Degenerative Scoliosis

Degenerative scoliosis or adult-onset scoliosis is defined as a curvature of the spine of at least 10 degrees.

The more common variety is known as “de novo” scoliosis, and is caused by degeneration of the facet joints and intervertebral discs occurring gradually over a period of time during adulthood. The scoliosis is usually located in the low back or lumbar spine (Figure 1).

The less common variety may begin from the teenage years as adolescent idiopathic scoliosis but may not be diagnosed until later in adulthood. The scoliosis may have curves located at the mid back (thoracic spine), low back (lumbar spine), or both.

An x-ray of degenerative scoliosis located in the low back or lumbar spine

Figure 1


Common Symptoms

Pain and / or stiffness in the mid to low back. The pain can also radiate down into the buttocks and legs. There may also be cramps over the thighs and calves.
Tingling and/or numbness over the buttocks and legs.
Weakness and loss of muscle bulk over the legs.
The symptoms usually appear gradually, and are worse in the morning as well as towards the end of the day. They are also more prominent during standing and walking, and less during sitting.
As the scoliosis worsens in the curvature, the shoulders and/or hips may become uneven, and at the same time, the patient will become shorter in height. The patient may also be more hunched forwards (kyphosis). In cases of severe scoliosis, the patient may experience pain as the ribs come into contact with the hip. At the same time, the rib cage may also start to push against the heart, lungs, and abdominal organs.

Contributing Factors to Symptoms

Nerve compression
Facet joint arthritis
Degenerated discs
Scoliosis

Diagnosis

(i) Medical History

The location of pain as well as the triggering factors are especially important to the doctor to narrow down the cause and source of the pain.

(ii) Physical examination

The posture of the spine will be assessed. The strength, sensation, and reflexes of the legs will also be checked.

(iii) Imaging scans

X-rays

Standing x-rays of the whole spine are done to assess the degree of scoliosis (Figure 2) and kyphosis. Bending x-rays of the low back may also be done to rule out any mal-alignment of the low back.

An x-ray of a spine with degenerative scoliosis

Figure 2

MRI

MRI provides a closer assessment of any evidence of compression of the nerves, and if there are, what are the offending structures (e.g. discs, bone spurs, thickened ligaments).

An MRI scan of a spine with degenerative scoliosis

Figure 3(i)

An MRI scan of low back (lumbar) spinal disc with degenerative scoliosis

Figure 3(ii)


Treatment

The treatment objective is to reduce pain and/or any neurological symptoms.

Non-Surgical

Physiotherapy

The goal is to strengthen the back and/or keep it flexible. This can include hydrotherapy in a pool. In the pool, the body’s buoyancy in water helps counteract the effects of gravity, thus enabling the patient to condition the muscles while putting less stress on the lower back. Sometimes, the physiotherapist can perform soft tissue releases to improve the blood circulation in the back, as well as loosen the muscles and joints of the back.

Medications

Medications are also useful in reducing the pain and inflammation of the low back. These may include the use of non steroidal anti inflammatory medications, muscle relaxants, and nerve stabilizers.

Acupuncture

Acupuncture treatment may be recommended. This has been found to be useful especially in reducing pain in the acute phase of the inflammation, allowing physiotherapy to exert a greater therapeutic effect. Acupuncture is also useful if a patient is not able to tolerate taking medications for various reasons.

Corset/Brace

A corset or brace may be recommended occasionally to help reduce painful motion in the back and decrease stress across the facet joints. However, the scoliosis will not be improved with the use of the brace, unlike in adolescent idiopathic scoliosis.

Spinal Injection

Spinal injections may be offered if the patient does not respond adequately to the above measures. The injections frequently target the facet joints and nerves which are responsible for the symptoms. These injections deliver the anti-inflammatory medications directly to the affected area in the back via x-ray guidance. The procedure is done in the operating room to ensure sterility and access to x-ray imaging facilities.

Surgery

If the pain and/or neurological symptoms continue to significantly affect the quality of life despite undergoing the above-mentioned treatment, surgery may be considered. The recovery time after surgery is significant, ranging from 2 to 12 months, so the symptoms should be severe enough to warrant such a procedure. The objectives of surgery are to preserve the function of the nerves as well as relieve pain and /or neurological symptoms. Sometimes degenerative scoliosis curves can exceed 50 degrees and continue to progress, and this is another indication for surgery, lest there be major spinal balance problems, severe pain, and cardiopulmonary complications.

Decompression surgery is one surgical method. It involves removing the lamina, ligamentum flavum, disc and part of the facet joint, in order to relieve pressure on the nerves. This may be done in a keyhole or minimally invasive fashion thereby reducing damage to the normal tissue structures.

More commonly, the decompression surgery is combined with a fusion. This is often necessary as a decompression alone in the setting of a scoliosis curvature, may potentially cause the spine to become more unstable and cause the scoliosis to worsen. However, decompression surgery without fusion may be recommended for elderly patients with mainly nerve compression symptoms at one level of the spine. Avoiding fusion may speed up the recovery process in such potentially frail patients.

A fusion refers to “joining” the multiple spine segments to create a stable spine. This requires implants of various types to maintain the stability while the bones “join” together. Implants commonly used include cages, screws, and rods. The fusion surgeries are usually done from the back (posterior approach), but in some cases they can be done by going through the front or the side (Figure 4). Sometimes in complex cases, the doctor may stage the surgery into two procedures. That means the doctor will perform the first part of the surgery on day 1 and the second part 3 to 5 days later.

An x-ray of spinal fusion surgery where is done by going through the side

Figure 4

The fusion could be long (span much of the back) or short (fuse only one or two vertebral levels). If scoliosis is severe, a long fusion is often needed in order to stabilize the spine and partially correct the scoliosis (Figures 5). The short fusion could be an option for a more moderate scoliosis, or if the surgical attention is only directed at the segments of the spine that are causing nerve compression.

An x-ray on a side view of the spine with long fusion surgery

Figure 5A

An x-ray on a back view of the spine with long fusion surgery

Figure 5B

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