Understanding Adult Scoliosis

Understanding Adult Scoliosis
By Dr Jeb McAviney BSc., MChiro., MPainMed., FCBP Welcome to the first module for SpineCor Adult Scoliosis treatment. The training to become a certified SpineCor Adult Treatment provider is broken down into three modules. Module one is a theory overview of concepts in scoliosis, particularly adult scoliosis and back pain. Module 2 is a more in-depth look at the application of the New SpineCor Adult brace for the treatment of Adult Scoliosis. Module three is a practical module. Completion and passing the test of the two online modules is a requirement prior to attending the practical module.

Adult Scoliosis Adolescent Scoliosis in the Adult (ASA) &
Degenerative De-Novo scoliosis (DDS) There are two main categories of scoliosis in adults. Adolescent scoliosis in the Adult (ASA) De-Novo Degenerative Scoliosis (DDS) Although these are the two most common presentations it is important that scoliosis due to a pathological or disease aetiology is always ruled out.

Adult Scoliosis ASA 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 Scoliosis in Adults can be pre-existing for example a previous Adolescent Scoliosis in and Adult. Or Adults can suffer a new onset of Scoliosis usually degenerative De-novo Scoliosis. Regardless of these two onset the primary complaint of Adults suffering from these types of scoliosis is Pain. Secondary to Pain, Aesthetics and Scoliotic progression are also considerations.

ASA 1 Usually smaller flexible curves in younger adults 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. ASA1 are usually smaller more flexible curves in younger adults years old. Posture and Cosmetic issues tend to be the main problem. Pain can be an issue particularly in unbalanced curves i.e. RT1. There is a potential reducibility in both the abnormal posture and cobb magnitude. The picture shows a relatively well balanced thoraco-lumbar curve. Pain and Aesthetics were both considerations for this 21 year old female.

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 2 are usually larger more rigid curves in middle aged adults 30 to 40 years of age. Pain and posture equally issues. Pain can be an issue even in balanced curves, usually because the spine is less flexible and an early degenerative process is starting. Intervention in ASA 2 could potentially to stop progression to ASA 3 - (This idea of early intervention at “middle age” is also suggest by Schwab Spine 2002)

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. ASA 3 are usually larger, very rigid curves in older adults 40+. Pain is the primary issue. Moderate to severe degenerative changes are present. ASA 3 are commonly present as lumbar curves. Or other curves with lumbar pain. The only way to distinguish ASA 3 lumbar curves and DDS Lumbar curve is via history of scoliosis. If there is no previous history of scoliosis this could indicate a 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. Degenerative De-Novo Scoliosis is a new scoliotic curve that develops in the Adult as a result of degenerative instability. These are usually lumbar curves and are unbalanced. There magnitude can be large, and they are always rigid curves in older adults usually 50+. Pain is the primary issue although these cases have a high rate of progression than ASA. There are 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) In studies by Perennou and Robin et al the prevalence of degenerative adult scoliosis, ASA and DDS in patients with back pain has been studied. Perennou found that out of 671 LBP sufferers, 7.5% had evidence of scoliosis on x-ray. The prevalence of scoliosis increased with age; 2% before 45 years (most likely ASA) up to 15% after 60 years (probably DDS). Robin et al. found that out of 554 LBP patients aged 50 to 84, 30% had a spinal curvature greater than 10 degrees. At 5 year follow up an additional 10% had this magnitude of scoliosis These studies suggest that a significant number of older people have an adult scoliosis and its prevalence and progression is directly related to advancing age and that is strongly associated with lower back pain in this population.

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” In studies by Perennou and Robin et al the prevalence of degenerative adult scoliosis, ASA and DDS in patients with back pain has been studied. Perennou found that out of 671 LBP sufferers, 7.5% had evidence of scoliosis on x-ray. The prevalence of scoliosis increased with age; 2% before 45 years (most likely ASA) up to 15% after 60 years (probably DDS). Robin et al. found that out of 554 LBP patients aged 50 to 84, 30% had a spinal curvature greater than 10 degrees. At 5 year follow up an additional 10% had this magnitude of scoliosis These studies suggest that a significant number of older people have an adult scoliosis and its prevalence and progression is directly related to advancing age and that is strongly associated with lower back pain in this population.

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,
ASA mean, 40° DDS mean, 25° Radiographic parameters correlating with pain were identical for these groups This appears to substantiate the belief that a common end pathway (degenerative instability and unfavorable lumbar vertebral alignment) among both groups of patients is related to symptoms rather than the degree of curvature or the cause of the original scoliosis. There is a link between some radiographic factors and development of spinal pain in patients with adult scoliosis. This was study by Schwab and published in Spine in 2002. Patients with ASA had larger major scoliosis curvatures than patients with DDS (ASA mean, 40°; DDS mean, 25°) Although the radiographic parameters correlating with pain were identical for these groups This appears to substantiate the belief that a common end pathway (degenerative instability and unfavorable lumbar vertebral alignment) among both groups of patients is related to symptoms rather than the degree of curvature or the cause of the original scoliosis.

