BackCare

Adult scoliosis

2009 Author: Ian Harding

Ian Harding, consultant spinal surgeon, describes this condition.

Scoliosis is widely considered to be a problem of children, but the vast majority of people with scoliosis are adults and in a large number of these it causes a great deal of discomfort and disability. In adults, scoliosis can be extremely painful and is an important cause of back pain in many patients. Historically (and currently) an emphasis has been on the treatment of childhood spinal deformity and the problem in adults is either not been diagnosed or (when it is diagnosed) ignored because of the erroneous belief that nothing can be done.

Adult spinal deformity can be an untreated childhood problem that has progressed/degenerated or (more commonly) it can be degenerative – which develops de novo after the age of 50. Childhood spinal deformity may progress in adulthood and become a real problem requiring treatment as a young adult or middle age but it is in the more elderly that the problem becomes very common. At a conservative estimate, 10% of over 60s and 20% of over 70s have a spinal deformity but, as in all conditions that can cause back pain, it is important to diagnose the cause of the pain if you can which relies on correlating symptoms, examination findings and imaging studies. It cannot be overemphasised enough that back pain is not a diagnosis but a symptom. Until a diagnosis has been made, invasive treatments – no matter how large or small – are extremely difficult to justify.

Pain from scoliosis in adults can be axial back pain or nerve pain from neurological compression. The pain usually becomes worse in the standing or sitting position but is relieved by lying. In the case of nerve pain, this is why MRI should be interpreted with great caution as it is taken lying down. MRI scans are very good at ruling out serious pathology such as tumours, but an over reliance on its findings means that some cases of nerve compression are often missed and more importantly some patients have surgery for nerve compression with the deformity not having been recognised. This may lead to suboptimal results at best or worsening the condition at worst – and often revision surgery is needed. Even small deformities can cause agonising nerve compression and to simply take the pressure off the nerve with an operation simply leads to the spine collapsing down again as soon as the patient walks because support and correction of the deformity has not been achieved. Standing MRI is now available but is limited by its static nature, poor imaging of bone and the fact that in severe cases it is not well tolerated, but it is a move in the right direction. MRI cannot replace the usefulness of standing x-rays at this stage in the evaluation of spinal deformity (Figure 1).

Standing x-rays are mandatory to rule out deformity in the patient over 50 undergoing spinal surgery and should be requested in younger individuals where deformity is clinically suspected. Once the diagnosis has been made then the decision to treat is multifactorial with an emphasis placed on patient wishes and needs.

Figure 1: MRI reported as normal – no deformity or nerve compression seen while supine. Standing x-rays reveal a different picture in a 55 year old patient with severe back and leg pain.		Figure 2: Occasionally single level fusion and decompression may be indicated.

In order to recognise spinal deformity clinically, the spine should be observed in a lying and standing position and a forward bend test performed. The position of the head and pelvis should also be noted. One of the aims of the spine is to place the head above the bottom – this is called ‘balance’ – and in spinal deformity this is often compromised and the spine, pelvis and lower limbs have to adapt to rebalance the spine. This can lead to a multitude of problems and together with the actual contour of the spine is extremely important to recognise. If there are any concerns that deformity may exist then standing x-rays should be requested.

Technological advances and the development of new techniques means that almost anything can be done to the adult patient with spinal deformity but it is very important to do the right thing. Non-operative treatments include medications, physiotherapy, osteopathy, chiropractic treatment and where tolerated a soft lumbar can be used for short periods to give pain relief but there is no role of bracing to correct deformity. Non-operative treatments should generally be the first port of call and are all that is needed in many. Injections have an important diagnostic role to play although may also give some therapeutic relief but they have no proven long term efficacy. It is important to identify a particular source of pain eg a particular nerve root if surgery is to be considered as it may be possible to perform limited surgery with large benefit in some patients (Figure 2).

In other patients with significant imbalance, severe discomfort and a failure to respond to non-operative measures then correctional deformity surgery may be indicated to rebalance the spine, provide permanent pain relief and prevent further problems.

There are a wide range of operations possible that are not within the scope of this article because of the wide range of clinical presentations. In the young adult, in principle the surgery is often very similar to the surgery in children where the spine is often still quite flexible but with the age the untreated childhood deformity can become very stiff and problematic. Treatment of this is often very rewarding, particularly as the patients are often young females with families that are really struggling and have often been told nothing can be done. In these cases a dual approach is often needed to release the spine anteriorly before performing posterior surgery secondarily (Figure 3).

Figure 3a		Figure 3b
Figure 3c		Figure 3d
Figure 3: Combined anterior posterior approach for severe symptomatic deformity not responding to non-operative treatment in 38 year old.

In the more elderly, often the most common problem is leg pain and sometimes it may be possible to alleviate this with a relatively small procedure to fuse a single level. In others, the only surgical option is to correct the deformity in entirety to redress imbalance and decompress nerves and alleviate pain. Large operations in elderly patients have complications and warrant careful decision making pre-operatively, but new techniques and modern instrumentation reduce this. During surgery, modern spinal cord monitoring and blood saving techniques are the norm and instrumentation holds the spine well – even in osteoporotic bone the use of cement and kyphoplasty makes this possible.

In summary, adult scoliosis is eminently treatable and, in my opinion, largely remains undiagnosed or ignored in the UK. It can cause significant disability and in an ever demanding and elderly population is going to become an even bigger problem. An open multi-disciplinary approach is needed with careful attention made regarding decision making when surgery is considered. Surgery can be of great benefit and ranges form minimal interventions through to major re-alignments procedures. An increasing recognition by clinicians that the problem exists and is treatable is by no means universal, but with continued profile raising, education and continued research this will hopefully change.