The adult scoliosis
Summary (3 min read)
Introduction
- This disorder has been known for some time, but only a very few surgeons dealt with it.
- Progress in surgical techniques and technology is significantly supported by progress in anaesthesia for spinal surgery and by more sophisticated and precise diagnostic imaging and differentiated application of invasive and functional diagnostic tests.
- This trend is likely to continue when the authors consider the fact that in 25 years from now, a significant part (more than 10%) of the population in the industrialized societies will be over 65 years old.
Classification
- A scoliosis is diagnosed in adult patients when it occurs or becomes relevant after skeletal maturity with a Cobb angle of more than 10 in the frontal plain [1, 55].
- Surgical management consists of either decompression, correction, stabilization and fusion procedures or a combination of all of these.
- This curve also could be termed ‘‘discogenic curve’’ and is basically the result of an asymmetric degenerative change of the disc with the consecutive development of a frontal deviation and concomitant rotation with the facet joints on one side as a pivot (Fig. 1).
- In both situations, however, there may be a significant degeneration and deformity present in the sagittal as well as in the frontal plain of the short lumbar curve.
Secondary degenerative scoliosis (Fig. 6)
- Adult secondary degenerative scoliosis is mostly located in the thoracolumbar and lumbar as well as lumbosacral spine.
- These secondary curves with the causes outside of the spine primarily do not have a relevant rotation, however are basically deviations in the frontal plain.
- Owing to bone weakness, there may be fractures, which create an asymmetric configuration with expression of either kyphosis or scoliosis or both together.
- Pathomorphology and pathomechanism in adult scoliosis Degenerative adult scoliosis, specifically in the lumbar spine, is characterized by quite a uniform pathomor- phology and pathomechanism.
- The osteophytes of the facet joints and the spondylotic osteophytes, however, may not sufficiently stabilize a diseased spinal segment; such a condition leads to a dynamic, mostly foraminal stenosis with radicular pain or claudication type pain (e.g. Fig. 11).
Clinical presentation
- The back pain can be combined with radicular leg pain.
- It may, however, only become relevant, when the curve has reached a certain amount of degrees and/or when osteoporotic asymmetric collapse may contribute relevantly to the curve.
- Therefore, a surgical intervention may occasionally be indicated in order to avoid a further progression and degeneration in a patient with potential medical risks [3, 4. 7].
- Cosmesis may occasionally play a role in younger patients below 40 years with an early secondary degenerated idiopathic thoracolumbar or lumbar scoliosis.
Diagnostic evaluations
- In addition to the standard clinical examination, patients with symptomatic adult scoliosis need precise conventional imaging and often require interventional radiological procedures, such as sequential discograms, facet blocks, epidural blocks and preferentially, a myelogram combined with a CT scan [24, 25, 34, 36, 57].
- MR imaging of degenerative scoliosis is often very polymorphic due to the complex pathology, parts of which may still be difficult to understand and may leave us uncertain as to the leading pathology.
- Therefore, the discogram serves to provide both direct pain provocation and localization and as a double test for pain evaluation, when the pain disappears after the intradiscal depot of medication.
- If, despite all these tests, the pain remains unexplained, it may be helpful in rare cases to put on a Fig. 5 a and b A 28-year-old female patient 15 years after Harrington correction and fusion to L5.
- Back pain almost entirely disappeared b temporary cast in the form of a thoracolumbar orthosis (TLO) or thoracolumbosacral orthosis (TLSO) to see whether an overall stabilization and fusion of the whole scoliotic spinal area could be beneficial for the patient, specifically in cases of an overall tendency of the spine to statically collapse.
Therapeutic decision (Fig. 14)
- The indication for or against surgery and, more specifically, the type of surgery to be performed, involves complex decision-making.
- Certainly, surgery is only an option when the non-surgical measures have no effect or do not promise any relevant long-term help.
- Therapeutic epidural and selective nerve root blocks as well as facet joint blocks may help to control the pain temporarily.
- In order to plan the most promising surgical procedure for each patient, a clear understanding of the prominent symptoms or clinical signs is mandatory.
- *Plomb line from the centre of the head b Fig. 7 Secondary degenerative scoliosis due to a hip arthrodesis for a posttraumatic damage of the left hip: left convex, long thoracolumbar curve with secondary rotational deformity.
Surgical procedures
- A surgical approach to degenerative adult scoliosis is obviously complex in terms of decision making, i.e., ascertaining the surgical indication and choosing the patient and the procedure appropriately.
- The same may be true when an isolated decompression is done at the bottom of a rigid curve, i.e., at the transition to the mobile part of the lumbar spine, usually L4/5 or L5/S1.
- Stabilization and fusion in situ may be more than appropriate in which case overall decompensation of the spine can usually then be avoided.
- Such a combined procedure, however, may not be well tolerated by more elderly patients over 60 years or in reduced general health.
- If the spine above (in adult lumbar scoliosis mostly the thoracic spine or the thoracolumbar junction) is rigid, either physiologically developed over the years, or acquired by a previous fusion of a thoracic curve, it may not follow the correction executed in the lumbar spine.
Osteoporosis
- Osteoporosis is a major concern in the treatment of adult scoliosis.
- This is the time when degenerative scoliosis may become increasingly symptomatic because the curve may progress due to the asymptomatic load on weakened vertebrae, which get more wedged and deformed.
- The industry has offered all kinds of instrumentations with big diameter screws and adapted threads to improve bone purchase.
- Cement reinforcement of the screw anchorage is another alternative which has been advocated [8, 37].
