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Scoliosis
What is adult scoliosis?
Adult scoliosis refers to a broad spectrum of spinal deformities in adulthood.
The main difference from childhood scoliosis is that adults with scoliosis usually experience significant pain, which is often the reason they seek medical attention. Adult scoliosis often worsens over time, with increased pain and growing difficulties in daily life.
Adult scoliosis involves “rigid” curves—deformities that are not easily corrected—which presents a major challenge for surgical treatment.
What are the types of scoliosis?
The types of adult scoliosis are:
- Idiopathic scoliosis, which remains untreated from adolescence and progresses into adulthood, worsening the deformity and causing more severe pain.
- Degenerative scoliosis, caused by degeneration of the intervertebral discs.
- Scoliosis caused by spinal fractures.
- Neuromuscular scoliosis, occurring in adults with muscular dystrophies or other neuromuscular conditions.
Pain is common due to disc and joint degeneration. Patients may show neurological signs from nerve compression. Age-related scoliosis often comes with reduced bone density or osteoporosis, which can significantly affect treatment.
What is congenital scoliosis?
Congenital scoliosis is a spinal deformity caused by abnormally formed vertebrae, usually occurring during spinal development between the 4th and 6th weeks of gestation.
There are three types of congenital scoliosis:
- Scoliosis due to the presence of a hemivertebra (a wedge-shaped vertebra).
- Scoliosis due to unilaterally fused vertebrae (failure of vertebrae to separate on one side).
- Scoliosis from a combination of the above two.
The number, location, and growth potential of hemivertebrae determine the severity of congenital scoliosis. Simple vertebral anomalies may be discovered incidentally later in life, but multiple or severe anomalies often present in infancy.
Are there associated disorders?
Patients with congenital scoliosis may have other organ anomalies: 10% have heart defects, 25% have urinary system anomalies, and 30% have other spinal abnormalities.
Systematic evaluation is essential, especially before surgery, including heart and kidney ultrasound and a full spinal assessment. Findings may include spinal cord lipomas, adhesions in the spinal canal, or bony separations of the spinal cord (diastematomyelia). Treating these findings takes priority over scoliosis surgery.
What is early-onset scoliosis?
Early-onset scoliosis (EOS) refers to scoliosis in children under 10 years old.
- Infantile scoliosisoccurs from birth to 3 years old.
- Juvenile scoliosisoccurs from 4 to 10 years old.
These children have significant growth potential, so scoliosis is more likely to progress.
What is Idiopathic Scoliosis?
Idiopathic scoliosis (IS) is the most common form of scoliosis, primarily appearing during adolescence. It is called “idiopathic” because its exact cause is unknown. However, it often occurs in multiple members of the same family, suggesting a genetic component. In Greece, there are no precise statistics, but in the United States, about 500,000 adolescents are estimated to have scoliosis.
Classification by Age of Onset:
- Infantile scoliosis:from birth to 3 years
- Juvenile scoliosis:from 3 to 9 years
- Adolescent scoliosis:from 9 to 18 years
Adolescent scoliosis accounts for 80% of all idiopathic scoliosis cases. Within this classification, IS is further divided into cases occurring before and after age 5.
The risk of progression is highest during adolescence, particularly during the juvenile growth spurt (around age 11 in girls and 13 in boys). Significant curves occur more frequently in girls, who require treatment eight times more often than boys, as their curves are more likely to progress. Nevertheless, the majority of scoliosis patients do not require any treatment.
Diagnosis and Symptoms
Idiopathic scoliosis causes spinal deformity but does not usually cause pain. Patients with IS may experience back pain, such as low back pain, similar to their peers, without increased frequency or severity. When pain accompanies scoliosis in children, the cause is typically not the scoliosis but another underlying spinal pathology, such as a tumor.
Visible signs of scoliosis include:
- One shoulder higher than the other
- Prominence of one shoulder blade
- Rib prominence or asymmetry on one side
- One hip higher or more prominent than the other
- Asymmetry of the waist
Scoliosis is often first noticed by a pediatrician or school nurse. The most common screening test for mild scoliosis is the Adam’s forward bend test, where the child bends forward with arms outstretched and knees straight. The examiner observes the back for asymmetry of the spine and torso.
