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Degenerative Scoliosis

In talking about scoliosis, doctors toss around some pretty unflattering terms: "deviation," "defect," "deformity," "co-morbidity," "degeneration." But don't take it personally. In a medical context, each term has a specific meaning that's not as dodgy than it sounds. Read on, and you'll see what we mean.

What is adult degenerative scoliosis?

Scoliosis is the lateral (sideways) curvature of the spine by 10° or more. Adults can develop scoliosis as a result of tumors, multiple sclerosis, or other problems. On this page, we’ll limit our discussion to scoliosis associated with age-related degeneration. For more info on degenerative processes, see Osteoarthritis and Disc Degeneration.

Adult degenerative scoliosis (ADS) is a form of scoliosis in which vertebral rotation pulls the spine laterally, causing it to deviate from its normal position into an S-shaped or C-shaped curvature. This lateral curvature, which doctors call a deviation, deformity, or defect, can affect the entire spine or only a portion of it.

ADS is often painful. If the curvature is severe enough, it can restrict lung expansion and compromise breathing. Other complications associated with the spinal deformity can occur, too. For example, sometimes a vertebra in the affected segment slips sideways, a type of spondylolisthesis called lateral subluxation.1

How common is adult degenerative scoliosis?

Researchers have tried to determine the percentage of adults with ADS in the United States. Their estimates vary widely, from 6% all the way up to 68%. As is often the case in estimating disease prevalence, a lot depends on how you define the disease.2 One thing scientists can say for sure, though, is that the condition affects an equal number of men and women and is usually diagnosed around age 60 to 70.3

What causes degenerative scoliosis?

A vertebral bone typically has four facet surfaces on the back. These facets lie above and below the spiny part of the vertebra—the little knob you can see and feel beneath the skin. The two facets above are known as the superior facets, and the two below are the inferior facets. Ligaments surrounding the joint work with the spinal musculature to keep the facets aligned, so that their flat upper and lower surfaces meet up properly.

As we age, the facet joints and surrounding structures deteriorate. Cartilage wears away. We lose muscle and bone mass. Discs dry out and flatten. Ligaments calcify and lose their tautness. If structures on the right and left sides of the spine degenerate—that is, break down or deteriorate-at different rates, the facet surfaces will be pulled off track, like gears that no longer mesh. And anyone over age 50 knows that your body isn’t courteous enough to age symmetrically.

What are the symptoms of degenerative scoliosis?

Nearly all ADS patients have pain, particularly lower-back pain and leg pain, especially when walking (a symptom known as intermittent claudication). Unsteadiness or poor balance are also common. The pain of ADS tends to be diffuse — that is, generalized rather than located at a specific spot. You may feel that the pain radiates out in all directions from the center of the defect. Most patients also have pain caused by foraminal stenosis, or compression of the nerve roots where they enter and exit the spine. The nerves must pass through small openings called foramen, which may be narrowed by the unusual configuration of the spine.

How is degenerative scoliosis diagnosed?

The Scoliosis Research Society–Schwab spinal deformity classification system (2012) is widely used to categorize scoliosis according to its severity, location, direction, and cause.4 To categorize your scoliosis accurately, your doctor will use clinical criteria (signs and symptoms), imaging studies (such as x-rays and MRI), and a thorough physical examination

How is degenerative scoliosis treated?

Regardless of which activities you engage in during your recovery, studies show that patients who get back on their feet quickly have shorter hospital stays, fewer complications and hospital readmissions, and a more successful recovery.5

Physical therapy

Physical therapy can restore lost muscle mass, which takes some of the burden off of lax ligaments, alleviates pain, and improves flexibility. Using a corset-like or rigid plastic brace can improve posture and support the spine. Water aerobics or other aquatic therapy relaxes the back, improves body mechanics, and tones the back muscles. Modalities used to relieve the pain of ADS include massage, heat, ice, and electrical stimulation (see “What Is Transcutaneous Electrical Nerve Stimulation [TENS]?” in the FAQs section).

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen (Aleve) and ibuprofen (Advil), are useful in managing the pain of ADS. Muscle relaxants can be useful, too, and antidepressants, antianxiety agents, and sleep aids can address the depression, stress, and sleeplessness often associated with ADS.

Opioid medications— prescription narcotic drugs that relieve pain—may be prescribed sparingly. If doctors and patients use them carefully and responsibly, opioids can be an effective supplement to your pain management plan, particularly in the postoperative period and as you begin rehabilitation.

Surgery

In patients with ADS, time does not heal all wounds. A degenerative disorder like ADS is, by definition, progressive. In fact, the degree of curvature typically increases about 3 degrees per year.1 If scoliosis begins to compromise your respiratory function, surgery to halt progression of the disease becomes even more urgent. Your age and the severity of your pain must be considered, too. Your doctor will help you decide when it’s time to schedule surgery.

The Adult Spine

Correction of spinal curvature in an adult is more challenging than in a child because the adult spine is rigid and…well, let’s just say it’s no longer in its prime. A child’s spine is more flexible and forgiving. In most cases, aside from its abnormal curvature, the spine of a young person with scoliosis has no other pathologic features—no disc degeneration, arthritis, calcification, bone spurs, or other unwelcome surprises.

In an adult spine, on the other hand, the surgeon must not only address the abnormal curvature, but also find workarounds for unrelated structural issues, such as bone spurs or fractures. Fortunately, most of these anatomic landmines can be identified in advance, with the aid of MRI or other imaging techniques. The surgeon can then account for them in his or her operative plan.

Co-Morbidities

Your options for ADS surgery depend in part on the presence or absence of co-morbidities. In doctor-speak, the word morbidity simply refers to disease. A co-morbidity, then, is a coexisting, usually chronic disease that you have along with scoliosis. Patients who have diabetes, heart or kidney failure, and other serious co-morbidities are at higher risk than those with no serious health problems. The same is true, of course, with any kind of surgery.

Keyhole procedures reduce the surgical risk dramatically and spare you the lengthy, grueling recovery that used to do hand in hand with scoliosis correction.

Safe New Surgical Options

Fortunately, even patients with significant co-morbidities can usually undergo keyhole surgery. Keyhole procedures reduce surgical risk dramatically and spare you the lengthy, grueling recovery that used to go hand in hand with scoliosis correction. In a traditional procedure, the surgeon first had to use his scalpel to cut away layers of muscle and other tissue. Thus the patient endured a great deal of trauma, and perhaps significant blood loss, even before the surgeon reached the spine. The risk of infection was higher, and the patient’s hospital stay and recovery time were lengthy even if he or she was in good overall health.

In a keyhole procedure, the surgeon reaches the vertebrae and surrounding structures through an incision no larger in diameter than a dime. A tube is then inserted through this opening, creating a tunnel through which surgical instruments can be passed. These instruments go straight to the spine through this canal, without cutting through the overlying musculature.

Once there, the surgeon guides the instruments using magnified fluoroscopic images. Most patients recover quickly and can then walk or bend or sit without pain, perhaps for the first time in years. (See our Patient Stories.) That might seem pretty ordinary, but if you’re the patient, it’s nothing short of remarkable.

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