by dr jeb mcaviney bsc., mchiro., mpainmed., fcbp

By Dr Jeb McAvineyBSc., MChiro., MPainMed., FCBP

Adolescent Scoliosis in the Adult (ASA) &Degenerative De-Novo scoliosis (DDS)

Adult ScoliosisASA is pre-existing AIS but in

adulthood

DDS is a new development

of scoliosis in adulthood.

The primary concern in most

adult cases is Pain

Progression and Aesthetics

are also considerations

ASA 1• Usually smaller flexible curves in

younger adults 18-30 years old

• Posture and Cosmetic issues are

the main problem.

• Pain can be an issue particularly in

unbalanced curves

• Potential reducibility in both

abnormal posture and Cobb.

ASA 2• Usually larger more rigid curves in

middle aged adults 30-40• Pain and posture equally issues.• Pain can be an issue even in

balanced curves.• Often start to see early

degenerative changes• Intervention in ASA 2 could

potentially to stop progression to ASA 3

ASA 3• Usually large, rigid curves in older

adults 40+• Pain is the primary issue.• Moderate to severe degenerative

changes present.• Most commonly lumbar curves.• No previous history of scoliosis

could indicate Degenerative De Novo Scoliosis DDS.

Degenerative De-Novo Scoliosis (DDS)• New curve in adult developed as a

result of degenerative instability.

• Usually lumbar curve, unbalanced.

• Large, rigid curves in older adults 50+

• Pain is the primary issue.

• Moderate to severe degenerative

changes present.

Prevalence of Adult Scoliosis in Back Pain Perennou et al; 671 LBP patients:

7.5% had evidence of scoliosis.

Prevalence of scoliosis increased with age;

2% before 45 years (most likely ASA)

15% after 60 years (probably DDS)

Prevalence of Adult Scoliosis in Back Pain Robin et al;554 LBP patients

Aged 50 to 84 30% scoliosis >10°

At 5 year follow up 40% scoliosis >10°Additional 10%

“a significant number of older people have an adult scoliosis” and its prevalence and progression is directly related to advancing

age”

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,

Schwab’s research identifies these radiographic parameters as important:

•Level of regional balance.

•Instability

•Pathologic mechanical loads of the spinal elements


He identifies these correlations with pain:

•Lateral vertebral olisthy, (side slip)

•L3 and L4 endplate obliquity angles,

•Decrease in lumbar lordosis,

•Increased thoraco-lumbar kyphosis


• The Cobb angle of the scoliotic deformity had no statistically significant correlation to the VAS.

• Early intervention in a middle-aged adult with scoliosis may be preferable to treating advanced deformity in that same person once he or she has become elderly.

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003

298 patients

The purpose of the study was to correlate radiographic measures of deformity with patient-based quality of life and health status assessments in adult scoliosis.


The most significant findings were:Positive (anterior) Sagittal Balance

Greater pain Diminished physical function Poorer self image Poorer social function

Coronal shift > 4 cm Poorer function Greater pain

Compared to patients with a coronal shift < 4 cm.


Key PointsPositive (anterior) sagittal balance predicts clinical symptoms in adult spinal deformity.Thoracolumbar and lumbar curves have worse outcomes than thoracic curves.Significant coronal imbalance was associated with pain and dysfunction.


Progression of Adult Curves• Progression in ASA 1&2 is generally not a major concern unless the

curve is already very large >60 deg

• Danielson and Nachemson in Spine 2003 found that 36% of adolescents with scoliosis had progressed by more than 10° after 22 years.

• ASA 3 and DDS can become moderate to severely progressive due to degenerative instability and or hormonal influence.

• The most progressive DDS cases often have osteoporosis as a co-morbidity

Progression of Adult Curves

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007

Two main types were identified:

1) Type A • Adolescent scoliosis• Progresses after skeletal

maturity


Two main types were identified:

2) Type B • Progresses late in adulthood:• Pre-existing stable adult scoliosis

with late progression• De novo late-onset scoliosis.


Progression was measured at a liner rate specific to each curve.

“We did not find any correlation between the initial Cobb angle and slope of progression in the

overall population.”


Role menopause plays

In 8 women with type A scoliosis with a long progression comprising menopause, no change of slope was observed at menopause.

Patients with type B scoliosis were all women and exclusively presented a lumbar or thoracolumbar single curve.

In type B, 11 out of 20 of these patients progressed at the time of menopause.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007Summary

The progression of adult scoliosis is linear. It can be used to establish an individual prognosis.

Two main types exist: Adolescent scoliosis, which continues to progress (type A)

ASA 1&2Late onset scoliosis, either pre-existing stable adolescent

scoliosis or de novo (type B). ASA3 & DDSMenopause constitutes a period of deterioration for type B.

Progression of Adult CurvesType BM

Menopause

DDS Development

50 yr old woman minor LBP 5 years latter developed DDS

Adult Scoliosis TreatmentIncreased Life Expectancy vs. Long term Quality of LifeIncreased Life Expectancy vs. Long term Quality of Life• Degenerative pathologic conditions in aging persons are increasingly of

concern in regards to long term quality of life and independence

• The focus of medical treatment in Adult cases is usually on regional degenerative pathologic conditions such as stenosis, spondylolisthesis, disc degeneration etc. rather than the deformity itself!

“Although the common degenerative conditions of the spine are frequently treated as focal pathologic states, it appears intuitive that deformity of the spinal column, by altering the mechanical loading conditions, can accelerate the degenerative cascade.” Schwab et al, Spine 2002

Adult Scoliosis TreatmentRigid vs. Dynamic Orthosis for Treatment

Rigid DynamicMuscle Atrophy in unstable system Limitation of movementSelf image issues Comfort issuesUseful in Neuro-degenerative cases

Muscle rehabilitation and stabilizationAllows movementNot visible under clothingRelatively comfortableSuitable for long term useNot suitable for Neuro-degenerative

cases

Goal is improvements in Sagittal and Coronal balance not a forced reduction in Cobb angle

Corrective Movement & Spinal Loading

CLASSIFICATION CORRECTIVEMOVEMENT

BRACEIN PLACE

LEFT LUMBAR

SpineCor Adult Treatment

SpineCor and Sagittal BalanceCorrective movement for Anterior Sagittal Balance

First have the patient stabilise their lordosis by the contraction of abdominal and gluteus muscles.

Second translate the base of the thorax slightly forwards and upwards.

SpineCor Adult Brace

Examples of Adult treatment Patient A 26 year old female, Painful adolescent idiopathic

scoliosis as an adult (ASA1). Pain 7/10. 8 to 12 hours for 3 months Gradual relief of pain to 2/10. 32 deg right thoracic scoliosis. Improvement of 8 degrees to 24

deg. Relief of 1-2/10 and spinal

correction have been maintained for over 2 years .

Courtesy of Dr Tom Pappas

Examples of Adult treatment Patient B 47 year old female Degenerative De-Novo Adult

Scoliosis. (DDS) Pain 7/10. Immediate relief of pain to 3/10. A 40 deg degenerative lumbar

scoliosis. Improvement of 7 degrees to 33

deg. Pain relief of 0-3/10 maintained

for over 2 years Note the improved left lateral

shift showing “spinal off loading”. Courtesy of Dr Tom Pappas

Thank you Thank you

by dr jeb mcaviney bsc., mchiro., mpainmed., fcbp

Documents

prevalence of scoliosis

fcbpadolescent scoliosis

original scoliosis

evidence of scoliosis

ageadult scoliosis

spinal elementsadult

previous history of

new development of scoliosis