Once skeletal maturity or growth is completed, a patient with adolescent idiopathic scoliosis is now said to have adult idiopathic scoliosis. The distinction is important for while a patient with Adult Idiopathic Scoliosis may still need treatment for progression, pain is a much more common indication for treatment. Normal degenerative changes of the spine may be accelerated by curvature and the patient with adult idiopathic scoliosis may be at higher risk for skeletal pain or extremity pain due to nerve compression. If treated, adult idiopathic scoliosis should never lead to neurologic (paralysis) or cardiopulmonary (heart or lung failure) deterioration.
The goal of treatment in patients with adolescent idiopathic scoliosis is to prevent the curve from progressing past 40 degrees. The importance of the 40 degree mark is that bracing becomes ineffective at this curvature for mechanical reasons. Of secondary importance though is the statistical finding that in adults, curves less than 40 degrees rarely progress and when they reach 50 degrees, they may increase at mean rate of 1degree/year. Studies have also shown that at 60 degrees, pulmonary function (breathing health) may deteriorate and at 100 degrees, severe cardiopulmonary dysfunction is seen. The orthopedic spine surgeon will commonly use these curve measurements as parameters for treatment.
Evaluation of the adult with scoliosis always starts with a careful history and physical examination. Documentation of pain location and duration are critical for individualizing treatment. A patient with a gray area curve measuring 49 degrees may be complaining of radiculopathy or nerve pain in the leg or arm which may be amenable to local treatments such as steroid blocks. In these cases, treatment of the curve may take on secondary importance. The physical examination may reveal decompensation of the trunk. As the spine ages, it becomes less flexible. Compensatory curves in a child may not be able to balance the curves as that child becomes an adult leading to decompensation or imbalance of the head relative to the pelvis. For example the patient may find herself leaning to the left or right or leaning forward when standing or walking. Decompensation can cause pain due to the fatiguing of muscle as it attempts to “right” the imbalanced spine (for further discussion, see Flatback section.)
Scoliosis x-rays in the standing position are critical in evaluating the patient. Size, location, and balance of the curves help determine the best treatment for the individual. CT and MRI scans sometimes are necessary to better evaluate points of nerve compression. If pain is the major complaint by the patient, treatment similar to patients with non-scoliotic spine pain may be attempted. These consist of anti-inflammatory medications, physical therapy, professional spinal manipulation, steroid blocks, and cardiopulmonary rehabilitation. A course of bracing may be helpful to alleviate symptoms temporarily, although it should be kept in mind that all bracing tends to produce muscle weakness from disuse atrophy. Antidepressant medications have been shown in select individuals to allow the more effective implementation of conservative measures through behavioral mediated pain reduction. Surgery is reserved for progressive curves over 50 degrees or painful curves refractory to conservative treatment. Cosmesis is a rare indication for surgery due to the unpredictability of esthetic results.
A patient should understand the risks/benefits of any surgical procedure and surgical decision-making should be individualized to the patient. Expected results should include 70-95% pain reduction although the frequency of painful intervals may not change. Curves can routinely be corrected to 40% of there original size, but the surgical goal should more importantly be viewed as producing a fused spine that leaves the patient balanced (for a complete discussion of the importance of balance in spinal fusion surgery see spinal balance).
Surgical strategy will depend on the location of the curve, the size of the curve, whether the patient presents with or without a balanced spine, and whether spine pain or nerve root compression are the presenting complaints. In general, thoracic curves that are stiff, unbalanced or greater than 60 degrees will require an anterior disc removal and fusion, followed by a posterior fusion with instrumentation. Almost complete correction of the curves can be achieved by the use of thoracic pedicle screws. See examples of Scoliosis cases Dr. Pashman has perfomed. Commonly, the anterior surgery can be accomplished by thoracoscopic, or video assisted techniques. In limited cases, anterior only fusion with instrumentation can be attempted. Smaller, balanced thoracic curves with associated flexible compensatory lumbar curves can be approached posteriorly with fusion and instrumentation.
To view video of pedicle screw insertion, click on the picture below. This is video of a surgical procedure, and may not be suitable for all audiences