless spinal deformity. The curve in the spine does not cause pain. If pain is present, it should be investigated further and not attributed to the curve.

The most common physical finding in teens with scoliosis is the prominence of the ribs on one side. This so-called "rib hump" is best observed by parents or health care providers when viewing the teen bending forward. The ribs on one side of the back will often seem higher than the other side. Other findings include one scapula or shoulder blade that may seem more prominent than the other is. Careful observation of the standing teen may also reveal that one shoulder is higher than the other. One hip may seem higher and give the appearance that one leg is longer than the other is (it usually is not). Clothes fit differently than they used to. There are also patients who have a large curve and hide it very well clinically, without much noticeable deformity.

Concerns for Teens

What Happens to Teens Who Have Scoliosis?

For teens with scoliosis, the period of time carrying the greatest risk that the curve will get bigger (curve progression) is during the adolescent growth spurt. For girls, this may be from age 11-14 and usually lasts for 18 months after the first menstrual period. For boys, it is usually between ages 13-17. During this period of rapid growth, the curve can increase up to 1 or 2 degrees per month. It is not uncommon for parents wonder where the curve came from so quickly. Some parents feel guilty for not noticing the curve sooner.

The nature of adolescent idiopathic scoliosis is one of possible rapid progression, and parents should not feel guilty. The likelihood of curve progression depends on the size of the curve in relation to the amount of growth the teen has remaining. For young teens who are still growing and have curves greater than 20 degrees, there is a 68% chance the curve will get larger over the next few years. If a teen’s growth is nearly complete and the curve is around 20 degrees, there is less chance the curve will ever increase. Most small and medium sized curves stop getting bigger once the body is finished growing.

The spinal curvature will continue to be the same size throughout life that it was when the patient was a teen. If the curve is more than 40-50 degrees during the teen years, it will likely continue to get larger during adulthood, though at a much slower rate.

Conservative Treatment Options

For simplicity and patient education, we break down scoliosis into three levels of severity.

SMALL CURVES: 10-25 degrees. These patients are treated with observation. For teens still growing, follow-up x-rays are needed every 4 months until growth stops.

MEDIUM CURVES: 26-40 degrees. If the patient is still growing, a brace should be considered. We use a custom molded TLSO (thoraco-lumbo-sacral orthosis) for most patients and our success rates have been similar to the national experience. The brace is about 70% successful at preventing curve progression. Nearly one third of patients that wear the brace experience curve progression anyway. The brace does not make the curve improve or go away. Successful bracing means that the patient avoids surgery because the curve does not increase. Successful bracing keeps the curve at the same degree it was when bracing was started.

Certain types of braces (TLSO, Boston, Milwaukee, and Charleston have been studied by members of the Scoliosis Research Society and are successful in treating scoliosis. Some other types of braces have been widely advertised by their entrepreneur developers but their use is not supported by adequate data. If you have any questions about whether your brace is adequate, contact the Scoliosis Research Society or a SRS member in your area.

Treatments which have NOT been shown to have any affect on curve progression:

• physical therapy
• exercise program
• chiropractic manipulation
• medications
• electrical muscle stimulation
• certain types of braces
• back packs

A TLSO type brace is the only form of conservative care shown to affect the progression of scoliosis when compared to no treatment at all.

LARGE CURVES: 45 degrees and higher. These patients have a large enough deformity to warrant surgery in many cases. Remember that bracing does not improve a curve. It only prevents the curve from getting larger, if it works. Wearing a brace is a less attractive option for severe curves since the curve will still be large at the conclusion of treatment. For this reason, bracing is usually not an option for these patients. Without surgery, progression of these large curves during adulthood still remains a risk. 

Surgery for Adolescent Idiopathic Scoliosis

The decision to have surgery to correct scoliosis is a highly personal decision. This type of decision should always be made on an individual basis with consultation from the patient, parents, and their Spine Surgeon. Many patients and their families find additional information from national and local scoliosis support groups. We encourage our patients get in touch with the Arizona Chapter of the Scoliosis Association (480-839-9822).

Indications For Surgery (Who Needs It?)

