Surgery and other treatment options for adult scoliosis

Spine surgeons have been debating the best methods for treating adult scoliosis for years. Curvature of the spine often causes more back pain, leg pain, and other symptoms in adults than teens because adults can also have spinal stenosis, which is degeneration of the discs between the vertebrae and narrowing of the opening for spinal nerves. Still, there is no good evidence for adults with scoliosis as to whether it is better to have corrective surgery or whether nonsurgical treatment such as physical therapy or nerve injections is sufficient.

To help answer this question, doctors at nine centers in North America followed more than 200 adults who suffered from lumbar scoliosis – deformities that affect the lower part of the spine. The NIH-funded trial was conducted between 2010 and 2017 and is the only government-funded study of spinal deformity in adults.

The research effort, led by spine surgeon Keith H. Bridwell, MD, of the Washington University School of Medicine in St. Louis, found that surgery often helps patients recover. It helped straighten their curvature and they had less pain. But the researchers also found that those who did not have surgery generally did not experience more severe pain or more severe spinal deformity over a two-year follow-up period. In fact, they found that the most important factor in deciding whether or not to operate is the extent of the patient's difficulties and how much this difficulty affects daily life.

The new findings were published Feb. 20 in The Journal of Bone and Joint Surgery. "If patients expect less pain or better function, they probably won't see improvement unless they have surgery," said Bridwell, the study's senior researcher and J. Albert Key Distinguished Professor of Orthopedic Surgery. "On the other hand, if patients' quality of life is adequate and the goal is simply to keep them from getting worse, nonsurgical treatment is probably fine."

About 15 percent of adults in the U.S. have some type of spinal deformity, and the most common is lumbar scoliosis. Some adults have scoliosis since puberty; others develop the condition as adults. Many experience no symptoms, but a significant percentage develop back pain, leg pain, and even lose 10 cm of torso height from the waist up due to deformity.

"Many doctors have recommended surgery before a patient's condition worsens," said first author of the study, Michael P. Kelly, an associate professor of orthopedic surgery at the University of Washington. "However, we found that, on average, patients are less likely to deteriorate rapidly. Those who do not have severe pain and can easily perform daily activities seem to progress slowly, and often their symptoms are not severe enough to risk surgery."

The risks of surgery include surgical complications such as infection and non-fusing of the vertebrae, which often means that patients will need another operation.

A total of 286 patients, 144 in the non-operative group and 142 in the operated group, were included in the study. All were symptomatic patients aged 40 to 80 years who had a curve of at least 30 degrees in the lower spine. Disability levels were measured with spinal pain and disability questionnaires. Patients who did not have surgery were treated with treatments such as physical therapy, anti-inflammatory drugs, and pain medication injections directly into the nerve roots along the spine. Of the patients who did not have surgery during the study period, 29 changed their minds or their condition worsened and decided to have surgery.

Bridwell said that in general, patients who had surgery felt less pain after surgery and were able to function better in their daily lives two years later. However, over the study period, 14 percent of patients who had surgery required at least one additional surgery to correct any subsequent complications.

At the end of the study, on average, surgical patients had recovered. Meanwhile, those who did not have surgery were functioning at about the same level after two years, but most did not get worse. Kelly and Bridwell said that individual patients' satisfaction with their degree of disability appears to be the best guide to whether or not they choose to have surgery.