Adult scoliosis: Surgical indications, operative management, complications, and outcomes

In this section we are discussing the patient over the age of 20 years with idiopathic scoliosis, with or without superimposed degenerative changes. Many adult scoliotics seek medical treatment because of deformity, back pain, or both. Nonoperative measures for back pain include intermittent nonsteroidal anti-inflammatory drugs, physical therapy geared towards trunk strengthening and aerobic conditioning, alteration of lifestyle, and other general supportive measures. Frequently, the long term results of conservative treatment are disappointing. Bracing does not seem to have a role in altering the natural history of adult scoliosis, but may be helpful for certain patients who are not surgical candidates. Progression of the deformity to an unacceptable degree, and/or pain resistant to conservative treatments, are the usual surgical indications in the middle-aged and older adult. For the younger adult, magnitude of deformity (radiographic and clinical) are relative indications. Technical issues that must be considered by the surgeon include whether to include distal lumbar levels (the fractional curve) including L5-S1, decisions regarding combined approaches, and whether these are best done same day versus staged, and fixation to the sacrum/pelvis. Correction or maintenance of coronal and sagittal balance with long fusions (to the sacrum) is complex and critical. Complications and pseudoarthroses occur much more frequently in adults compared to the adolescent scoliosis patient. Nutritional depletion is known to be a significant problem in a high percentage of patients having combined surgery. Therefore, nutritional supplementation should be instituted in the high risk patient, and its role warrants future investigation. Evaluation of the results should include radiographic measures, as well as measures of pain relief, functional assessment, and patient satisfaction. Prospective randomized studies in this area do not exist, though retrospective reviews suggest a majority of patients feel that they have benefited from the surgery and have gained some pain relief. Basic patient assessment measures such as Oswestry or SF-36 are not disease-specific enough to evaluate surgical treatment outcomes of adult scoliosis. Future investigations should include the long term influence of a significant idiopathic deformity on degenerative lumbar disc disease. In the future, prospective use of validated instruments will hopefully shed more light on these issues.