SCOLIOSIS : On Adults

Adult Scoliosis

What is Adult Scoliosis? The normal, healthy spine is straight when seen from the front or the back (frontal plane). When seen from the side, the healthy spine has several mild curvatures. By obtaining an X-ray of a standing person, the exact contour of the spine can be measured and then compared to normal values to determine if a significant spinal deformity is present. Scoliosis is defined as a lateral deviation of the spine. More precisely, if the spine, seen on an antero-posterior radiograph (abbreviated as "AP", ie. seen from the front), has a curvature that measures more than 10 degrees then a scoliosis is present. (figure 1) When a curvature, or scoliosis, is mild then one may not be able to detect any abnormality without an X-ray. On the other hand, moderate or severe scoliosis can be noted due to an asymmetry of the back. A tilted waistline and skin folds may be present, as well as a hunching, or protrusion of the back. Frequently, such an asymmetry in the back is more noticeable with leaning forward. There are many types of scoliosis, and people of all ages can be affected by scoliosis. In adults, scoliosis can result from several conditions, but most types fall into two different categories. In the first category is a person who had a scoliosis as a child/adolescent and the abnormal spine curve has increased into adult life or is becoming painful with aging. The second category of adult scoliosis is seen in patients who have never had a scoliosis as a child but begin to develop an abnormal curvature with aging. The spinal deformity in degenerative scoliosis is usually a mild side curvature involving predominantly the lower levels of the spine. Symptoms related to adult scoliosis are mostly due to degeneration (wear and tear) of structures that support the spine. These changes which are often called "arthritis of the spine" can occur at all levels of the back (neck, upper back and lower back). With aging and arthritis, a gradual narrowing of the discspaces between vertebrae, wearing out of the joints, as well as narrowing of the space available for the nerves (a condition known as stenosis) can develop.  Spinal stenosis is a narrowing of the open spaces within your spine, which can put pressure on your spinal cord and the nerves that travel through the spine to your arms and legs. Spinal stenosis occurs most often in the lower back and the neck. While spinal stenosis may cause no signs or symptoms in some people, other people may experience pain, tingling, numbness, muscle weakness, and problems with normal bladder or bowel function. Spinal stenosis is most commonly caused by wear-and-tear changes in the spine related to osteoarthritis. In severe cases of spinal stenosis, doctors may recommend surgery to create additional space for the spinal cord or nerves Although degeneration of the spine is part of the normal aging process in all people, it appears that in most people the spine becomes stiffer with age but does not develop a lot of abnormal curvature and causes only minimal or no pain. In other people the spine loses its structural stability with aging and gradually develops abnormal curvatures that can be painful and lead to symptoms including back pain, stooped posture, leg problems (numbness, heaviness, tingling, pain and weakness) and progressive difficulty in walking which requires frequent rests and activity limitation. How is Scoliosis evaluated? An evaluation by a spine specialist is important when scoliosis is present. In addition to a comprehensive medical evaluation and examination, scoliosis is assessed by obtaining X-rays of the entire spine in the standing position. Scoliosis is confirmed when an X-ray reveals a lateral deviation (curve) measuring more than 10 degrees. (Figure 2) In patients who have leg symptoms or difficulty walking, further tests may be ordered by your physician to more closely evaluate the spinal canal and the nerveswhich lead from the spine to the legs. This may require an MRI or CAT scan, and possibly a myelogram. Who needs treatment, and what are the treatment options for Adult Scoliosis? Treatment of adult scoliosis is directed at the particular problem, which is causing symptoms in a patient. In some patients the leg numbness or weakness is most bothersome while in others it may be back pain alone. The fact that someone has a scoliosis does not necessarily mean that pain or disability is present. Many people have scoliosis and require no particular treatment. Prior to any treatment a clear diagnosis and discussion of treatment options with a specialist is necessary. Non-operative treatment options Most commonly the first approach to treatment for adult scoliosis is 'conservative treatment' (ie. non-surgical). In general, patients who are experiencing back pain and fatigue, and are otherwise in good health, pursue a guided back strengthening program. With a rehabilitation program for re-conditioning muscles of the spine it may be possible to improve support and posture leading to a reduction of abnormal alignment and motion in the spinal column, thereby reducing pain. In order for the exercises to be effective they must be performed regularly. It may take weeks or months for exercises to lead to an improvement in symptoms. In addition to strengthening exercises it is important to maintain overall good health by eating properly, sleeping well and not smoking. For patients with severe pain, and evidence of instability the addition of a back brace may be very helpful. Bracing may help reduce motion across the spine and provide the sensation of increased support. Bracing does not eliminate the need for physical therapy, and exercises can often be performed while wearing the brace. Practical tips on living with a brace If your physician has recommended a brace you must understand that this is not an easy treatment method and does not replace the need for other treatments such as physical therapy. It is essential that you have a customized brace made which will fit your body shape. Everyone has a unique body shape, and particularly a patient with scoliosis will have a shape that requires detailed attention in the making of a brace. There are many types of braces and your physician will determine which is most suitable for you. Initially, any brace will seem awkward to wear and may even be quite uncomfortable. To give bracing a fair chance be patient and get used to wearing your brace in a gradual manner. It may be a good idea to start wearing the brace for only an hour at a time and then increasing this daily until after a week or so you can tolerate the brace for most of the day. During bathing and while in bed the brace can usually be removed, your physician will guide you in specific instructions. Injection therapy has been applied to cases of adult scoliosis. Although injections have not been clearly proven to lead to long-term success for many patients, there are particular cases where some relief can be obtained. Surgical treatment Surgery should be reserved for those cases when a specific cause for discomfort has been identified and all non-operative treatments have failed. The patient must carefully consider the risks of surgery against the possible benefits. Detailed discussions with a spine specialist are essential prior to considering invasive treatments. What types of surgery are performed for Adult Scoliosis? Any surgical procedure for adult scoliosis should only be considered after careful review of all non-surgical options and failure of the 'conservative' treatment approaches. Only very rarely is surgery an emergency or first treatment. The type of surgical procedure performed for adult scoliosis will depend upon several factors. Most importantly, a detailed pre-operative evaluation is essential to clearly define the problems at hand. The goal of surgery is to correct the abnormalities while providing a stable spine to avoid future problems. Depending upon the main problems of a particular person, one of a variety of different surgical procedures may be performed. For instance, if the primary problem is spinal stenosis (narrowing of the spinal canal which leads to nerve compression/irritation) then decompression alone may be performed. For a problem of spinal instability such as spondylolisthesis (forward slippage of one portion of the spine over another),  Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a condition of the spine whereby one of the vertebra slips forward or backward compared to the next vertebra. Forward slippage of an upper vertebra on a lower vertebra is referred to as anterolisthesis, while backward slippage is referred to as retrolisthesis. Spondylolisthesis can lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis). Spondylolisthesis is most common in the low back (lumbar spine) but can also occur in the mid to upper back (thoracic spine) and neck (cervical spine). a surgeon may recommend a decompression accompanied by a fusion and possible instrumentation (placement of screws and rods). In cases of progressive deformity with severe pain and nerve symptoms a surgeon may recommend a correction of the scoliosis and a spinal fusion from the front and back of the spine.

