scispace - formally typeset
Search or ask a question
Journal ArticleDOI

The adult scoliosis

Max Aebi1
18 Nov 2005-European Spine Journal (Springer-Verlag)-Vol. 14, Iss: 10, pp 925-948
TL;DR: Overall, a satisfactory outcome can be expected in well-differentiated indications and properly tailored surgical procedures, although until today prospective, controlled studies with outcome measures and pre- and post-operative patient’s health status are lacking.
Abstract: Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 degrees in the coronal plain. Adult scoliosis can be separated into four major groups: Type 1: Primary degenerative scoliosis, mostly on the basis of a disc and/or facet joint arthritis, affecting those structures asymmetrically with predominantly back pain symptoms, often accompanied either by signs of spinal stenosis (central as well as lateral stenosis) or without. These curves are often classified as "de novo" scoliosis. Type 2: Idiopathic adolescent scoliosis of the thoracic and/or lumbar spine which progresses in adult life and is usually combined with secondary degeneration and/or imbalance. Some patients had either no surgical treatment or a surgical correction and fusion in adolescence in either the thoracic or thoracolumbar spine. Those patients may develop secondary degeneration and progression of the adjacent curve; in this case those curves belong to the type 3a. Type 3: Secondary adult curves: (a) In the context of an oblique pelvis, for instance, due to a leg length discrepancy or hip pathology or as a secondary curve in idiopathic, neuromuscular and congenital scoliosis, or asymmetrical anomalies at the lumbosacral junction; (b) In the context of a metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures. Sometimes it is difficult to decide, what exactly the primary cause of the curve was, once it has significantly progressed. However, once an asymmetric load or degeneration occurs, the pathomorphology and pathomechanism in adult scoliosis predominantly located in the lumbar or thoracolumbar spine is quite predictable. Asymmetric degeneration leads to increased asymmetric load and therefore to a progression of the degeneration and deformity, as either scoliosis and/or kyphosis. The progression of a curve is further supported by osteoporosis, particularly in post-menopausal female patients. The destruction of facet joints, joint capsules, discs and ligaments may create mono- or multisegmental instability and finally spinal stenosis. These patients present themselves predominantly with back pain, then leg pain and claudication symptoms, rarely with neurological deficit, and almost never with questions related to cosmetics. The diagnostic evaluation includes static and dynamic imaging, myelo-CT, as well as invasive diagnostic procedures like discograms, facet blocks, epidural and root blocks and immobilization tests. These tests may correlate with the clinical and the pathomorphological findings and may also offer the least invasive and most rational treatment for the patient. The treatment is then tailored to the specific symptomatology of the patient. Surgical management consists of either decompression, correction, stabilization and fusion procedures or a combination of all of these. Surgical procedure is usually complex and has to deal with a whole array of specific problems like the age and the general medical condition of the patient, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis and possibly previous scoliosis surgery, and last but not least, usually with a long history of chronified back pain and muscle imbalance which may be very difficult to be influenced. Although this surgery is demanding, the morbidity cannot be considered significantly higher than in other established orthopaedic procedures, like hip replacement, in the same age group of patients. Overall, a satisfactory outcome can be expected in well-differentiated indications and properly tailored surgical procedures, although until today prospective, controlled studies with outcome measures and pre- and post-operative patient's health status are lacking. 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.

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.

