Signs and Symptoms of Adult Degenerative Lumbar Scoliosis

Scoliosis can start in later life too

Rosemary Marchese, Physiotherapist

Adult degenerative scoliosis, or denovo scoliosis, is a structural change of the spine with a higher incidence than adolescent idiopathic scoliosis. The aging population has resulted in more and more cases of this type of adult scoliosis presenting in general practice (1). The longer we live, the more likely we will face degenerative changes in the spine. This can predispose us to the onset of scoliosis that only starts in adulthood. Sure, there can be many patients facing scoliosis that started in early childhood or adolescence, but there is this growing number of people that need our attention – adults with a new case of scoliosis.

How does Adult Denovo Scoliosis Occur?

This type of scoliosis occurs because of spinal degeneration. This involves asymmetric degeneration of the intervertebral discs and facet joints at different levels, which leads to unequal loading of the spinal column (2, 3). This asymmetric loading, coupled with degeneration, creates instability in the spine, leading to curve progression and an eventual 3D deformity (4). The lumbar spine is particularly at risk of disc degeneration and thus it’s easy to see why this condition often occurs in the lumbar spine.

Osteophytes will form at the facet joints and vertebral end plates, which will add to any already existing narrowing of the spinal canal (4). This is then exaggerated by ligamentum flavum hypertrophy and calcification (4). Foraminal stenosis results (5, 6).

Instability of the spinal column then causes further destruction of the fact joints and intervertebral discs. Clinically, we may see this as spondylolisthesis or lateral listhesis, or both. Patients who have had extensive facetectomies during spine surgery are also at risk of instability and the onset of scoliosis.

Does Adult Scoliosis Hurt?

Indeed it often does. Back pain and leg pain are common in these patients, with incidence reports varying between 40-90% (7). Back pain happens for many reasons, such as:

• muscle fatigue
  

  

• facet arthropathy
• degenerative disc disease (1).

Loss of lumbar lordosis often accompanies degenerative scoliosis. This can contribute to muscle fatigue and secondary pain.

In addition to back pain, the patient may also have leg pain secondary to foraminal nerve root compression or from neurogenic claudication due to central spinal stenosis (8).

Sagittal Alignment in Adults with Degenerative Scoliosis

Sagittal alignment is super important and has been correlated with health-related measures of quality of life (9-12). Positive sagittal balance has been correlated with the prevalence of back pain (10). Lumbar lordosis reduces with age and this reduction in lumbar lordosis is associated with difficulty maintaining spinal balance. This leads to pain and disability (13). Added to this is the fact that thoracic kyphosis increases with age and adds to changes in global spinal alignment.

In the beginning, as sagittal imbalance starts to take place, the patient will attempt to bring their head into alignment with their pelvis in the sagittal plane. This leads to a compensation of retroversion in the pelvis and hip extension. However, more severe and fixed deformities eventually are accompanied by hip and knee flexion and thoracic flexion in an attempt to balance out the lumbar lordosis. The result is that ‘hunched over’ look you see in elderly people as they navigate and shuffle through their world. At an extreme end of the scale, they may be holding onto a walker, and really struggling to maintain an upright posture at all.

Diagnose and act Early

There is often more of a fuss on scoliosis that exists in children and adolescents, but we mustn’t forget this adult population who are experiencing denovo scoliosis. Perhaps you will see early signs in a patient in your clinic who presents with back pain. Have they got reduced lumbar lordosis? What is their overall sagittal balance like?

Full length standing posterior anterior and lateral radiographs of the spine are required to accurately evaluate the spinal structural changes. In this way you can assess:

• coronal balance
• sagittal balance
• hip and pelvic parameters
• structural changes, such as the appearance of osteophytes
• the presence of any spondylolisthesis or lateral listhesis.

Nonoperative treatment can be considered for adult patients with denovo scoliosis in the absence of significant stenotic and/or radicular symptoms (14).

Surgery, Bracing, or Scoliosis Specific Exercises for Adults?

While bracing in adults is an area requiring further research, there is some evidence to suggest it does play a role in management of adults with scoliosis. There is evidence by Palazzo et al (2016) showing that bracing may be effective in slowing down the rate of progression in adult scoliosis (15). This gives patients some hope that it indeed may be worth trying bracing as an option before considering surgery.

The other good news is that scoliosis specific exercises have been shown to be superior to natural history in adults who have scoliosis (16). The authors of this study suggest that scoliosis specific exercises should be considered as the ‘first line treatment’ especially in patients refusing scoliosis surgery (16).