Schwab’s research identifies these radiographic parameters as important: Level of regional balance. Instability Pathologic mechanical loads of the spinal elements 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 He identifies these correlations with pain: Lateral vertebral olisthy, (also referred to as lateral listhesis) L3 and L4 endplate obliquity angles, Decrease in lumbar lordosis, Increased thoraco-lumbar kyphosis

Regional balance in the coronal plane was measured by a plumbline from S1 to T1
The endplate obliquities of L2 – L5 were measured by constructing a line along the most tilted superior or inferior endplate L2 –L5 and measuring the angle of tilt compared to a horizontal line. The level at which true instability (olisthy) was present was measured by constructing parallel lines to the lateral margin of adjacent vertebra and measuring the lateral distance between there lines.

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. 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. Patients with positive sagittal balance measured from C7 to the posterior margin of the sacrum had the most significant compromise in health status when compared to patients who were in neutral balance or negative global sagittal balance. Patients with positive sagittal balance reported greater pain, diminished physical function poorer self image and social function

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003 The most significant findings were: Positive (anterior) Sagittal Balance Greater pain Diminished physical function Poorer self image Poorer social function Patients with positive sagittal balance measured from C7 to the posterior margin of the sacrum had the most significant compromise in health status when compared to patients who were in neutral balance or negative global sagittal balance. Patients with positive sagittal balance reported greater pain, diminished physical function poorer self image and social function

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003 Coronal shift > 4 cm Poorer function Greater pain Compared to patients with a coronal shift < 4 cm. The most significant findings for patients with no prior surgery were noted in the assessment of coronal and sagittal balance. Patients with coronal shift greater than 4 cm reported poorer function based on the SRS-22 and greater pain on the SF-12 and ODI compared to patients with a coronal shift less than 4 cm.

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003 Key Points Positive (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. Positive (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 in ASA 1&2 is generally not a major concern unless the curve is already very large >60 deg. Published in their paper in Spine 2003 Danielson and Nachemson 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 Chopin et. al. studied progression of scoliosis during adulthood based on standard categories. They found that, lumbar curves progressed on average 1.8°/y, thoracolumbar curves 1.4°/y, thoracic curves 1.2°/y, double curves thoracic 0.8°/y, lumbar 0.9°/y

Progression of Adult Curves
Spinal Degeneration Soft tissue integrity lost Functional unit instability increased Progression Scoliosis Boney adaptation (Wolffs Law) As adults do not grow, one of the main progressive factors in Adolescents is not present in Adult cases. In progressive adult curves a different theory of progression is suggested. Either dues to pre-existing biomechanical issues such as pre-existing scoliosis or due to segmental injuries the functional unit of the spine begins to degenerate. As a result of this degeneration soft tissue integrity is lost (due to Davis’s law). This loss of soft tissue integrity leads to functional unit instability. This instability allows further scoliotic progression. Over a period of time the bone tries to adapt and further degeneration occurs ( due to Wolff’s law) This is another vicious cycle of progression, however it revolves around degenerative instability as apposed to growth modulation.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et. al
Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Two main types were identified: Type A Adolescent scoliosis Progresses after skeletal maturity In this paper two main types of scoliosis were identified: The first type was Type A , this corresponds to adolescent scoliosis, which continues to progress after skeletal maturity at a liner rate specific to each curve. The second type was Type B which progresses late in adulthood: either a pre-existing stable adult scoliosis that progresses late or a de novo late-onset scoliosis. A sub group of Type B progressed at Menopause. One significant finding of these authors was that they did not find any correlation between the initial Cobb angle and slope of progression in the overall population.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 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. In this paper two main types of scoliosis were identified: The first type was Type A , this corresponds to adolescent scoliosis, which continues to progress after skeletal maturity at a liner rate specific to each curve. The second type was Type B which progresses late in adulthood: either a pre-existing stable adult scoliosis that progresses late or a de novo late-onset scoliosis. A sub group of Type B progressed at Menopause. One significant finding of these authors was that they did not find any correlation between the initial Cobb angle and slope of progression in the overall population.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 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.” In this paper two main types of scoliosis were identified: The first type was Type A , this corresponds to adolescent scoliosis, which continues to progress after skeletal maturity at a liner rate specific to each curve. The second type was Type B which progresses late in adulthood: either a pre-existing stable adult scoliosis that progresses late or a de novo late-onset scoliosis. A sub group of Type B progressed at Menopause. One significant finding of these authors was that they did not find any correlation between the initial Cobb angle and slope of progression in the overall population.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 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. Menopause was found to play a role in progression some adult scoliosis curve. 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. A sub group of Type B progressed at Menopause.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Summary 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&2 Late onset scoliosis, either pre-existing stable adolescent scoliosis or de novo (type B). ASA3 & DDS Menopause constitutes a period of deterioration for type B. 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&2 Late onset scoliosis, either pre-existing stable adolescent scoliosis or de novo (type B). ASA3 & DDS Rotatory subluxation seems to be the initial element of progression for type B, while it is the consequence of progression for type A. Menopause constitutes a period of deterioration for type B.

