Adult Degenerative Scoliosis

Introduction

Welcome to BodyHelp Wellness Education's patient resource about Adult Degernative Scoliosis.

A normal healthy spine will be straight when seen from the front or the back. When seen from the side, the normal spine forms a gentle S curve.

Scoliosis is an abnormal or exaggerated curve of the spine from the side or from the front or back. Adult degenerative scoliosis is different from the type of scoliosis that occurs in teenagers. Adult degenerative scoliosis occurs after the spine has stopped growing and results from wear and tear on the spine. The condition most often affects the lumbar spine.

This guide will help you understand:

what parts make up the spine
what causes adult degenerative scoliosis
how your doctor will diagnose this condition
what treatment options are available

Anatomy

What parts make up the spine?

The spine is made up of 24 moveable bone segments called vertebrae. The spine is divided into three distinct portions. There are seven cervical or neck vertebrae, 12 thoracic or mid-back vertebrae and five lumbar or low back vertebrae.

The spine is made up of three general parts. The top portion is the cervical spine and connects with the skull or cranium. The middle portion is the thoracic spine and is identified by the ribs that attach to each of the vertebrae. The lower portion is the lumbar spine. It connects with the pelvis at the sacrum.

The vertebra stack on top of one another and are separated by discs. The spine has normal curves. When looking at the spine from the side, the spinal column is not straight up and down, but forms an S curve. The cervical spine has an inward curve called a lordosis. The thoracic spine curves outward. This curve is called a kyphosis. The lumbar spine usually has an inward curve or a lordosis. The S curve seen in the side view allows for shock-absorption and acts as a spring when the spine is loaded with weight. This S curve maintains balance of the spine in a forward and backward plane.

The spinal cord travels within a canal made by the vertebra. Branching off of the spinal cord are nerve roots. These nerves then supply arm, trunk, and leg muscles for movement. They also supply muscles of organs such as the bladder.

Discs are fluid-filled cushions between the vertebrae. Facet joints are small joints connecting each vertebra in the back that allow movement. Facet joints are lined with cartilage. The cartilage is a covering of the joint surface that gives some cushion and protects the bone. It is also slippery which helps with motion.

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Causes

What causes adult degenerative scoliosis?

Adult degenerative scoliosis can be a result of scoliosis from childhood. The curvature may increase during adulthood and become painful. Scoliosis that happens in childhood is usually idiopathic, meaning there is no known reason for it.

Any part of the spine can be affected by scoliosis including the cervical, thoracic, or lumbar vertebrae. Most often the lumbar spine is affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven.

The most common cause of adult degenerative scoliosis is from degeneration, known as wear and tear. It usually occurs after the age of 40. In older women, it is often related to osteoporosis. Osteoporosis is the loss of calcium in the supporting bone. This makes the vertebrae weak.

In adult degenerative scoliosis, the spine loses its structural stability and becomes unbalanced. This imbalance of the spine causes changes in the way the forces of the spine are directed. The larger the scoliotic curve becomes, the faster these changes cause degeneration of the spine. This creates a vicious cycle where increasing deformity causes more imbalance, that in turn causes more deformity. While this process occurs very slowly, it usually continues to slowly progress until something is done to restore the balance in the spine.

When there is an S curve when viewing the spine from the front, the condition is called scoliosis. The scoliotic deformity may also affect the normal S curve that the spine has when viewed from the side. These curves are normal and required to maintain the proper balance of the spine. Many patients with scoliosis actually lose the normal curves of the spine.

Our body has a natural tendency to try to maintain a balance where the head is straight above the middle of the pelvis. If one leg is longer that the other, and the pelvis tilts, the spine will curve in the opposite direction to place the head above the center of the pelvis. If there is a curve in a portion of the spine, then the remainder of the spine will bend in the opposite direction to try and keep the head above the middle of the pelvis.

The scoliotic curve has a convex and concave side. The convex side is simply the outside of the curve where concave is the inside of the curve. The spine above and below the curve will tend to bend in the opposite direction in an attempt to balance the spine. Remember, the body will always try to place the head immediately above the middle of the pelvis. The concave side will tend to have more compression of the facet joints and possibly the nerve roots. This can lead to more pain from arthritis on the concave side of the curve and may lead to pain, weakness and numbness into the legs from the compressed nerve roots. These nerve changes are called radiculopathy.

In adult degenerative scoliosis, there is gradual narrowing of the discs that cushion between the vertebrae. The cartilage and joint surfaces of the facet joints in the spine can wear out, causing arthritis. This can cause back pain.

Stenosis is a term meaning narrowing. There are times when the canal for the spinal cord is narrowed. The openings for the nerve roots may also be narrowed. This will usually cause compression of the nerve structures. When the spinal cord or spinal nerves are compressed, pain, changes in feeling and/or motor function of the muscles can happen.