Did you find this useful? Give us your feedback

Content maybe subject to copyright    Report

Max Aebi
The adult scoliosis
Received: 26 October 2005
Accepted: 26 October 2005
Published online: 18 November 2005
Ó Springer-Verlag 2005
Abstract Adult scoliosis is defined as
a spinal deformity in a skeletally
mature patient with a Cobb angle of
more than 10° in the coronal plain.
Adult scoliosis can be separated into
four major groups: Type 1: Primary
degenerative scoliosis, mostly on the
basis of a disc and/or facet joint
arthritis, affecting those structures
asymmetrically with predominantly
back pain symptoms, often accom-
panied either by signs of spinal ste-
nosis (central as well as lateral
stenosis) or without. These curves
are often classified as ‘‘de novo’’
scoliosis. Type 2: Idiopathic adoles-
cent scoliosis of the thoracic and/or
lumbar spine which progresses in
adult life and is usually combined
with secondary degeneration and/or
imbalance. Some patients had either
no surgical treatment or a surgical
correction and fusion in adolescence
in either the thoracic or thoracol-
umbar spine. Those patients may
develop secondary degeneration and
progression of the adjacent curve; in
this case those curves belong to the
type 3a.Type 3: Secondary adult
curves: (a) In the context of an ob-
lique pelvis, for instance, due to a leg
length discrepancy or hip pathology
or as a seco ndary curve in idio-
pathic, neuromuscular and congeni-
tal scoliosis, or asymmetrical
anomalies at the lumbosacral junc-
tion; (b) In the context of a meta-
bolic bone disease (mostly
osteoporosis) combined with asym-
metric arthritic disease and/or ver-
tebral fractures. Sometimes it is
difficult to decide, what exactly the
primary cause of the curve was, once
it has significantly progressed.
However, once an asymmetric load
or degeneration occurs, the patho-
morphology and pathomech anism in
adult scoliosis predominantly lo-
cated in the lumbar or thoracolum-
bar spine is quite predictable.
Asymmetric degeneration leads to
increased asymmetric load and
therefore to a progression of the
degeneration and deformity, as ei-
ther scoliosis and/or kyphosis. The
progression of a curve is further
supported by osteoporosis, particu-
larly in post-menopausal female pa-
tients. The destruction of facet
joints, joint capsules, discs and liga-
ments may create mono- or multi-
segmental instability and finally
spinal stenosis. These patients pres-
ent themselves predominantly with
back pain, then leg pain and clau-
dication symptoms, rarely with
neurological deficit, and almost
never with questions related to cos-
metics. The diagnostic evaluation
includes static and dynamic imaging,
myelo-CT, as well as invasive diag-
nostic procedures like discograms,
facet blocks, epidural and root
blocks and immobilization tests.
These tests may correlate with the
clinical and the pathomorphological
findings and may also offer the least
invasive and most rational treatment
Eur Spine J (2005) 14: 925–948
DOI 10.1007/s00586-005-1053-9
REVIEW
M. Aebi
Institute for Evaluative Research in
Orthopaedic Surgery, University of Bern,
Bern, Switzerland
M. Aebi
Department of Orthopaedics,
Hirslanden-Salem Hospital,
Stauf facherstrasse 78, 3014 Bern,
Switzerland
E-mail: max.aebi@MEMcenter.unibe.ch
Tel.: +41-31-6315930
Fax: +41-31-6315931