The main indications for surgery of adults may include:

• presence of progressive neurological deficit (14)
• disability as a result of the deformity (14)
• associated severe pain (this article)
• documented curve progression with coronal and sagittal imbalance and disability (17).

The size of the curve is not correlated with symptom severity in adults (18, 19) and so it’s a good idea to not allow patients to focus on Cobb angle.

In our clinical experience not all adults want surgery, even if it has been recommended to them by a surgeon. Looking at the research gives us hope and reason to give patients options before surgery. Scoliosis specific exercises, sometimes coupled with bracing where required, are potential viable treatment options to try for many patients.

References:

1. Ploumis, A., Transfledt, EE., and Denis F. (2007). Degenerative lumbar scoliosis associated with spinal stenosis. Spine J.  7(4):428–43610.1016/j.spinee.2006.07.015.
2. Herkowitz, HN. and Kurz, LT. (1991). Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991; 73(6):802–80810.2106/00004623-199173060-00002.
3. Murata, Y., Takahashi, K., Hanaoka, E., Utsumi, T., Yamagata, M., and Moriya, H. (2002). Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis. Spine (Phila Pa 1976). 27(20):2268–227310.1097/00007632-200210150-00016.
4. Kotwal, S., Pumberger, M., Hughes, A. and Girardi F (2011). Degenerative scoliosis: a review. HSS J. 7(3):257–26410.1007/s11420-011-9204-5.
5. Garfin, SR. and Herkowitz, HN. and Mirkovic S.  (2000). Spinal stenosis. Instr Course Lect. 49:361–374.
6. Sengupta, DK. and Herkowitz, HN. (2003). Lumbar spinal stenosis: treatment strategies and indications for surgery. Orthop Clin North Am. 34(2):281–29510.1016/S0030-5898(02)00069-X.
7. Bradford, DS., Tay, B. and Hu SS. (1999). Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976). 24(24):2617–262910.1097/00007632-199912150-00009.
8. Scani, E., Bartolozzi, P., Logroscino, CA, et al. (1986). Natural history of untreated idiopathic scoliosis after skeletal maturity. Spine (Phila Pa 1976). 11(8):784–78910.1097/00007632-198610000-00007.
9. Jackson, RP. and McManus, AC. (1994). Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size: a prospective controlled clinical study. Spine (Phila Pa 1976). 19(14):1611–161810.1097/00007632-199407001-00010.
10. Glassman, SD., Bridwell, K., Dimar, JR., Horton, W., Berven, S. and Schwab F. (2005). The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 30(18):2024–202910.1097/01.brs.0000179086.30449.96.
11. Schwab, F. Patel, A. Ungar, B. Farcy, JP. and Lafage, V. (2010). Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976).35(25):2224–223110.1097/BRS.0b013e3181ee6bd4.
12. Glassman, SD. Carreon, L. and Dimar, JR. (2010). Outcome of lumbar arthrodesis in patients sixty-five years of age or older: surgical technique. J Bone Joint Surg Am. 92(suppl 1, pt 1):77–8410.2106/JBJS.I.01300.
13. Lu, DC., Chou, D. (2007). Flatback syndrome. Neurosurg Clin N Am. 18(2):289–29410.1016/j.nec.2007.01.007.
14. Wong, E., Altaf, F., Oh, LJ., and Gray, RJ. (2017). Adult degenerative lumbar scoliosis. Orthopedics. 40(6). https://doi.org/10.3928/01477447-20170606-02
15. Palazzo, C., Montigny, JP., Barbot, F., Bussel, B., Vaugier, I., Fort, D., Courtois, I., and Marty-Poumarat C. (2017). Effects of Bracing in Adult With Scoliosis: A Retrospective Study. Arch Phys Med Rehabil. 98(1):187-190. doi: 10.1016/j.apmr.2016.05.019. Epub 2016 Jun 22. PMID: 27343345.
16. Negrini, A., Negrini, M. G., Donzelli, S., Romano, M., Zaina, F., & Negrini, S. (2015). Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis: a long-term cohort study. Scoliosis, 10, 20. https://doi.org/10.1186/s13013-015-0044-9
17. Bradford, DS., Tay, BK. and Hu, SS. (1999). Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976). 24(24):2617–262910.1097/00007632-199912150-00009.
18. Schwab, F., Patel, A., Ungar, B., Farcy, JP, and Lafage V. (2010). Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 35(25):2224–223110.1097/BRS.0b013e3181ee6bd4.
19. Schwab, FJ., Smith, VA., Biserni, M., Gamez, L., Farcy, JP., Pagala, M. (2002). Adult scoliosis: a quantitative radiographic and clinical analysis. Spine (Phila Pa 1976). 27(4):387–39210.1097/00007632-200202150-00012.