ADULT SCOLIOSIS By Kenneth J. Paonessa Most people associate scoliosis with young children or teenagers but it is not uncommon to have an adult over 18 years old who develops scoliosis or who becomes aware that they have it. Up to 20% of adults older than 65 years old will have some type of scoliosis curve in their spine. The term scoliosis refers to a side to side curvature in a person’s spine which would normally be straight. Anytime that the spine curves more than 10 degrees out of straight it would be considered abnormal . When a teenager develops a scoliosis curve in their spine it needs to be monitored at least 2 to 4 times a year because a teenagers spine is still growing. Once they have stopped growing and turn 18 years of age these curves in most cases will not progress as long as they are not greater than 40 degrees. In general there are three types of adult scoliosis. The first type is a patient who had scoliosis as a teenager or younger child but either did not have treatment or their scoliosis curve was not discovered until they were older than 18 years old. Most of these patients do not have pain in their backs or legs and the curvature is found by having an xray for some other unrelated problem such as a kidney stone or having a chest xray for a cough. Most of these patients need no treatment as long as their curve is not severe such as over 45 to 50 degrees. If their curve is less than that they may be suggested to have another xray in a year or two. If they have a small amount of back pain or have problems with back stiffness they may be referred to either a physical therapist or chiropractor for some treatment. If they have a leg length inequality (have one leg shorter than the other) they may be referred to have a small lift or pad put into their shoes to balance the length of their legs. If their curves are greater than 45 to 50 degrees at first diagnosis surgery to correct the curvature may be discussed with them especially if they have back pain or appear out of balance (their head is not even over their hips and pelvis). The second type of adult scoliosis would be a person who had a mild scoliosis less than 35- 40 degrees as a teenager that was observed or treated with a brace but as they grew older the scoliosis worsened. This is a situation that is rare to occur in patients less than 50 years old but occurs more frequently in patients older than 50 or 55 years old. The curvature may worsen because they have developed osteoporosis (which is softening of the bone that occurs in women who are postmenopausal) or in patients who have developed some type of arthritis of the discs (which are the spacers between the vertebrae bones). The arthritis of the discs could occur at the midpoint of the scoliosis curvature or below the curvature typically in the lumbar spine (the area of the spine closer to the pelvic bone). The third type of Adult Scoliosis would be a curvature of the spine that develops completely anew in a patient who had a straight spine as a teenager or young adult. This normally occurs in an older group of patients typically over 60 to 65 years of age, as opposed to the first two groups. This group of patients usually are equally men and women. The first two groups of patients are usually at least 2/3 women. The third groups of patients usually have smaller curvatures because their spines were straight as a younger adult but many of them need some type of treatment or even surgery because they have back pain or sciatica (leg pain caused by a nerve being pinched in the spine). This group’s curves are almost always occurring in the lower lumbar spine. There are many symptoms that patients with adult scoliosis can develop. They can develop mechanical back pain, muscle fatigue, rib cage pain, or sciatica or claudicating leg pain. Mechanical back pain is pain limited to the area of the spine where the scoliosis is or sometimes in the lower part of the spine below a curvature in the thoracic spine. This pain could be from arthritis of the discs or even of the back part of the vertebrae or facet. Muscle fatigue can develop if the scoliosis has caused a person‘s head to not be perfectly balanced over their pelvis bone. Their back muscles get tired from having to hold themselves upright against gravity. A patient who has this problem is said to be “Out of Balance”. Rib cage pain can develop with a severe scoliosis more than 60 degrees when a person’s ribs become so close to their pelvic bone that they are actually rubbing against each other. Usually there is a 3 or 4 inch gap between a person’s rib cage and their pelvic bone. This gap can be lost when a severe scoliosis develops. Sciatica or claudicating leg pain is caused by the spinal nerves in the lower lumbar spine being pinched either by arthritis that has developed or by bulging of the discs between the vertebrae. If the nerves are the lower nerves in the spine the pain may radiate down the leg towards the knee or calf, or even into the foot. This pain may be a sharp, stabbing type of pain or be more of a dull aching pain almost like a toothache. It may also cause numbness down the leg or if the nerve is significantly compressed there may be weakness walking due to the nerve compression. If the pain only develops when a patient is walking and goes away when they stop walking and sit down it is called claudicating leg pain. If it is a sharper stabbing pain it is usually called sciatica. TREATMENT OF ADULT SCOLIOSIS In most cases of adult scoliosis treatment will not require surgery. Many patients with mild curves less than 20 degrees and moderate curves less than 30 degrees can be treated with physical therapy or possible chiropractic treatment. Usually encouragement of an active lifestyle including some type of aerobic exercise such as walking or swimming is also included. This tends to help the bones in the spine stay stronger and the curve will have less of a chance of getting worse with advancing age. Weight loss close to a person’s recommended weight is also helpful and tends to encourage the curve from getting worse. If the patient is having significant arthritis pain, anti-inflammatory medication such as Ibuprofen may be prescribed. If a patient has primarily lower lumbar back pain from the scoliosis, a back support or back brace may be prescribed to support the spine when a patient has weak discs in that area of the spine . This would be used temporarily for support until the pain lessens or may be recommended to be used when doing more strenuous activities such as yard work, housework or even during the regular workday. If a patient has severe sciatica or claudicating leg pain another option is an epidural steroid injection. This is an outpatient procedure in which a needle is placed near the spinal canal where the nerves are under compression and a steroid is injected along with sterile saline to attempt to concentrate the medication to relieve the pain. Sometimes up to three of these shots can be done over several weeks to lessen the pain. In a small number of cases the only option may be surgery. Patients who have severe narrowing of the nerves (spinal stenosis) or who have severe arthritis affecting the discs and causing severe back pain may need surgery. The goal in surgery would be to relieve the most pain with the most limited or minimal surgery. If the scoliosis curve is not severe and the patient’s spine is balanced and compression on the nerve is limited to only 1 or 2 discs the surgery can be done by a minimally invasive surgery (MIS). The compression on the nerves may be able to be relieved without having to fuse any discs and the patient would keep their full mobility. Minimally invasive surgeries (MIS) can sometimes be done through a very small incision only 1 to 2 inches long. If the compression of the nerves is spread over several areas or the scoliosis curvature is severe and associated with arthritis that is painful in several areas or if the person’s spine is severely “Out of Balance”, then a more involved surgery may be necessary. Many times these more involved surgeries would involve placing metal rods that attach to the spine by way of hooks or screws to hold the spine in place while it heals after surgery. If the scoliosis is in a patient who is 50 or 55 years old it can be done usually as a single surgery, ( Figure 1 a and b.) . Figure 1 a + b. This mid 20 year old woman had progressive scoliosis with a curve over 60 degrees. She required fusion of her thoracic spine to correct this. If the patient is over 55 to 60 years old or the curvature is very severe the surgery may be spread over two days with the surgeries being separated by 5 to 7 days. This can lessen the risk of complication. Usually these surgeries need to be done by someone who specializes in Adult Scoliosis. Figure 2 . This 78 year old woman had severe back pain and severe leg pain with scoliosis and also severe spinal stenosis (narrowing of the space for the nerves). She underwent fusion with decompression of the nerves in the lumbar spine.