INTRODUCTION
A normal healthy spine will be straight when seen from the front or the back. When seen from the side, the normal spine forms a gentle S curve. Scoliosis is an abnormal or exaggerated curve of the spine from the side or from the front or back. Adult degenerative scoliosis is different from the type of scoliosis that occurs in teenagers. Adult degenerative scoliosis occurs after the spine has stopped growing and results from wear and tear of the spine. The condition most often affects the lumbar spine.
CAUSES
What causes adult degenerative scoliosis? Adult degenerative scoliosis can be a result of scoliosis from childhood. The curvature may increase during adulthood and become painful. Most often the lumbar spine is affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven.
The most common cause of adult degenerative scoliosis is from degeneration, known as wear and tear. It usually occurs after the age of 40. In older women, it is often related to osteoporosis. Osteoporosis is the loss of calcium in the supporting bone. This makes the vertebrae weak.
In adult degenerative scoliosis, the spine loses its structural stability and becomes unbalanced. This imbalance of the spine causes changes in the way the forces of the spine are directed. The larger the scoliotic curve becomes, the faster these changes cause degeneration of the spine. This creates a vicious cycle where increasing deformity causes more imbalance, that in turn causes more deformity. While this process occurs very slowly, it usually continues to slowly progress until something is done to restore the balance in the spine.
When there is an S curve when viewing the spine from the front, the condition is called scoliosis. The scoliotic deformity may also affect the normal S curve that the spine has when vised from the side. These curves are normal and required to maintain the proper balance of the spine. Many patients with scoliosis actually lose the normal curves of the spine.
In adult degenerative scoliosis, there is gradual narrowing of the discs that cushion between the vertebrae. The cartilage and joint surfaces of the facet joints in the spine can wear out, causing arthritis. This can cause back pain.
Stenosis is a term meaning narrowing. There are times when the canal for the spinal cord is narrowed. The openings for the nerve roots may also be narrowed. This will usually cause compression of the nerve structures. When the spinal cord or spinal nerves are compressed, pain, changes in feeling and/or motor function of the muscles can happen.
Degenerative scoliosis is more common the older we get. As our population ages, adult scoliosis will be even more common. It will be an increasing source of deformity, pain, and disability.
SYMPTOMS
What does adult degenerative scoliosis feel like? Most people who have scoliosis will notice the deformity it can cause. There is usually a hump (rib hump) in the back. One shoulder and/or side of the pelvis may be lower than the other. You may have noticed that you have shrunk in height. You may not be able to stand up straight. For many, there is no significant pain caused by the scoliosis. Other symptoms may include:
- Decreased range of motion or stiffness in the back
- Pain involving the spine
- Stiffness and pain after prolonged sitting or standing
- Pain when lifting and carrying
- Pain may travel to areas away from the spine itself. It may cause pain in the buttocks or legs
- Spasm of the nearby muscles
- Difficulty walking
- Difficulty breathing
DIAGNOSIS
How will my doctor know if I have adult degenerative scoliosis?
Your doctor will ask you several questions about your pain, function, what makes your pain better and worse, when it started, bowel or bladder function, motor function, and whether you have had previous surgery.
Your doctor will perform a physical examination that will include observation of your posture in standing position both sideways and from the front and back to assess for scoliosis. Mobility of your spine and hips, as well as walking ability will be evaluated.
A neurological exam that includes testing reflexes with a small rubber hammer, and testing of sensation will likely be included.
Your doctor will want to start with x-rays to measure the degree of the scoliosis. X-rays provide pictures of the alignment of the vertebra. Using a device to measure angles held up to the x-ray image, the degree of curvature of the spine can be measured. X-rays can also give your doctor information about how much degeneration has occurred in the spine. They show the amount of space between the vertebrae.
If you are having pain into your leg(s), or difficulty with bowel or bladder function, your doctor will likely order a magnetic resonance imaging (MRI) scan. The MRI scan provides a better image of the soft tissues such as discs, nerves, and the spinal cord. The MRI machine uses magnetic waves rather than x-rays to show the soft tissues of the spine. The pictures show slices of the area imaged.
