Kathryn Swiatek
Description
Adult scoliosis is defined as a spinal deformity in a skeletally mature person who exhibits an angle of more than ten degrees in the coronal plane using the Cobb angle.1 Adult scoliosis can develop from spinal degeneration that occurs due to the aging process, or has been present since adolescence, but has become more progressive and symptomatic as an adult. With spinal degeneration, there is an axial rotation of the spinal segments which causes lateral olisthesis, leading to ligament laxity and curvature of the spine.2
Classifications1
Adult scoliosis can be further divided into four major categories:
Type 1: Primary degenerative scoliosis (de novo scoliosis)
Primary degenerative scoliosis begins to occur with the deterioration of spinal discs and/or facet joint degeneration.
Type 2: Idiopathic adolescent scoliosis of the thoracic/lumbar spine which has progressed into adulthood.
Type 3: Secondary degenerative scoliosis
(a) Scoliosis following idiopathic or other forms of scoliosis, or has occurred due to a leg length discrepancy that has created pelvic obliquity, hip pathology, it lumbosacral transitional anomaly.
(b) Scoliosis secondary to a metabolic bone disease, along with asymmetric arthritis disease and vertebral fractures
Anatomy
The spine's normal curves occur at the cervical, thoracic, and lumbar regions. The cervical and lumbar regions exhibit a slight lordosis curve, while the thoracic spine has a slight kyphotic curve. These curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.3 However, a scoliotic spine will have a lateral deviation either to the right or left, and in some cases, both.
As the curve of the spine begins to move laterally, the involved vertebrae are forced to rotate as well. If rotation occurs at the thoracic level of the spine, this can impact the ribs at the same time, causing rotation and resulting in rib prominence on the opposite side of the curve. Therefore, increased kyphosis and lordosis may also occur.4
Prevalence
Adult scoliosis affects approximately 4-8% of the adult population over the age of 18.5 De novo scoliosis is the most prevalent in people over the age of 60, where it is estimated that 32% of the population exhibit a mean Cobb angle of greater than 17 degrees.6 Because metabolic bones diseases, such as osteoporosis and osteomalacia, are more common in females, women are more likely to suffer from adult scoliosis than men.2
Clinical Presentation
Common characteristics of scoliosis are lateral curves of the spine to the right or left, head displacement to the side in which the spine curves, decreased forward flexion and/or lateral flexion, asymmetrical shoulder and pelvic position, and possible rib hump caused from the rotational deformity on the convex side.4
The most frequent clinical problem of adult scoliosis is back pain.1 This back pain can be caused from either the curve of the spine or at the apex of the curve, or from localized facet joint compression.1,3 Furthermore, pain can also occur from paravertebral back muscles in spasm, standing or sitting postures, and certain physical activities.
A second symptom present in adult scoliosis is radicular pain and claudication symptoms when standing or walking. The radicular pain may be attributed to root compression or traction, and can occur on either the convex or concave side of the spinal curve.1,7
A third clinical presentation that can be seen, although rare, is difficulty with respiration. Because the lungs are contained within the thoracic cavity, any distortion of the cavity may alter the position of the lungs and impair their function. Thus, scoliosis can cause rotation of the intrathoracic trachea or bronchi, causing airway obstruction.1,8
Finally, curve progression may also be a symptom in adult scoliosis. For those with de novo scoliosis, the curve in a spine may continue to increase with continued degeneration. The physician will measure the curve with each visit to track any progression of the curve.
Potential Etiologies
Adult scoliosis can develop in one of two ways. The first possible cause is that the disease developed during childhood or adolescence, but went untreated. Thus, the curvature has continued to progress.
The second possible cause occurs from degeneration of the spine. This may be attributed to disc degeneration, facet degeneration, osteoporosis, compression fracture, or a combination of any of these pathologies. These conditions most commonly affect the lumbar vertebrae, and can cause changes in vertebral height, shape, or basic structural integrity.3
Evaluation
An evaluation of a patient with potential scoliosis will begin with a thorough history and physical examination. Inquiring about a history of idiopathic adolescent scoliosis can help to rule out the possibility of degenerative idiopathic scoliosis. Additional questions should include gait disturbances, changes in standing or sitting posture, and location and type of pain, if any.2
A physical examination of the patient begins with assessing standing posture. The trunk, pelvis, and shoulder girdle are viewed in the posterior, lateral, and anterior views to see if there is any rotation. Asymmetry in any of these regions should be documented and measured to compare against the contralateral side.