Introduction
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].
Most of the pages were devoted to scoliosis in childhood
and adolescence. Only the introduction of spinal instru-
mentation, first Harrington rods and Dwyer instrumen-
tation, and later Zielke, and finally CD-instrumentation
with all the following third generation pedicle instru-
mentations, shifted the focus to the major problem of the
adult scoliosis [1, 2, 8, 13, 23, 27, 32, 35, 38, 40, 45, 58, 59,
62]. This disorder has been known for some time, but only
a very few surgeons dealt with it. Patients were in an age
group which was considered to be too risky to undergo
major spine surgery; the surgical technical issues were
widely unsolved due to the lack of powerful instrumen-
tation; the bone stock was considered too poor for a major
corrective surgery; and the patients were generally made
to believe that they had to live with this ailment.
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. Increased pa-
tient awareness, the patient’s unwillingness to accept
their limitations and pains [54], and the gradual shift in
the demographics towards a ‘‘grey society’’, make adult
scoliosis with all of its different forms and clinical pre-
sentations, a much more frequent problem in a general
spine practice than the scoliosis of children and ad oles-
cents. This trend is likely to continue when we 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].
Type 1: Primary degenerative scoliosis (‘‘de novo’’ form),
mostly located in the thoracolumbar or lumbar spine [6,
19, 20 24, 25 27, 33, 43, 48, 52, 53].
Type 2: Progressive idiopathic scoliosis in adult life of
the thoracic, thoracolumbar, and/or lumbar spine [ 5, 8,
36, 42, 46, 61, 71, 72].
Type 3: Secondary degenerative scoliosis.
(a) Scoliosis following idiopathic or other forms of
scoliosis or occurring in the context of a pelvic
obliquity due to a leg length discrepancy, hip
pathology or a lumbosacral transitional anomaly,
mostly located in the thoracolumbar, lumbar or
lumbosacral spine [11, 24, 34, 44, 50, 64].
(b) Scoliosis secondary to metabolic bone disease
(mostly osteoporosis) combined with asymmetric
arthritic disease and/or vertebral fractures [10, 15,
29, 51, 70].
Therefore, scoliosis can be present since childhood or
adolescence and become progressive and/or symptomatic
in adult life; or scoliosis may appear ‘‘de novo’’ in adult
life without any precedence in earlier life.
Clinically, the most prominen t groups are secondary
(type 3) and primary (type 1) degenerative adult
scoliosis. In elderly patients, both forms of scoliosis may
be aggravated by osteoporosis, which also holds true for
the type 2 scoliosis [24, 29, 70]. All three types of
scoliosis may primarily appear at a certain stage as
degenerative scoliosis, and degenerative scoliosis is
for the patient. The treatment is then
tailored to the specific symptom-
atology of the patient. Surgical
management consists of either
decompression, correcti on, stabil-
ization and fusion procedures or a
combination of all of these. Surgical
procedure is usually complex and
has to deal with a whole array of
specific problems like the age and
the general medical condition of the
patient, the length of the fusion, the
condition of the adjacent segments,
the condition of the lumbosacral
junction, osteoporosis and possibly
previous scoliosis surgery, and last
but not least, usually with a long
history of chronified back pain and
muscle imbalance which may be very
difficult to be influenced. Although
this surgery is demanding, the mor-
bidity cannot be considered signifi-
cantly higher than in other
established orthopaedic procedures,
like hip replacement, in the same age
group of patients. Overall, a satis-
factory outcome can be expected in
well-differentiated indications and
properly tailored surgical proce-
dures, although until today pro-
spective, controlled studies with
outcome measures and pre- and
post-operative patient’s health status
are lacking. 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 defor-
mity and degeneration of the spine.
Keywords Adult scoliosis Æ Degen-
erative scoliosis Æ Spinal steno-
sis Æ Adult deformity Æ Secondary
scoliosis
926