TREATMENT
What treatment options are available?
Most of the time treatment of adult degenerative scoliosis is conservative care, meaning non-surgical. Rarely is surgery necessary. Treatment decisions for adult degenerative scoliosis are based on how much pain you are experiencing, how much the condition is affecting your ability to function and whether or not you are having symptoms of nerve compression.
NONSURGICAL TREATMENT
Whenever possible, doctors prefer treatment other than surgery. The first goal of nonsurgical treatment is to ease pain and other symptoms so the patient can resume and maintain normal activities as soon as possible.
Your doctor may prescribe treatment from a physical therapist. Much of the pain from adult degenerative scoliosis is the result of muscle spasm. This spasms occurs when the normal muscles must work harder than normal try to restore the balance to the spine. The muscles become fatigued and begin to spasm. This causes pain.
The physical therapist can help you with positions and exercises to ease these symptoms. The therapist can design an exercise program to improve flexibility of tight muscles, to strengthen the back and abdominal muscles, and to help you move safely and with less pain.
You may also be prescribed medication to help you gain better control of your symptoms so you can resume normal activity swiftly. There are many anti-inflammatories available.
Bracing may provide some help especially when the scoliosis is painful or unstable. Braces that are made to fit may be more comfortable and effective but they are more expensive than off-the-shelf braces or supports. There are also unloading braces to help relieve pressure on the discs, nerves and joints of the spine.
If symptoms continue to limit your ability to function normally, your doctor may suggest an injection into the spine to help with pain. Your doctor may recommend facet injections into the joints of the spine. A procedure called radiofrequency ablation may provide more lasting benefit. Epidural or transforaminal injections into the spine can also be helpful. A series of injections may be more helpful to provide temporary decrease in pain.
If you have osteoporosis, discuss with your doctor how you can optimize your treatment for this condition to slow the progression of osteoporosis. Adequately treating the osteoporosis can help reduce the progression of the scoliosis.
SURGERY
Surgery is usually considered when non-surgical treatments have not provided enough relief from pain – or when the nerves of the spine are being damaged. Surgery is more common when the curvature is continuing to increase and the imbalance of the spine is clearly getting worse. Surgery to correct adult degenerative scoliosis is both complex and difficult. Most surgeons would not suggest surgical intervention except as a last resort when all conservative measures have failed and the pain is intolerable.
The goal of surgery is to improve the balance of the spine and remove pressure on any of the nerves of the spine. Surgery to relieve pressure on the nerves is called a decompression. Surgery to reinforce the area that is unstable is called a fusion.
REHABILITATION
What can I expect during recovery and treatment?
NONSURGICAL REHABILITATION
Physical therapy is important for strengthening muscles of the spine, abdomen, hip girdle, and legs. Stretching of certain muscles may also be recommended. Stretching or traction applied to the sides of the curve is sometimes used by physical therapists. Exercises must be done on a regular, ongoing basis. It may be possible to improve posture and motion.
Activity modification such as limited lifting or avoidance of prolonged sitting or standing may be helpful. Occasional use of a cane or walker to improve walking tolerance may be recommended.
Use of ice or heat may prove beneficial. Your doctor or physical therapist can provide you with guidelines.
Your physical therapist may advise you to participate in weight bearing exercises to help strengthen your bones and muscles. These may include activities such as walking, toning with the use of weights or other resistance.
AFTER SURGERY
Your surgeon may suggest a brace following surgery, to ensure that you do not bend too far and to support your spine.
You will be allowed to get in and out of bed and walk shortly after surgery. Lifting is usually limited during the initial recovery period. You will gradually be allowed to resume your usual activities after several weeks or months.
It may be recommended that you have physical and occupational therapy after your surgery to help you regain strength and independence with daily activity. They also will help you with activity modification.