3 million Adult 10 million...Copyright ScoliCare © 2016 · Conclusion: Conservative care in...

Copyright ScoliCare © 2016 · www.scolicare.comCopyright ScoliCare © 2016 · www.scolicare.com

AdultScoliosis

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The number of Australians aged 65 and over is expected to increase rapidly, from around 3 million in 2010 to between 7‐

10 million in 205611 Population Projections, Australia, 2006–2101

AGEING POPULATION = AGEING SPINES!


The prevalence of Scoliosis increases with age....

• 0.3% – 0.5% in children

• 2% – 4% above the age of 18 years

• 9% in over 40 year olds

• 30%+ in over 60 year olds

• 50%+ in over 90 year olds

2010 Journal of Bone and Joint Surgery ‐ British Volume, Vol 92‐B, Issue 7, 980‐983

Spine 2011 Apr 20;36(9):731‐6.

AGEING SPINESAND SCOLIOSIS


• Adolescent Scoliosis in Adults (ASA) is a pre‐existing AIS in adulthood

• Degenerative De Novo Scoliosis (DDS) is a new development of scoliosis in adulthood –No previous history

• The primary concern in most adult cases is pain and disability

• Progression and aesthetics can also be considerations

ADULTSCOLIOSIS


• Can be any curve type seen in adolescents

• ASA can be stable or progressive

• ASA can develop a degenerative stage later in life

• Pain usually an issue early on in unbalanced curves particularly thoracolumbar or lumbar curves

• Though often not painful until later in adulthood

• Patients may present post‐surgically

• Often progressive later in life in a degenerative phase

ADOLESCENTSCOLIOSIS IN ADULTS


• 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-NOVOSCOLIOSIS (DDS)

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Asymmetric Spinal

Degeneration

Soft tissue integrity lost

Functional unit instability increased

ScoliosisProgression

Boney adaptation (Wolffs Law)

PROGRESSION OF ADULT CURVES


Asymmetric Spinal

Degeneration




Boney adaptation (Wolff’s Law)



Asymmetric Spinal

Degeneration







Asymmetric Spinal

Degeneration







Asymmetric Spinal

Degeneration







Asymmetric Spinal

Degeneration







Pain Disability

Progression Aesthetics

Problems Associated with Adult Scoliosis


Adolescent

• Highly progressive• Pain not over riding issue• Often Flexible• Correction Primary goal

Adult• Slowly progressive (Unless DDS)

• Pain main issue• Usually rigid• Limited amount of correction

ADULTS VSADOLESCENT


Presentation:

• Less degeneration and instability

• Pain to varying degrees

• Worse in unbalanced curves

SCOLIOSIS IN YOUNGER ADULTS


SCOLIOSIS IN YOUNGER ADULTS



Presentation

• More degeneration and instability

• Usually painful

• Often have claudication symptoms

• Worse in unbalanced curves

SCOLIOSIS IN OLDER ADULTS


• MYTH: Scoliosis does not progress unless the curve is 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.

• Chopin et al. studied average progression of curve classifications in adults

• lumbar curves 1.8°/y • thoracolumbar curves 1.4°/y• thoracic curves 1.2°/y• double curves thoracic 0.8°/y, lumbar 0.9°/y

• DDS Avg 3 deg per year

PROGRESSION OFADULT CURVES


• Marty‐Poumarat et.al. Spine 2007

• Purpose: To define types of adult scoliosis, mode of progression, and to establish an individual progression profile.

• 51 scoliosis patients ‐ 48 female, 3 male

• Mean age at first x‐ray 37yrs (17‐60)

• All but 8 of the patients reported low back pain

• 22 reported nerve root pain

• 4 were pain‐free

• Overall, there were 51 thoracolumbar and lumbar curves, including 30 single major curves

NATURAL HISTORY OF PROGRESSIVE ADULT SCOLIOSIS


Marty‐Poumarat et.al. Spine 2007

Two main types were identified:

1) Type A

• Adolescent scoliosis

• Progresses after skeletal maturity




2) Type B

• Progresses late in adulthood

• Pre‐existing stable adult scoliosis with late progression

• De novo late‐onset scoliosis




• Progression was measured at a linear rate specific to each curve.

“We did not find any correlation between the initial Cobb angle and slope of progression in the overall population.”




The role menopause plays:

In Type A, 8 women with a long progression showed no change of slope at menopause

Patients with Type B 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




Findings

• The progression of adult scoliosis is linear

• It can be used to establish an individual prognosis

• Two main types exist:

• A) Adolescent scoliosis, which continues to progress, during adulthood

• B) Late onset scoliosis, either pre‐existing stable adolescent scoliosis or de novo

• Rotatory subluxation

• 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 but not for Type A



Risk of progression in de novo low‐magnitude degenerative lumbar curves: natural history and literature review.

Chin KR, Furey C, Bohlman HH. Am J Orthop (Belle Mead NJ). 2009 Aug;38(8):404‐9.


54 yr old woman ‐ 25°Right Lumbar ASA

18 months later ‐ 35 °


50 yr old woman minor LBP 5 years later developed DDS


July 2011 October 2012

26° 45°


• PERENNOU ET AL

• 671 LBP patients:

• 7.5% had evidence of scoliosis

• Prevalence of scoliosis increasedwith age

• 2% before 45 years (most likely ASA)

• 15% after 60 years (probably degenerative)

PREVALENCE OF ADULT SCOLIOSISIN BACK PAIN CASES


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”

PREVALENCE OF ADULT SCOLIOSISIN BACK PAIN CASES


• One of the Key treatment factors is postural balance

• Postural balance is a predictor to development of pain

• Postural balance can be improved in adults even if there is poor Cobb angle reducibility

POSTURALBALANCE


• Sagittal Balance is a measure of the neutral, forward or backwards potions of the trunk relative to the sacrum.