therefore the main bulk of adult scoliosis. Beyond the
proposed classification, the degenerative adult scoliosis
could also be subdivided into scoliosis which have their
aetiology in the spine itself an d those scoliosis with the
aetiology beyond the spine (Table 1). Schwab et al.
proposed recently a radiographic classification including
type I–III scoliosis, characterized by the a/p and lateral
view in standing position. They correlated the classifi-
cation I–III with increasing severity of self-reported pain
and disability [55]. Boachie-Adjei [8 ] considers specifi-
cally the idiopathic adult scoliosis (our type 2 scoliosis)
and uses the age as a classifying criteria combined with
degenerated changes: patients with idiopathic adult
scoliosis below and above 40 years of age.
This review will concentrate on the forms of adult
scoliosis which present themselves most frequently in a
spinal practice and which are considered in the above-
presented classification.
Type 1 scoliosis: the primary degenerative scoliosis
(‘‘de novo’’ scoliosis) (Fig. 1)
The primary degenerative curve develops mostly on the
grounds of primarily limited disc degeneration in one or
more motion segments. 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). The apex of this curve is usually be-
tween L3 and L4 or L2 and L3 or, second most frequent,
between L1 and L2. These curves tend to go along with a
significant rotational translation of the apical vertebra.
In some cases the primary cause of the degener ative
process may be localized in the facet joints where a wide
variety of dystrophic formation, malformation, and
misalignment can occur. When this occurs at the lum-
bosacral junction, then the curve belongs rather to the
type 3a curves, following lumbosacral anomalies.
It is difficult to state whether some curves in this group
could be considered as ‘‘resting’’ idiopathic scoliosis.
There are obviously curves that only develop in adult life
and may appear like idiopathic scoliotic curves; however,
upon closer look, they rather may have developed on the
basis of a degenerated disc. The primarily degenerative
curves usually are less severe in terms of frontal angulation
than the curves in secondary degenerative idiopathic sco-
liosis [24, 25]. The primary degenerative scoliosis is
therefore mostly a lumbar or thoracolumbar curve con-
sisting of a frontal as well as a sagittal deviation in the
Table 1 Potential of curve progression
Type Description Etiology Problem located
in the spine
beyond the spine
Type I Primary degenerative scoliosis
(‘‘de novo’’ scoliosis)
mostly lumbar
or thoracolumbar curve
apex at L2/3 or L/4 most
frequently
Asymmetric disc
degeneration and facet
joint degeneration
+
Type II Progressive idiopathic
scoliosis of the
lumbar and/or
thoracolumbar spine
(e.g. double major curve)
Idiopathic scoliosis present
since adolescence or
childhood, progression
due to mechanical
reasons or bony and/or
degenerative changes
+?
Type III (a) Secondary adult scoliosis
mostly thoracolumbar,
lumbar-umbosacral
Secondary to an adjacent
thoracic or thoracolumbar
curve of idiopathic,
neuromuscular or
congenital origin
Obliquity of the pelvis due
to leg length discrepancy
or hip pathology with
secondary lumbar/
thoracolumbar curve
Lumbosacral transitional anomaly
++
Type III (b) Deformity progressing
mostly due to bone
weakness with, e.g.,
osteoporotic fracture with
secondary deformity
Metabolic bone disease, osteoporosis + +
927

form of mostly a flat back or lumbar kyphosis [5, 6, 8, 19,
23, 31, 36]. The sagittal malalignment is usually respon-
sible for the severe postural back pain of the patients.
These curves are shorter than the idiopathic curves an-
d—at least in the beginning—the deformity of the indi-
vidual vertebral body is less expressed than in idiopathic
scoliosis [24, 25]. This only occurs as a consequence of
erosion and destruction of the endplates and facet joints
due to spondylosis and spondylarthritis. Also, there is a
difference in the bone density between the primary and
secondary degenerative curves. Spinal stenosis is more
often seen in primary degenerative scoliosis than in sec-
ondary degenerated idiopathic curves [2, 6, 8, 21, 26, 44].
The disc degeneration ends up with spondylosis, disc
bulging, osteophytes, and facet joint arthritis with hyper-
trophic capsules, ligamentum flavum, and calcification of
these structures with osteophytes, all on the costs of the
space in the spinal canal and foramina, thus contributing
to the formation of spinal stenosis, be it a foraminal lateral
stenosis or a central stenosis or both (Fig. 2).
Type 2 scoliosis: progressive idiopathic scoliosis
in adult life (Fig. 3)
The idiopathic curves and curves with other aetiology
of secondary degeneration present themselves in a
variety of forms, depending on whether these curves
have been treated non-surgically or not at all or
whether they have had a fusion, with or without
instrumentation, of the main thoracic and thoracol-
umbar curve [46]. In the latter case the degeneration
appears in the adjacent curve and belongs to the type
3a curves (see below) (Figs. 3, 4). 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. The sagittal
deformity is almost always exclusively a flat back
syndrome or a loss of physiological lordosis and in
extreme situations a real kyphosis. The degenerated
idiopathic scoliosis mostly in the lumbar and/or tho-
racolumbar spine is quite frequently combined with
spinal stenosis at a relatively young age, specifically in
the adjacent lower segment after Harrington instru-
mentation. This adjacent segmental spinal stenosis,
mostly below a long fused idiopathic scolios is, appears
about 15–20 years post-surgical with Harrington rods
(Fig. 5). There are not yet similar long-term results
available for cases which have been treated with one
of the CD-type third generation instrumentation that
allow superior restoration of the sagittal alignment,
possibly protecting the spine from developing rapid
adjacent segment degeneration [3, 4, 7, 21, 39, 56].
Type 3 scoliosis:
Secondary degenerative scoliosi s (Fig. 6)
Adult secondary degen erative scoliosis is mostly located
in the thoracolumbar and lumbar as well as lumbosacral
spine. This scoliosis occurs either with its cause within
the spine or outside the spine. Those scoliosis with the
cause inside of the spine are either secondary to an
adjacent curve, be it an idiopathic, neuromuscular or
congenital curve, or it may be the consequence of a
Fig. 1 Type 1 adult scoliosis: de
novo scoliosis. a at 33 years
(8°), b at 50 years (25°), c at
55 years (40°)
928

