Management of adult degenerate scoliosis (ADS) is challenging. The vast majority of patients diagnosed with ADS are usually treated non-operatively initially to help manage their symptoms.
Surgery is an option for ADS but in some patients surgery may not be appropriate for various reasons and some patients may select non-surgical measures as their treatment of choice. Surgery for ADS in patients over 60 has a high complication rate and unless there is a clear possibility of significant post-operative benefit it is better they be managed conservatively. Most patients would be able to self manage their symptoms with lifestyle modification and intermittent use of medication to help the pain.
Some patients with ADS may not be able to manage their symptoms by simple measures as described above. In that case the non-surgical management would depend on the type of symptoms patients present with. The most common symptoms would be 1) back pain, 2) nerve pain or nerve related symptoms ie, pain radiating down the legs like sciatica (pain caused by irritation or compression of the sciatic nerve) or symptoms suggestive of neurogenic claudication whereby an individual may find that they can walk for a certain distance and have to stop and sit down to help the symptoms. 3) Irregular posture – Although scoliosis usually causes a sideways bend, degenerative scoliosis patients may also have loss of sagittal (anatomical plane which divides the body in half) spinal alignment as they would find that they tend to lean forwards when they stand or walk. This loss of spinal alignment can lead to muscle fatigue which could affect one’s ability to walk and mobilise comfortably to carry on with the day-to-day activities and function.
Non-surgical options with regards management of back pain
Analgesia (pain killers) are the most common treatment option to help with pain which is usually provided by GP. There is evidence in the medical literature to support the use of analgesia to help back pain but prolonged use of analgesia should be monitored and discussed with the doctors to assess their risks.
Conservative measures ie, physiotherapy, chiropractic treatment, osteopathy or alternate methods are gathering more support eg, pilates or yoga are routinely utilised by individuals to help with back pain. There are exercise programmes available in some places and the feedback from the individuals attending these classes is very favourable. These therapies usually help the muscles in the back so as to allow controlling the spine better which would help with regards mobility and function. Various studies in medical literature support muscle strengthening as a useful option to control back pain symptoms. The above options would in a way be the mainstay of treatment as they would help the condition and symptoms and help maintain function and ongoing care.
Some of the therapist’s might use other options apart from exercises to help the pain ie, TENS machines, shockwave therapy, ultrasound, accupressure, accupuncture which have mixed evidence in medical literature but are an option to help with the symptoms and part of the therapist’s armamentarium.
But on some occasions managing back pain is difficult despite utilising the above measures and in those scenarios one of the options for management would be to consider referral for a pain management programme via the local pain clinic. The various techniques utilised by the pain team usually would include the appropriate use of medication to help with the pain or injections to help the symptoms. The injections that could be offered would depend on each individuals symptoms and potential pain source as per the assessment by the clinician. The options with regards injections for back pain would include:
1) facet joint injections ie, injection of steroid into the facet joints which are the joints of the spine which lie behind the spinal cord and are done under local anaesthetic usually and under XX-rayX-ray guidance.
2) facet joint denervation – if the facet joint injections help the symptoms for a reasonable duration, then one could consider performing facet joint denervation or rhizolysis whereby we can ablate the nerve endings supplying the facet joint . This could help the pain arising from the facet joint for a prolonged period of time.
The evidence for the use of facet joint injections and facet joint denervation in medical literature is variable but their use for patients with low back pain is supported by National Institute for Health & Care Excellence (NICE) as one of the options to help patient’s symptoms.
Another option which has been shown to benefit patients with low back pain and could be considered to help patient’s symptoms is an intensive rehabilitation programme or functional restoration programme. These type of programme’s usually include input from physiotherapy, pain management and psychology. These programmes have been shown to improve low back pain symptoms. This treatment option is recommended by NICE for patients with low back pain as the evidence in the medical literature is fairly favourable.
Non-surgical options for management of altered posture or loss of spinal alignment
In patients with loss of spinal alignment apart from conservative therapies one could consider using mechanical measures ie, a brace to support the spine. The various spinal braces available would range from soft corset which is essentially made of canvas type material or a soft corset supplemented with metal strips supporting the back or a fully moulded jacket made of thermoplastic usually which is moulded to fit around the trunk.
These braces can help support the spine and help improve the spinal alignment which could potentially help mobility and function in a similar fashion as a knee brace or braces used for other joints in the body which are more commonly utilised. Again the evidence with regards use of bracing in the medical literature is varied and is not commonly utilised in day-to-day practice although on a case-by-case basis one could be offered a brace which could be used on occasions to help with their function and mobility.
Some individuals use walking aids which would help them to be in an upright position rather than stand bending forwards. These potentially help with the walking and function. The walking aids could vary from a walking stick, two sticks, crutches or the use of other devices eg, rollator frames. Walking aids are usually found to be a very useful in managing degenerate scoliosis patients by helping improvement in their mobility and function. These also provide a sense of security and safety to avoid falls which possibly could have other inadvertent consequences.
Non-surgical management of symptoms related to spinal nerve pain
Some of the patients with ADS may have nerve related symptoms because of a trapped nerve causing sciatica or difficulty walking any distance and they would prefer to sit after walking a certain distance which in the medical terms is called neurogenic claudication. Surgery usually is the preferred treatment of choice for patients with nerve related symptoms. But surgery can be challenging as isolated surgery to free the nerve ie, spinal decompression may not be adequate treatment as we may have to stabilise either a short segment of the spine or stabilise longer segment of the spine so as to correct and realign the ADS. Both options have their inherent risks. But as discussed above, surgery may not be an option for everyone with nerve pain with degenerative scoliosis.
Like for back pain analgesia would be an appropriate first line of non-surgical treatment. Some of the additional medications usually prescribed by doctors would be gabapentine, pregabalin or amitriptyline to help with the nerve related symptoms.
If the pain is persistent despite medication one can trial a spinal nerve block which is done under local anaesthetic and under X-rayX-ray guidance to inject local anaesthetic and steroid around the specific nerve root to help and control the nerve related symptoms. These could not only be used mainly to control the nerve pain but also may have a good diagnostic element to help localise the pain source so that if required the patient could have limited surgery to decompress the nerve to help improve the symptoms if that is a feasible option.
Epidural injection is another option that is utilised to help with the symptoms. An epidural injection is usually done under local anaesthetic and X-rayX-ray guidance which would either be a caudal epidural or a lumbar epidural injection and both these injections go around the spinal cord rather than a specific nerve root like the spinal nerve block. The caudal epidural injection is injected just above the level of the tail bone and the lumbar epidural injection is injected into the lumbar spine which is roughly at the level of the waist line. The evidence in literature is fairly supportive of these treatment options ie, spinal nerve blocks or epidural injection.
The above management options are for the common mechanical symptoms patients with ADS would present with. One may have to use one or a mixture of the options as above to help with the symptoms. The decision with regards which are the best options to offer to help the symptoms would be based on the assessment by the clinician or the therapist treating the patient.
Consultant Orthopaedic Spinal Surgeon
University Hospital Llandough, Cardiff