Sometimes spondylolisthesis occurs. This is slippage of one vertebra on the other. This can happen in adult degenerative scoliosis when the vertebrae do not stack on top of one another like they are supposed to. One vertebra may be shifted sideways or forward, not lining up as it should. The slippage is graded from I to IV, one being mild, IV often causing neurological symptoms.

In rare and severe cases, the chest may become deformed because of scoliosis. This may affect the lungs and heart. This can lead to breathing problems, fatigue, and even heart failure.

Degenerative scoliosis is more common the older we get. As our population ages, adult scoliosis will be even more common. It will be an increasing source of deformity, pain, and disability.

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Symptoms

What does adult degenerative scoliosis feel like?

Most people who have scoliosis will notice the deformity it can cause. There is usually a hump (rib hump) in the back. One shoulder and/or side of the pelvis may be lower than the other. You may have noticed that you have shrunk in height. You may not be able to stand up straight. For many, there is no significant pain caused by the scoliosis. Other symptoms may include:

Decreased range of motion or stiffness in the back
Pain involving the spine
Stiffness and pain after prolonged sitting or standing
Pain when lifting and carrying
Pain may travel along the nerve distribution and be felt in areas away from the spine itself. It may cause pain in the buttocks or legs
Spasm of the nearby muscles
Difficulty walking
Difficulty breathing

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Diagnosis

When you first visit BodyHelp Wellness Education, we will ask you several questions about your pain and function, what makes your pain better and worse, when it started, if there have been changes in bowel or bladder function, or changes in motor function, and whether you have had previous surgery.

Our therapist will perform a physical examination that will include observation of your posture in standing position both sideways and from the front and back to assess for scoliosis. Mobility of your spine and hips, as well as walking ability will be evaluated. A neurological exam that includes testing reflexes with a small rubber hammer, and testing of sensation will likely be included.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the therapists at BodyHelp Wellness Education have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

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Surgery

Surgery is usually considered when non-surgical treatments have not provided enough relief from pain - or when the nerves of the spine are being damaged. Surgery is more common when the curvature is continuing to increase and the imbalance of the spine is clearly getting worse. Surgery to correct adult degenerative scoliosis is both complex and difficult. Most surgeons would not suggest surgical intervention except as a last resort when all conservative measures have failed and the pain is intolerable.

Adult degenerative scoliosis is a disease of older people. As a result, the overall health of the individual is important when making decisions about whether or not to consider surgery. Other illnesses, such as heart disease, lung disease or diabetes, may increase the risk of medical complications either during or after the operation and make surgery too risky.

Surgeons must consider the quality of the bone of the spine as well. Older individuals are more likely to have some degree of osteoporosis. This makes the bone weaker. Weaker bone may not be able to hold the instrumentation, the rods and screws necessary to correct the spine. If the bone weakened by osteoporosis cannot hold the screws necessary to hold the spine aligned as it fuses, this can lead to failure of the entire operation.

The goal of surgery is to improve the balance of the spine and remove pressure on any of the nerves of the spine. Surgery to relieve pressure on the nerves is called a decompression. Surgery to reinforce the area that is unstable is called a fusion. To accomplish the goals of the surgery requires several steps.

First, the surgeon must be able to adequately see the area of spine to be corrected. This is called the exposure. The surgery usually requires an incision in the back. In some cases, surgery will also need to be performed on the front of the spine. This may require an incision in the abdomen or from the side of the body to allow the surgeon to reach the front of the spine. Sometimes a combination of both is necessary.

Next, the surgeon must perform a decompression so that all nerves are free of any pressure. This is accomplished by removing any bone spurs or disc material that is causing pressure on the spinal nerves.

The surgeon must then mobilize the spine. Usually after the decompression is finished, the spine is mobilized a great deal. Removing bone spurs and disc material also loosens the contracted scar tissue around the spine and allows the surgeon to straighten the spine back toward normal.

Finally, the surgeon must insert the screws and rods that will hold the spine in the new position while the fusion occurs. Two special screws called pedicle screws are inserted into each vertebra. These special screws are then attached to metal rods that hold the vertebrae in alignment.

Bone graft is placed between each vertebra. This bone graft will form a solid bone bridge between each vertebra and allow the spine to grow together - or fuse. The combination of the pedicle screws and the metal rods is called the instrumentation. This instrumentation forms the strut that will hold the spine in the correct alignment until the spine fuses.

Once the spine has fused, it will remain in the balanced position. The instrumentation is no longer really necessary, as the fused bone of the spine is now what is keeping the spine from collapsing again. The instrumentation is rarely removed and only removed when it is causing a problem. Restoring balance to the spine should decrease pain and reduce the risk of future problems.

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