Coping with pain

Adult Degenerative Scoliosis is a common condition, thought to affect approximately 1 in 3 adults. In  most people the condition affects  all 3 planes, ie, sideways (scoliosis), front to back (kyphosis) and cross-section (rotational). Occasionally in some degenerative conditions, one vertebra is slipping forward or sideways from the one below.


How does ADS occur?

In most cases, ADS occurs out of the blue with no pre-existing spinal conditions and that is called De-Novo scoliosis. In other circumstances, degeneration (wear and tear) occurs in someone who is known to have had childhood scoliosis. Conditions can also develop after previous spinal surgery either at the site of previous surgery or above or below it. Whatever the form, the underlying cause is malalignment of the spine.


Why does it develop and what is degeneration?

The process of degeneration is a fact of life. Just the same way that skin becomes wrinkled, hairs become grey, other tissues of the body including spine will undergo degeneration. . The speed, pattern and extent of this varies according to each individual and is determined by the interplay of the genetic make-up and environmental factors. Some 90 ninety-year olds’ spine may not show any sign of degeneration whilst the spine of a 40-year-old may be degenerate from top to bottom. Some environmental factors such as heavy physical jobs and smoking have shown some association with this, however, we do not have all the answers.


Does spinal degeneration always cause ADS and if not why?

The pattern of degeneration in the spine is not always symmetrical, similar to how shoes are worn out. It is not completely understood why but, in some individuals, discs are worn out before other small joints of the back  (facets) and sometimes the discs are worn out more on one side than the other. This pattern may be influenced by the way that we are programmed to walk, carry things or do tasks. Whatever the reason if several discs of the spine are worn out on one side more than the other side, it is natural for the whole spine to lean to one side. This is an extremely simplistic way to look at spinal conditions as other factors such as protective muscular spasms or leaning forward or sideways to relieve nerve compression may make the spine look curved.


Is this a dangerous condition and is it likely to progress?

Generally, ADS is neither dangerous nor sinister unless associated with other conditions or if there is significant compression of nerves or spinal cord and this is not very common. That said, the risks depend on the size and type of the curve. The curve in degenerative conditions is often stable and progresses very slowly, if at all.


Is ADS always painful?

ADS could exist for many years without the patient knowing about it and  is discovered when the patient is investigated for other reasons and the curvature of the spine is picked up. It is, therefore, reasonable to assume that scoliosis may remain without any symptoms for many years. What triggers the symptoms is not entirely clear.


What are the common complaints that symptomatic patients with ADS present with?

The most common complaint is pain which in terms of severity could range from minor discomfort to severely disabling and in terms of character could take the form of a minor annoying dull ache, to sharp stabbing, to burning. Location of the pain could be around the area of maximum curvature or in areas or joints where compensation is taking place to balance the body upright. It could also present as sciatica type pain (pain caused by irritation or compression of the sciatic nerve) in the distribution of a nerve or nerves which, as a result of the combination of wear and tear and curvature, have been pinched. Other complaints may include numbness or weakness in the distribution of the pinched nerves, loss of height as the discs lose their height and the curve folds on itself or simply appearance of the curve itself becomes unacceptable.


What could be the cause of pain in ADS? And is pain a sign of continuing damage leading to my back crumbling?

As I mentioned above, ADS is not always painful but when pain is present –  like all pains – it is perceived as a sign of damage. However, the pain associated with ADS, when there are no other conditions, is mostly not a sign of continuous damage nor an indication that the spine is crumbling. This pain can be because of a variety of causes directly or indirectly related to the condition and depending on the cause, pain can present with different characteristics, patterns, severity and location. They include but not limited to:


1. Pain of muscular origin which can take the form of muscular fatigue, exhaustion, overwork or protective spasm. When the spine is straight, the line of gravity passes through the energy-efficient line for muscles to maintain the posture in different activities. However, when there is a spinal condition even when mild and there is no significant disturbance in the line of gravity,  muscles on either side of the spine have to work differentially to maintain the upright posture and this leads to exhaustion and overwork of a group of muscles. This  in turn presents like a dull ache with a bit of burring or hot feeling or even numbness or odd sensation in that group of muscles. This feeling is typically not felt when lying down or resting or early in the morning and felt mostly at the end of the day when standing on your feet for a length of time. Carrying shopping, rucksacks and other weights often make it worse.  Muscle overwork and pain becomes worse with more severe curves. Under these circumstances, efficient line of gravity falls either in front of the body called sagittal imbalance, or side of the body called coronal imbalance or combined called global imbalance. Under these circumstances, the muscles have to work much harder to maintain an upright posture and therefore express the unhappiness of their overwork by pain and spasm. This pain that a lot of people find difficult to describe can be sharp, stabbing, catching or continues pressure like someone digging a blunt object in that area.