Patients with any of the following could be candidates for surgery:

• Curves greater than 40 - 45 degrees in a teen who is still growing
• Large curves which cause spinal imbalance
• Curves associated with neurological signs and symptoms (Not adolescent idiopathic)
• Curves larger than 50 degrees in patients who have stopped growing

Surgical Approaches

There are three approaches to scoliosis surgery currently used, namely anterior only (from the front), posterior only (from the back), or combined anterior and posterior. There are various techniques using these approaches.

Anterior - This is done by making an incision in the side of the chest or flank, removing the discs, and filling them with bone graft often taken from a rib. The bone goes on to heal and the spine becomes fused. Screws are inserted into the vertebrae and a rod connects the screws. The spinal curvature is corrected and held in place with the rod and screws. Screws, rods, and hooks are usually made from a titanium alloy or from surgical grade stainless steel.

Posterior - This is the traditional technique for surgically treating scoliosis, approaching the spine from the back. The muscles are spread aside (not cut) and the spine is exposed. Bone screws and sometimes hooks or cables are used to attach to the spine and are connected together by rods. The hooks, screws, and rods are manipulated to correct the deformity, and bone graft is laid on top to fuse the spine in its new straightened position.

Combined Anterior and Posterior (Front-Back) - This is reserved for very young patients or those with the largest and stiffest spinal deformities. Both front and back surgeries are usually done the same day under the same general anesthetic. The anterior part is usually done first and can often be done through the scope, saving patients from a large flank incision (see section on thoracoscopic surgery). The posterior surgery follows.

Results

The object of surgery is to safely straighten the curve and stop its progression. Safety is always first. In most cases, the severity of the curve can be improved at least 50% (average of 67%) with surgery. We do not try to make the spine perfectly straight since it is usually not safe to do so.

Our success rate at achieving our surgical goals without any complications is about 92%. Patients and parents are almost always happy with the functional and cosmetic results.

Complications

The most common complication is the failure of the spine to fuse solidly, despite good bone graft and instrumentation. These so-called "nonunions" occur in 5% of patients. If there is no loss of correction and if there is no pain associated with the nonunion, it can be observed without further surgery. If pain is present, revision surgery may be required to fuse the unfused segment.

There is a 2% risk of infection with this type of surgery. It occurs despite antibiotics being given before, during, and after surgery and is usually attributed to bad luck. When it is diagnosed, usually in the first several weeks following surgery, a revision surgery is needed to thoroughly clean out the spine wound in order to prevent a chronic infection from setting in. Occasionally more than one "wash out" surgery may be required to get rid of the infection.

The risk of instrumentation failure is about 1%. When this happens, revision surgery may or may not be required, depending on several factors.

Other complications can occur but are very rare, occurring in less than 1 per 100. According to the Scoliosis Research Society data, the risk of paralysis with scoliosis surgery is about 1 per 2000 cases. Thankfully, we have never had a case.

We have our patients donate blood before surgery whenever possible. It they need blood, we give them their own blood back. The risk of contracting hepatitis from a blood transfusion from the blood bank is around 1 per 10,000. The risk of getting AIDS from infected blood is about 1 per 100,000. Neither of these risks applies if the patient receives their own blood back.

The risk of death from surgery is about 1 per 1,000,000. Thankfully, we have never had a case.

Recovery

Even though we have come light years in our technology and approach to scoliosis surgery since the 1970's, it is still major surgery. Hospitalization is usually about 4-6 days. Teens are up walking right away and are ready to go back to school in 3 weeks (no lifting more than 5 pounds). No exercise more than walking is allowed for the first 6 months. After that, jogging and gentle swimming is started. After 9-12 months from surgery, patients are allowed to do most everything except collision sports (football, rugby, rodeo, etc.).

Long-Term Outlook After Surgery

Once the spinal curvature is corrected and successfully fused, a normal or near normal life can be resumed. Most people do not have significant back pain, even long after surgery. Patients who were fused low in the lumbar spine (L4 or lower) while in their teens are more likely to have some back pain later in life.

