Virginia Spine Institute

Operative Treatments
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Adult Scoliosis Correction

The term adult scoliosis refers to an abnormal curvature of the spine in a patient who has finished growing. Scoliosis is an abnormal curvature of the spine that affects approximately seven million people in the United States. The curvature can be to the right or the left side and also involves a twisting or rotation of the bones of the spine [Figure 1]. As the vertebrae rotate, this may cause clinical change in the appearance of the patient's back [Figure 2] and may also lead to painful degeneration of the spine leading to back pain or nerve pain or alter lung and heart function.

Figure 1: For patients with scoliosis, the spine develops a curvature as seen in the drawing on the right.

Figure 2: A photograph of a patient with scoliosis taken from behind. The curvature is seen between the shoulder blades (thoracic spine).

Adult scoliosis can develop as the result of a curvature that was present in childhood and was never treated. However, adult scoliosis can also develop in a patient without any previous history of a scoliosis. Adult scoliosis that develops in a patient with a previously straight spine is called adult degenerative (or adult de novo) scoliosis. Adult scoliosis typically arises from a combination of spinal degenerative conditions including disc degeneration, compression fracture, osteoporosis, and spinal stenosis (Figure 3).

Figure 3: This is a 64 year old female with no previous history of scoliosis or spinal issues. She complained of worsening back and leg pain and had trouble standing upright or walking. X-rays show that disc degeneration has caused a scoliosis measuring 47°.

SYMPTOMS:

Symptoms of scoliosis may include back pain, leg length discrepancy, uneven hips, or abnormal gait. The patient may notice that one shoulder is higher than the other, a prominent shoulder blade, or visual curvature of the spine. Some patients with scoliosis first notice that their clothes no longer fit correctly.

As the curvature leads to degeneration of the discs and bones of the spine, a number of symptoms can occur such as:

1. Leg length discrepancy
2. Irregular gait
3. Pain
4. Difficulty standing or sitting upright
5. Spinal stiffness
6. Nerve damage
7. Truncal imbalance
8. Rib prominence
9. Spinal instability
10. Cardiac or pulmonary (heart and lung) problems

NON-OPERATIVE TREATMENT OPTIONS:

Many patients with adult scoliosis do not have any specific symptoms and most patients never require surgical treatment. For patients with symptoms from their scoliosis, a number of non-operative treatment options are available to help treat the patient's pain and maximize function. The physicians at the Virginia Spine Institute evaluate the patient's overall physical well being to determine an appropriate exercise and physical therapy routine. For most patients a combination of aerobic weight bearing exercises and core muscle strengthening exercises are utilized. For some patients, physical therapy, spinal mobilization techniques, or chiropractic treatment can be beneficial for treating symptoms of the scoliosis. However, none of these treatments are effective in reducing the size of the curvature.

Medication management for some patients with scoliosis can include the use of anti-inflammatory medications or pain medications. Medications to treat pain from compressed nerves can also be used. Spinal injections can be performed to treat areas where arthritis is causing pain or leading to nerve irritation.

WHEN IS SPINE SURGERY RECOMMENDED FOR ADULT SCOLIOSIS?:

Surgery to correct adult scoliosis is an option for the patient if the nonsurgical treatments do not relieve their pain or symptoms. Surgery is also needed for patients whose curves are getting bigger over time or who have curvatures that are leading to nerve compression and causing symptoms such as numbness, weakness, or pain. In general curves greater than 45° and curves with severe degenerative changes are best treated with surgical reconstruction. Surgical reconstruction for adult scoliosis involves some correction of the curvature. The goals of the surgery are to relieve pain and to prevent the curvature from getting worse in the future [Figure 4].

Figure 4: This is a 70 year old woman who developed worsening posture and shortness of breath. She saw her pulmonologist for a lung evaluation and was told that worsening scoliosis was causing her trouble breathing. She saw Dr. Good at the Virginia Spine Institute and was diagnosed with a double curvature in her thoracic spine with both curves measuring over 60°. Dr. Good performed a scoliosis reconstruction surgery with partial correction and fusion of both curves. X-rays taken post-operatively show improvement in her scoliosis and her breathing has returned to normal.

Surgery to correct adult scoliosis may be performed from the back of the spine (posterior approach) or the front or side of the spine (anterior or lateral approach), or some combination of anterior and posterior surgery together. The surgical approach utilized depends on the type of curvature that is present, the patient's symptoms, and is also dependent on what type of surgery the patient may have had previously. Before deciding on the approach for surgery, the doctors at the Virginia Spine Institute review the patient's x-rays, imaging tests, and clinical examination multiple times to formulate the surgical plan. The final recommendation for each patient is based on the desire to formulate the least invasive and safest procedure for each patient [Figure 5].

Figure 5: This patient is a 31 year old woman who was diagnosed with scoliosis at age 9. She was treated in a brace until she was 16 years old. Over time, her curvature has gotten bigger and she began to have more back pain with pain radiating into her leg. After a complete evaluation, the doctors at the Virginia Spine Institute performed a two-stage operation to correct her scoliosis. The first surgery was performed through a small incision below her belly-button and the second through a posterior approach in the back. X-rays performed post-operatively show correction of her scoliosis and good standing posture. She has returned to her previous job teaching horseback riding.

Adult scoliosis correction surgery utilizes spinal implants (rods and screws) to correct the scoliosis and hold the spine stable in that position while the spine fuses or mends. When the spine fuses, those segments of the spine heal together and are no longer mobile. Spine fusion is achieved using bone graft taken from the patient's spine intra-operatively in the area of surgery and for some patients bone morphogenetic protein is utilized to increase the chance that the spine will fuse correctly.

The expert team at the Virginia Spine Institute do NOT routinely take bone graft from the patient's hip or iliac crest. Iliac crest bone graft is used by many surgeons to achieve spine fusion, however this increases the patient's pain and lengthens recovery time. The physicians at Virginia Spine Institute are proud to have worked to pioneer the use of bone morphogenetic protein, a genetically engineered substance, that improves the success of spinal fusion and avoids the pain of hip graft harvest for the patient. The physicians at Virginia Spine Institute have a long-standing track record using bone morphogenetic protein in a safe and effective manner.

NUMBER OF VERTEBRAE FUSED:

For patients with scoliosis, the surgeons try to fuse the smallest number of vertebrae possible. This helps to preserve the greatest amount of motion in the spine. The physicians at the Virginia Spine Institute are committed to formulating the least invasive and safest procedure for each patient.

1. Adult Scoliosis: A Patient’s Story
2. Dr. Good’s Scoliosis Surgery Teaching Booklet