Degenerative scoliosis, also known as adult-onset scoliosis, is defined as a spinal curvature 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 during adulthood. The scoliosis curve is usually located in the low back or lumbar spine (Figure 1).

The less common variety may begin during 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 of Degenerative Scoliosis

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.

Symptoms usually develop 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, the shoulders and/or hips may become uneven, and the patient may gradually lose height. The patient may also become 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

Nerve compression

Facet joint arthritis

Degenerated discs

Scoliosis

Diagnosis and Assessment

Medical History

The location of pain as well as the triggering factors are important in helping the doctor determine the source of pain.

Physical Examination

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

Imaging Scans

X-rays

Standing X-rays of the whole spine are performed 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 malalignment 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 nerve compression, and if present, what the offending structures are (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

Non-Surgical Treatment

Physiotherapy

The goal is to strengthen the back and/or keep it flexible. This can include hydrotherapy in a pool. The buoyancy of water helps reduce stress on the spine, enabling the patient to condition the muscles while placing less strain on the lower back. Sometimes, the physiotherapist can perform soft tissue releases to improve blood circulation in the back, as well as loosen the muscles and joints of the back.

Medications

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

Acupuncture

Acupuncture treatment may be recommended. This has been found to be useful especially in reducing pain during the acute phase of inflammation, allowing physiotherapy to exert a greater therapeutic effect. Acupuncture is also useful if a patient is unable to tolerate medications for various reasons.

Corset / Brace

A corset or brace may occasionally be recommended 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 responsible for the symptoms. These injections deliver anti-inflammatory medications directly to the affected area in the back under X-ray guidance. The procedure is done in the operating room to ensure sterility and access to imaging facilities.

Surgery

If the pain and/or neurological symptoms continue to significantly affect quality of life despite undergoing the above-mentioned treatments, spine 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 nerve function 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, to avoid major spinal balance problems, several 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 performed using a keyhole or minimally invasive spine surgery technique, thereby reducing damage to normal tissue structures.

More commonly, decompression surgery is combined with a fusion. This is often necessary as decompression alone in the setting of a scoliosis curvature may potentially cause the spine to become more unstable and worsen the scoliosis.

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 help speed up the recovery process in potentially frail patients.

A spinal fusion refers to “joining” multiple spine segments to create a stable spine. This requires various implants to maintain stability while the bones “join” together. Commonly used implants include cages, screws, and rods.

Fusion surgeries are usually performed from the back (posterior approach), but in some cases they can be performed through the front or the side (Figure 4).

Sometimes in complex cases, the doctor may stage the surgery into two procedures. This means the first part of the surgery is performed on day 1, followed by the second part 3 to 5 days later.

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

Figure 4

The fusion may be long (spanning much of the back) or short (fusing only one or two vertebral levels). If scoliosis is severe, a long fusion is often needed to stabilise the spine and partially correct the scoliosis (Figure 5).

A short fusion may be an option for more moderate scoliosis, or if surgical treatment is only directed at the spinal segments causing nerve compression.

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

Figure 5A

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

Figure 5B

When to Consult a Spine Specialist

Degenerative scoliosis may lead to worsening back pain, spinal imbalance, nerve compression, and reduced mobility over time. Early assessment by a spine specialist may help determine whether non-surgical treatment or scoliosis surgery is appropriate based on the severity of symptoms and spinal curvature.

	Dr Hee Hwan Tak Orthopaedic Surgeon & Spine Specialist MBBS (Singapore) \| FRCS (Edinburgh) \| FRCS (Glasgow) \| FAMS (Ortho)
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