Next, leg length and pelvic obliquity are assessed, also in standing. If the physician believes that the spinal curve is a result of a leg length discrepancy, he can test this hypothesis by placing a lift in the shoe to see if the curve is corrected.2
If a patient is complaining of neurological symptoms, such as radiculopathy, then a neurological exam will also be a part of the evaluation. Motor strength, reflexes, sensation, gait, and cranial nerves are tested to differentiate where the neurological deficits could be originating from.2
Special Orthopedic Tests
There are a variety of tests and measures a physical therapist can perform if he suspects that scoliosis is present. One of the most common special tests used in the clinic is the Adam’s Forward Bend Test. This test requires the patient to bend forward, instructing him to "try to touch your toes." When viewed from behind, scoliosis is suspected if a thoracic or lumbar prominence is apparent. The Adams Forward Bend test is considered to be the best non-invasive clinical test to evaluate scoliosis.9
If a rib hump is present, then a third special test is to measure the angle of rotation using a inclinometer or scoliometer. The therapist places the instrument over mid-thoracic area and records the degree measure. Next, a measurement is taken over the mid-lumbar area, approximately 2 inches above iliac crest. If either measurement is 5 degrees or more, scoliosis may be present. Scoliometer or inclinometer readings of 5 degrees or more have high likelihood of Cobb angle greater than 10 degrees on X-rays.9
Finally, simple palpation can be used to feel for any variance in shape of the spine, or if muscles in the thoracic or lumbar regions feel more prominent one side than the other.
Diagnostic Testing
If a physician or therapist suspects that scoliosis is present, an X-ray is ordered to obtain a view of the spine. X-rays indicate if the scoliotic curves are structural or non-structural. Posterior-anterior and lateral views are taken, and the Cobb angle is measured from these films. The X-rays allow the physician to view any curve progression, vertebral rotation, or degeneration in the spine.10 In addition, CT myelography is indicated for those patients whose X-rays exhibited a doubled-curved spine, increased kyphosis, wide spinal canal, thin pedicles, or somatosensory impairments.10
Provocative testing can also be used to determine whether the pain is due to the spinal deformity, or whether it is from a nerve compression or disc problem. In trying to differentiate the cause of back pain, a discogram can be administered. During a discogram, dye is injected into the center of a spinal disc. Then, an X-ray or CT scan is performed to see whether there is damage or degeneration present.2 Tests like these are important because they help to determine which treatments to proceed with for the patient.
Conservative Treatment
Treatment for the majority of individuals with adult scoliosis is non-operative. Exercise and conditioning is often the mainstay of non-operative treatment and helps the patient maintain function and energy level, as well as control back pain. A low-impact aerobic exercise program may include walking, swimming, yoga, or cycling, along with resistance training. Exercise may help improve cardiopulmonary reserve, promote endorphin production, control weight, and possibly delay or retard onset of age related osteoporosis.
Bracing is rarely used in the adult patient because the spine has already reached skeletal maturity. However, it may still provide pain relief to those who are not good candidates for surgery. Bracing tends to be avoided in the middle age patient so that the muscles of the back do not become too dependent on the support provided by a brace and begin to decondition.
For patients with degenerative scoliosis secondary to osteoporosis or osteomalacia, management includes calcium and vitamin D supplements, as well as exercise and resistance training to decrease and prevent further degeneration.
Finally, for patients who present with severe back pain and radicular symptoms, nerve root blocks or epidural steroid injections are administered to help alleviate pain. Injections can be used to prolong the need for surgical interventions.
Surgery & Post-Op Treatment
Surgical correction of adult degenerative scoliosis is not common. However, it may be necessary under the following conditions:2
- When non-operative treatment methods have failed and pain persists
- The curvature is progressive or excessive (curves of over 45 degrees)
- There is evidence of cardiopulmonary problems caused by the curvature
Depending on whether the scoliosis is a result of vertebral degeneration or progression from adolescence, there are a variety of surgical techniques that may be performed.