SAGITTALBALANCE



• Measure of the side shift

• Shift of T1 (or C7) relative to S1

• Central Sacral Vertical Line (CSVL) is drawn.

• Vertical line through S1

• The horizontal distance between this line and the middle of T1 is then measured

CORONALBALANCE

S1

T1


• E.g. Altered coronal balance

• T1 is shifted to the left of S1

• The green line is the CSVL

• The Red Line is the T1 plumb

line

• The distance between the two

is the coronal in‐balance.

CORONALBALANCE


The most significant findings were:

• Positive (anterior) Sagittal Balance was related to:

• Greater pain

• Diminished physical function

• Poorer self image

• Poorer social function

Adult Scoliosis: Clinical and Radiological features that relate to Pain

Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis Glassman, et al. Spine 2003


The most significant findings were:

• Coronal shift > 4 cm

• Poorer function

• Greater pain

• Compared to patients with a coronal shift < 4 cm.




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





“Adult Scoliosis ‐ A Quantitative Radiographic and Clinical Analysis” Schwab et al. Spine 2002



• Schwab identifies these correlations with pain:

• Lateral vertebral olisthy, (side slip)

• L3 and L4 endplate obliquity angles

• Decrease in lumbar lordosis

• Increased thoraco‐lumbar kyphosis


• 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



• 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

ADULT SCOLIOSISTREATMEMT


Treatment of Adult Scoliosis


Conclusion: Conservative care in general may be a helpful option in the care of adult deformity, but evidence for this is lacking. Unfortunately, no treatment option within conservative care has support within the literature as a preferred solution. Basic clinical research at any level would be helpful to further clarify the options.

A Systematic Literature Review of Non‐surgical Treatment in Adult Scoliosis (Both ASA and DDS)

Results: There is Level IV (Case series) evidence on the role of physical therapy, chiropractic care, and bracing.

Background: Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. A prerequisite to surgical intervention is usually failure of all appropriate conservative care. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity

Clifford R. Everett, MD, MPH, and Rajeev K. Patel, MDSPINE Volume 32, Number 19S, pp S130–S134


TREATMENT OF ADULT SCOLIOSIS

Dr Max Abi Eur Spine J (2005) 14: 925–948


Does Treatment (Nonoperative and Operative) Improve the Two-Year Quality of Life in Patients With Adult Symptomatic Lumbar Scoliosis: A Prospective MulticenterEvidence-Based Medicine Study

(DDS)


Surgical intervention of Progressive Adult Scoliosis


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ADULT SCOLIOSIS TREATMENTRigid vs. Dynamic Orthosis for Treatment

RIGID• Primary goal Stabilization

• Good Pain relief for degenerative curves

• Only alternative to surgery if goal is to stop progression

• Useful in Neuro‐degenerative cases

DYNAMIC

• Primary goal Pain relief

• No evidence to support stabilization

• Not suitable for Neuro‐degenerative cases


INDICATIONS FORTREATMENT


INDICATION FOR PAIN

PAIN • Related to focal pathologies and underlying spinal misalignment :

• Spinal Stenosis• Disc degeneration• Facet degeneration


Postural• Cosmetic

• Rib humping• Side shift or hip hiking • Chronic poor

posture/slouching,• Postural support.

INDICATION FORPOSTURE


Postural• Preventative

• Postural scoliosis (pseudo scoliosis)

• Postural deformity of scoliosis e.g. coronal balance)

• Age related degenerative posture

• Compression fracture risk reduction

• Anterior sagittal balance• Posterior sagittal balance

INDICATION FORPOSTURE


Progression• De Novo Scoliosis

• Adolescent Scoliosis

in Adult

• Hyper kyphosis

• Postural Scoliosis

• Anterior Sagittal

balance

INDICATION FORPROGRESSION


• Post traumatic stabilisation

• Inability to self fit or remove the brace

• Primary concern unrelated to spinal positioning e.g. neurological pain related to diabetic neuropathy

CONTRAINDICATIONS


WEARING RECOMMENDATIONS

• Temporary pain relief or postural support

• No minimum, worn on an as needed basis • Medium to long term pain relief postural support

• 8‐16 hrs, minimum 3‐6 months then gradual reduction to “as‐ needed” wear.

• Worn while active i.e. during day at work.• Severe Pain, Scoliotic progression

• Full time (20/24 hr) wear • Minimum 24 months, could become permanent

treatment

PROTOCOL FORADULT TREATMENT


Dealing with elderly can be challenging

• Communication• Expectation• Suitability • Support

SPECIAL NEEDSFOR ADULT CASES


• Also age and menopause related

• Vertebral collapse gives a poor prognosis

• Consider surgical referral if severe

OSTEOPOROSIS


Case Study of Combined SEAS and ScoliBrace in

flexible ASA

Goal of treatment:

Improve cosmetics Improve posture Change surgical Dx




Insert Slide 226 Video






One Month 3 Months 6 Months


• Limited evidence exists for conservative treatment of Adult scoliosis

• There is a rationale for the selective use of specific exercises and

bracing in moderate ASA cases

• Success seems to be greater in flexible unbalanced curves with a

large postural displacement

• In “Progressive Degenerative” adult curves there seems to be a

limited rationale for conservative treatment

• Surgical referral may be the best management

• However where patients have significant co‐morbidities

conservative treatment may play an important role

ADULT SCOLIOSISSUMMARY


THANK YOU FOR YOUR ATTENTION!

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