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Scoliosis

Introduction

Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with more than 10° of curvature of the spine (in the coronal plane).

Anatomy

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Pathogeneis

There are many causes of adult scoliosis including degenerative development of adult scoliosis, untreated or missed adolescent scoliosis, iatrogenic from prior surgery, tumors and trauma.

With aging, the nucleus propulsus or disk loses hydration. This causes subsequent degeneration and protrusion of the annulus. With continued dehydration of the disk, the nucleus is unable to perform its function of converting this strain effectively; pressure ensues on the annulus causing a decrease space for the spinal cord. With the nucleus propulsus losing disk height, the facet joints undergo increased and abnormal biomechanics. This abnormal biomechanics leads to asymmetric loading of the spine which then leads to both coronal and sagittal plane deformities of the spine. This process continues until scoliosis either develops de novo, or progresses from adolescents.

Natural History

There is an estimated 500,000 adults in the United States with adult scoliosis. Most of these patients are middle aged and elderly.
Several authors have concluded that adolescent scoliosis progress up to 1° per year; it is not surprising that untreated adolescent scoliosis may present with an adult form.  These patients may experience pain more frequently than their non-scoliosis counterparts.

Patient History and Physical Findings

Patients present with a chief complaint of pain for the most part. A thorough history and physical is performed including abdominal reflexes and a rectal examination if indicated.

Imaging and Diagnostic Studies

Standard standing plain posterior-anterior, lateral, and occasionally side-bending and flexion-extension scoliosis films on a scoliosis cassette are required. The posterior-anterior radiographs are used to measure the Cobb angle, the central sacral vertebral line, and the neutral vertebrae as well as to evaluate the shoulder alignment. The lateral radiographs are used to evaluate the kyphosis and sagittal balance of the patient. The bending films are used to decide which curves are structural and which curves are non-structural.

A magnetic resonance imaging study may be used to evaluate soft tissues, the patency of the disks, and to evaluate nerve root compression among other things.

A CT scan may be used to better define bony landmarks for pre-operative considerations, or to help with a diagnosis.

Differential Diagnosis

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Treatment

Nonoperative treatment
Nonoperative therapy includes physical therapy to strengthen core musculature, anti-inflammatory medications, a stretching program and educational material.

Activity modification and lifestyle changes, along with pain management are also part of the treatment algorithm. Bracing is usually not tolerated in this population, but may be tried in some patients.

A second line of non-operative treatment would include nerve root blocks, facet blocks and rhizotomy. Narcotic medications should be minimized.

Operative treatment
Operative treatment may include a posterior approach, an anterior approach, a lateral approach, or a combination of these approaches. Osteotomies may be performed to correct sagittal balance deformities. Decompression may be included depending on the patient's symptoms. Additionally, segmental hardware may also be used to correct coronal scoliosis, or to prevent continued progression of the curve.

Indications and contraindications

Indications for surgery are individualized with expectations, risks, benefits and alternatives discussed with the patient. Indications for surgery may included documented curve progression, absolute curve magnitude, and unremitting pain and function deterioration

Although coronal scoliosis is important, literature has suggested that sagittal balance may be more important for patient satisfaction. Deformity correction should include both coronal and sagittal correction during surgical intervention.

Pearls and Pitfalls

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Postoperative Care

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Outcome

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Complications

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Selected References

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Academic Resources

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