Posterior fixation is one of the most common procedures used to improve adult scoliosis.11 Two rods are fixated on either side of the spine with wires and pedicle screws to prevent further rotation of the spinal segments. The procedure can also be performed using an anterior approach, which is at the discretion of the surgeon.
For patients with degenerative scoliosis, spinal fusions are sometimes performed to prevent further breakdown and deformity of the bone. Typically, spinal fusions will occur in the lumbar vertebrae and extend down to the sacrum where the majority of force is being displaced.11 Pelvic fixation may also be required to provide optimal stability.
Osteotomies are another surgical technique used to achieve greater degrees of segmental correction beyond the inherent flexibility of the curve.11 One of the most common types of osteotomies is a facetectomy, which involves removing the inferior articular processes of multiple thoracic and/or lumbar vertebrae “to enhance coronal correction with posterior instrumentation.”11
For patients with a rib hump caused from a thoracic curve, a thoracoplasty may also be a surgical option. Thoracoplasty is the removal of approximately four to six segments of adjacent ribs that protrude. The removal of ribs is based on either their prominence or by which ones are unlikely to be realigned by correction of the curvature alone.11 Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery.
The length of recovery following surgery for adult scoliosis is variable depending on the nature of the deformity preoperatively, the extent of surgery required, and the age of the patient. Patients may return to full activities as soon as three months after surgery, or as late as six to nine months following the procedure. Often, patients benefit from rehabilitation and physical therapy programs that include strengthening and stretching exercises.1
Contraindications to surgery apply to elderly patients who are not healthy enough to undergo such surgery or with severe osteoporosis that makes them poor candidates for surgical intervention.
Posterior screw fixation
Therapeutic Modalities
The symptoms and physiology in the adult patient with spinal scoliosis is more complex when compared to a child or adolescent with scoliosis12. Even with the use of a brace, the progression of the disease cannot be halted. Therefore, the goal of using modalities on adult patients with scoliosis is to treat the secondary symptoms. These include back pain, muscle imbalances, and posture.
One of the most basic treatments to alleviating pain and discomfort is cryotherapy. Cryotherapy can decrease pain by decreasing pain fiber transmission and nerve conduction velocity13. Application of ice packs or ice massage are two common techniques that can be applied to sore, painful back muscles caused from the spinal deformity. Unless the patient is unable to lie on his stomach, he should lie prone while the cold therapy is being administered. Extra layers of towels or clothes should be used based on patient tolerance to avoid the risk of ice burns or peripheral nerve injuries.
In an acute flare up of back pain due to scoliosis, thermotherapy can also be an option. By applying moist heat packs to the painful area of the back, nerve conduction velocity increases, and the conduction latency of sensory and motor nerves decreases13. Thus, there is a perceived reduction in pain perception. Unless the patient is unable to lie prone, he should lie on his stomach with the warm packs placed over the painful area. It is important to keep in mind that additional towels may be needed if the patient is lying supine on the heat pack to reduce the risk of a burn. The application of heat should not exceed 108 degrees, or go longer than 20 minutes13. Gentle stretching should follow heat therapy to improve the collagen extensibility of the aggravated muscles.
In addition, ultrasound can also be used as a modality in controlling the pain in back muscles. One MHz frequency ultrasound is considered appropriate for heating tissue up to 5 cm deep13. Duration and frequency of ultrasound in the adult scoliosis patient is going to vary, since there are a variety of causes responsible for the spinal deformity. Depending on whether the scoliosis is a result of collapsed vertebrae or idiopathic beginning during adolescence, several studies indicate that ten minutes of ultrasound 2-3 times per week for 3-4 weeks resulted in a reduction of pain6.
Muscles imbalances and weakness are also another secondary symptom associated with scoliosis. According to the overload principle, the greater the load placed on the muscle and the higher the contraction produced, the more strength the muscle will gain13. This is an important concept in scoliosis, as the weakened muscles can lead to a lateral or kyphotic posture. To help retrain and strengthen the back musculature, neuromuscular electrical stimulation (NMES) can be utilized. The electrical current produced from stimulation recruits muscle fibers to fire, causing increased load on the muscles ipsilateral to the spinal curve, and thus an increased balance in musculature12. However, as stated previously, NMES will not halt the progression of the curving spine; it will only help to strengthen the muscles around it.