In some patients over time, arthritis develops in the next level below the fusion. When this occurs, back pain slowly increases as the arthritis increases. Bone spurs may form and pinch the spinal nerves, causing leg pain. This is called spinal stenosis. To alleviate the pain, surgery is required to clean out the bone spurs and extend the fusion lower in the lumbar spine.

About 5% of patients will at some point in their lives need to have their hooks and rods removed for some reason. Occasionally, a fluid collection or bursa forms over the implants and they become painful to touch and hurt with changes in the weather. Surgery to remove hardware is no where near as major as the initial surgery.

What If My Curve Is Large But I Decide Not to Have Surgery?

Spine surgeons who take care of both adult and pediatric patients with scoliosis as we do often have 30 and 40 year old women come in with moderately severe scoliosis. These women invariably tell stories of not being allowed to have surgery in their teens. Later, as mature adults, they want to have their curves corrected and regret that they did not do it as teens when it would have been more convenient with a quicker recovery and better correction while the spine is more flexible. This is a very common scenario.

Thoracic curves that are allowed to become large can cause general health problems. As the curved spine takes up more space in the chest, patients become short of breath with exercise and minor activity. Very large curves can even lead to congestive heart failure. Measurable lung function decline begins when curves are in the 70-80 degree range.

Large curves in the lumbar region often lead to premature spinal arthritis. This causes back pain, spinal imbalance, and spinal nerve compression during adulthood. The trunk shortens as the curve increases, and the ribs begin to rub on the rim of the pelvis. The lumbar spine does not have any outside support such as the rib attachments in the thoracic spine. Once the curve reaches a certain point, it often becomes relentlessly progressive.

There are also some obvious cosmetic consequences to having a large untreated scoliosis. One study from Sweden even found that women with severe scoliosis were much less likely to get married. While no one would ever suggest that surgery should be done for purely cosmetic reasons, the body contour improvements that accompany surgery can be very gratifying.

 

Overview

As arthritis begins to affect the spine, the discs lose their water content and consequently their ability to serve as the "shock absorber" of the spine. The facet joints in the back of the spine begin to wear out and lose their ability to maintain normal spinal alignment. The vertebrae begin to slip or abnormally move. This may lead to spinal instability, nerve compression, and pain. As both the disc and the facet joints lose their ability to maintain normal spinal motion, the spine can settle asymmetrically, leading to scoliosis.

When the lumbar spine was straight as an adult but develops a curve later in life (usually in the 60 years + age group), it is termed De Novo or spontaneous development of degenerative scoliosis. This can occur earlier in patients who have had spinal surgery for laminectomy. It never occurs without significant arthritis.

Signs, Symptoms and Challenges of Degenerative Scoliosis

The most common sign of scoliosis is a prominence in the ribs on one side of the thoracic spine. In the lumbar spine, there is sometimes a prominence on one side, though often not. The prominence or "rib hump" is most apparent when bending forward. Sometimes there seems to be an asymmetry in the waist, with one side being indented more than the other. Clothes begin to fit differently than before.

If the scoliosis is severe and unstable, spinal imbalance is common. Imbalance implies that patients lean to one side or forward when they try to stand straight upright. They may feel like they are tipping to one side, or have the sense that they are falling forward. Most people with adult scoliosis notice that they are not as tall as they used to be.

Spinal instability occurs when the disc and facet joints are so worn out that they can no longer maintain normal spinal alignment. Pain comes from the arthritic joints as well as from the adjacent nerves, which are pinched and stretched as a result. Buttock pain can occur due to referred pain from the arthritic spine, or it could be a manifestation of a more significant problem with nerve compression. Spinal nerve roots become pinched when arthritic bone spurs form around them and block their exit route from the spinal column. This condition is called Spinal Stenosis. In addition to buttock pain, other symptoms such as leg pain, numbness, tingling, and weakness are common. If any of these findings are present, advice from a physician should be sought without delay.

If spinal stenosis or nerve compression in the back is severe enough, control of bowel and bladder function will be lost. This however is a rare event, but when it happens, it is a surgical emergency. If the pressure on the nerves is not relieved quickly, control of bladder and bowel may never be regained. Again, this is a very rare occurrence and we only see 2 or 3 cases each year.

