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June 2009

New Treatments for Scoliosis in Older Patients

Shane Burch, M.D.
Orthopedic Surgeon
UCSF Spine Center

Scoliosis, a common spinal disorder affecting both the young and old, is becoming more prevalent in adults as the population ages, with typical onset between age 50 and 80.

Treatment in this older population presents particular challenges due to common co-morbidities, such as osteoporosis. As physicians who treat spinal disorders become more familiar with the condition, treatment algorithms are being established for older patients. Advances, including innovative minimally invasive surgical approaches, advanced neuromonitoring techniques and 3-dimensional imagining, allows for limited anesthesia, quicker mobilization and recovery, and ultimately improved quality of life.

Scoliosis is defined as a curve in the vertebral column or bend in the coronal plane of the body.

In young patients, scoliosis typically affects adolescents going through a growth spurt, but it can occur at any time during development. The cause of this form, known as adolescent idiopathic scoliosis, is unknown.

In older patients, scoliosis occurs due to asymmetric degeneration caused by wearing through the faccet joints and intervertebral discs.

A feature of degenerative scoliosis is micro-instability. There is often forward, lateral and rotational slippage of vertebrae on vertebrae. Motion between these degenerative levels is often painful. If the changes in the spine are such that the curve coincides with narrowing of the spinal canal, one or more nerve roots may be pinched, resulting in spinal stenosis and leg pain.

Diagnosis

Making a diagnosis of scoliosis is usually accomplished with plain radiographs that document the curvature of the spine. Full-length, standing anteroposterior and lateral films should be obtained to assess the sagittal and coronal balance allowing the magnitude of the curve to be measured. More important than the coronal bend is the loss of sagittal alignment that occurs with scoliosis in older patients.

The degree of a patient's curve in the coronal plane may not reflect the medical condition of the patient. For example, a patient with a 65 degree thoracolumbar curve may be perfectly fit and enjoy an excellent quality of life. Similarly, a patient with a smaller curve, such as 30 degrees, may suffer from severe back and leg pain. A patient with a mild curve may have much more back pain and leg pain than a patient with a curve of larger magnitude.

X-rays are used to determine how fast the curve is progressing. MRIs and CT scans are utilized to determine the nature of stenosis and the relative health of the discs above and below the curve.

Non-Operative Treatment

In most cases, treatment for adult scoliosis begins with a combination of non-operative therapies that may be administered for weeks to months. These include:

  • Physical therapy to stabilize the spine
  • Anti-inflammatories and mild narcotics to relieve back pain
  • Epidural steroid injections to relieve leg pain

Advanced Surgical Treatment

For patients who continue to suffer with severe back pain or leg pain, surgery may be required. It is important to note the age should not restrict an individual's treatment options.

New approaches that limit doses of anesthesia and effectively and safely restore a patient's quality of life are now available. These include new minimally invasive surgical techniques, such as the XLIF (eXtreme Lateral Interbody Fusion) or DLIF (Direct Lateral Interbody Fusion) procedures that create a small portal in a patient's flank to operate, minimizing muscle stripping but maximizing access to the intervertebral disc. These approaches not only offer the surgeon the ability to correct the coronal bend but also restore the patient's sagittal balance. Restoring the sagittal balance in a patient with scoliosis is perhaps the single most important factor contributing to a good outcome following treatment.

One concern with this approach is damage to the nerves running along the psoas muscle, which may be encountered during the procedure. To limit potential nerve injuries, researchers at UCSF Medical Center have advanced the field of neuromonitroing to limit nerve injury during spine surgery.

Similarly, smaller portals make visualizing the spine more challenging. To limit these potential pitfalls, surgeons at UCSF use state-of-the-art 3-dimensional intra-operative imaging techniques to facilitate these and other procedures. This technique allows the spine to be visualized clearly despite limited access or altered anatomy, facilitating placement of instrumentation with greater accuracy while increasing procedure safety. Research regarding 3-dimensional intra-operative imaging is ongoing at UCSF.

In older patients with scoliosis, our surgeons combine the use kyphoplasty or vertebroplasty to augment posterior instrumentation in patients with osteoporosis who undergo spinal deformity surgery. These techniques combat the effects of osteoporosis by augmenting the cancellous vertebral bone with bone cement to restore the strength of an old vertebra to that of a young vertebra, limiting the post-surgical failures secondary to weak bone.

UCSF Spine Center

The UCSF Spine Center is one of the largest centers of its kind in the country, treating 10,000 patients a year. The center brings together world-renowned specialists in neurosurgery, orthopedic surgery, neurology, physiatry and other specialties to design the most effective treatment for each patient's condition. The most advanced treatments are available, including minimally-invasive cervical and lumbar techniques, motion-sparing surgery, complex revision spine surgery and computerized 3-dimensional surgery.

The center treats the full spectrum of spinal disorders from complex and difficult to diagnose conditions to those that have failed previous treatment. We care for people of all ages — including children — through the full course of treatment and recovery.

In addition, our experts are at the forefront of basic scientific research to better understand spinal conditions as well as develop and test new technologies and treatments.

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (800) 444-2559
Email referral.center@ucsfmedctr.org

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