Initially and if adjacent parts of the spine or nearby other joints such as hips and knees, still are supple and have flexibility, the patient compensates, and this is called compensated imbalance. For example, if the line of gravity falls in front of the body, in order to maintain a forward line of vision, the patient may have to extend their necks and hips which in turn leads to pain in the back of their neck and at the front of their hips. When the limit of this mechanism is reached then the patient has to bend their knees which leads to pain felt in their thighs and at the front of their knees. In rare circumstances, the whole compensatory mechanism fails known as a decompensated imbalance in which a person cannot maintain an upright balance even with aid.


2. Pain as a result of pressure on a nerve is called neuropathic pain. The process of wear and tear can sometimes narrow the routes taken by individual nerves travelling from the spine to supply different parts of the limbs. As a result, these nerves can be pinched. The pain as a result of  this is a sharp, annoying, and unpleasant  and sometimes makes people nauseous. The pain is typically continuous but is worse at rest which is why people with this pain stand and walk around to relieve it. It can also cause sleep disturbance. It may cause protective muscle spasm in the back. Degeneration can also cause narrowing of the whole of the spinal canal leading to a condition called spinal stenosis (the literal meaning of stenosis is the abnormal narrowing of a passage in the body). Spinal stenosis can cause nerve pain described above as well as a different type of pain called spinal claudication. This is an unpleasant cramping pressure felt in the lower back, buttocks, the back of the thighs and calves when standing and walking and relieved by rest and sitting. Although the symptoms are often symmetrical (felt on both sides equally) the pattern and severity vary in different people. The pain because of pinching of the nerves sometimes can be associated with tingling and pins and needles, sometimes numbness and much less commonly, weakness. Although any of the above can occur in the absence of scoliosis, ADS is commonly seen to be associated with them. Pinching and irritation of the nerves can also happen due to condition alone. When the spine is bent sideways, the nerve holes on the side where the spine is bending (concavity of the curve), naturally get narrower which, if severe could pinch the nerve. Conversely, nerves on the side where the curve is bending away from (convexity of the curve) can be stretched leading to similar symptoms without any physical pinching.


3. Pain due to actual degeneration of the spine in the area of the curve. Although the process of wear and tear is slow and often not painful, occasionally this process, for some individuals, becomes irritated and inflamed and therefore painful. The spine or vertebral column is formed by joining of individual bones called vertebrae. The adjacent vertebrae are joined by discs in the middle of the front of the spine and two small joints on either side of the back of the spine called facets. The pain can come from the inflamed discs, facets or both. This pain is likely to be a continuous ache or even pain with stiffness which presents at both rest and movement. There may be some night discomfort and turning in bed can also cause pain. There may also be an associated protective muscle spasm.


4. Mechanical and instability pain. Occasionally when scoliosis is severe and the trunk gets shorter as a result of wear and tear, the patient tilts on one side. Consequently, the lower ribs on the concavity of the curve knock on the top of the pelvis and this causes a mechanical pain. This pain is called costo-pelvic impingent. In such cases, there will be no space between the pelvis and the ribs. As explained earlier, occasionally one vertebra may start to slip either forward or sideways called anterolisthesis and lateral listhesis respectively. When the slippage is excessive, sudden movement in line with the direction of slippage causes a sharp pain followed by prolonged muscle spasm and a dull ache.


5. The above pains need to be distinguished from pains due to more serious underlying problems which when present require more urgent attention.


A- If the pain is unrelenting and continuous, day and night with sometimes history of loss of appetite and weight loss or if there is a history of previous treatment for a tumour or cancer.

B- If the pain is associated with fever, night sweats.

C- If the pain is associated with a recent history of fall or accident after which the pain has become worse.

D- If the pain is associated with significant numbness and weakness in one or both limbs, particularly if there is a history of disturbance in bladder and bowel control.


Overall patients with ADS may have one or a combination of different types of pains described above. The problem remains how this can be explained to the professionals and how professionals can work out what type of pain is being described and try to relate that with the patient’s history, examination and investigation. This remains the most challenging part of trying to help a patient with ADS. Pain is entirely subjective and for that reason often people cannot fully describe the physical, emotional and psychological burden that their pain has put upon them. More frustratingly for them is when their treating professionals show signs that either they do not understand their description of pain or worse they do not believe them. More recently in some pain clinics, there has been a move towards using images to help patients describe their pain.


What is the best treatment for ADS?