PROGNOSIS

In general, the severity of the scoliosis depends on the degree of the curvature and whether it threatens vital organs, specifically the lungs and heart.

• Mild Scoliosis (less than 20 degrees). Mild scoliosis is not serious and requires no treatment other than monitoring.
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• Moderate Scoliosis (between 25 and 70 degrees). It is still not clear whether untreated moderate scoliosis causes significant health problems later on.
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• Severe Scoliosis (over 70 degrees). If the curvature exceeds 70 degrees, the severe twisting of the spine that occurs in structural scoliosis can cause the ribs to press against the lungs, restrict breathing, and reduce oxygen levels. The distortions may also cause dangerous changes in the heart.
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• Very Severe Scoliosis (Over 100 degrees). Eventually, if the curve reaches over 100 degrees, both the lungs and heart can be injured. Patients with this degree of severity are susceptible to lung infections and pneumonia. Curves greater than 100 degrees increase mortality rates, but this problem is very uncommon in America.

Some experts argue that simply measuring the degree of the curve may not identify patients in the moderate and severe groups who are at greatest risk for lung problems. Other factors (spinal flexibility, the extent of asymmetry between the ribs and the vertebrae) may be more important in predicting severity in this group.

EFFECTS ON BONES

Scoliosis is associated with osteopenia, a condition characterized by loss of bone mass. Many adolescent girls who have scoliosis also have osteopenia. Some experts recommend measuring bone mineral density when a patient is diagnosed with scoliosis. The amount of bone loss may help predict how severely the spine will curve. Preventing and treating osteopenia may help limit further curve progression.

If not treated, osteopenia can later develop into osteoporosis. Osteoporosis is a more serious loss of bone density that is common among postmenopausal women. Adolescents who have scoliosis are at increased risk of developing osteoporosis later in life.