Although little evidence exists that supports the use of traction in treating adult scoliosis, there are a few products that exist that may promote the relief of pain associated with scoliosis. For example, the Scoliosis Traction Chair is designed to “incorporate de-rotation, de-compression, and lateral traction while simultaneously providing stabilization of the posterior thoracic rib arch”14 Furthermore, it isolates the trunk rotator muscles ipsilaterally, providing isometric conditioning to strengthen the weakened core musculature. The Scoliosis Traction Chair also incorporates Whole Body Vibration (citation) as a means of retraining the neuro-muscular proprioceptive pathways. According to Kerschan et al, this vibration increases bone density, relieves pain & inflammation, and increase flexibility by stimulating the various tissues and systems of the body14.
Therapeutic modalities following surgical intervention can include cryotherapy and thermotherapy. However, because surgery typical includes the insertion of metal rods and plates to hold the spine in place, modalities utilizing electrical current or traction are contraindicated.
Additional Web Based Resources
http://www.scoliosis.org
http://www.thescoliosisfoundation.org
http://www.scoliosiscare.org
http://my.clevelandclinic.org/multimedia/transcripts/orr_adult_scoliosis_transcript.aspx
http://www.adultscoliosis.com
http://www.spineuniverse.com/conditions/scoliosis/scoliosis-adults
http://www.scoliosisassociates.com/subject.php?pn=practice1023
http://www.e-radiography.net/radpath/c/cobbs-angle.htm
http://www.youtube.com/watch?v=cKF3SS2tHNw
References
1. Aebi Max. The adult scoliosis. Eur Spine J. 2005;14: 925-948. 10.1007/s00586-005-1053-9
2. Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus. 2010;28(3):E1.
10.3171/2010/FOCUS09271.
3. Dawson EG. Scoliosis in Adults. SpineUniverse. http://www.spineuniverse.com/conditions/scoliosis/scoliosis-adults.
Updated May 2010. Accessed November 2010.
4. Goodman CG, Fuller KS. Pathophysiology: Implications for the physical therapist. 3rd edition. St Louis, MO: Saunders
Elsevier; 2009.
5. Schwab F, Dubey A, Gamez L. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer
population. Spine. 2005;30(9): 1082-5.
6. Birkes JK, White AP, Albert TJ. Adult Degenerative Scoliosis: a review. Neurosurgery. 2008;63:A94-A103.
10.1227/01.NEU.0000325485.49323.B2.
7. Smith JS, Fu KM, Urban P. Neurological deficits in adults with scoliosis who present to a surgical clinic: incidence and
association with the choice of operative versus nonoperative management. J Neurosurg Spine. 2008;9:326-331.
10.3171.SPI.2008.9.10.326.
8. Koumbourlis AC. Scoliosis and the respiratory system. Pediatr Resp Rev. 2006;7:152-160.
10.1016.j.prrv.2006.04.009.
9. Simpson R, Gemmell H. Accuracy of spinal orthopaedic tests: a systematic review. Chiropractic & Osteopathy.
2006;14:26. 10.1186/1746-1340-14-26.
10. Cassar-Pullicino VN, Eisenstein SM. Imaging in scoliosis: What, why, and how? Clinical Radiology. 2002;57:543-562.10.1053/crad.2001.0909.
11. Heary RF, Kumar S, Bono CM. Decision making in adult deformity. Neurosurgery. 2008;63:A69-A77.
10.1227/01/NEU.0000320426.59061.79.
12. Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A. Pain and disability determine treatment
modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine.
2009;34(20): 2186-2190.
13. Cameron MH. Physical agents in rehabilitation: from research to practice. 3rd edition. St Louis, MO: Saunders
Elsevier; 2009.
14. Kerschan-Schindl K, Grampp S, Henk C, Resch H, Preisinger E, Fialka-Moser V, Imhof H. Whole-body vibration exercise leads to alterations in muscle blood volume. Clin Physiol. 2001;21:377-82.
