When you think of scoliosis, you might assume it’s a spinal disorder that begins when you’re young. However, adults can develop scoliosis, too—even if they never had it as a child. To help shed light on the distinctions between adult and childhood scoliosis, SpineUniverse spoke with Editorial Board member Kevin R. O’Neill, MD, MS, a spine surgeon who specializes in both adult and pediatric scoliosis.
Q: What is the difference between pediatric and adult scoliosis?
Dr. O’Neill: Scoliosis describes curvature of the spine in the coronal plane (an imaginary line dividing the front and back halves of the body), which is a side-to-side S-shaped curve.
The other common form of scoliosis seen in adults is called degenerative or de novo (new) scoliosis. In this form, degeneration—or aging of the discs and joints in the spine—occurs asymmetrically, causing tilting and even slipping between the vertebrae. As this cascades from one level to the next, a curve of the spine can develop. This form of scoliosis primarily affects the lumbar spine.
Q: If a patient has scoliosis surgery in their youth, is that a predictor for scoliosis in adulthood?
Dr. O’Neill: Currently, surgical treatment for scoliosis involves at least partial straightening of the curve, followed by permanently linking the individual vertebral bones together and getting them to grow into a solid piece of bone—a process called spinal fusion. If that fusion process is successful, the curve will usually not progress further as the patient gets older. However, it is still possible that the areas of the spine either above or below the fused portion of the spine can develop problems related to spine curvature.
Q: Will I develop a compensating curve above or below the scoliosis?
Dr. O’Neill: Yes, that is a likely possibility. A compensating curve occurs above or below the primary and largest area of the scoliosis curve. It occurs because our bodies work hard to keep our heads centered over our pelvis. When a curvature of the spine develops in one direction in one area of the spine, it is common that the areas just above and below will curve in the opposite direction to balance this out and keep the head over the pelvis.
Q: What, if any, risk factors predispose an adult to degenerative scoliosis?
Dr. O’Neill: Unfortunately, relatively little is known about the risk factors for adult degenerative scoliosis. While smoking and obesity are commonly linked to accelerated degeneration of the spine, it remains unclear what factors are involved that cause an abnormal curvature to develop.
Q: Is adult scoliosis a progressive disorder?
Dr. O’Neill: It has been shown that idiopathic curves (those that start in youth) that are greater than about 45-degrees in magnitude can continue to worsen during adulthood. Generally, if worsening does occur, the progression occurs at about 1 to 2 degrees per year. This is the rationale for performing scoliosis surgery in kids with curves greater than that threshold – to prevent worsening over time.
Q: Besides the abnormal spinal curvature, what symptoms may accompany adult scoliosis?
Dr. O’Neill: Beyond the curvature itself and resulting effects on a patient’s appearance, scoliosis can also have a variety of other symptoms that are generally related to degeneration of the spine.
Arthritis and/or disc degeneration can lead to back pain. Spinal stenosis (an abnormal narrowing of the spinal canal) can cause back pain that is worse when standing or walking (a condition called neurogenic claudication). Nerves can sometimes be compressed, and may cause radiculopathy and sciatica with pain, numbness, tingling, or weakness in the leg.
Q: Will wearing a special back brace eventually correct or straighten my spine?
Dr. O’Neill: Braces have been shown to be successful at stopping the progression of scoliosis in teenagers who have adolescent idiopathic scoliosis. However, once a patient stops growing, braces have not been shown to be effective at either straightening the curve or preventing progression of the curve. A brace may help manage pain in adults, but it can sometimes cause worsening pain because it may weaken the muscles that support the back.
Q: How are symptoms of adult scoliosis treated without surgery?
Dr. O’Neill: Back pain can be managed with medications, such as anti-inflammatory drugs (NSAIDs) and muscle relaxers. Physical therapy may also be beneficial, particularly in regard to staying flexible, having strong abdominal and core muscles, and cardiovascular fitness. Patients might also consider chiropractic care, massage therapy, or even acupuncture. If a patient has symptoms related to spinal stenosis or radiculopathy, an epidural steroid injection may reduce pain. Often, several of these nonoperative treatments are attempted before considering surgery.
Q: When may surgery be recommended?
Dr. O’Neill: Surgery is often recommended for teenagers when the magnitude of the curve exceeds approximately 45-degrees. In this case, surgery is being done to prevent the possibility of curve progression through adulthood.
In adults, progression or worsening of the curve is one reason a physician may recommend surgery. A second reason surgery may be recommended is if a patient has spinal stenosis or radiculopathy, and has not responded to medical or other treatments over several weeks. In these cases, it is important to account for the scoliosis when treating patients, as the surgical options for someone with scoliosis may differ compared to someone without scoliosis.Another reason surgery is recommended is if patients start to lean more and more forward. While scoliosis—which is side to side bending of the spine—is perhaps better known to most people, it is actually abnormally increased kyphosis (or decreased lordosis) – bending of the spine back to front – that may cause increased back pain and symptoms.
Q: What type of surgery may be necessary?
Dr. O’Neill: The goals of surgery in scoliosis are to remove any significant areas of nerve compression, improve the degree curvature (scoliosis, lordosis, AND kyphosis), and stabilize the spine though a spinal fusion. This will generally involve placing instrumentation, such as screws, rods, or cages. Surgery is often performed over several vertebral levels and is often more complex than common surgeries for degenerative conditions, which are performed over only a few levels. For that reason, patients should seek a surgeon who has subspecialized training and experience in treating scoliosis in adults.
Increasingly, minimally invasive techniques are used to accomplish the goals of surgery while allowing faster patient recovery and reducing complications. The decision to perform open, traditional surgery versus minimally invasive—or a hybrid of the two types—is made based on the individual patient’s needs, as well as the comfort level of the surgeon in using the various available techniques. The key is to maximize the speed of recovery while not compromising the long-term results of the surgery.
Q: Can surgery be performed at an outpatient spine center?
Dr. O’Neill: Because of the complexity of the surgery that is required, patients undergoing surgery for scoliosis are admitted to a hospital following their surgery to ensure a safe recovery.
Q: What advice do you give your patients with adult scoliosis?
Dr. O’Neill: I recommend surgery only when other treatment options have not provided the amount of improvement patients seek, and I offer minimally invasive surgical options, when it’s appropriate. I work with patients to make sure they understand their condition and their treatment options. I also work to understand their goals, expectations, and the support network they have in place. I try to prepare patients and their support network for what to expect during the recovery process. Surgery for adult spine deformities can result in dramatic improvements for patients, but can be a stressful and sometimes lengthy recovery process. By working with patients on these issues before surgery, it helps to build trust, decrease anxiety, and ultimately to improve outcomes.