Scoliosis in Adults
From Diagnosis to Treatments
What is scoliosis? Scoliosis is a medical term taken from a Greek word meaning curvature. This disease is known to develop in adults over the age of 18, and it causes the spine curve laterally (to the side) to the left or right.
Adult scoliosis is caused by:
- Progression of the disease from childhood. This usually occurs when scoliosis is not treated early or went unnoticed during childhood. The scoliotic curves may be thoracic, lumbar, or both.
- The asymmetric degeneration of spinal elements. This may be caused by osteoporosis, disc degeneration, compression fracture, or a combination. These conditions usually affect the lumbar spine and can affect vertebral height, shape, or basic structural integrity.
- Combination of numbers 1 and 2.
The spine's normal curves occur at the cervical, thoracic, and lumbar regions, and these curves can be seen when looking at the spine from the side (in the image below, it's the spinal illustration on the left).
These natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.
The normal spine viewed posteriorly (from behind) appears straight from neck to buttocks. However, a scoliotic spine bends to the left or right, resembling the letter S or C.
Scoliosis is a complex, 3-dimensional disease. To understand this concept, consider that in some cases, as the spine curves abnormally, the involved vertebrae are forced to rotate. If rotation occurs at the thoracic level of the spine, vertebral turning impacts the rib cage and may result in rib prominence on the opposite side of the curve.
In severe cases, lung and heart function can be compromised.
Back pain is the primary complaint associated with adult scoliosis. Pain is more common and severe in the lumbar spine. When the pain is thoracic, rest often alleviates it. This may be confused with arthritis pain.
Although scoliosis is known to cause deformity (eg, humpback), seldom is this the catalyst that brings the patient to a physician. Scoliosis may cause the patient's ears, shoulders, rib cage, and pelvis to lack symmetry. An asymmetric pelvis can lead to trunk imbalance and may make the patient appear as though listing to one side.
Scoliosis can cause rib prominence on one side and leg length discrepancy, which often results in gait dysfunction.
Pain, difficulty sitting or standing, stiffness, and spinal rigidity are often associated with scoliosis. Rarely does adult scoliosis cause neurologic complaints. However, a complete medical and orthopaedic evaluation by a physician with experienced in adult scoliosis is essential.
Adult scoliosis requires a careful review of the patient's personal and family medical histories. Any history of smoking is noted.
Spinal joint and/or peripheral vascular disease is assessed for involvement as these are known to cause back pain similar to scoliosis.
In severe scoliosis, the patient's cardiopulmonary (heart and lung) function may be evaluated.
A thorough physical examination reveals a lot about the health and general fitness of the patient. The exam provides a baseline from which the physician can measure the patient's progress during treatment.
The physician will observe the patient standing (front and back) and look for any asymmetric abnormalities in the shoulders, rib cage, waist, and pelvis. Patients with scoliosis may present humpback, one hip higher than the other, or appear to be listing to one side.
The physical examination also includes:
- Adam's Forward Bending Test requires the patient to bend forward at the waist. Viewed posteriorly (from behind), scoliosis is suspected if a thoracic (mid-back) or lumbar (low-back) prominence is apparent.
- A rib hump can be measured in degrees using a Scoliometer. While the patient is bent at the waist, the scoliometer is placed over the rib hump.
- Leg length is measured and compared to determine discrepancy.
- A plumb line held posteriorly at the 7th cervical vertebral (C7) is allowed to hang below the buttocks. In a normal spine, the line passes through the gluteal crease (middle of buttocks). In scoliosis, the scoliotic portions of the spine may fall to the right or left of the line.
- Palpation determines spinal abnormalities by feel. The ribs (thoracic) or lumbar muscles may feel more prominent on one side of the spine than the other.
- Range of motion measures the degree to which a patient can perform movements of flexion, extension, lateral bending, and spinal rotation. Asymmetry is also noted.
The neurological evaluation includes an assessment of the following symptoms:
- paresthesias (eg, tingling)
- extremity sensation and motor function
- muscle spasm
- bowel/bladder changes
Particular attention is given to identifying the pain pattern.
Radiographs Can Show the Scoliosis
X-rays indicate if the scoliotic curves are structural (major) or non-structural (minor). The patient stands to reveal the entire length of the spine when PA (posterior/anterior, or back and front) and lateral (side) x-rays are taken. Side bending AP x-rays are sometimes used to evaluate spinal flexibility.
Scoliosis Curve Classification
Curves are classified according to pattern (shape) and magnitude (severity). There are several way to categorize scoliosis curves:
- King Classification divides scoliotic curves into one of five patterns. For example, King Type III curves are primarily single thoracic curves.
- Cobb Angle Measurement uses a standard full-length AP x-ray. Geometric calculations determine the angle of the curve in degrees.
- Nash-Moe technique measures pedicle rotation by dividing the vertebral body into segments. The segment into which the pedicle is located quantifies rotation.
The following symptoms of scoliosis may be used to determine treatment options:
- persistent pain that cannot be alleviated
- deformity progression
- reduced cardiopulmonary (heart and lung) function (this is rare).
Conservative non-surgical treatment for adult scoliosis may include:
- moist heat
- medication for pain and inflammation
For adult scoliosis, bracing is rarely used to help control pain. It will not correct or cure scoliosis.
Most patients with adult scoliosis do not require surgery.
Surgery may be considered if any of the following exist:
- Thoracic (mid-back) curve greater than 50 degrees with persistent pain
- Progressive thoracolumbar (mid and low back) curve
- Lumbar (low back) curve with persistent pain
- Decreased cardiopulmonary (heart and lung) function due to thoracic curve
- Appearance, deformity
Pain control is the usual reason for surgery for scoliosis in adults.
The spinal surgeon decides the procedure(s) that will provide the most benefit to the patient.
Surgical intervention may include the removal of an intervertebral disc (discectomy) combined with spinal instrumentation and fusion. Spinal instrumentation utilizes rods, bars, wires, screws, and other types of medically designed hardware.
Combined with fusion, instrumentation stabilizes spinal segments, enhances fusion, and provides a more permanent solution.
These procedures may enable the patient to sit upright, thereby reducing the risk for cardiopulmonary complication and may increase mobility. This type of surgery can be performed safely on adults with spinal deformity, usually with excellent results.
Whether the treatment course is conservative or surgical, physical therapy may be incorporated to build muscle strength and to increase range of motion and flexibility. It is important to closely follow the instructions given by the physician and/or physical therapist.
Any doubts concerning vocational and recreational restrictions should be discussed with your physician and/or physical therapist. They will be able to suggest safe alternatives and help you safely go about your daily life after scoliosis treatment.