lumbosacral anomaly, specifically with a hemisacraliza-
tion (Fig. 6). Scoliosis outside of the spine is due to
pelvic obliquity in the context of a hip pathology or a leg
length discrepancy (Fig. 7). 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. Only over time there is a translational
displacement of vertebras close to the apex.
Adult scoliosis due to bone weakness (Fig. 8)
These deformities are mostly due to metabolic bone dis-
ease or diseases which have a secondary impact on the
strength of the bone (e.g. Morbus Adison) (Fig. 8). The
most frequent cause for a secondary deformity due to
metabolic bone disease is osteoporosis. Owing to bone
weakness, there may be fractures, which create an asym-
metric configuration with expression of either kyphosis or
scoliosis or both together. It may also occur when a pre-
existing scoliosis, respectively kyphosis, is aggrava ted by
an osteoporotic fracture [29, 65, 70].
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 asymmetric degen-
eration of the disc and/or the facet joints leads to an
asymmetric loading of the spinal segment and conse-
quently of a whole spinal area. This again leads to an
asymmetric deformit y, for example, scoliosis and/or
kyphosis. Such a deformity again triggers asymmetric
degeneration and induces asymmetric loading, creating
a vicious circle (Fig. 9) and enhancing curve progres-
sion. On the one hand, the curve progression is given
by the patho mechanism of an adult degenerative curve,
and on the other hand by the specific bone metabolism
of the post-menopause female patients with a certain
degree of osteoporosis, who are most frequently af-
fected by the degenerative form of scoliosis. The po-
tential of individual asymmetric deformation and
collapse in the weak osteoporotic vertebra is clearly
increased and cont ributes further to the curve pro-
gression.
The destruction of discs, facet joint s and joint
capsules usually ends in some form of uni- or multi-
segmental sagittal and/or frontal latent or obvious
instability. There may be not only a spondylolisthesis,
meaning a slip in the sagittal plain, but also transla-
tional dislocations in the frontal plain or rather three-
dimensionally when expressing itself in a rotational
dislocation (Figs. 1, 3, 6, 15). The biological reaction
to an unstable joint or, in the case of the spine, an
unstable segment, is the formation of osteophytes at
the facet joints (spondylarthritis) and at the vertebral
endplates (spondylosis), both contributing to the
increasing narrowing of the spinal canal together with
Fig. 2 Secondary changes in degenerative scoliosis: facet joint
hypertrophy, recessal stenosis
929

