Understanding Adult Scoliosis

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Understanding Adult Scoliosis

• By Dr Jeb McAviney
• BSc., MChiro., MPainMed., FCBP

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Adult Scoliosis

• Adolescent Scoliosis in the Adult (ASA)
• Degenerative De-Novo scoliosis (DDS)

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Adult Scoliosis

• ASA is pre-existing AIS but in adulthood
• DDS is a new development of scoliosis in
  adulthood.
• The primary concern in most adult cases is Pain
• Progression and Aesthetics are also
  considerations

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ASA 1

• Usually smaller flexible curves in younger adults
  18-30 years old
• Posture and Cosmetic issues are the main problem.
• Pain can be an issue particularly in unbalanced
  curves
• Potential reducibility in both abnormal posture
  and Cobb.

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ASA 2

• Usually larger more rigid curves in middle aged
  adults 30-40
• Pain and posture equally issues.
• Pain can be an issue even in balanced curves.
• Often start to see early degenerative changes
• Intervention in ASA 2 could potentially to stop
  progression to ASA 3

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ASA 3

• Usually large, rigid curves in older adults 40
• Pain is the primary issue.
• Moderate to severe degenerative changes present.
• Most commonly lumbar curves.
• No previous history of scoliosis could indicate
  Degenerative De Novo Scoliosis DDS.

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Degenerative De-Novo Scoliosis (DDS)

• New curve in adult developed as a result of
  degenerative instability.
• Usually lumbar curve, unbalanced.
• Large, rigid curves in older adults 50
• Pain is the primary issue.
• Moderate to severe degenerative changes present.

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Prevalence of Adult Scoliosis in Back Pain

• Perennou et al
• 671 LBP patients
• 7.5 had evidence of scoliosis.
• Prevalence of scoliosis increased with age
• 2 before 45 years (most likely ASA)
• 15 after 60 years (probably DDS)

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Prevalence of Adult Scoliosis in Back Pain

• Robin et al
• 554 LBP patients
• Aged 50 to 84
• 30 scoliosis gt10
• At 5 year follow up
• 40 scoliosis gt10
• Additional 10
• a significant number of older people have an
  adult scoliosis and its prevalence and
  progression is directly related to advancing age

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Adult Scoliosis - A Quantitative Radiographic
and Clinical Analysis, Schwab et al. Spine 2002,

• ASA mean, 40
• DDS mean, 25
• Radiographic parameters correlating with pain
  were identical for these groups
• This appears to substantiate the belief that a
  common end pathway (degenerative instability and
  unfavorable lumbar vertebral alignment) among
  both groups of patients is related to symptoms
  rather than the degree of curvature or the cause
  of the original scoliosis.

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Adult Scoliosis - A Quantitative Radiographic
and Clinical Analysis, Schwab et al. Spine 2002,

• Schwabs research identifies these radiographic
  parameters as important
• Level of regional balance.
• Instability
• Pathologic mechanical loads of the spinal
  elements

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Adult Scoliosis - A Quantitative Radiographic
and Clinical Analysis, Schwab et al. Spine 2002,

• He identifies these correlations with pain
• Lateral vertebral olisthy, (side slip)
• L3 and L4 endplate obliquity angles,
• Decrease in lumbar lordosis,
• Increased thoraco-lumbar kyphosis

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Adult Scoliosis - A Quantitative Radiographic
and Clinical Analysis, Schwab et al. Spine 2002,

• The Cobb angle of the scoliotic deformity had no
  statistically significant correlation to the VAS.
• Early intervention in a middle-aged adult with
  scoliosis may be preferable to treating advanced
  deformity in that same person once he or she has
  become elderly.

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Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis Glassman,
et al. Spine 2003

• 298 patients
• The purpose of the study was to correlate
  radiographic measures of deformity with
  patient-based quality of life and health status
  assessments in adult scoliosis.

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Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis Glassman,
et al. Spine 2003

• The most significant findings were
• Positive (anterior) Sagittal Balance
• Greater pain
• Diminished physical function
• Poorer self image
• Poorer social function

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Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis Glassman,
et al. Spine 2003

• Coronal shift gt 4 cm
• Poorer function
• Greater pain
• Compared to patients with a coronal shift lt 4 cm.

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Correlation of Radiographic Parameters and
Clinical Symptoms in Adult Scoliosis Glassman,
et al. Spine 2003

• Key Points
• Positive (anterior) sagittal balance predicts
  clinical symptoms in adult spinal deformity.
• Thoracolumbar and lumbar curves have worse
  outcomes than thoracic curves.
• Significant coronal imbalance was associated with
  pain and dysfunction.