As the spine ages, it becomes stiffer. Flexibility is greatest in the teen years, and usually declines starting in the 40-50 age group. Stiffness of the spinal joints can become severe as bone spurs form and prohibit motion. In some cases, the bone spur formation is so severe that all motion is lost at one or more levels in the spine. We all achieve our maximum bone density at about age 30-35. After age 35-40, there is a slow decline in the amount of bone present in the spine. After age 60, and particularly after menopause in women, the loss of bone becomes visible on x-rays. This is osteoporosis. If the bone loss becomes severe, spontaneous fractures can occur in the spine. These fractures can lead to scoliosis or kyphosis.

As we get older, our general health can become more of a problem. Chronic disease processes such as high blood pressure, diabetes, and heart disease are prevalent among American Seniors. When scoliosis becomes a problem in seniors, other health issues must be considered when treatment options are considered.

Conservative Treatment

Nearly all patients with adult scoliosis will respond to conservative treatment and lead a normal, functional life. When pain is present, it is usually short term and manageable. Treatment for adult scoliosis should almost always begin with a non-invasive approach. Our philosophy is, "Try the easy things first."

Non-steroid Anti-inflammatory Drugs (NSAIDS) have been the cornerstone of medical therapy for arthritic and inflammatory conditions. These medications can quiet the pain and stiffness caused by degenerating discs and joints.

Physical Therapy is an excellent way to improve function, flexibility, endurance, and decrease pain. Usually the therapist will work with patients toward becoming less symptomatic, and maintaining the improvement with an active home exercise program. Working out in a supervised environment with the help of a physical therapist is the best way to achieve it. On average, therapy lasts 2-3 times per week for 4-8 weeks.

It is very important that adult patients with scoliosis get into the habit of doing a daily exercise routine. This will improve the strength of the trunk muscles and take some of the stress off from the spine. Often when pain occurs, it is because the patient is not doing his or her exercises.

Sometimes a back brace is helpful in getting some relief from back pain in patients with degenerative scoliosis. A word of caution is in order however: the brace should not be used without faithful compliance with an active exercise program. Brace wear without exercise tends to lead to a weaker spine that becomes dependent on the brace. Daily exercises and occasional (when needed) brace wear lead to the best results, where bracing is concerned.

Medical management of osteoporosis and general health is important to maintaining an active lifestyle into old age, especially in patients with scoliosis. Solving small problems before they become big ones has always been good advice.

Passive manipulation (Chiropractic) is not an acceptable treatment for scoliosis of any kind. Passive manipulation of the spine provides short term symptomatic relief for muscle spasm, but does not impact the size of the curve or the rate of progression. Patients with scoliosis are encouraged to not rely on chiropractic “adjustments” as a means of treatment since these are essentially equal to no treatment at all.

Correction of Spinal Deformity

Reasons Surgery Might Be Considered

Few patients with adult degenerative scoliosis will ultimately require surgery. When necessary, the goals of surgery are to stop curve progression, stabilize the spine, establish correct spinal balance, decrease back and leg pain, and increase function with as little surgery and as few complications as possible. Patients who require surgery to straighten, stabilize and fuse their spinal curvature are patients with:

• Increasing curvature over time (it will continue to get worse)
• Unstable spine that hurts despite conservative care
• Nerve compression causing pain, numbness, or weakness
• Spinal imbalance which is painful or progressive
• Large curve which will progress (better to do these earlier while health is good and before osteoporosis starts or worsens)

Surgical Options and Results

If the main problem is leg pain caused from a disc herniation, this can usually be taken care of with a small surgery to remove the disc fragment and decompress the nerve. A large procedure to correct the scoliosis and fuse the spine is not necessary. Sometimes leg pain is caused by bone spurs that are compressing the spinal nerves. This is spinal stenosis. If stenosis is the problem, the solution usually will require removal of the offending bone spurs to get pain relief. If adequate bone is to be surgically removed to decompress the pinched nerves (laminectomy), the spine is often rendered somewhat unstable in the process. Back pain will increase, leg pain may return, and the spinal curvature will get bigger if the spine is not fused at the same time. In these cases, correction of the curve and fusion with bone graft and instrumentation is required to stabilize the spine and prevent what would be a certain need for future surgery.