Citations
More filters
Journal ArticleDOI
20 May 2012-Spine
TL;DR: Data from this study show that there is excellent inter- and intra- rater reliability and inter-rater agreement for curve type and each modifier and the high degree of reliability demonstrates that applying the classification system is easy and consistent.
Abstract: Study design Inter- and intra-rater variability study. Objective On the basis of a Scoliosis Research Society effort, this study seeks to determine whether the new adult spinal deformity (ASD) classification system is clear and reliable. Summary of background data A classification of adult ASD can serve several purposes, including consistent characterization of a clinical entity, a basis for comparing different treatments, and recommended treatments. Although pediatric scoliosis classifications are well established, an ASD classification is still being developed. A previous classification developed by Schwab et al has met with clinical relevance but did not include pelvic parameters, which have shown substantial correlation with health-related quality of life measures in recent studies. Methods Initiated by the Scoliosis Research Society Adult Deformity Committee, this study revised a previously published classification to include pelvic parameters. Modifier cutoffs were determined using health-related quality of life analysis from a multicenter database of adult deformity patients. Nine readers graded 21 premarked cases twice each, approximately 1 week apart. Inter- and intra-rater variability and agreement were determined for curve type and each modifier separately. Fleiss' kappa was used for reliability measures, with values of 0.00 to 0.20 considered slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1.00 almost perfect agreement. Results Inter-rater kappa for curve type was 0.80 and 0.87 for the 2 readings, respectively, with modifier kappas of 0.75 and 0.86, 0.97 and 0.98, and 0.96 and 0.96 for pelvic incidence minus lumbar lordosis (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA), respectively. By the second reading, curve type was identified by all readers consistently in 66.7%, PI-LL in 71.4%, PT in 95.2%, and SVA in 90.5% of cases. Intra-rater kappa averaged 0.94 for curve type, 0.88 for PI-LL, 0.97 for PT, and 0.97 for SVA across all readers. Conclusion Data from this study show that there is excellent inter- and intra-rater reliability and inter-rater agreement for curve type and each modifier. The high degree of reliability demonstrates that applying the classification system is easy and consistent.

892 citations

Journal ArticleDOI
TL;DR: The 2016 SOSORT guidelines were developed based on the current evidence on CTIS and include a total of 68 recommendations divided into following topics: bracing, PSSE to prevent scoliosis progression during growth, other conservative treatments, respiratory function and exercises and assessment.
Abstract: The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines’ version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS). Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016. The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation “I” and level of evidence “II”. Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8. The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

457 citations

Journal ArticleDOI
15 Dec 2010-Spine
TL;DR: The morbidity in adult scoliosis surgery is minimized with less invasive techniques, and the rate of major complications in this study compares favorably to that reported from other studies of surgery for degenerative deformity.
Abstract: Study design Prospective multicenter nonrandomized institutional review board-approved observational study of clinical and radiographic outcomes of the extreme lateral interbody fusion (XLIF) procedure in adult scoliosis. Objective Perioperative measures from this longitudinal study were compiled to identify the short-term results and complications of the procedure. Summary of background data The surgical treatment of adult scoliosis presents a treatment challenge. Neural decompression with combined anterior/posterior instrumented fusion is often performed. These procedures have been reported to carry a high risk of complication, particularly in the elderly patient population. Over the past decade, less invasive surgical approaches to neural decompression and fusion have been popularized and have recently been applied in the treatment of degenerative scoliosis. To date, there has been little published data evaluating these treatment approaches. Methods A total of 107 patients who underwent the XLIF procedure with or without supplemental posterior fusion for the treatment of degenerative scoliosis were prospectively studied. Intraoperative data collection included surgical procedural details, operative time, estimated blood loss, and surgical complications. Postoperative complications, length of hospital stay, and neurologic status were recorded. For this report, perioperative data (inclusive of outcomes through the 6-week postoperative clinic visit) were evaluated. Results In all, 107 patients (mean age, 68 years; range, 45-87) were treated with XLIF; 28% had at least 1 comorbidity. A mean of 4.4 levels (range, 1-9) were treated per patient. Supplemental pedicle screw fixation was used in 75.7% of patients, 5.6% had lateral fixation, and 18.7% had stand-alone XLIF. Mean operative time and blood loss were 178 minutes (58 minutes/level) and 50 to 100 mL. Mean hospital stay was 2.9 days (unstaged), 8.1 day (staged, 16.5%), 3.8 days overall. Five patients (4.7%) received a transfusion, 3 (2.8%) required intensive care unit admission, and 1 (0.9%) required rehabilitation services. Major complications occurred in 13 patients (12.1%): 2 (1.9%) medical, 12 (11.2%) surgical. Of procedures that involved only less invasive techniques (XLIF stand-alone or with percutaneous instrumentation), 9.0% had one or more major complications. In those with supplemental open posterior instrumentation, 20.7% had one or more major complication. Early reoperations (3) (all for deep wound infections) were associated with open posterior instrumentation procedures. Conclusion The morbidity in adult scoliosis surgery is minimized with less invasive techniques. The rate of major complications in this study (12.1%) compares favorably to that reported from other studies of surgery for degenerative deformity.

