Degenerative Adult-Onset Scoliosis
Degenerative adult scoliosis is caused by the gradual deterioration of the facet joints, which makes the straight spine shift and curve to one side. Adult-onset scoliosis is different from curvature of the spine seen in children and adolescents.
Risk Factors & Symptoms
The risk factors for scoliosis that arises in adulthood include advanced age, genetic predisposition, ligament laxity, collagen disorders, lifestyle (smoking, obesity, long-term heavy manual labor) and connective tissue disorders (lupus, scleroderma). Adult scoliosis is also frequently related to osteoporosis and can develop after surgery that results in a spinal imbalance. Additionally, some adults treated for childhood scoliosis may need revision surgery.
Symptoms include the slow progression of increasingly severe low back pain, forward leaning, significant non-alignment of the spine and loss of height, as well as weakness, numbness and pain in the lower extremities, bladder and bowel dysfunction, dyspnea and fatigue.
When possible, degenerative adult- onset scoliosis is first treated medically with anti-inflammatories, pain medications, physical therapy and exercise. Surgery is usually recommended for patients with uncontrollable pain, spinal stenosis, extensive and progressive thoracolumbar curvature and decreased cardiopulmonary function, as well as significant impairment of daily function.
Scoliosis surgery for adults can be more challenging than that used with children and adolescents because of several factors, including the patient’s age and increased chance of medical comorbidities; the existence of osteoporosis, which can make fusion difficult; failure of the spine to fuse; and the potential for neurological injury.
A Surgical Case Study
A 70-year-old woman with a history of laminectomy using instrumentation and fusion, was experiencing uncontrollable back and leg pain that was worsening steadily and preventing her from walking or standing for more than 30 seconds.
A thorough physical examination, X-rays, CT scans and MRIs found disc desiccation at every level in the thoracic spine, stenosis at T11-T12, significant kyphotic deformity and thoracolumbar scoliosis with a lateral bend to the left side; the curvature measured 35 degrees.
Otherwise healthy, she was diagnosed with degenerative adult-onset scoliosis — a condition estimated to affect as much as 68% of adults over age 65. When she presented to Artem Vaynman, MD, a Board Certified NYU Winthrop Hospital neurosurgeon, who specializes in complex and minimally invasive spine surgery, she was refractory to medication, with immobilizing pain and weakness laying waste to the quality of her life.
“The combination of the compression of the spinal nerves and the significant spinal curvature was causing back pain and lower- extremity weakness,” explained Dr. Vaynman. “Recent studies have found that the disability of patients with severe progressive spinal deformity can be compared to that experienced by patients with bilateral leg amputations.”
“This patient was definitely a candidate for surgery,” Dr. Vaynman said. “Her spine was considerably unbalanced; she was leaning both forward and to the side. We recommended operating in two stages. While I knew the surgeries would be complex and not without risk, I felt they were basically safe and would help relieve her pain, which was compromising virtually every aspect of her life.”
The first stage consisted of an L2-L3 anterolateral decompression diskectomy with interbody fusion in order to free the nerves from com- pressing material and alleviate the pain. It involved the use of a lateral cage system to achieve anterior decompression of the spinal cord and neural tissues.
The second surgery, a posterior thoracolumbar instrumented fusion from T10 to the pelvis, was designed to align the spine, stop the curve’s progression and provide spinal stability. In this case, Dr. Vaynman essentially welded the vertebrae together using bone autograft and allograft. He then supported the area with bilateral posterior metallic rods and fixation screws extending from the thoracic region to S1.
During both procedures, intraoperative fluoroscopy, as well as somato-sensory-evoked and motor-evoked potentials were employed to monitor and detect any changes in spinal cord integrity during manipulation and curve correction. The complex procedures were performed on the same day over a total of 10 hours.
“Six weeks postoperatively, X-rays showed excellent spinal alignment,” reported Dr. Vaynman. “And several months later, with her walking and ability to stand dramatically improved, the patient reported she was pain-free.”
1. Schwab F, Dubey A, Gomez L, et al. Adult scoliosis prevalence SF-36 and nutritional narameters in an elderly volunteer population. Spine 2005;30:9:1082-1085.