Degenerative Adult Scoliosis
Introduction
Degenerative adult scoliosis occurs when the combination of age and deterioration of the spine leads to the development of a scoliosis curve in the spine. Degenerative scoliosis begins after the age of 40. In older patients, particularly women, it is also often related to osteoporosis. The osteoporosis weakens the bone making the bone more likely to deteriorate. The combination of these changes causes the spine to lose its ability to maintain a normal shape. The spine begins to “sag” and as the condition progresses, a scoliotic curve can slowly develop.
The purpose of this information is to help you understand:
- The causes of degenerative adult scoliosis
- How a diagnosis is made in degenerative adult scoliosis
- Degenerative adult scoliosis and its treatment
Anatomy
In order to understand your symptoms and treatment choices, you should start with some understanding of the general anatomy of your spine. This includes becoming familiar with the various parts that make up the spine and how they work together.
Please review the document, entitled:
Causes
When scoliosis occurs (or is discovered) after puberty, the condition is called “adult scoliosis”. Adult scoliosis can be the result of untreated or unrecognized childhood scoliosis, or it can actually arise during adulthood. The causes of scoliosis that begins in adulthood are usually very different from those of childhood scoliosis.
Scoliosis that develops in adulthood can be a “secondary” cause of another spinal condition that affects the vertebrae of the spine. Other conditions might include degeneration, osteoporosis (loss of bone mass), or osteomalacia (softening of the bones). Scoliosis can also appear following spinal surgery for other conditions. The surgery may cause an imbalance in the spine that leads to scoliosis. Most of these “secondary” causes of scoliosis are considered degenerative adult scoliosis.
Symptoms
Degenerative adult scoliosis usually begins as low back pain. While there may also be a deformity that causes the back to look peculiar, usually it is pain that brings patients into the spine specialist’s office. The pain is probably not coming from the curve. Rather, the degeneration occurring in the spine is causing pain in the low back, and the degeneration process is causing the curve to form.
A combination of the degeneration of the spine and scoliosis deformity may cause pressure on nerves and possibly even the entire spinal cord. This can lead to: weakness, numbness, and pain in the lower extremities. In severe cases, pressure on the spinal cord itself may cause loss of coordination in the muscles of the legs making it difficult to walk normally.
Diagnosis
If scoliosis is suspected in an adult, a diagnosis must be made before an appropriate treatment plan can be developed.
History
In order to make a proper diagnosis and rule out other possible conditions, the first step is to take a history. The provider may ask about the following:
- Family History – Scoliosis tends to run in families, so it may have a genetic cause. Your provider will want to know if anyone else in your family has the problem.
- Date of Onset – When did you first notice the appearance of your spinal condition?
- Measured Curve Progression – The doctor will want to see if the curve has gotten worse. Any past X-rays taken of your spine can be very helpful as a comparison. The doctor will compare new X-rays with old ones, measure the size of the rib hump, and measure changes in your height.
- The Presence or Absence of Pain – Not all cases of scoliosis produce pain. However, if there is pain, the doctor will need to know where it is, what brings on or intensifies the pain, and if there is any radicular pain. Radicular refers to pain that radiates away from the spine to other parts of the body. This usually comes from irritation of the nerves as they leave the spine.
- Bowel or Bladder Dysfunction – Are you having problems knowing when you have to urinate or have a bowel movement? This is extremely important because it could signal the presence of serious nerve damage.
- Motor Function – Has there been a change in how your muscles work? This may be the result of pressure on the nerves or spinal cord itself.
- Previous – If you have had any surgery on your spine, it may have caused some degenerative scoliosis due to weakened muscles. In order to evaluate your condition properly, it is important that your physician knows about any spinal surgery you have had in the past.
Physical Exam
The spine specialist will then perform a physical examination. During the exam, the provider will try get an understanding of the curve in your back and how it is affecting you. This means first trying to get a “mental picture” of how the spine is curved from examining your back and watching you move about. The provider will measure the size of the rib hump deformity and the flexibility you have bending in certain directions. Finally, your nerves will be tested by: checking your sensation, your reflexes, and the strength of your muscles.
Additional Tests
Usually, after the examination, X-rays will be ordered that allow the provider to see the structure of the spine and measure the curve. During the X-rays, you will be asked to hold certain positions while standing or lying on a table, and you will need to hold very still while pictures are taken of your spine.
Depending on the outcome of your history, physical examination, and initial X-rays, other tests may be ordered to look at specific aspects of the spine. The most common tests that are ordered are: the MRI scan – to look at the nerves and spinal cord; the CAT scan – to get a better picture of the vertebral bones; and special nerve tests – to determine if any nerves are being irritated or pinched.
Treatment
The treatment for degenerative scoliosis is usually conservative, meaning non-surgical. Treatment that is commonly recommended includes: medications, exercise, and certain types of braces to support the spine. Mild pain medications may be recommended for use when needed. Usually strong pain medications, such as narcotics, are not recommended due to the risk of addiction. For further description of the medication used for back pain and spine conditions, you may wish to refer to the document entitled:
A Patient’s Guide to Pain Medications for Back Pain (separate document)
If osteoporosis is present, then treatment of the osteoporosis may slow the progression of the scoliosis as well. This can be accomplished in several ways. The current recommendations include: increasing your calcium and vitamin D intake, hormone replacement therapy, and weight-bearing exercises.
Spine Braces and Orthotics
The use of a spinal brace may provide some pain relief. However, in adults, it will not cause the spine to straighten. Once you have reached skeletal maturity, bracing is used for pain relief rather than prevention. If there is a difference in the length of your legs (or if the scoliosis causes you to walk somewhat crooked), special shoe inserts, called orthotics, or a simple shoe lift may reduce your back pain.
Surgical Treatment
In some cases of degenerative scoliosis, surgery may be recommended. Your spine surgeon may recommend surgery if you have nerve problems that are becoming steadily worse or uncontrollable pain. Nerve problems can arise from several different causes. If the nerve roots are being irritated or pinched because of the scoliosis, surgery may be necessary to remove the pressure. The symptoms are muscle weakness, pain, numbness, tingling, or a combination of these.
If the degeneration and the scoliosis have caused a condition called spinal stenosis, surgery may be recommended. Spinal stenosis is a narrowing of the spinal canal that causes pressure on the spinal cord itself. Spinal stenosis results from spinal degeneration that has led to the growth of bone spurs. Eventually the spurs take up space in the spinal canal, causing it to become smaller. This leads to bone pressing on the spinal cord and its nerve roots. The lack of space lessens the nerves’ supply of blood and oxygen, and this can lead to numbness and pain in both legs.
Surgery to relieve pain due to scoliosis is a controversial topic. Spinal surgery is serious and can lead to complications; therefore, not all physicians consider pain reason enough to recommend an operation. However, if the pain is chronic and debilitating, it is an option that can be discussed with your doctor.
Surgical Options
The options for surgery include decompression and spinal fusion. Decompression is a term that means remove the pressure. In spinal surgery, decompression is done to remove whatever is putting pressure on the nerves or spinal cord. Usually this means reducing or removing whatever part of the spine is causing the pressure (such as a degenerated disc or bone spur).
Decompression is commonly combined with a spinal fusion to straighten the spine and stop the progression of the curve from scoliosis. This means that after taking away the damaging pressure, two or more of the vertebrae are fused together to provide spinal stability. Once the bones are fused, they become one, long column. Because these fused spinal vertebrae are no longer made up of separate bones and joints, there will be no movement or flexibility in that area.