344 citations

Journal ArticleDOI
TL;DR: The view that the modern concept of FJ OA is consonant with the concept of OA as a failure of the whole joint, and not simply of facet joint cartilage is presented.
Abstract: Osteoarthritis (OA) of the spine involves the facet joints, which are located in the posterior aspect of the vertebral column and, in humans, are the only true synovial joints between adjacent spinal levels. Facet joint osteoarthritis (FJ OA) is widely prevalent in older adults, and is thought to be a common cause of back and neck pain. The prevalence of facet-mediated pain in clinical populations increases with increasing age, suggesting that FJ OA might have a particularly important role in older adults with spinal pain. Nevertheless, to date FJ OA has received far less study than other important OA phenotypes such as knee OA, and other features of spine pathoanatomy such as degenerative disc disease. This Review presents the current state of knowledge of FJ OA, including relevant anatomy, biomechanics, epidemiology, and clinical manifestations. We present the view that the modern concept of FJ OA is consonant with the concept of OA as a failure of the whole joint, and not simply of facet joint cartilage.

342 citations

Journal ArticleDOI
TL;DR: These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method, and it is possible to understand the lack of research in general on CTIS.
Abstract: The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS). All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting. The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D. These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

334 citations

References
More filters
Journal ArticleDOI
15 Sep 2005-Spine
TL;DR: This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance, and shows that kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine.
Abstract: Study Design.This study is a retrospective review of 752 patients with adult spinal deformity enrolled in a multicenter prospective database in 2002 and 2003. Patients with positive sagittal balance (N = 352) were further evaluated regarding radiographic parameters and health status measures, includ

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]....

    [...]

Journal ArticleDOI
TL;DR: Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not, and operations for conditions other than a herniated disc were associated with more complications and greater use of resources than were operations for removal of a hernia.
Abstract: We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patient's age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.

517 citations

Journal ArticleDOI
TL;DR: Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not, and operations for conditions other than a herniated disc were associated with more complications and greater use of resources than were operations for removal of a hernia.
Abstract: We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patient's age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.

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]....

    [...]

  • ...The surgical decision is also influenced by the patient’s general health, age, condition of bone quality, and the patient’s expectations [3, 15]....

    [...]

  • ...(b) Scoliosis secondary to metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures [10, 15, 29, 51, 70]....

    [...]

  • ...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]....

    [...]

Journal ArticleDOI
01 Oct 1986-Spine
TL;DR: In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population, and the cosmetic appearance of these patients at long-term follow-up was better than that at the end of growth, even though the curves progressed.
Abstract: A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.

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]....

    [...]

Frequently Asked Questions (12)
Q1. What are the contributions in this paper?

In this paper, the authors defined scoliosis as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 in the coronal plain. 

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. 

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. 

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. 

The second important symptom of adult degenerative scoliosis is radicular pain and claudication symptoms when standing or walking [57, 73]. 

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. 

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. 

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. 

The sagittal deformity is almost always exclusively a flat back syndrome or a loss of physiological lordosis and in extreme situations a real kyphosis. 

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. 

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. 

Keywords Adult scoliosis Æ Degenerative scoliosis Æ Spinal stenosis Æ Adult deformity Æ Secondary scoliosistherefore the main bulk of adult scoliosis.