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Progression of Adult Curves

• Progression in ASA 12 is generally not a major
  concern unless the curve is already very large
  gt60 deg
• Danielson and Nachemson in Spine 2003 found that
  36 of adolescents with scoliosis had progressed
  by more than 10 after 22 years.
• ASA 3 and DDS can become moderate to severely
  progressive due to degenerative instability and
  or hormonal influence.
• The most progressive DDS cases often have
  osteoporosis as a co-morbidity

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Progression of Adult Curves
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Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007

• Two main types were identified
• Type A
• Adolescent scoliosis
• Progresses after skeletal maturity

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Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007

• Two main types were identified
• 2) Type B
• Progresses late in adulthood
• Pre-existing stable adult scoliosis with late
  progression
• De novo late-onset scoliosis.

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Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007

• Progression was measured at a liner rate specific
  to each curve.
• We did not find any correlation between the
  initial Cobb angle and slope of progression in
  the overall population.

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Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007

• Role menopause plays
• In 8 women with type A scoliosis with a long
  progression comprising menopause, no change of
  slope was observed at menopause.
• Patients with type B scoliosis were all women and
  exclusively presented a lumbar or thoracolumbar
  single curve.
• In type B, 11 out of 20 of these patients
  progressed at the time of menopause.

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Natural History of Progressive Adult Scoliosis
Marty-Poumarat et.al. Spine 2007

• Summary
• The progression of adult scoliosis is linear. It
  can be used to establish an individual prognosis.
• Two main types exist
• Adolescent scoliosis, which continues to progress
  (type A) ASA 12
• Late onset scoliosis, either pre-existing stable
  adolescent scoliosis or de novo (type B). ASA3
  DDS
• Menopause constitutes a period of deterioration
  for type B.

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Progression of Adult CurvesType B
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Progression of Adult CurvesType BM
Menopause
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DDS Development
50 yr old woman minor LBP
5 years latter developed DDS
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Adult Scoliosis Treatment

• Increased Life Expectancy vs. Long term Quality
  of Life
• Degenerative pathologic conditions in aging
  persons are increasingly of concern in regards to
  long term quality of life and independence
• The focus of medical treatment in Adult cases is
  usually on regional degenerative pathologic
  conditions such as stenosis, spondylolisthesis,
  disc degeneration etc. rather than the deformity
  itself!
• Although the common degenerative conditions of
  the spine are frequently treated as focal
  pathologic states, it appears intuitive that
  deformity of the spinal column, by altering the
  mechanical loading conditions, can accelerate the
  degenerative cascade. Schwab et al, Spine 2002

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Adult Scoliosis TreatmentRigid vs. Dynamic
Orthosis for Treatment

• Rigid

• Dynamic

• Muscle Atrophy in unstable system
• Limitation of movement
• Self image issues
• Comfort issues
• Useful in Neuro-degenerative cases

• Muscle rehabilitation and stabilization
• Allows movement
• Not visible under clothing
• Relatively comfortable
• Suitable for long term use
• Not suitable for Neuro-degenerative cases

Goal is improvements in Sagittal and Coronal
balance not a forced reduction in Cobb angle
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Corrective Movement Spinal Loading
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SpineCor Adult Treatment
LEFT LUMBAR
CORRECTIVE MOVEMENT
BRACE IN PLACE
CLASSIFICATION
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SpineCor and Sagittal Balance

• Corrective movement for Anterior Sagittal Balance
• First have the patient stabilise their lordosis
  by the contraction of abdominal and gluteus
  muscles.
• Second translate the base of the thorax slightly
  forwards and upwards.

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SpineCor Adult Brace
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Examples of Adult treatment

• Patient A
• 26 year old female,
• Painful adolescent idiopathic scoliosis as an
  adult (ASA1).
• Pain 7/10.
• 8 to 12 hours for 3 months
• Gradual relief of pain to 2/10.
• 32 deg right thoracic scoliosis.
• Improvement of 8 degrees to 24 deg.
• Relief of 1-2/10 and spinal correction have been
  maintained for over 2 years .

Courtesy of Dr Tom Pappas
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Examples of Adult treatment

• Patient B
• 47 year old female
• Degenerative De-Novo Adult Scoliosis. (DDS)
• Pain 7/10.
• Immediate relief of pain to 3/10.
• A 40 deg degenerative lumbar scoliosis.
• Improvement of 7 degrees to 33 deg.
• Pain relief of 0-3/10 maintained for over 2 years
• Note the improved left lateral shift showing
  spinal off loading.

Courtesy of Dr Tom Pappas
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Thank you