Progression of Adult Curves Type B
Soft tissue integrity lost Functional unit instability increased Rotational Subluxation Scoliosis Boney adaptation (Wolff’s Law) Boney Degeneration This cycle demonstrates a possible aetiology and cycle of progression in type B curves unaffected by menopause. A loss of integrity of the soft tissues. This leads to instability of the functional unit. The result of this is a rotational subluxation. This results in scoliosis. The asymmetrical loading due to the scoliosis causes boney adaptation via Wolff’s law This boney adaptation accelerates the degenerative process and scoliotic progression.

Progression of Adult Curves Type BM
Soft tissue integrity lost Functional unit instability increased Rotational Subluxation Scoliosis Boney adaptation (Wolff’s Law) Boney Degeneration Menopause This cycle demonstrates a possible aetiology and cycle of progression in type B curves unaffected by menopause. A loss of integrity of the soft tissues. (The loss of soft tissue integrity is made hormonally worse though menopause) This leads to instability of the functional unit. The result of this is a rotational subluxation. This results in scoliosis. The asymmetrical loading due to the scoliosis causes boney adaptation via Wolff’s law This boney adaptation accelerates the degenerative process and scoliotic progression.

DDS Development 50 yr old woman minor LBP 5 years latter developed DDS

Adult Scoliosis Treatment
Increased 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 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 Treatment Rigid vs. Dynamic Orthosis for Treatment
Muscle Atrophy in unstable system Limitation of movement Self image issues Comfort issues Useful in Neuro-degenerative cases Muscle rehabilitation and stabilization Allows movement Not visible under clothing Relatively comfortable Suitable for long term use Not suitable for Neuro-degenerative cases The majority of SpineCor practitioners have experience treating AIS. In Adult treatment it is important to realise that both the natural history and the goals of treatment are very different when dealing with Adults compared to Adolescents. In Adolescents the scoliosis is generally, more highly progressive, (although common) Pain is Not over riding issue, the curves are often flexible and correction or progression stabilization are the primary goals. In Adults the curves are generally slowly progressive (with the exception of some types of DDS). Pain is the main issue. The curves are usually rigid and therefore only a limited amount of correction can be achieved. Goal is improvements in Sagittal and Coronal balance not a forced reduction in Cobb angle

Corrective Movement & Spinal Loading
Here is an example of the power of a correctly applied corrective movement. In flexible cases Cobb angle reductions can be seen. However in most adult cases the changes are not so large. What is seen is the alteration in coronal balance. Here we can see a right thoracic type 1 AIS scoliosis. As well as the geometry of the curve it’s self, it is clear that the coronal balance is not normal and the decompensation of the spine is not balanced. This has an effect on the normal loading of the spine, particularly the lumbar and thoracic spine, and can lead to pain. By applying the corrective movement the coronal balance is normalised and the decompensation of the spine is more balanced. If this can be promoted in the brace then it should lead to pain relief, postural improvements and a cessation of progression.

SpineCor Adult Treatment
LEFT LUMBAR CORRECTIVE MOVEMENT BRACE IN PLACE CLASSIFICATION Here is a summary of bracing process including classification, corrective movement and brace fitting. Firstly the type of curve is classified. This involves clinical and radiological evaluations. The patient is then taught a corrective movement for the type of curve. The SpineCor brace is then applied to dynamically reproduce this corrective mevement.

SpineCor and Sagittal Balance
Corrective 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. As will set ups in the SpineCor systems, it is important to have the patient actively position themselves in the Corrective movement prior to brace fitting. Lets review the corrective movement for Hyperkyphosis. 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 As will set ups in the SpineCor systems, it is important to have the patient actively position themselves in the Corrective movement prior to brace fitting. Lets review the corrective movement for Hyperkyphosis. 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.

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 . Patient A 26 year old female, painful adolescent idiopathic scoliosis as an adult (ASA1). Pain prior to SpineCor average daily pain of 7/10. Using the SpineCor daily 8 to 12 hours for 3 months she had a gradual relief of her pain to an average 2/10. The initial x-ray shows a 32 deg right thoracic scoliosis. In the SpineCor 1 month after fitting the x-ray shows an improvement of 8 degrees to 24 deg. Her pain relief of 1-2/10 and spinal correction have been maintained for over 2 years by using the SpineCor Pain Relief brace on an occasional basis. 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”. Patient B 47 year old female with Degenerative De-Novo Adult Scoliosis. (DDS) Her pain prior to treatment was rated as an average daily pain of 8/10. In the SpineCor brace she had an immediate relief of her pain to 3/10. The initial x-ray shows a 40 deg degenerative lumbar scoliosis. In the SpineCor x-rays show an improvement of 7 degrees to 33 deg. Her pain relief of 0-3/10 and spinal correction have been maintained for over 2 years, using the SpineCor Pain Relief Brace on a daily basis. Note the improved left lateral shift showing “spinal off loading”. Courtesy of Dr Tom Pappas

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Understanding Adult Scoliosis

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