Outcome and complications
- Complications may result from indication and misjudgement of the case, non-suitable patients, wrong technical performance, implant failure, a lack of achieving balance in the sagittal and frontal planes, and complications which cannot necessarily be explained [3, 4, 15, 17, 21, 26, 47].
- Postoperatively no claudication symptoms anymore, however, persistent back pain Fig. 18 Type 2 scoliosis (progressive idiopathic scoliosis in adult life): A 39-year-old female patient with AIS, significant loss of lumbar lordosis preoperatively.
- Postoperative restoration of lordosis and circumferential fusion with PLIF at the lumbosacral junction in order to avoid non-union.
- In the first series, the complication rate was comparable to those in other studies and the overall results were satisfactory [56, 59, 61, 63].
- When analyzed, regarding their overall daily activity by different questionnaires [50], most of these patients irrespective of age have improved in almost all categories of quality of life, and the use of regular pain medication is reduced substantially in more than 70% of these patients.
Conclusion
- The complexity of the relationship between clinical signs, symptoms, pathomorphology, and pathophysiology of adult—mostly lumbar, degenerative scolio- Fig. 19 a A 61-year-old female patient with back pain and claudication symptoms.
- B Decompression, stabilization and fusion, while omitting L5/S1; 1 year postoperatively disc space L5/S1 still quite high, c 28 months postoperatively, collapsed disc space L5/S1 with L5 radicular syndrome due to foraminal stenosis sis—remains one of the big challenges in spinal surgery.
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References
1,531 citations
"The adult scoliosis" refers background in this paper
...This is especially true when the lumbar curve is accompanied by the loss of lumbar lordosis [22]....
[...]
517 citations
262 citations
"The adult scoliosis" refers background in this paper
...The expert’s opinion is divided, whether in such cases a lumbosacral fusion should be included right from the beginning, or whether a wait and see attitude should be taken and only fuse the lumbosacral junction in case there are significant clinical problems from this area [8, 10, 12, 15, 30, 37]....
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...The surgical decision is also influenced by the patient’s general health, age, condition of bone quality, and the patient’s expectations [3, 15]....
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...(b) Scoliosis secondary to metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures [10, 15, 29, 51, 70]....
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...Complications may result from indication and misjudgement of the case, non-suitable patients, wrong technical performance, implant failure, a lack of achieving balance in the sagittal and frontal planes, and complications which cannot necessarily be explained [3, 4, 15, 17, 21, 26, 47]....
[...]
256 citations
"The adult scoliosis" refers background in this paper
...Type 2: Progressive idiopathic scoliosis in adult life of the thoracic, thoracolumbar, and/or lumbar spine [5, 8, 36, 42, 46, 61, 71, 72]....
[...]
...Twenty-five years ago, a book chapter about scoliosis with special emphasis on the adult and/or degenerative scoliosis was relatively small [5, 11, 20, 43, 53, 62, 64]....
[...]
...form of mostly a flat back or lumbar kyphosis [5, 6, 8, 19, 23, 31, 36]....
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Frequently Asked Questions (12)
Q2. What are the non-surgical treatment options for scoliosis?
The non-surgical treatment options [9, 20, 34, 46, 67] consist basically of non-steroid anti-inflammatory medication, muscle relaxants, pain medication, muscle exercises, swimming and occasionally gentle traction, while avoiding manipulations and physical activation that may increase the pain.
Q3. What is the common cause of a lumbosacral junction de?
depending on the cause of the curve, the lumbosacral junction usually is degenerated: disc space narrowing, facet joint arthritis, vertebral obliquity and possibly rotational deformity and sometimes even spontaneous fusion of L5 to S1 might be a consequence of a lumbosacral transitional anomaly or a progressed degeneration.
Q4. What causes asymmetric degeneration of the disc and/or facet joints?
The asymmetric degeneration of the disc and/or the facet joints leads to an asymmetric loading of the spinal segment and consequently of a whole spinal area.
Q5. What is the second important symptom of degenerative scoliosis?
The second important symptom of adult degenerative scoliosis is radicular pain and claudication symptoms when standing or walking [57, 73].
Q6. What is the important part of a scoliosis procedure?
As patients, who present themselves with significant clinical problems in the context of adult scoliosis, get older, minimal invasive procedures to address exactly the most relevant clinical problem may become more and more important, basically ignoring the overall deformity and degeneration of the spine.
Q7. What is the important consideration in the case of a posterior release?
The posterior pedicular systems nowadays allow a powerful manipulation, correction, and stabilization of the lumbar spine, as long as a proper posterior release precedes the corrective and stabilization procedure.
Q8. What is the way to treat adult degenerated scoliosis?
Whether the emerging dynamic fixation devices or even disc arthroplasty will be an option in the surgical treatment of adult degenerated scoliosis remains to be considered as more experience is acquired with that kind of implant.
Q9. What is the common type of deformity in the sagittal spine?
The sagittal deformity is almost always exclusively a flat back syndrome or a loss of physiological lordosis and in extreme situations a real kyphosis.
Q10. What is the common time for degenerative scoliosis?
This is the time when degenerative scoliosis may become increasingly symptomatic because the curve may progress due to the asymptomatic load on weakened vertebrae, which get more wedged and deformed.
Q11. How many patients have improved their quality of life?
When analyzed, regarding their overall daily activity by different questionnaires [50], most of these patients irrespective of age have improved in almost all categories of quality of life, and the use of regular pain medication is reduced substantially in more than 70% of these patients.
Q12. What is the main bulk of adult scoliosis?
Keywords Adult scoliosis Æ Degenerative scoliosis Æ Spinal stenosis Æ Adult deformity Æ Secondary scoliosistherefore the main bulk of adult scoliosis.