In the management of ADS, one size does not fit all and the best treatment for each patient is the one which is individually tailored for that patient having taken into account the symptoms, condition, fitness and patient’s choice.


I have tried physiotherapy and did not work. How could you correct my curve with that?

Physiotherapy as part of a comprehensive physical therapy programme remains the initial and mainstay of treatment for ADS.

As mentioned above some of symptoms in this condition relate to muscular overactivity and spasm as a result of imbalanced posture. Although physiotherapy will not be able to correct the curve, it will improve the tone and strengthen the muscles to cope with the condition better. Physical therapy, however, needs to be supervised at least initially so that it takes into account characteristics of that individual so that if the patient cannot cope with one set of exercises a different regime is tried. Furthermore, sufficient time needs to be allowed for improvement to be perceived. It will also need to be of multimodality including massage and local treatment. Along this line, yoga, pilates, swimming and overall remaining active have shown to help. Along with physiotherapy, sometimes psychotherapy including cognitive behavioural therapy is helpful.


Are you saying I am imagining all of this?

There is no doubt that ADS in some cases can cause disabling pain but why some people cope with this pain better than others may at least in part have an explanation in the patient’s psychological well-being and coping mechanisms.


Continuous pain combined with a fear of unknown together with a sense of getting old and hence one’s body is failing is known to lead to psychological maladjustment and even clinical anxiety and depression. That is why combining physical and psychological therapy has shown to be effective in treating chronic pain. Some people can simply cope with the pain and some people find it difficult due to the reasons above. It doesn’t mean you’re mad but it is how the mind works. Everybody is different.


By taking pain killers, am I going to mask the pain so that I can damage my back further without realising? Do the painkillers have side effects?

Sensible and safe use of painkillers is beneficial and effective in controlling pain in this group of patients.  No evidence to date has shown that the use of painkillers will mask the pain, nor has it shown that it will lead to more structural damage. In fact, in order to be able to comply with the physical therapy programme, it is often recommended that the patient should go on a short course of pain killers during the initial period.  Overall input from a multidisciplinary team is helpful. The type and duration of painkillers depend on the type of pain, as well as the patient’s past medical history and previous use of pain killers.

A general rule of thumb is to keep it simple, regular and short course. Strong drugs such as opiates (morphine family) should be avoided, particularly over a long period.

All painkillers have side effects and certain cautions need to be exercised to reduce this risk. For example, Non-steroidal anti-inflammatory drugs (NSIDs) should be avoided if there is a history of severe asthma, blood pressure, or gastric ulcer. Your GP is the best person to be consulted regarding this.


Can bracing help? Can it correct the curve?

Overall bracing has not shown to be as effective in adults as when it is used for scoliosis in children. In severe rigid forms of scoliosis, its usefulness is very much in doubt as it can cause pressure problems and sores and sometimes respiratory compromise in at-risk individuals. In some milder and slightly supple cases, it can help with pain and spasm of muscles, however, prolonged use of a brace can make the muscles weaker and hence be counterproductive with physical therapy which is trying to build and improve the muscle condition. Bracing is also reported by some patients to control some of the sharp pains experienced when there is lateral or anterior slippage associated with their condition. Bracing however is not effective in the presence of spinal stenosis and can make the symptoms worse as brace takes away the protective and relieving mechanism of leaning forward.


Can I be helped in any other way?

With ADS, sometimes a specific type of pain related to a specific area predominates and if it was not for that, the rest of symptoms arising from the condition itself can be coped with. For example, a nerve being pinched in one area or a few facets in the concavity of the curve being overloaded and particularly inflamed and irritated. Under these circumstances, a targeted nerve root block or a diagnostic facet medial brunch injection can help. If the medial brunch block is positive in getting rid of pain, then a procedure called radiofrequency treatment of facets can give some longer-lasting pain relief which can be repeated in the future.


Is a big operation the only way out or I can be helped with a smaller operation?

There are occasions such as those described above, that the most troublesome symptoms can be tied to a localised problem. Injection therapy sometimes can help to determine that.

Under these circumstances, a localised decompression (taking the pressure off the nerve or nerve) plus or minus a localised limited fusion operation can be extremely effective in getting rid of or limiting a bulk of the symptoms.


In summary, big surgery for ADS is not the inevitable end. Although corrective surgery has shown to be effective and successful, it is associated with a high level of serious complications which is not acceptable to some if not most patients. There are many other ways with lower risks that patients’ symptoms can be helped and controlled with allowing the patients to a have a reasonable quality of life before resorting to a corrective operation.

Masood Shafafy, Consultant Spinal Surgeon, Nottingham University Hospitals

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