The next step is spinal X-rays, usually taken in a standing posteroanterior view, to confirm the diagnosis and measure the curve using the Cobb method (accuracy: ±3–5°). X-rays should include the upper pelvis, which helps estimate remaining growth using the Risser sign (scale 1–5).
MRI is required only in rare situations:
- Presence of neurological signs (e.g., hyperreflexia)
- Before any treatment in juvenile scoliosis
- Left thoracic curves (curves that bend left, which is unusual)
Management of Idiopathic Scoliosis
Based on findings, IS management can be either conservative (observation or bracing) or surgical.
Bracing
- Braces halt progressionbut cannot reduce existing deformity. About 25% of curves may continue to progress despite bracing.
- Bracing is most effective during periods of rapid growth, the time when curves are most likely to worsen.
- In girls, the start of menstruation marks the end of the major growth period, confirmed with radiological signs (Risser sign, hand X-ray) and secondary sexual characteristics (breast development, pubic hair).
- Curves larger than 50°may continue to progress into adulthood; therefore, the goal of bracing is to achieve a final adult curve under 50°.
Most common braces:
1. Thoracolumbosacral orthosis (TLSO):
- Custom-molded to fit the child’s body
- Worn under clothing
- Applies three-point pressure on the spine
- Worn 16–21 hours/day, removable for sports
- 2. Charleston brace:
- Nighttime brace that bends the body opposite the curve
- Suitable only for mild single thoracic curves
- Bracing is unnecessary in skeletally mature children, as progression risk is minimal. Typical ages: girls 11–13 years, boys 12–14 years.
- A 30° curve in a nearly mature child should be monitored but not braced.
Evidence for Bracing:
The BrAIST study (2013, NEJM) confirmed the effectiveness of bracing and helped establish usage guidelines, including duration and daily schedule.
Is there conservative treatment for management?
Non-surgical treatment has been shown to be largely ineffective for halting scoliosis progression in adults. Over time, patients typically experience worsening deformity and increasing limitations in daily activity.
Therefore, conservative treatment is generally recommended only for mild cases of adult scoliosis. It mainly involves physical endurance exercises to help patients maintain high energy levels and activity while managing spinal pain. Combined with physical therapy and judicious use of pain medication, this approach can provide relief for many patients.
Epidural corticosteroid injections may also be used, especially when nerve compression is present. Bracing is rarely effective in adult scoliosis, primarily because adult patients often cannot tolerate braces, and prolonged use can weaken the muscles. Braces may, however, provide temporary relief for patients who are not candidates for surgery.
Another important aspect in adult scoliosis management is osteoporosis, which should be treated appropriately with medication.
Surgical Management
Surgery is indicated for patients whose scoliosis is progressing and whose pain is not controlled by conservative treatment. Other indications include neurological symptoms or leg pain.
Contraindications for surgery include advanced age, poor general health, or severe osteoporosis.
Surgery in adults can be performed posteriorly (from the back of the spine) or in combination with an anterior approach (through the abdomen). Severe, rigid scoliosis often requires osteotomies (bone removal) to achieve better spinal alignment. Discs are frequently replaced with bone grafts to improve the likelihood of spinal fusion.
Ρομποτική στην αντιμετώπιση σκολίωσης
Πλέον, η χειρουργική αντιμετώπιση της σκολίωσης μπορεί να πραγματοποιηθεί με τη βοήθεια ρομποτικής τεχνολογίας. Η ρομποτική σπονδυλοδεσία αποτελεί μια νέα προσέγγιση που επιτρέπει μεγαλύτερη ακρίβεια στην τοποθέτηση των υλικών και μικρότερο χρόνο χειρουργείου. Η τεχνική αυτή μπορεί να φανεί ιδιαίτερα χρήσιμη σε πολύπλοκες παραμορφώσεις, μειώνοντας τον κίνδυνο επιπλοκών και την πιθανότητα λανθασμένων τοποθετήσεων. Παράλληλα, συμβάλλει στην ασφαλέστερη και πιο ελεγχόμενη αποκατάσταση της σπονδυλικής στήλης.
Postoperative Instructions
Recovery speed after adult scoliosis surgery depends on the extent of the surgery, the patient’s age, and their preoperative physical condition.
- Most patients return to normal activities around 3 monthspost-surgery.
- In more extensive cases, full recovery may take 6 to 9 months.
Most adult scoliosis patients report greater satisfaction with surgical treatment compared to conservative management, despite the associated risks and potential complications.