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

SPINE PROBLEMS IN PREVIOUSLY TREATED SCOLIOSIS PATIENTS

After 20 years or more, scoliosis patients who were previously treated with surgery experience small but significant physical impairments (mainly mild back problems), compared to their peers without scoliosis. More people with a history of scoliosis report having to take days off from work, compared to people who never had the condition. In general, however, most patients experienced a similar quality of life to peers who never had the condition.

The following are some possible causes of later back problems in people with a history of treated scoliosis:

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• Spinal fusion disease. Patients who are surgically treated with fusion techniques lose flexibility and may experience weakness in back muscles due to injuries during surgery.
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• Disk degeneration and low back pain. With disk degeneration, the disks between the vertebrae may become weakened and rupture. In some patients, particularly those treated with the first generation of the Harrington rods, years after the original surgeries the weight of the instrumentation can cause disk and joint degeneration severe enough to require surgery. Treatment may involve removal of the old rods and extension of the fusion into the lower back. Still, most patients do not experience significant back pain from these problems.
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• Height loss. Fusion of the spine may inhibit growth somewhat. However, much of the growth takes place in long bones, which are not affected.
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• Lumbar flatback. This condition is most often the result of a scoliosis surgical procedure called the Harrington technique, which eliminated lordosis (the inward curve in the lower back). Adult patients with flatback syndrome tend to stoop forward. They may experience fatigue and back and even neck pain.
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• Rotational trunk shift (uneven shoulders and hips).

Evidence suggests that previous treatment with braces may also cause mild back pain and more days off, but problems appear to be less than with surgery. In one study, dysfunction was comparable to people without a history of scoliosis.

PROBLEMS IN ADULT-ONSET OR UNTREATED CHILDHOOD SCOLIOSIS

Pain in adult-onset or untreated childhood scoliosis often develops because of posture problems that cause uneven stresses on the back, hips, shoulders, necks, and legs.

Many individuals with untreated scoliosis will develop spondylosis, an arthritic condition in the spine. The joints become inflamed, the cartilage that cushions the disks may thin, and bone spurs may develop. If the disk degenerates or the curvature progresses to the point that the spinal vertebrae begin pressing on the nerves, pain can be very severe and may require surgery. Even surgically treated patients are at risk for spondylosis if inflammation occurs in vertebrae around the fusion site.

LONG-TERM EMOTIONAL IMPACT OF SCOLIOSIS AND ITS TREATMENTS

Emotional Impact in Childhood. The emotional impact of scoliosis, particularly on young girls or boys during their most vulnerable years, should not be underestimated. Adults who have had scoliosis and its treatments often recall significant social isolation and physical pain. Follow-up studies of children who had faced scoliosis without having strong family and professional support often report significant behavioral problems. Fortunately, current treatments are solving many of the problems that previous generations had to deal with, including unsightly bracing and extremely painful surgeries with little pain control.

Emotional Effects in Adults. Of some concern are the growing numbers of adults with scoliosis. This group experiences considerable problems in general health, social functioning, emotional and mental health, and pain.

Older people with a history of treated scoliosis may carry negative emotional events into adulthood that have their roots in their early experiences with scoliosis. Patients who were treated for scoliosis may often have limited social activities, a poorer body image, and slight negative effect on their sexual life. Pain appears to be only a minor reason for such limitation.

EFFECTS ON PREGNANCIES AND REPRODUCTION

Women who have been successfully treated for scoliosis have only minor or no additional risks at all for complications during pregnancy and delivery. A history of scoliosis does not endanger the child. Pregnancy itself, even multiple pregnancies, does not increase the risk for curve progression. Women who have severe scoliosis that restricts the lungs, however, should be monitored closely.

RESPIRATORY IMPAIRMENT

Patients with severe deformities, particularly those with underlying neuromuscular disorders, may develop what is called restrictive thoracic disease. This term refers to problems in breathing and, at times, trouble obtaining enough oxygen due to a smaller chest cavity. This smaller chest cavity results from the deformities or surgery. The restricted chest cavity is also less able to expand when breathing.

RISKS OF CANCER FROM MULTIPLE X-RAYS

Some evidence suggests a slightly higher risk for breast cancer and leukemia in patients who had multiple x-rays. Risks are highest in patients who had the largest radiation exposure, such as those who had been surgically treated.

Patients who simply received x-rays for untreated idiopathic scoliosis, or scoliosis caused by uneven length of the legs or hip abnormalities have a very low risk for future complications.