When back pain, progressive deformity, or spinal imbalance are primary factors, the curve should be straightened and fused. The amount of correction obtained with surgery is sometimes limited compared to the corrections seen in the pediatric patients. This is due to increased spinal stiffness in adults.

Surgical Technique to Correct Scoliosis

Once the decision for surgery has been made, the operative plan is formulated. Patients are routinely asked to donate blood before surgery to be stored and used during their surgery. The spinal cord function is usually monitored throughout the surgery to make sure there is no compromise to spinal cord function. Bone graft material and spinal instrumentation may need to be arranged for ahead of time. Surgery to correct adult scoliosis is the most challenging surgery done in orthopedics, and is likely among the most complex and demanding surgeries of any kind being performed today. This type of surgery requires at least one assisting surgeon and often a surgical team, and can take from 3-14 hours to accomplish.

Anterior Surgery

If the spine must be fused anterior or from the front, a thoracic or general surgeon will be a part of the surgical team to safely mobilize the great blood vessels off the spine where the spine surgeon will work. The incision may be through the side of the chest, through the side of the abdomen, or through the front of the abdomen, depending on what is needed at the time of surgery. The purpose of anterior surgery is to remove the discs, and fill the space with bone graft or Bone Morphogenetic Protein (see below). This serves to improve the correction which can be achieved and improve the reliability of the fusion.

Sometimes the spine is "instrumented" from the front, meaning that screws are placed into the vertebra and attached to a rod that will correct the deformity and stabilize the spine.

More recently, the thoracoscope has been used in spine surgery. We can now remove discs from the thoracic spine and insert bone graft without making a large incision. All of the work is done through a few one-inch incisions on the side of the chest.

Posterior Surgery

Most of the correction of scoliosis is done from the back of the spine. If nerves are compressed by bone spurs or a disc herniation, the offending structures can be removed to allow more room for the nerves. The spine is then "instrumented" by the placement of hooks or screws that attach to the vertebrae. These hooks and screws are then attached to rods that span the curve. The instrumentation is then distracted, compressed, or rotated in order to correct the spinal curvature. Without instrumentation, the curve cannot be corrected.

Bone graft is always used in scoliosis surgery. The spine must be fused in its new corrected and straightened position. The graft most commonly comes from the patient's own pelvis. Sometimes bone-bank bone is used when there is not sufficient bone available form the patient. Newer uses for Bone Morphogenetic Protein include posterior scoliosis fusions.

Results from Surgery

Adult patients who undergo major spinal surgery to correct their scoliosis generally do well. Pain is greatly improved or eliminated in the majority (80% in our series). The fusion is successfully achieved and the correction maintained long-term in 80-95% of people who have mild to moderate scoliosis corrected with or without nerve root decompression. In our series of recent patients, curve correction is averaging 67 – 79%, depending on the type of scoliosis.

Complications can occur however, such as failure of the spine to solidly fuse, failure of the spinal hardware (<2%), infection (2-4%), nerve injury (<1%), medical complications, and others. The patients who are at greatest risk for complications are smokers, people taking steroids and those with severe osteoporosis or poor nutrition.

 

The Leading Edge of Spine Research and Advanced Surgical Technique

This animation demonstration of a revolutionary surgical hardware system and technique developed by Dr. Dennis Crandall of the Sonoran Spine Center in Phoenix, Arizona, USA.

This technique is identified by Campbell's Operative Orthopaedics as the "Crandall Method" for treating scoliosis, kyphosis, and spondylolisthesis.

Campbell's is a widely used resource for orthopedic surgery and "...an essential resource for the operative orthopedic surgeon." (— JAMA)

* The surgical technique shown is for illustrative purposes only. The technique(s) actually employed in each case will always depend upon the medical judgement of the surgeon exercised before and during surgery as to the best mode of treatment for each patient.
-- Medtronic Sofamor Danek USA, Inc.