Scoliosis is a lifetime condition. It is sometimes described as a diagnosis that patients carry “from cradle to cane.” People with scoliosis in early childhood through the end of adolescence do not commonly have a lot of pain. However, they may have curves in the spine that progress in size, becoming quite large by the time their bones stop growing. On the other hand, adults may or may not have large curves but experience much more pain, particularly as they enter their 50s and later.
Evaluating scoliosis in any patient, child or adult, begins with a thorough history and physical exam. In children and adolescents, doctors closely monitor how the curve is changing over time. They also assess how much the patient is expected to continue to grow. The method may be as simple as measuring the patient’s height at each office visit. When the change in height in one year is less than half an inch (1 cm), this roughly marks the final stages of vertical growth. The patient would also receive x-rays every three to four months to measure and monitor for a worsening of the curve.
During times when bones grow quickly, it is not uncommon for the curve to worsen by 20 to 25 degrees in a year in young patients. Pediatric and adolescent scoliosis evaluations are more to measure the presence and rate of curve progression and the amount of skeletal growth remaining. This helps healthcare providers estimate the risk that the curve will get worse. A thorough workup would be done if young patients were found to have significant pain, which is relatively uncommon. The most likely cause of pain is muscular issues, and appropriate physical therapy or exercises can help. Goals for children and adolescents are to limit the progression of the spine’s curve and to allow these patients to get to skeletal maturity without significant worsening of their scoliosis.
For adults with scoliosis, either back pain or leg pain is very common. Evaluation and goals for treatment are determined by a healthcare professional. Adult scoliosis patients are no longer growing, so rapid curve progression is not the norm. Curves are expected to increase approximately zero to one degree per year. For this reason, evaluation of adult patients is driven more by determining where and why patients are feeling pain. Pain can be caused by muscle spasms, nerve compression, progressive degeneration of the joints in the spine or pelvis or other less common reasons. Evaluations may require specialty consultations including pain management, physiatry and neurology, among others. Imaging tests could include MRI and CT scans and multiple special x-ray radiographic views. Ultimately, the evaluation is specifically tailored to each individual patient’s needs. Goals for treatment are to minimize or eliminate pain and to monitor the spine for worsening of the deformity.
Pediatric and adolescent patients with small curves may want to consider the Schroth method of strengthening exercises to limit worsening of the curve and possibly decrease it. When curves in young patients are between 25 and 45 degrees, they will typically be assigned brace treatment. This sets the spine to allow for straight vertical growth until the child stops growing, when the brace would no longer be needed.
Curves that ultimately become 50 degrees or greater may make pediatric and adolescent patients candidates for surgery. Surgery is done to halt curve progression, stabilize the spine and correct the scoliosis as much as possible. This would traditionally be performed with fusion surgery through a posterior, or rear, approach to the spine. Metal rods and other implants are used to correct the shape of and immobilize the spine, and the bones are prepared and grafted to all weld or fuse together. Posterior fusion for advanced scoliosis has been used for decades and has a great deal of research supporting its success and safety. More recently, new techniques that do not require spine fusion, along with research on these techniques, are being performed. Outcomes reported may show it to be a better treatment option for certain groups of young patients.
Scoliosis management in adults is historically different, as the curve is unlikely to progress quickly. Management of adult patients with spine deformity is typically guided by the person’s symptoms. Exercise and physical therapy (possibly also using the Schroth method), medications and injections are all potentially helpful.
Surgical treatment in adults is typically much more involved and complicated than in younger patients. Different approaches may be used, including posterior instrumented fusion, posterior laminectomy and decompression, anterior fusion, and more subtle changes in surgical technique for patients with softer bone (i.e., osteopenia, osteoporosis) or other issues. It is important that adult patients have a complete medical evaluation and are optimized prior to surgery to minimize any complications. More recently, minimally invasive techniques are being implemented to meet the same surgical goals. This allows patients to have less exposure to surgical trauma, a faster recovery, and a much earlier return to their normal life than was possible 10 years ago.
Dr. Matthew Cunningham has clinical interest in thoracic and lumbar spine care for adult and pediatric patients, and degenerative problems in adults. In consideration of each and every patient, he focuses on the discovery and refinement of less-invasive, less-painful, and less-disruptive ways to correct spinal pathology.